General Principles

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• Always let your senior know if you're worried or unsure about a patient

• Always examine and assess the patient yourself - don't trust someone else's assessment

• Get baseline exams at the beginning of your shift on any patients that are labelled as "sick" by your day team

• Eat and rest  when you can

• Use your nurses - many have been around for a long time and have a good sense of when to be worried

• Be sure to clarify any unclear instructions or orders during signout - specific contingency plans are key

• Touch base with your senior throughout the night

• Organization is important - find your preferred style and stick to it

• Write things down - a lot can happen during the night; don't rely on just your memory

• Don't procrastinate - take advantage of quiet moments to finish your notes, follow-up on tasks, etc. as you never know what's coming next

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COMMON PAGES BY SYSTEM (AND HOW TO APPROACH THEM)

 

Neurology

 

Pager message:

“Patient is having a seizure, please advise.”

 

Background: 

Seizures can be a daily, regular occurrence for some patients and the ominous sign of neurologic malfunction in others.  Some patients will have “pseudoseizures” or “non-epileptiform seizures” that can be hard to distinguish from epileptiform seizures.  Therefore, the correct response to this page really depends on the individual patient.  When getting signout on patients with known seizure disorders, you should find out what response the primary team wants.

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Assessment (chart and numbers): 

The first thing to address is the stability of the patient.  You should check to see if the patient is having any problems with oxygen saturations with the seizure, as that will be the most immediate threat to the patient’s health.  The next question is to figure out whether or not the patient has a history of seizures.  The neurology service often admits patients for video EEGs, and they will actually try to provoke seizures by sleep depriving the patients or taking away their home medications.  Prematurely stopping these seizures may prevent them from getting the data they need.

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Assessment (physical exam): 

Patients having seizures should be assessed as rapidly as possible.  Attend to their ABCs and try to get a pulse oximeter on them if they do not have one already.  Try to get a sense of what their seizure activity looks like so that you can describe it to your senior or to the day team.  Patients with non-epileptiform seizures may have unusual writhing movements, may break spontaneously out of them, and may have no post-ictal phase.

 

Consider: 

If the seizure lasts more than five minutes, you should consider try to break the seizure by giving IV or PR lorezapam.  If that doesn’t work, you may give a second dose of lorezapam or consider loading with fosphenytoin.  If the seizure still doesn’t break, or if the patient continues to have seizures without returning to baseline, this should be considered status epilepticus and the patient should be transferred to the PICU.  By that point, your senior resident should already be involved.  Brain damage may occur after ~25 minutes of seizure activity!

 

If the seizure breaks but the patient has no history of seizure disorder, you should discuss with your senior resident whether you need to do a workup for the patient. 

 

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Pager message:

“Patient is in pain” or “Patient is very irritable”

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Background: 

Pain, sometimes considered the fifth vital sign, is an important part of the inpatient experience but is completely subjectively assessed by the patient himself or herself.  As such, it can be difficult to know exactly what to do in each situation.  If pain has been a chronic issue during a patient’s hospitalization, it is best to get signout from the day team about what specific approach they would like you to take.

 

Assessment (chart and numbers): 

Some patients will have a clear reason to be in pain (a common example are patients with sickle cell or leukemia), and their primary team will want you to be liberal with pain medications.  Other patients will have a complex constellation of symptoms that are probably related to other psychosocial issues and chronic medical problems, and their primary team will want you to stay away from pain medications.  Take a look at their records to see what pain medications (and at what doses) have worked in the past.  You may also want to look at their vital sign trends to see if they track with real pain (i.e. tachycardia, tachypnea, and elevated blood pressures).  There are also pain scales (FLACC for pre-verbal, Wong-Baker faces for verbal patients) that can help objectively track the severity of the pain.  New complaints of pain may be the signs of an evolving disease process and should definitely be taken seriously.

 

Assessment (physical exam): 

You should assess complaints of pain in patients in a timely fashion, as they can cause significant distress and may be the warning sign of problems to come.  When examining these patients, pay special attention to what could be causing the pain (e.g. chest pain could be a pneumothorax or a pulmonary embolism, abdominal pain could be appendicitis or intussusception, etc).  A good physical exam will help you make a well-informed assessment and plan.  Remember to demonstrate empathy for the patients and their families; no one likes to see a loved one suffer.

