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Practical Approach to Pediatric Intensive Care
Praveen Khilnani
SECTION ONE: BASIC PRACTICAL ISSUES
CHAPTER 1:
Managing Any Pediatric Emergency: A Practical Approach
CLINICAL ASSESSMENT
STABILIZATION
If Respiratoy Distress
If Shock
After Each Intervention Reassess
Other Supportive Therapy
Common Indications for the PICU Admission
SUMMARY
Stabilizing the Pediatric Patient (Flow chart 1.1)
TAKE HOME MESSAGE
CHAPTER 2:
Pediatric Basic Life Support
INTRODUCTION
The BLS Sequence for Infants and Children
Safety of Rescuer and Victim
Check for Response (Box 1)
Activate the EMS System and Get the AED (Box 2)
Position the Victim
Open the Airway and Check Breathing (Box 3)
Open the Airway: Lay Rescuer
Open the Airway: Health Care Provider
Check Breathing (Box 3)
Give Rescue Breaths (Box 4)
Comments on Technique
Barrier Devices
Bag-Mask Ventilation (Health Care Providers)
Ventilation Bags
Precautions
Two-Person Bag-Mask Ventilation
Gastric Inflation and Cricoid Pressure
Oxygen
Masks
Nasal Cannulas
Pulse Check (for Health Care Providers) (Box 5)
Rescue Breathing Without Chest Compressions (for Health Care Providers Only) (Box 5A)
Chest Compressions (Box 6)
Coordinate Chest Compressions and Breathing (Box 6)
Compression-Only CPR
Activate the EMS System and Get the AED (Box 7) (may not be applicable in the Indian scenario)
Defibrillation (Box 8)
CPR Techniques and Adjuncts
Foreign-Body Airway Obstruction (Choking)
Relief of FBAO
SPECIAL RESUSCITATION SITUATIONS
Children With Special Health Care Needs
Ventilation with a Tracheostomy or Stoma
Trauma
Drowning
SUMMARY
CHAPTER 3:
Pediatric and Neonatal Cardiopulmonary Resuscitation
PEDIATRIC ADVANCED LIFE SUPPORT
RESPIRATORY FAILURE
SHOCK
AIRWAY
Oropharyngeal and Nasopharyngeal Airways
Laryngeal Mask Airway
OXYGENATION AND ASSISTED VENTILATION
Oxygen
Pulse Oximetry
Bag-Mask Ventilation
Two-Person Bag-Mask Ventilation
Gastric Inflation
Ventilation through an Endotracheal Tube
Rapid Sequence Intubation
Cuffed Versus Uncuffed Tubes
Endotracheal Tube Size
Verification of Endotracheal Tube Placement
Exhaled or End-Tidal CO2 Monitoring
Esophageal Detector Devices
Transtracheal Catheter Ventilation
Suction Devices
Circulation
Backboard
CPR: Techniques and Adjuncts
Extracorporeal Membrane Oxygenation
Cardiovascular Monitoring
Vascular Access
Intraosseous Access
Venous Access
Endotracheal Drug Administration
EMERGENCY FLUIDS AND MEDICATIONS
Estimating Weight
Fluids
Medications for Pediatric Resuscitation and Arrhythmias
PULSELESS ARREST (FIG. 3.1)
“Shockable Rhythm”: VF/Pulseless VT
Defibrillators
Energy Dose
AEDs
Defibrillation Sequence
Torsades de Pointes
Treatment
BRADYCARDIA (FIG. 3.2)
TACHYCARDIA AND HEMODYNAMIC INSTABILITY (FIG. 3.3)
Narrow-Complex (0.08 Second) Tachycardia
Probable Supraventricular Tachycardia
Wide-Complex (> 0.08 Second) Tachycardia
Tachycardia with Hemodynamic Stability
SPECIAL RESUSCITATION SITUATIONS
Trauma
Children with Special Health Care Needs
Ventilation with a Tracheostomy or Stoma
POSTRESUSCITATION STABILIZATION
Respiratory System
Cardiovascular System
Neurologic System
Renal System
Interhospital Transport
Family Presence during Resuscitation
Termination of Resuscitative Efforts Family Presence during Resuscitation
ANTICIPATION OF RESUSCITATION NEED
INITIAL STEPS
Temperature Control
Clearing the Airway of Meconium
