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#98: Rapid Responses – What Can the PICU Do For You? (Part 2)

November 22, 2023 | By

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Summary: 

Rapid heart rate at a rapid response? Not to worry, this collaboration with PedsCrit will give you the confidence you need to take step right in. Join Dr. Nada Mallick as she takes us through Part 2 of our Rapid Response Series, highlighting calls for tachycardia in high risk patients!


Rapid Response Show Notes

What happens at a rapid response?

A rapid response team is a designated team of clinicians who can be assembled quickly to bring critical care expertise to a deteriorating patient’s bedside. In a rapid response, this team formally evaluates the patient to provide necessary emergency medical treatment and determine if they need escalation of care. In most children’s hospitals, a rapid response team consists of an experienced nurse, a respiratory therapist, and a representative from the PICU.2,3 This PICU representative can be a fellow, attending physician, advanced practice provider, or charge RN.

When Dr. Mallick attends a rapid response, she first examines the patient to make sure that they do not need emergent medical intervention. After examining the patient, Dr. Mallick asks the primary team for the story. Usually, the patient’s front-line provider will be tasked with presenting the patient to the ICU.

After hearing the patient story, Dr. Mallick and her team will decide if the patient needs transfer to the intensive care unit or not. If the patient is being transferred to the ICU, a member of the rapid response team will often stay to assist the floor nurse while an ICU room is being prepared and help transport the patient to the ICU. Front line providers are crucial during this time to help the rapid response team order and provide emergent diagnostic procedures and treatments.

If a patient does not require transfer to the ICU, Dr. Mallick will often plan with the primary team for interventions to help diagnose or treat the patient and set a time interval to re-evaluate the patient. Common diagnostic interventions include x-rays, labs, and cultures. Common treatments include chest physiotherapy and suction, antibiotics, and fluid boluses. After an intervention is planned, Dr. Mallick will set a time interval to re-evaluate the patient and determine if they need ICU transfer. Each hospital has their own protocol for who re-evaluates a patient after a rapid response and when, but the presence of the primary team is often crucial to provide continuity and ownership of the patient.

Presentation & Key Interventions

How should I present my patient to the PICU?

Many intensivists believe that a good rapid response presentation starts with the sentence: ‘we called this rapid response for: _____,’ and is followed by a brief presentation in the SBAR format.4

SBAR is an abbreviation that stands for ‘Situation, Background, Assessment, and Recommendation.’ After you state the situation, you provide the relevant medical background, your assessment of the situation, and finish the presentation with your recommendation.

For example, if you were calling a rapid response for escalation of a patient on continuous albuterol for status asthmaticus with worsening hypoxemia, you would say:

  • Situation – “We are calling this rapid response for hypoxemia and respiratory distress.”
  • Background – “This is a 13yo with moderate persistent asthma who has been admitted for 3 days for status asthmaticus. She is experiencing worsening hypoxemia requiring 60% FiO2 on continuous albuterol for the past hour. We have given magnesium and intramuscular epinephrine. A chest x-ray from 30 minutes ago is hyperexpanded wedge-shaped atelectasis of her left lower lob, and she is experiencing one-word dyspnea and worsening retractions.”
  • Assessment – “Continuous albuterol is insufficient respiratory support at this time…”
  • Recommendation – “…and I think she would benefit from BiPAP.”

This presentation structure allows the PICU to focus on pertinent details and focuses the team on the potential ICU therapy.

Case #1: Hypoxemia and Increased Work of Breathing

It’s 3am in peak respiratory season. Your pager beeps- it’s a rapid response on the acute care floor. While you’re putting on your PPE, the acute care charge RN tells you it’s an infant with bronchiolitis who is experiencing increased work of breathing.

You enter the room, the monitor shows a heart rate of 164, a saturation of 92% and a respiratory rate of 70. A well-nourished infant about 6 months old, sitting up in the bed supported by a parent on a nasal cannula; the flow rate is set to about 4L/min. A pediatric intern stands at the bedside, holding their patient list.

You ask for the patient presentation, and the team says: ‘this is a rapid response for increased work of breathing. This is a 6-month-old ex-36-week girl with bronchiolitis on day 8 of illness. Currently requiring 4L NC to maintain saturations above 90%. Also having decreased PO intake, decreased urine output, and fevers.’

Respiratory exam shows scattered crackles and diminished air movement on the right-hand side. Last temp was 39.5. Cap refill is ~2s, and the child is crying without tears. Abdomen is soft, without hepatomegaly.

In this case, Dr. Mallick notes the increased work of breathing and tachycardia and recommends escalating respiratory support. In some children’s hospitals, it is possible to ask a respiratory therapist to set up non-invasive respiratory support (high-flow nasal cannula or BiPAP), during a rapid response.

Dr. Mallick also notes that fevers, tachycardia, and worsening respiratory distress are not typical after 8 days of illness in bronchiolitis. She broadens her differential by asking for labs and a chest x-ray. Many intensivists believe that if a rapid response is called for respiratory failure, a chest x-ray should be obtained prior to the RRT to help the PICU team diagnose and risk-stratify the underlying lung disease.5 Dr. Mallick also states that if hypovolemia is expected, a fluid bolus should be given prior to the RRT, because this can both treat and risk-stratify the patient.