 

Consider: 

There are many kinds of pain medication that can be considered, but each of them come with their own side effects.  Check to make sure the patient is not in any kind of organ failure as most pain medications are metabolized by either the kidneys or the liver.  In general, acetaminophen is usually okay for patients even with some liver problems, but check with your senior resident if there are any questions.  If the usual OTC medications aren’t cutting it, you can step up to opioids (both PO and IV).  If there is frequent PRN pain medication required, you should consider putting the patient on something standing (e.g. around the clock PO pain medication, a course of IV toradol, or a PCA).  Some senior residents would like to know about ANY pain medications you order, while others will be fine with you giving anything that’s over-the-counter.  Again, new or changing complaints of pain should be investigated for an underlying cause.

 

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Cardiology

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Pager message:

“Patient’s line is no longer working”

 

Background: 

Intravenous lines are placed in almost all inpatients at UCLA and provide access for the administration of certain medications and fluids.  Some of the more central and permament lines can also be utilized for drawing blood.  However, they do put the patient at risk for infection the longer patients have them in. 

 

Assessment (chart and numbers): 

It is very rare for the patient at UCLA to not require IV access, but a chart review can help you determine whether the patient requires any IV medications or fluids.  Your signout should also have a current list of the patient’s access.  Patients with longer projected hospitalizations should have central lines in place, but that is usually the decision of the day team.

 

Assessment (physical exam): 

Check to see what the issue with the line is.  PIVs that are not infusing may have infiltrated, and the IV site will be swollen and tender.  Central lines may not draw blood back but may still infuse, meaning that they will still be good for medications and fluids, but not for lab tests.  Check with the bedside nurse for any help with lines; if you don’t know, ask!  And don’t pull anything out yourself, as more permanent lines may be sutured into the skin.

 

Consider: 

If the patient doesn’t need an IV line right away, you can sometimes wait for the day team to make a decision on whether it is absolutely necessary.  There are also more resources during the day time including a specialty pediatric PICC service.  Usually, though, waiting isn’t an option.  If the patient only needs a peripheral IV, you can ask the nurses to retry or ask them to contact another nurse (charge nurses, PICU nurses, and NICU nurses can sometimes get lines that others can’t).  If you feel confident about your own PIV placing skills, you’re welcome to give it a shot, too, but this is not expected of interns.  If a patient is very dehydrated, placing an IV line can be made even more difficult.  Sometimes rehydrating with PO, G-tube, or NG tube fluids can help.  If a central line isn’t working, you can consider using tissue plasminogen (tPA) to break down any clots.  If the patient has a Port-A-Cath, which has a reservoir that is accessed by a needle, you can ask the nurse to remove the needle and re-access the line.  Issues with hemodialysis catheters should be addressed by the hemodialysis nurse (call the page operator to be connected with the appropriate person).

 

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Pager Message:

“Patient has had low heart rate”

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Background:  

Heart rates normals are established for the age and size of the patient.  Low heart rates are often noted by nurses because they fall outside of what’s been written on the admission orders.  However, they can rarely be evidence of conduction problems.  A very sick patient can have a low heart rate, but usually there will be some other symptoms for which you will be paged.

 

Assessment (chart and numbers): 

Check to see if the patient has had a history of bradycardia at night or if the patient has any cardiac issues (like cardiac surgery) that would predispose them to a low heart rate.  You might also want to reference any EKGs done in the past for this issue.

 

Assessment (physical exam): 

A patient with a low heart rate should almost always be examined.  ABCs, of course, come first.  Many of these patients will already be on cardiac monitors, and you should be able to get a general sense on whether the patient is in sinus rhythm or not.  You should also see if the heart rate is regular or irregular.  Another trick is to stimulate (wake up) the patient or get them to do light exercise if they’re already awake (as long as it’s safe to do so).  If the heart rate increases, this is a reassuring sign that the low heart rate is not due to a conduction problem.

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Consider: 

If the patient’s heart rate doesn’t increase with stimulation or exercise, you can consider getting an EKG to look for conduction problems like heart block.  You should ask your senior resident or the PICU fellow to read it with you. 

 

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Pager Message:

“Patient has had fast heart rate”

 

Background: 

Heart rates normals are established for the age and size of the patient.  Fast heart rates are sometimes noted by nurses because they fall outside of what’s been written on the admission orders.  However, they can also be evidence of other systemic problems or a primary cardiac problem.  Tachycardia, especially if it is persistent, should be taken very seriously.

 

Assessment (chart and numbers): 

Take a look to see what the patient’s underlying problems are and if they have had a history of tachycardia.  A fast heart rate can either be due to an abnormal heart (e.g. supraventricular tachycardia) or a normal heart responding to an abnormal condition (e.g. dehydration, systemic inflammation, pain, etc).  You can trend the patient’s vital signs over the past several hours, days, or weeks to get a sense for where the patient normally is.