Periodic Evaluation at 30-Second Intervals
Administration of Oxygen
Positive-Pressure Ventilation
Initial Breaths and Assisted Ventilation
Devices used for Assisted Ventilation
Assisted Ventilation of Preterm Infants
Endotracheal Tube Placement
CHEST COMPRESSIONS
MEDICATIONS
Route and Dose of Epinephrine Administration
Volume Expansion
Naloxone
POSTRESUSCITATION CARE
Glucose
Induced Hypothermia and Avoidance of Hyperthermia
WITHHOLDING AND DISCONTINUING RESUSCITATION
Withholding Resuscitation
Discontinuing Resuscitative Efforts
A. HEALTH CARE PROVIDER (HCP)
1. Activate
2. Airway
3. Breathing
4. Circulation
5. Foreign Body Airway Obstruction
B. LAY RESCUER
No Jaw Thrust in Trauma Victim (use head tilt chin lift to open airway)
30:2 Ratio of Compression to Ventilation (for all ages except newborn)
FOREIGN BODY OBSTRUCTION
MAJOR BLS CHANGES FOR ALL RESCUERS
MAJOR PALS CHANGES
RHYTHM DISTURBANCES AND DEFIBRILLATION
POSTRESUSCITATION CARE
NEONATAL RESUSCITATION
CHAPTER 4:
Airway Management
AIRWAY MANAGEMENT TECHNIQUES
Oral and Nasal Devices
Laryngeal Mask Airway (LMA)
Bag Mask Ventilation
Endotracheal Intubation
Elective Oral Endotracheal Intubation
Emergency Oral Endotracheal Intubation (RSI-Rapid sequence intubation) (Fig. 4.11)
Nasotracheal Intubation
DIFFICULT INTUBATION
MANAGEMENT OF DIFFICULT INTUBATION
Awake “Blind Intubation”
Direct Laryngoscopy
Bullard Laryngoscope
Indirect Approach
Fiberoptic Intubation (Figs 4.14 and 4.15)
Prism Devices (Hufman Prism) or Dental Mirror
Lighted Stylet or Lightwand
Retrograde Translaryngeal Intubation
Transtracheal Ventilation
Surgical Access of the Airway
Percutaneous Cricothyroidotomy
Tracheostomy
Difficult Intubation due to Laryngeal and Tracheal Obstruction
Intubation Failure
SUMMARY
CHAPTER 5:
Transport of a Critically Ill Child
ORGANIZATION OF A CRITICAL CARE TRANSPORT SYSTEM
Ground Transport
Air Transport
COMPONENTS OF A NEONATAL AND PEDIATRIC CRITICAL CARE TRANSPORT PROGRAM
Transport Dispatch System
Communication with Neonatal or Pediatric Intensivist (The Intensivist)
Response Time
Critical Care Transport Team
TRAINING AND SKILLS FOR TRANSPORT TEAMS
Pediatric Critical Care Transport Team
Technical Skills
Preferred Technical Skills
Cognitive Skills
Neonatal Critical Care Transport Team
Technical Skills
Preferred Skills
Cognitive Skills
Transport Process
Upon Arrival to Referral Institution
Consent
Assessment and Stabilization
Call Back to Prepare the PICU/NICU
Transport Equipment and Medications
Aeromedical Transport
Boyle's Law
Daltons Law
Cabin Altitude
PREVENTION OF COMPLICATIONS DURING AIR TRANSPORT OF PEDIATRIC AND NEONATAL PATIENTS
Gas Expansion
Decreased Partial Pressure of Oxygen
Stresses of Flight
FURTHER READING
CARDIAC ARREST
Epinephrine
Newborn
Child
Adult
Atropine
Dextrose
Defibrillate
Cardioversion
ENDOTRACHEAL (ET) INTUBATION
GLASGOW Coma Scale
ANALGESIA AND SEDATION
REVERSAL AGENTS
ANTIBIOTICS
ASTHMA, ANAPHYLAXIS, STRIDOR
CARDIAC MEDICATION AND DRIPS
ENDOCRINE
HYPERKALEMIA
MALIGNANT HYPERTENSION
SEIZURES
INCREASED INTRACRANIAL PRESSURE
RAPID SEQUENCE INTUBATION
HEAD INJURY
MISCELLANEOUS DRUGS
CHAPTER 6:
Consensus Guidelines for Pediatric Intensive Care Units in India
INTRODUCTION
UNIT DESIGN
Size of the PICU
Room Layout and Bed Area
Power Supply and Temperature Control
Beds
Crash Cart (Resuscitation Trolley)
Central Station
X-ray Viewing Area
