Pediatric Intensive Care Unit (PICU)

This was definitely one of my all-time favourite clinical rotations. I was very apprehensive prior to beginning the rotation, as I had no previous experience with pediatrics and I had heard that PICU was a challenging practice. I discovered that it was actually very similar to other ICUs, with some nuances of course. I found that once I had a handle on pediatric specific resources and literature I was quickly able to integrate into the team. It did remain a struggle to remember to convert to dosing everything by weight though! Understanding of pharmacokinetics and dynamics plays a key role in PICU practice, given then PK/PD differences between children and adults, which was an aspect of this practice that I particularly enjoyed. Overall, I am very glad that I elected to do this rotation and the experience I gained will be invaluable moving forward, even if I never have another opportunity to practice in pediatrics.

Learning Goals and Objectives:

1. Be able to select appropriate pediatric drug information resources to help make safe and effective pharmacotherapeutic recommendations for my patients.

Luckily the BCCH publishes their own dosing handbook/formulary which was an essential daily resource for me. They also have an online formulary which I sometimes referred to. I also frequently utilized the pediatric section of Lexicomp, Sanford’s guide to antimicrobial therapy, and the University of Louisville Kidney Disease Program Pediatric Drug Book.

2. Perform and document the application of pharmacokinetics to clinical practice in the pediatric population for vancomycin and at least 2 other drugs.

I had the opportunity to perform several PK interpretations throughout the rotation. One thing that struck me was how rapidly some children were able to clear vancomycin. We would typically begin dosing at 15mg/kg q6h, but would still have trough levels coming back <10. To attain adequate trough levels I had to escalate one septic boy to almost 35mg/kg q6h!

3. Be able to describe the nuances of sedation and pain/agitation/delirium management in the pediatric population.

This was another interest area of mine because of the often long-term use of benzodiazepines for sedation in pediatrics compared to adults. Propofol is used much less frequently in pediatrics due to the risk and devastating consequences of PRIS rendering midazolam the frequently used alternative. This necessitated consideration of benzodiazepine withdrawal and long weaning schedules for both benzodiazepines and opioids. Another interesting medication which sometimes required weaning was dexmedetomidine. I saw several patient on prolonged infusions of dexmedetomidine (>10-14 days) whereas prior to this I had never seen infusions of this length in adults. After this length of therapy dexmedetomidine withdrawal is a real phenomena and consists primarily of agitation, insomnia, and fever (these withdrawal symptoms can be hard to distinguish from concurrent withdrawal from opioids and benzos. The strategy to manage alpha-2 agonist withdrawal would be to switch to oral clonidine at a dose of 2-4mg/kg q4-6h, taper off of benzos and opioids, then rapidly taper off clonidine over a few days.

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