 

Assessment (physical exam): 

ABCs, especially paying close attention to the patient’s perfusion.  You can also try listening to see if there is a regular or irregular heart rate.  A look at the patient’s monitor can help you figure out if the patient has a narrow or wide complex tachycardia.  Look for signs of dehydration or sepsis as another explanation for the tachycardia.

 

Consider: 

If the tachycardia is wide-complex or if it is interfering with perfusion, you should consider calling a rapid response.  Otherwise, you should direct your assessment and management to the underlying cause.  An EKG can help elucidate whether the heart rate is sinus or not, and you should ask your senior resident or the PICU fellow to read it with you.  A bolus of fluid may be helpful if there are symptoms of dehydration, and is generally okay to give to anyone without hemodynamically significant cardiac disease or renal disease.  If the patient looks septic, you should start antibiotics right away. 

 

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Pager Message:

“Patient is having an irregular heart rate”

 

Background: 

“Irregular heart rates” other than tachycardia or bradycardia usually means premature ventricular or premature atrial contractions (PVCs or PACs) in the pediatric population.  These are often noted by the telemetry technicians who are observing patients on cardiac monitors.  You should figure out at signout from the day team whether the patient has been known to have rhythm issues and what the primary service would like to do for them.

 

Assessment (chart and numbers): 

Knowing whether the patient has a known history of cardiac disease or cardiac surgery can help you figure out if this is a new or old problem.  Patients with electrolyte disturbances (e.g. on TPN, severe diarrhea, or end-stage renal disease) will have more reason to have irregular heart rates.

 

Assessment (physical exam): 

ABCs, especially patient perfusion, are important in assessing these patients.  Check the heart rate yourself and see what the tracing looks like if the patient is on a cardiac monitor.  Often, though, by the time you examine the patient, the heart rate will be normal.

 

Consider: 

If the patient’s perfusion is abnormal, consider calling a rapid response.  An EKG with a rhythm strip can help you look more closely if the heart rate continues to be abnormal.  The telemetry technicians can also print out the events that they’ve noted.  Isolated PACs and PVCs can be normal, but if they start happening in strings of twos or threes, you should investigate.  A common cause of PVCs is hypomagnesemia, so checking a level and repleting low magnesium will get the patient through the night.  If the patient has a central line, a chest x-ray can be used to check if the line is too far and irritating the myocardium.

 

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Pager Message:

“Patient has chest discomfort.”

 

Background: 

Chest pain or chest discomfort in the pediatric population has a very wide differential but is usually benign.  However, patients at UCLA have specific conditions that can set them up for more serious causes of chest pain.  Therefore, they should be assessed more thoroughly for these complaints.

 

Assessment (chart and numbers): 

You will have to familiarize yourself with the wide differential of chest pain to know what to look out for.  Obviously, a history of cardiac surgery or cardiac transplant should make you suspicious for a cardiac cause (such as post-transplant coronary artery disease).  Hypercoagulable or hematologic disorders (like sickle cell) may also predispose patients to problems like myocardial infarctions or acute chest syndrome.  Rheumatologic patients can have pericarditis.  You should review their vital sign trends, especially their heart rate, respiratory rate, and oxygen saturation levels.

 

Assessment (physical exam): 

ABCs as always.  Check to see the distribution of the chest pain and whether it is worsened by certain positions or with deep breaths.  Also, check to see if the pain is reproducible with palpation.  A good lung exam can help you assess for a possible pneumothorax.

 

Consider: 

Your workup should be driven by the patient’s underlying conditions and your physical exam findings.  Patients with benign chest pain like costochondritis can be tried on NSAIDs.  You can consider a chest x-ray to look for things like pneumothoraces, pericarditis, or acute chest syndrome.  An EKG can also help with looking for pericarditis.  More specialized tests like echocardiograms or CT scans should first be discussed with your senior.

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Respiratory

 

Pager Message:

“Patient is having trouble breathing”

 

Background: 

The majority of pediatric codes are respiratory, not cardiac.  Therefore, respiratory distress is probably one of the most common emergent conditions you will encounter in residency.  Respiratory distress can be due to a myriad of causes, some of them more serious than others.

