Examples of endocrine emergencies in the ICU with Lara Smith, DNP, APRN, CPNP-AC/PC

At the 45th National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care, Lara Smith, DNP, APRN, CPNP-AC/PC, assistant professor, Department of Women, Children and Family Nursing, Rush University, joined Contemporary Pediatrics to discuss a few case-based examples of emergencies in the pediatric endocrine intensive care unit (ICU).

Transcript:

Lara Smith, DNP, APRN, CPNP-AC/PC:

My name is Lara Smith, I am a nurse practitioner and then pediatric ICU at St. Louis Children's Hospital. I am also a faculty member in the acute care nurse practitioner program at Rush University and have done the prior for 20+ years and the latter almost 5 years now that I've been teaching in that program. So over the course of time, I have seen a lot of things, and seen a lot of things in the ICU. I really wanted to take this opportunity with this presentation to kind of give people an idea of different types of things they might see, might run into, that certainly, if not all 3 of them, at least 2 of them are things you could see and one of which actually did present to primary care, their primary care office and try and help people understand what's going on and help with the evaluations of the type of endocrine problems that you have.

Contemporary Pediatrics:

Can you explain the cases you discussed in your session, "Endocrine Emergencies in the Pediatric ICU?"

Smith:

We have a couple issues with hyponatremia, so low sodium, for very interesting and very different reasons. One of which is a child with primary polydipsia. She was someone who presented to her primary care office with an incredibly low sodium level, had not been seen by a primary care provider in number of years and had her levels drawn. They were quite surprised and quite concerned about the level of the sodium that they had found, and sent her immediately to care, which was absolutely appropriate. That's what they should do. We were able to help her recover from that piece and actually really kind of make the determination of what actually was going on with her and the support that she needed. Primary polydipsia is kind of the catch all term, oftentimes seen and called psychogenic polydipsia, and so it was something that she needed, not just a quick medical resolution to, it's actually more kind of a long term process that involves therapy, and things like that to kind of help support her. Another one is the child who had an infection of the central nervous system, who ultimately it had, thankfully, a temporary cerebral salt wasting, and so required an enormous amount of salt to help support him. He had the unfortunate but expected complications you can have with that. He had some seizures, he had some issues with his neurologic status and required multiple times EEGs, OR, all kinds of things. This isn't something necessarily that someone would see in a primary care office, but it's something that can be seen certainly with CNS infections, and with subarachnoid hemorrhages and things like that, so could possibly present to a pediatricians office, unlikely, but could. More likely would probably be in an ER-type setting. So those were the 2 sodium balance issues that we were dealing with. Then the third one was actually a child who ultimately was diagnosed with adrenal insufficiency, which is something you can see and something I have actually diagnosed a couple times in the ICU. One episode though, not this particular one, one episode was someone who actually had significant family history of endocrine problems [and] he was kind of a setup for it. But this particular patient actually came in during COVID and came in with COVID, and came in in a very fulminant state, very acutely critically ill state. At that time, as most of us know, in pediatrics, we were seeing a lot of patients with multisystem inflammatory syndrome related to COVID, and so that's what initially we thought she had. So she came in very, very ill she actually turned around very quickly, which was very common with most of those kids with MIS-C. So we're said, 'okay, that was what the problem was,' and then a month later she represented. Because of the prior, her family was very much watching her very closely... They came in and she again, was very, very ill, but with a much shorter course of illness, so quite concerning, and ultimately with the laboratory values that we'd had from the prior presentation and the evaluation we had of her at that time, we tested her and ultimately she ended up with adrenal insufficiency. Looking back through her history, it was actually a little bit interesting, she actually had a couple of admissions for dehydration and vomiting. She had a lot of what they referred to as cyclic vomiting, and during this admissions have lower blood sugars. It was very interesting, because looking back we said, 'Oh, were these just early signs that this might be a problem for her?' But so subtle, and certainly would fit with the presentation that she had. She's vomiting, she's dehydrated, and sugar's a little low, she's not eating very well, not terribly surprising. But could that have been just the early stages of what she was going through? So it was just a really interesting presentation, and again, something that someone certainly could pick up in a pediatricians office.

Contemporary Pediatrics:

Is there a test that can be done in a pediatrician’s office for adrenal insufficiency, and what can primary care providers do or look for to lead to a diagnosis?

Smith:

I don't know the availability, but it is a relatively simple testing that you can do to determine if someone has adrenal insufficiency. It does require lab draws, so no one loves that. No parent loves that no child loves that. But the benefit to doing it and the risk of not doing it are pretty great and those types of patients, but it is something that it would be relatively accessible to most people, if not in their office, they would probably be relatively easily to refer to a place that would be able to do that for them. History taking is so very important and I think can get glossed over sometimes, but it it gives you so many clues to what you think what might be going on that and is so important. We have the family history, the patient's history themselves, the social history, those pieces of when a patient presents are so, so important.