Acute changes in condition: Caring for a child with ...
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Acute changes in condition: Caring for a child with myocarditis Looking at the first 48 hours of admission
Transcript of Acute changes in condition: Caring for a child with ...
Acute changes in condition: Caring for a child with myocarditis
Looking at the first 48 hours of admission
Demographics – introduction
Nosi 5 years old
Born in Zimbabwe
GIRL
TB HIVUNEXPOSED
1 of 4
children
15kg, well nourished
Now lives in
Langa, informal housing. Toilet
and H20 outside
Mum is primary caregiver
All the children have had measles in the last two weeks
Genogram
History
→ Presented to S12 at Red Cross
children’s hospital on Sunday at
14h30
→ Mum says she was fine this morning
but now “breathing fast and
noisy”
Assessment on arrival
Investigations:
Arterial blood gas: Gas exchange satisfactory,
Lactate 4.9, Glucose 20
Chest x-ray: extensive R side consolidation and
gross cardiomegaly
Initial management in S12
1. Diagnosed to be in congestive cardiac failure with right-sided pneumonia that has led to CARDIOGENIC SHOCK.
2. Intubated and ventilated 3. IV access gained and antibiotics given and morphine
commenced 4. Furosemide given to reduce the fluid load on the heart 5. Dobutamine commenced at 10mcg/kg/min to increase
the contractility of the heart 6. Echo performed: Normal structure but dilated LA and LV
→ ACUTE MYOCARDITIS, SECONDARY TO MEASLES? 7. Measles IGM sent to lab and Rapid performed 8. Referred to ICU
Transferred to ICU where…. Normal values
pH 7.16 7.35 – 7.45
pCO2 4.5 4.5 - 6
pO2 17.7 10 - 14
Base excess -15.5 +2 - -2
Bicarb 12.9 22 – 26
Lactate 8.2 Less than 2
Glucose 27 Less than 7
• Pink frothy secretions (pulmonary oedema): Sats = 100% but → HFO
• Temp up to 38.6oC
• BP now 110/89.
• Milrinone added at 1.5mcg/kg/min
• Liver size reduced
• Arterial line and central line placed.
At midnight on Sunday/Monday
• Nosi suctioned and turned prone. • BP and HR dropped and she had a
cardiac arrest. • After approx. 6 mins of CPR and x2 bolus of
adrenaline her re-started • Adrenaline 0.3 mcg/kg/min, dobulatime
10mcg/kg/min, Milrinone 1.5 mcg/kg/min • Urine output post arrest ↓to 0.2ml/kg/hr • Mum counseled as to the severity of Nosi’s
condition
Blood gases
12h28 01h00 01h25 02h00 Normal values
pH 6.914 7.26 7.095 7.313 7.35 – 7.45
pCO2 18.5 6.11 10.3 5.69 4.5 - 6
pO2 12.7 19.8 13.8 7.2 10 - 14
Base excess -5.4 -5.6 -5.9 -4.2 +2 - -2
Bicarb 17 19.4 18.2 20.6 22 – 26
Lactate 2.5 5.1 4.8 4.4 Less than 2
First blood gas post arrest was very poor
Decision made to switch her to conventional
ventilation
Initial ABG post switch
poor
Repeated 30 mins later and
better
20 hours later… (Tuesday morning, less than 48 hours
post admission)
Important message: Children can deteriorate very quickly BUT children
can also get better very quickly as well
Pathophysiology of myocarditis
The amount of damage
determines the severity of
symptoms and the prognosis of the
illness
Concerns:
• ↓cardiac output as a result of ↓contractility
• Volume overload
• ↑work on the heart
Management:
• No treatment for myocarditis
• Support cardiac function
• Find and treat the cause
Nursing care focusing on the myocarditis
• Mother to Child Interaction: o Mum been counselled as to the severity of the
situation o Needs updates + encouraged to be at the bedside
for her and Nosi’s comfort
• Pain and comfort: o Very deeply sedated initially to reduce the workload
on the heart. o Midazolam, morphine, valium + vecuronium as
required o Non-pharmacological analgesics as well
• Hydration:
o Fluid restricted to 45% of normal + Furosemide prescribed – to reduce fluid pressure on the heart
o Assess hydration regularly and urine output continuously.
o Check urea and creatinine – already abnormal + receiving many nephrotoxic medications
• Nutrition:
o Re-starting feeding is important (12 hours later)
o Increase slowly to check for tolerance post arrest.
• Microbial Load: o Polygam prescribed to replace antibodies. o Steriods given to reduce inflammation and weaken
immune system. o Strict VAP measures (↑risk of infection due to
weaken immune system + ?aspirated during induction)
o Administer prescribed gentamycin and check levels.
o Observe infection markers (WBC, Hb, CRP and bands) and act empirically if raised.
• Mucosal Integrity: o Refer to dermatology for her peeling feet
• Regulatory systems o Need to regulate the BP + heart rate and improve
cardiac output
o Dobutamine - increases HR but does reduce afterload Commenced in med reg but stopped once diagnosis
made.
o Milrinone - Doesn’t affect HR as much AND acts as a effective afterload reducer Commenced in ICU following diagnosis.
o Adrenaline - Required post arrest to increase HR and BP Important to reduce quickly as acts against the
Milrinone.
• Regulatory systems continued..
o Paracetamol given to reduce temperature
o Observe glucose and lactate on the blood gases – both reduced without intervention as Nosi improved.
o Ensure that Nosi gets sleep/settled time – provide quiet dark time in the ICU
‘Acute changes in condition’
Big changes can be happen in small amounts of time
THANK YOU!
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