 

Assessment (chart and numbers): 

This is one of the cases where you probably should make it to the patient’s bedside as soon as possible.  Don’t spend too much time trying to figure out all of the history.  While you’re on the way to the room, you can familiarize yourself with the patient’s underlying medical conditions and whether or not the patient has a clear reason to be in respiratory distress.  Almost any system can result in respiratory distress—patients could be having a seizure, an infection like pneumonia or bronchiolitis, an airway obstruction, an allergic reaction, heart failure, ascites, etc.

 

Assessment (physical exam): 

No exceptions—you should physically examine EVERY patient in respiratory distress.  Descriptive words like grunting, wheezing, “croupy cough” can mean very different things to different people, and the action plans based on the character of respiratory distress are quite different.  Upon entering the patient room, you should get a brief glimpse of how the patient looks—is he sick or not sick?  Is she breathing at a rate faster than you’d expect for her age?  Do you see retractions or flaring?  Do you hear grunting, stridor, or audible wheezing?  When listening with your stethoscope, make sure to get all lung fields and compare them to each other.

 

Consider: 

Have a low threshold to immediately let your senior resident know what’s going on or, if you’re concerned enough, call a rapid response.  An easy solution to an otherwise stable patient is to administer some oxygen to see if that improves the patient’s status.  Other management strategies really depend on the underlying cause, although common things include chest x-rays to look for consolidation or infiltration, albuterol or steroids for a lower reactive airway process, racemic epinephrine for croupy or upper airway obstruction, and sometimes a capillary or arterial blood gas to get an objective sense of the patient’s respiratory status (usually by that point, you’re calling the PICU for assistance).

 

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Pager Message:

“Patient has abnormal oxygen saturations”

 

Background: 

How is this different from respiratory distress?  Well, a patient can be in respiratory distress (e.g. tachypneic, flaring, and grunting) without having oxygen desaturations.  Alternatively, a patient may have abnormal oxygen saturations and not be in respiratory distress.  A classic example is a congenital cardiac patient with a mixing lesion, whose goal oxygen saturations may be 75-80%.  In fact, for these patients, an oxygen saturation greater than 90% may be an ominous sign.  Please see the cardiology section under educational resources for more information, or ask your senior to explain why.

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Assessment (chart and numbers): 

This is where the verbal signout or written signout can be helpful.  If goal saturations are not the usual >93%, the day team should tell you in signout.  If you don’t hear that specific detail on a cardiac patient signout, it’s reasonable to ask the person specifically what the day team has decided will be the optimal oxygen saturation.  If you have time, you can print out the patient’s most recent cardiac catheterization report (a.k.a. their “valentine”) to get a better sense of what their current anatomy is like.  Other patients may have drop their oxygen saturations at night while asleep due to obstructive sleep apnea or chronic lung disease.  These should all be noted in the signout.  If there is no mention of desaturations, the patient should be evaluated seriously.

 

Assessment (physical exam): 

As with respiratory distress, most patients with abnormal oxygen saturations should be examined.  Again, you should look for signs of respiratory distress if they haven’t already been noted.  You can also check the waveform on the pulse oximeter to see if the sensor is just not picking up (a good waveform looks like a regular sine wave).  The rest of your physical exam should be the same as if the patient were in respiratory distress.

 

Consider: 

The management for abnormal oxygen saturations depends on the patient and the way he or she looks.  For cardiac patients who are known mixers and should not go above 90%, the administration of oxygen may actually worsen their cardiac output and should be avoided.  If you have a poor waveform on the meter, you can try replacing or repositioning the probe, covering it with your hand, or making sure the patient’s fingernails aren’t painted (it works on a principle of infrared light). 

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Fluids, Electrolytes, and Nutrition

 

Pager Message:

“Patient needs TPN renewal”

 

Background: 

Total Parental Nutrition, or TPN, is an IV formulation of nutrition that is commonly utilized when enteral nutrition (i.e. the gut) cannot be given.  This is most common in our GI patient population, but can be seen in any census.  Usually TPN orders need to be written in the morning as it takes some time for the pharmacists to write.  Occasionally, you will get paged about renewing the TPN.

 

Assessment (chart and numbers): 

Since by definition this should only happen when the day team has forgotten to do its duties, you probably won’t have gotten signout about the TPN renewal.  This will rely on a little bit of detective work for you as you renew the chart.  You should check their most recent set of electrolytes, liver function tests, and triglycerides, as these are the main things that need to be examined on a regular basis for any patient on TPN.  The day’s progress note may have some hints as to changes that the day team wanted to make to the TPN.  If you don’t know or are not sure, ask your senior for help.