Storage
Clean and Dirty Utility Room
Waste Disposal
Conference Room
Stat Laboratory
Equipment
ORGANIZATION AND STAFFING
Medical Director/Intensivist Incharge5
Staffing Requirements
Medical Staff
Nursing Staff
ANCILLARY SUPPORT STAFF
LEVELS OF PICU CARE AND ADMISSION AND DISCHARGE CRITERIA6–8
Levels of PICU Care
Level 3 Care (tertiary level PICU)
Admission Criteria to Level 3 Care PICU 6,7
Admission Criteria to Level 2 Care (stepdown/high dependency PICU)
REFERENCES
CHAPTER 7:
Monitoring in the Pediatric ICU
CARDIOVASCULAR MONITORING
Cardiorespiratory Monitors
Hemodynamic Monitoring
Automated Non-invasive Blood Pressure (NIBP) Monitoring
Doppler Ultrasonic Technique
Arterial Pressure Monitoring
Central Venous Pressure (CVP) Monitoring
Cardiac Output
NON-INVASIVE ESTIMATION OF CARDIAC OUTPUT (CO)
CO Estimation from Expired Gas (indirect Fick's Principle)
CO2 Rebreathing Method
Differential Fick's Principle
Throughflow Technique using a Soluble Inert Gas
Impedance Cardiography
Ambulatory Impedance Cardiography
Pulse Contour Analysis
Invasive
PICCO System (Figs 7.3 and 7.4)
Lithium Dilution CO
Edwards
TEE (Trans Esophageal Echocardiography)
Doppler Measurement of Cardiac Output
Transesophageal Probe (TECO)
Disadvantages
RESPIRATORY MONITORING
Pulse Oximetry
Blood Gas Monitoring
Capnography
Arterial – end tidal CO gradient [(a – ET) pCO2]
NEUROLOGIC MONITORING
Intracranial Pressure (ICP) Monitoring (Fig. 7.6)
Electroencephalography
Transcranial Doppler Sonography
Newer Neurological Monitoring Techniques
CHAPTER 8:
Capnography
CHAPTER 9:
Pediatric Intensive Care Working Rounds and Documentation
GENERAL ADMITTING ORDERS
Record Keeping
General Guidelines
Admission Notes
Progress Notes
SOAP note - Subjective
SOAP note - Objective
SOAP note - Assessment
SOAP note - Plan
POMR (Problem oriented medical record) format
Problem by System
Example
IMPORTANT POINTS TO REMEMBER
Abbreviations
Prescription Do's and Don'ts
Transfer Note
Discharge Summary
SUMMARY
CHAPTER 10:
Nursing Care in the PICU
BRADYCARDIA ALGORITHM (FIG. 10.2)
TACHYCARDIA ALGORITHM (FIG. 10.3)
Narrow-Complex (0.08 Second) Tachycardia
Probable Supraventricular Tachycardia
Wide-Complex (> 0.08 Second) Tachycardia
Tachycardia with Hemodynamic Stability
PULSELESS ARREST
“Shockable Rhythm”: VF/Pulseless VT
Defibrillators
Energy Dose
AEDs (automatic external defibrillators)
Defibrillation Sequence
CARE OF THE HEMODYNAMICALLY UNSTABLE VENTILATED PEDIATRIC PATIENT
Cardiorespiratory Monitors
Hemodynamic Monitoring
Automated Non-invasive Blood Pressure (NIBP) Monitoring
Doppler Ultrasonic Technique
Care of Ventilatory Issues Related to Nursing
USE : D O P E
D Displacement, O Obstruction, P Pneumothorax, E Equipment failure
Routine Ventilator Management Protocol
PULSE OXIMETRY
Capnography
Position Changes
Mouth Care
Eye Care
Respiratory Care During Ventilation
General
Chest Physiotherapy (CPT)
Humidification
Aerosol Therapy
Endotracheal Suctioning
Minimizing Drug Errors
Accurate Intake and Output Chart
Intracranial Pressure (ICP) Monitoring
Dealing with Visitation and Families
Communication with the Families
Informed Consent
In the United states
Do Not Attempt Resuscitation (DNR)
Medical Futility
Assisted Suicide
Euthanasia
In India
Breaking Bad News: The Nurse's Role (for Pediatrics)
Helping Parents Face the Death of their Child
Communication
Facilitate Family Grieving
