Sun28November0628PM 46

A 2-year-old child is admitted to the Paediatric Intensive Care Unit (PICU) with suspected meningococcal sepsis. He is breathing spontaneously but his SpO2 is 82% despite receiving 15L/minute of oxygen via a reservoir rebreathing mask. He has already received a bolus of 20mL/kg crystalloid and antibiotics in the Emergency department his blood pressure is 40/10 mmHg and has a pulse rate of 220 beats/min.

Which of the following is the most appropriate immediate course of action?

(Please select 1 option)

Administer 240 mls of crystalloid, commence vasoactive agents and intubate with a size 4.5 mm uncuffed oral endotracheal tube, inserting a throat pack to obtain a seal

Administer 240 mls of crystalloid, commence vasoactive agents and intubate with a size 4.5 mm uncuffed oral endotracheal tube

Restrict fluids, maintain blood pressure with vasoactive agents and commence non-invasive CPAP

Administer 240 mls of crystalloid, commence vasoactive agents and intubate with a size 4 mm cuffed oral endotracheal tube, inflating the cuff until there is no leak

Administer 240 mls of crystalloid, commence vasoactive agents and intubate with a size 4 mm cuffed oral endotracheal tube, keeping the cuff pressure <20cmH2O Correct

Explanation

Fluids should not be restricted unless there is evidence of raised intracranial pressure or inappropriate ADH secretion.

Fluid resuscitation:

If there are signs of shock, give an immediate fluid bolus of 20 ml/kg 0.9% N. saline over 5-10 minutes via IV or IO routes.

If the signs of shock persist, a second bolus of 20 ml/kg of 0.9% N. saline or human albumin 4.5% solution should be administered.

Estimated weight formula is: weight = 3 x (age) + 7 = 13 kg

or

Estimated weight formula is: weight = (age+4) x 2 = 12 kg

In this scenario, the signs of shock persist despite fluid resuscitation (more than 40 mL/kg). The patient will require access to a healthcare professional experienced in the management of critically ill children and inotrope therapy (noradrenaline or adrenaline). The patient may require as much as 60 mL/kg of fluid.

There is at risk of impaired airway patency, pulmonary aspiration and oedema and cerebral oedema. Securing the airway with an endotracheal tube (ETT) is important at this stage. Ideally, it should be a cuffed tube (internal diameter calculated according to the formula ([age/4] + 3.5). For an uncuffed tube the formula is [age/4]+4.

The advantages of a cuffed tube include:

good seal/fewer leaks

easier to maintain ventilatory parameters

measuring CO2 more reliable (esp in neonates)

less changes of ETT and direct laryngoscopy attempts

too large ETT causes laryngeal damage (cuffed or uncuffed)

less aspiration

The tracheal tube cuff should be:

high volume low pressure

short length and subsequent management

adequate depth markings and not allow the cuff to be inflated in the subglottic region

Attention should be paid to maintaining the cuff pressure <20cmH2O to reduce the risk of tracheal mucosal injury.

Answer Statistics

1

5%

2

33%

3

1%

4

20%

5

43%

Times answered: 340