 

Assessment (physical exam): 

Unless you are paged about abnormal electrolyte values in conjunction with the TPN order (see below), you don’t really have to physically examine the patient.

 

Consider: 

As stated above, you’ll probably be safe renewing the TPN from the day prior.  If you have any questions, though, feel free to ask your senior.  Make sure you talk to pharmacy about how to write the order and where to fax it.

 

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Pager Message:

“Patient looks puffy”

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Background: 

A puffy appearance is most concerning for increased extravascular fluid.  This can happen as a result of capillary leak, volume overload, or decreased intravascular oncotic pressure.  A good understanding of the underlying medical problems and the physiology involved will direct how you respond to this kind of page.

 

Assessment (chart and numbers): 

There are a multitude of causes for increased extravascular volume.  You should get a sense for the underlying medical conditions that may contribute to this patient’s presentation.  If the patient has a history of congestive heart failure, his body may be inappropriately retaining fluid to increase cardiac output.  If the patient has a history of kidney failure, she may be unable to excrete whatever input she has.  If the patient has liver failure, he may not be producing sufficient albumin and has a decreased oncotic pressure.  You should get a sense for the patient’s volume state (check the I/Os and weight trends) and figure out what the overall fluid or weight goals are for the patient (hopefully you got specific signout from the day team).

 

Assessment (physical exam): 

You should evaluate for yourself whether the patient appears puffy.  The most important part of the assessment is to get a good respiratory exam, including counting off a respiratory rate and listening to all the lung fields.  Extravascular volume overload can result in pulmonary edema and resultant respiratory failure.  You should also get a sense for the extent of any pitting edema.  You should also do a focused physical exam depending on what you might suspected is the cause (e.g. a good cardiac exam includes checking the size of the liver for evidence of worsening function, etc).

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Consider: 

If the patient is unstable, especially from a respiratory standpoint, consider a rapid response or notify your senior.  If you want to get a better sense for pulmonary edema, you can get a portable chest x-ray.  The rest of the treatment depends on the underlying cause of volume overload.  Cardiac patients may require diuretic, renal failure patients may require dialysis (or more aggressive dialysis), liver patients may require albumin, etc.

 

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Pager Message:

“Patient’s electrolytes are abnormal”

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Background: 

Many of the patients will have “AM Labs” drawn exceptionally early in the morning (~4 AM) and you will often be paged about abnormal values that have come back at critical levels.  This section will focus on hyperkalemia, as this is probably the most crucial abnormal electrolyte value (hypo or hypernatremia would probably also be a good one to review).

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Assessment (chart and numbers): 

Depending on the degree of hyperkalemia, you can choose to spend more time perusing the chart versus starting immediate evaluation and management.  Hyperkalemia is probably the most feared electrolyte imbalance that can be fatal, as it can precipitate cardiac arrhythmia.  Any level greater than 6 should be considered an urgency.  Patients who have medical conditions that put them at higher risk (e.g. ESRD) may warrant more aggressive evaluation given that they may continue to trend upwards.  If you have a chance to look at the chart, you should evaluate where their electrolyte levels have been in the past, what new changes (e.g. to the TPN) were made that could explain these values, and/or if the day team made note of certain trends.

 

Assessment (physical exam):

Patients with severe electrolyte imbalances or those who are symptomatic from them should be assessed.  Hyperkalemic patients should also be examined for cardiac irregularities (look on the bedside monitor for obvious rhythm changes).

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Consider: 

If the hyperkalemia is mild or the sample is noted to be hemolyzed, you may choose to repeat the laboratory value stat.  You should consider placing them on a cardiac monitor, just in case.  You can also print out a rhythm strip to make sure there are no changes associated with hyperkalemia (peaked T waves, PR prolongation, widening QRS, etc).  The treatment of hyperkalemia includes albuterol, insulin / glucose, and bicarbonate to shift the potassium into the cells; furosemide to enhance renal excretion of potassium; kay-axelate to prevent further absorption of dietery potassium; and calcium gluconate to stabilize the cardiac membrane.  Other electrolyte abnormalities by and large can be addressed by the day team.  If you get paged about abnormal values early on in your shift, you can consult your code cards and talk to your senior about repleting any low values.

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Gastroenterology (GI)

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Pager Message:

“Patient’s G-tube is having problems”

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Background: 

Gastrostomy and jejunostomy tubes are very common on UCLA patients, particularly the ones on the GI service.  You should familiarize yourself early on the in the rotation about the differet types as well as routine care and maintanence.  Common pages include G-tube leakage, G-tube site bleeding, G-tube obstruction, and G-tube displacement.