The team discussed obtaining a blood gas at a rapid response, and Dr. Mallick stated that she prefers to use her physical exam to risk-stratify respiratory failure in this age group.

Case #2: Post-Op Hypotension

Your pager beeps for a rapid response on the Surgical Care Unit and you look at the chart: a 14-year-old girl with neuromuscular scoliosis and stage 5 chronic kidney disease who is post-op day 1 from a posterior spinal fusion. Her last charted blood pressure is 84/47 with a MAP of 59mmHg.

The surgery was complicated by about 700mLs of blood loss, for which she received an intra-operative transfusion. A JP drain is in place. Analgesia is provided via scheduled acetaminophen and PRN morphine. The patient is experiencing decreased urine output and has not had any fevers.

Pre-op electrolytes showed a creatinine of 1.2 and a BUN of 16. A post-op CBC showed a hemoglobin of 6.8, for which another blood transfusion was given. Electrolytes have not been drawn since before the surgery.

This is a clinical case of uncompensated shock presenting as hypotension. Drs. Mallick, Hodges, and Shanklin, discussed the potential causes of her presentation:6

  1. Distributive shock
    1. This patient could have an untreated infection leading to systemic vasodilation and distributive shock.
    2. This patient has chronic kidney disease. If she is metabolizing opioids incorrectly,
  2. Hypovolemic or hemorrhagic shock
    1. This patient could be hypovolemic from unrecognized blood or fluid loss, resulting in tachycardia and hypotension.
  3. Cardiogenic shock
    1. This patient could have unrecognized cardiac dysfunction or myocardial depression.
  4. Obstructive shock
    1. This patient could have a pulmonary embolism leading to tachycardia or hypotension.

On physical exam, the patient is alert but not oriented, falls asleep during your questioning. Cap refill is about one second, and she feels warm to your touch. Heart rate is 120. She is tachypneic with clear breath sounds bilaterally. On your abdominal exam, the abdomen is firm with tenderness to light palpation and rebound tenderness.

Dr. Mallick stated that this case is an excellent example of a physical exam guiding diagnosis and treatment. She emphasizes the importance of teamwork in this scenario, including rapid and direct communication with general surgeons, orthopedic surgeons, and the PICU charge nurse. Front line providers from the acute care floor are often extremely helpful when multiple me orders and consultants are needed.

Dr. Shanklin emphasizes that this case is a theoretical complication of spinal fusion surgery that she has never seen before.

Citations

1. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139-146. doi:10.1056/NEJMra0910926

2. Levin AB, Brady P, Duncan HP, Davis AB. Pediatric Rapid Response Systems: Identification and Treatment of Deteriorating Children. Curr Treat Options Pediatr. 2015;1(1):76-89. doi:10.1007/S40746-014-0005-1/TABLES/1

3. Gold DL, Mihalov LK, Cohen DM. Evaluating the Pediatric Early Warning Score (PEWS) system for admitted patients in the pediatric emergency department. Acad Emerg Med. 2014;21(11):1249-1256. doi:10.1111/acem.12514

4. Tews MC, Liu JM, Treat R. Situation-Background-Assessment-Recommendation (SBAR) and Emergency Medicine Residents’ Learning of Case Presentation Skills. J Grad Med Educ. 2012;4(3):370-373. doi:10.4300/JGME-D-11-00194.1

5. Gross CJ, Porter JJ, Lipsett SC, Monuteaux MC, Hirsch AW, Neuman MI. Variation in Management and Outcomes of Children With Complicated Pneumonia. Hosp Pediatr. 2021;11(3):207-214. doi:10.1542/hpeds.2020-001800

6. Bjorklund A, Resch J, Slusher T. Pediatric Shock Review. Pediatr Rev. 2023;44(10):551-562. doi:10.1542/PIR.2022-005630


Goal

Listeners will understand the objective of a rapid response and best practices for presentation, workup, and management in common rapid response scenarios.

Learning Objectives

After listening to this episode listeners will… 

  • Describe techniques for diagnosis and acute stabilization of impending hypoxemic respiratory failure from a complicated pneumonia.
  • Discuss workup for a patient with undifferentiated shock.
  • Describe options for ICU support for a patient who does not meet ICU criteria.

Disclosures

Dr. Nada Mallick is on the advisory board of FlexTogether, a respiratory rehab telehealth clinic.

Citation

Shanklin A, Hodges Z, Masur S, Mallick M, Berk J. “#98: Rapid Responses: What can the PICU do for you (Part 2)?”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ November 20, 2023.


 

Episode Sponsors

Uncommon Goods

Uncommon Goods is offering all Cribsiders listeners 15% off at uncommongoods.com/cribsiders

Episode Credits

Producer, Writer, and Show Notes: Alice Shanklin MD
Showrunner: Sam Masur MD
Cover Art: Chris Chiu MD
Hosts: Justin Berk MD, Alice Shanklin MD, Zachary Hodges MD, Sam Masur MD
Editor: Clair Morgan of nodderly.com
Guest(s): Nada Mallick MD

CME Partner

vcuhealth

The Cribsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit cribsiders.vcuhealth.org and search for this episode to claim credit.

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