On Call on 9 Tower: Anaphylaxis and Fever By Chase McNeil. . .

Just another fun night on call . . . You are called to the bedside of a patient with ALL admitted for routine chemo . . . Patient is flushed and wheezing . . . Developed while running chemo . . .

Just another fun night on call . . . You are called to the bedside of a 6y/o patient with ALL admitted for routine chemo . . . Patient is flushed and wheezing . . . Developed while running chemo . . . What do you do now? . . . What do you do? . . .

More info . . . You find out that the patient was receiving VP-16 for the first time . . . So this is . . .

More info . . . You find out that the patient was receiving VP-16 for the first time . . . So this is . . . Anaphylaxis! . . . Patient now with lip and tongue swelling. What next?

What Now? Get help via your spectralink… (call your acting chief and fellow!) As you are doing that…

What Now? Get help via spectralink . . . As you are doing that . . . NS bolus 20 cc/kg Benadryl 1mg/kg IV push Hydrocortisone 2 mg/kg IVP Zantac 1mg/kg

Congratulations You Saved the Day! Albuterol stat for wheezing . . . Scheduled benadryl/steroids Do NOT give VP16 again You are Super ‘tern

What if That Didn’t work? Wheezing worsened and what’s more, poor air entry . . . Stridor . . . BP 90/20 . . . Patient is agitated . . .

What if That Didn’t work? Epinephrine IV 1: 10,000; 0.01 ml/kg Followed by drip @ 0.1mcg/kg/min SQ/IM 1:1,000; 0.01 ml/kg

Whew . . . BP improved, respiratory distress improved . . . PICU fellow in the room . . . You are a super-hero . . . You’re bat-tern . . . Or something . . .

But what if there was real trouble? Epi given . . . BP improved but big-time respiratory distress . . . Rapid sequence intubation! 6 y/o . . . 30 kg What drugs . . . Tubes . . . Blades . . .

Real Trouble Get your gear together Miller 1 or 2 blade 5.0 or 4.5 tube uncuffed Because of airway edema in this patient you may need a smaller tube than normal. Drugs: The RSI in the clutch Atropine 0.01 mg/kg Versed 0.1 mg/kg Rocuronium 1 mg/kg For True rapid sequence there is no flush b/w meds

FYI: Other Anaphylactic Meds VP- 16 = etoposide Asparaginase Vitamin K Tobi And many more . . .

As was well until . . . You were resting on your laurels when you get another call . . . That dude in room 914 with AML has T= 103 with chills . . . His ANC= 50 What are you going to do?

Fever and Neutropenia Or “F&N” to those in the know . . . True medical emergency Risk for rapid decompensation into septic shock . . .

F&N What do you do: Get CBC w/ Diff, blood culture, CXR if sxs Start antibiotics . . . But which ones? With F&N you need to be thinking about pseudomonas, alpha-strep and staph . . . Even though really any bug can infect these patients and make them really, really sick…

F&N ALWAYS CALL YOUR FELLOW regarding your antibiotic choice – here are some guidelines (but again – talk to your team!) If low risk/no indwelling line: ceftazidime If line and low risk: ceftaz and vanc If toxic or high risk: vanc, gent and timentin BEWARE: There is a high risk of hypotension in these patients after starting antibiotics!

F&N As your patient was AML with fever and chills you start vanc, gent and timentin . . . 1 hour after starting antibiotics you get a call that HR = 170 and cap refill ~3 sec What do you do!!!

Sepsis Fluids, fluids, fluids . . . Surviving sepsis guidelines call for 3 NS boluses of 20cc/kg each in less than 15 minutes for shock Call acting chief/RRT, facilitate transfer to higher level of care

You saved the day! You are a great intern . . . You can now feel good about being on call . . .