 

Assessment (chart and numbers):

You should look in the chart to see what size and type of tube the patient has.  It can be helpful but not essential to know when the last G-tube was placed.  You can also check and see what has been done in the past for G-tube problems.

 

Assessment (physical exam): 

You can also look at the tube and/or button; usually the number is written somewhere on it.  This information can be important when talking with a consultant or fellow.

 

Consider: 

If you’re unsure about your exam, or if you’ve never worked with G-tubes before, you should consult your senior resident and/or the GI fellow.  For G-tube leakage, the button holding the tube in place may not be fully inflated, causing some seepage of fluid around the seal.  You can check how much fluid should be in the button and interrogate it to make sure it’s sufficient.  For G-tube bleeding, you can observe or, if it is actively oozing, apply some thrombin to stop the bleeding.  For G-tube obstruction, you can try using papain (a meat tenderizer) or Coca-Cola to break up the obstruction.  For displacement, you will need a replacement G-tube with the correct size and specifications, and you should speak with a senior resident before doing it for the first time.

 

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Pager Message:

“Does patient have to be NPO”

 

Background:  

Nil per os (nothing by mouth) is a common order written for patients on the UCLA wards.  Patients are placed NPO for a variety of reasons, including in preparation for anesthesia, aspiration risk, rapid breathing, concerns for malabsorption, etc.  It’s a very common page from the nurses to ask whether the patient needs to be NPO or not.

 

Assessment (chart and numbers): 

Hopefully, you will have gotten signout on whether the patient is NPO and the reasoning behind the decision.  If not, you can do some detective work to figure out why the patient cannot be allowed anything to eat.  Oftentimes it is because he or she is going for a study or a procedure the next morning.  Check and see in the last note or in the orders what the active plan is for the next day.  Sadly, though, sometimes patients are made NPO before procedures and never get restarted on their diet.

 

Assessment (physical exam): 

You usually do not need to physically examine the patient, although many times families want to speak to the on-call doctor (especially if the patient is hungry)!

 

Consider: 

It’s safest to leave the patient NPO if there is any question, assuming the day team is able to address it.  If so, make sure the patient has adequate hydration on board.  NPO guidelines for anesthesia can be found on the pediatric sedation request form, and it varies by age and kind of intake.  If you know the time of the procedure or study, you can move the NPO status to allow the patient something for comfort.  Certain meds should be given regardless of NPO status.  The obvious (and common at UCLA) ones are immunosuppressants for patients, which may need to be given at a specific time.  If there’s any question, ask your senior resident.

 

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Pager Message:

“Patient’s stool output is high”

 

Background: 

Unlike the pediatric wards at our other sites, high stool output at UCLA does not always mean an infectious cause.  Many of the GI transplant patients will have variable stool output as their new bowels are put to use.  The stool output is an important indicator of bowel health, and you will probably be asked to do a stool output check by the day team on at least some of the GI patients.  In general, for a patient with completely connected bowel, they should have less than 20 mL/kg of stool a day.  A patient with an ileostomy may be allowed up to 30 mL/kg of stool a day.  You should check with the day team what the goal stool output is for each of these patients.

 

Assessment (chart and numbers): 

If you haven’t heard specifically about stool output goals, you can take a look at the recent trends to see how much output the team has tolerated in the last few nights.  You can also see what recent changes have been made (usually the advancement of feeds) that could explain the increased stool output.  You should review the patient’s vital signs and I/Os, looking for signs of dehydration (e.g. low urine output), to know if a patient needs additional fluids or just a feed adjustment.  If the patient has been on antibiotics recently (and most of them have been), you can check to see if a C.Diff test has been sent.

 

Assessment (physical exam): 

In general, unless the patient’s numbers suggest dehydration, you don’t necessarily need to examine the patient.  However, if anything seems abnormal, you should at least eyeball the patient.

 

Consider: 

Assuming the stool output is solely due to feed advancement, you can consider several approaches.  Some residents will choose to decrease the feeds by whatever increment was advanced that morning (essentially undoing what the day team did).  Others will like to hold feeds for an hour or so and then restart them to see what happens.  Whatever your plan is, make sure to follow-up on any patient with abnormal output and see how they respond to your therapy.  Make sure that the patients are adequately hydrated with both maintenance and stool replacement fluids.  Some will like to send studies of malabsorption like pH and reducing substances (for carbohydrate malabsorption).  Patients (especially those with symptoms like fevers) may have an infectious etiology for their stool output; in those situations, you may want to send off studies for stool cell count, bacterial culture, viral culture, and ova and parasites.  Patients who have had recent antibiotics she be evaluated for C. Diff toxin (and should be placed on contact isolation).  Rarely, you may choose to send off stool osms to differentiate between secretory and osmotic diarrhea.

 

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Pager Message:

“Patient needs FK/Tacro dose ordered” or “Patient FK/Tacro levels abnormal”

 

Background: 

FK506, also known as Prograf or tacrolimus, is a common immunosuppressant utilized in transplant medicine.  Levels are often checked on a frequent (sometimes daily) basis, depending on where in the transplant timeline the patient is.  Any patient with a SBT or OLT should have their prograf order written by the transplant service.  Orders should be written during the daytime, but sometimes they slip through the cracks and you will be paged by the nurse or the pharmacist.

 

Assessment (chart and numbers): 

Is the patient status post SBT or OLT?  If so, then ask the nurse or pharmacist to page the transplant fellow.  Otherwise, you can consult the recent progress note to see what the patient’s dosing, level trend, and goal levels are.  Patients on Prograf may have increased levels with diarrhea or volume depletion.

 

Assessment (physical exam): 

In general, you don’t need to examine these patients.

 

Consider: 

Be very cautious about dosing FK if you’re not sure what the goal therapy is.  Talk it over with your senior resident, who may decide to page the subspeciality fellow.

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Renal:

 

Pager Message:

“Patient has had low urine output”

 

Background: 

Frequently, you will be asked to do I/O checks on patient and make sure they are urinating well.  Like kidney failure, low urine output can be due to a prerenal (e.g. dehydration), post-renal (e.g. urinary obstruction), or intrinsic (e.g. renal insufficiency) cause.  In certain cases, such as with oncology patients being treated with chemotherapy, a low urine output can lead to toxic effects of medication.  When getting sign-out on patients about I/O checks, you should be sure to figure out what the goal is and why the primary team wants you to watch their numbers.

 

Assessment (chart and numbers): 

The signout or last progress note should indicate any underlying medical conditions that are relevant.  You may also see goal urinary output on your signout.  You should also see how much urine the patient typically produces.  You should also take a look at the patient’s other vitals for hints as to the underlying cause—e.g. tachycardiac could indicate hypovolemia or cardiac failure, tachypnea or a fever could indicated increased insensible losses, etc.  Hypotension is a relatively late sign of hypovolemia in pediatrics and should be taken very seriously.

 

Assessment (physical exam): 

Your exam should focus on figuring out whether the patient looks dehydrated, fluid-overloaded, or neither.  You can also see if there is a mechanical problem that can be addressed (such as an obstructed foley).  Sometimes, it’s just a matter of asking the patient’s guardian if all voids have been calculated—maybe they threw out a few diapers or accidentally flushed the toilet.

 

Consider: 

If the patient seems like he or she might be dehydrated, it is usually safe to try a bolus of normal saline (so long as they don’t have cardiac disease or renal failure).  If the patient seems volume overloaded, you can cut down on any IV fluids being given.  Sometimes, warm compresses to the bladder or bladder massage can encourage a hesitant bladder to resume working.  Most patients with low urine output should be discussed with the senior resident, particularly if there are any potentially toxic medications being given.

 

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Infectious Disease:

 

Pager Message:

“Patient has a fever”

 

Background: 

The most worrisome possibility for any patient with a fever is bacteremia and/or septicemia i.e. a patient has a systemic inflammatory response to bacteria in the blood.  This is a major concern in patients who are neutropenic, where early recognition and treatment can save someone’s life.  If there is any question about how you should address a fever, discuss it with your senior resident without delay.

 

Assessment (chart and numbers): 

The most important thing to figure out is whether the patient is neutropenic or not.  To calculate neutropenia, take the WBC and find the percentage that is neutrophils.  ANC 1000-1500 is mild neutropenia, 500-1000 is moderate neutropenia, and <500 is severe neutropenia.  Severe neutropenia should always be taken seriously, as once your ANC drops below 500, patients are at increased risk for gram negative sepsis.  Most commonly, neutropenic patients will be on the heme-onc service, and you should receive on signout what the primary team’s fever threshold is for starting antibiotics.  The default should be 38 C or 100.4 F.  You should review their vitals for overall trends (i.e. gradually increasing heart rates are concerning for bacterial infection).  You should review the chart to see when the last cultures were, what antibiotics (if any) the patient is currently on, and when those antibiotics were started.  You should also see whether the patient is on immunosuppression (the majority of patients at UCLA are) to evaluate their risk of infection.  You should also see what possible sources of infection the patient has so that you know what to pay specific attention to on your physical exam. 

 

Assessment (physical exam): 

You should almost always evaluate fevers in an urgent fashion on the UCLA wards, as there are many patients with underlying medical problems that put them at serious risk for infection.  Get a general sense of sick versus not sick, and then evaluate them for specific kinds of infection.  Make sure to check any indwelling lines to look for local signs of inflammation.  Also, take a listen to their lung fields for any kind of respiratory process.  However, be warned that a neutropenic patient may appear falsely well with little to no signs of sepsis just before going into septic shock.

 

Consider: 

For any patient with neutropenia, they should be started on antibiotics within an hour of the fever.  This means antibiotics should be HUNG within the hour, not just ordered within the hour.  In these patients, you should be calling the pharmacy and FYI text page the on-call fellow.  In these patients, cefipime is usually a good first choice.  Sometimes, the fellow will also want you to start tobramycin, vancomycin, or an antifungal agent as well; make sure to let them know what you’re starting and they’ll contact you with their response.  If the patient is already on antibiotics but is still having fevers 24 hours afterwards, usually the fellows will want to add another antimicrobial to broaden the coverage—the assumption is the patient could still be having bacteremia with something that is not being treated.  If a patient with fever and neutropenia looks ill, you should call a rapid response or notify the PICU. 

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Taking cultures can help the day team figure out the length and mode of therapy, and should be directed towards possible infectious sites.  You can choose to take cultures from lines and/or peripheral blood, urine, cerebrospinal fluid, sputum, wound discharge, etc, depending on the patient.  Depending on the patient, you can send for both bacteria and fungal cultures.  You should consider fungal cultures in any patient who has been recently treated with antibiotics.

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Cultures taken before the administration of antibiotics can try to “catch” the bacteria as they pass through the blood, urine, or other bodily fluids.  Cultures taken after antibiotics have been started may be falsely negative as the antibiotics will sterilize those sites.  However, in an unstable or neutropenic patient, you should not delay antibiotics to get the cultures.  You also have to be careful with how you obtain cultures (e.g. in general you do not use urinary catheters or rectal instrumentation in a neutropenic patient).

 

Taking a CBC and running a differential can help you figure out if there is significant neutrophilia or bandemia, which is suggestive of a bacterial infection.  If you are very concerned about a patient, this laboratory can help you decide whether to start with very broad coverage for resistant or particularly pathogentic bacteria.  You may also consider a chest x-ray or other imaging study if you suspect a specific kind of infection. 

 

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Pager Mesage:

“Patient’s cultures are positive”

 

Background: 

As you may infer from the above, there are a lot of cultures sent at UCLA, and you may be called on a culture that you did not send.  The laboratory is required to notify a nurse or MD about all positive cultures, but they won’t tell you what to do with that information.

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Assessment (chart and numbers): 

When speaking to the lab, you should ask specifically whether there were multiple cultures sent from the same specimen and how many bottles are positive.  A quick review of the chart should tell you when those cultures were sent (based on the laboratory records) and why (based on the progress notes or essentris).  You can also look at CBCs drawn around the time of the culture to see if there is a left shift or not.  Check the patient’s current antibiotics, if any, and see if the patient’s coverage is adequate for the species of organism obtained.

 

Assessment (physical exam): 

Even if you think the cultures may not be truly positive, you should take a look at the patient before deciding the cultures are false positives.  If you are starting or changing therapy based on the cultures, you should let the patient and parent know.

 

Consider: 

If there are multiple organisms growing, especially with blood and urine cultures, the cultures may be contaminated with bacteria (and therefore falsely positive).  If the cultures only grew in 1 out of 2 bottles, it may also clue you in that it is contaminated.  Finally, if the cultures grow after 48 hours, it’s more likely to be a contaminant (except for certain bacteria like Fusobacterium that takes 4-5 days to gro).  Cultures that grow within 24 hours and in 2/2 bottles should be considered genuine and be started on the appropriate treatment.  If you think a culture is a contaminant and the patient appears stable, you can consider re-drawing the culture before starting antibiotics.  If you’re not sure, you should discuss it with your senior resident.  Either way, you should probably FYI the on-call fellow to let them know of your plan.

 

If you encounter other pages you think will be useful for this section, feel free to add them in future editions!         

Last modified: Friday, June 28, 2013, 2:34 PM