Team Approach
SUMMARY
1. OXYGEN THERAPY
Definition
Purpose
Articles
Methods of Oxygen Administration
Special Points to Remember
Humidification
Advantages of Humidification
Procedure
2. BLOOD TRANSFUSION
Definition
Purpose
General Instructions
Articles Required
Special Points to Remember
3. ELECTROCARDIOGRAM (ECG)
Placement of Chest Leads
Objectives
Nursing Intervention
Primary Phase
Performance Phase
Final Phase
4. SECURING AND CARE OF ENDOTRACHEAL TUBES (ETT'S)
Standards
Outcomes
Equipment
Procedure
Post Procedure
Special Precautions
5. DRAWING ABG'S FOR BLOOD GAS ANALYSIS
Policy
Outcomes
Procedure
Special Considerations
6. GUIDELINES FOR BLOOD CULTURE COLLECTION
Indications
Timing
Volume of Blood Per Set
Number of Sets of Blood Cultures
Site of Blood Culture
Labeling
PREPARATION OF THE SITE FOR CULTURE
7. CARE OF A PATIENT WITH CENTRAL LINE
A. Procedure: Central Venous Catheters
B. HEPARIN LOCK FOR CENTRAL VENOUS CATHETER LINES
Policy
Outcomes
Equipment
C. CENTRAL VENOUS CATHETER SITE DRESSING
Policy
Outcomes
Special Considerations
Equipment
Procedure
D. DRAWING BLOOD FROM A CENTRAL VENOUS CATHETER
Policy
Outcomes
Equipment
Procedures
E. REMOVAL OF CENTRAL VENOUS LINE STANDARDS
Policy
Outcomes
Equipment
Procedure
8. ARTERIAL PRESSURE MONITORING
A. ARTERIAL LINE PLACEMENT
Procedure
Procedure: Insertion of an Arterial Line
Policy
Outcomes
Equipment
B. SETTING UP A TRANSDUCER FOR INVASIVE PRESSURE MANAGEMENT
Procedure
C. DRESSING CHANGES TO RADIAL/FEMORAL ARTERIAL LINES
Policy
Outcomes
Equipment
Procedure
D. REMOVAL OF ARTERIAL LINE
Policy
Outcomes
Equipment
Procedure
Alert
9. PROCEDURE: PERICARDIOCENTESIS
10. PROCEDURE THORACOCENTESIS AND CHEST TUBE PLACEMENT (FIG. 10.6)
Procedure
11. CARE OF THE PATIENT WITH CHEST TUBE
Water Seal Drainage
Definition
Purpose
Methods of Water Seal Drainage System
One Bottle Method
Two Bottles Method
Three Bottles Method
General Instructions
12. URINARY CATHETERIZATION
13. SUCTIONING A PATIENT WITH A TRACHEOSTOMY TUBE
Policy
Outcomes
Post Procedure
14. SUCTIONING A PATIENT WITH AN ENDOTRACHEAL TUBE
Standards
Outcomes
Post Procedure
15. TRACHEOSTOMY CARE
Definition
Purpose
General Instructions
Articles Required
Procedure
16. TRACHEOSTOMY DRESSING
Policy
Outcomes
Equipment
Procedure
17. INSERTION OF PERITONEAL DIALYSIS CATHETER
Purpose
Articles Required
Procedure
Care of PD Catheters
General Instructions
Basic Peritoneal Dialysis Regime
PD Cycles
Comments
CHAPTER 11:
Procedures in Pediatric Intensive Care Unit
ABDOMINAL PARACENTESIS
Indications
Contraindications
Risks
Technique
Complications
Interpretation
Appearance
Cell Count
Chemistry
Ascitic Fluid Composition in Different Types of Ascitis
TRANSURETHRAL BLADDER CATHETERIZATION FOR INTRA-ABDOMINAL COMPARTMENT PRESSURE MEASUREMENT AND URINARY DRAINAGE
Transurethral Bladder Catheter Placement
Indications
Contraindications
Equipment
Technique
Complications
Intra Vesical Pressure Measurement for Abdominal Compartment Pressure Measurement
Indications for Intra-abdominal Pressure Measurement
Patients at Risk for Developing ACS
Patients with Signs of ACS
Equipment
Technique of Intravesical Pressure Monitoring
Interpretation of Intra-abdominal Pressure and Interventions
CHAPTER 12:
Flexible Bronchoscopy in Infants and Children
INDICATIONS
Contraindications
Bronchoscopic Equipment
1. OLYMPUS BF TYPE P60 (Table 12.4)
2. OLYMPUS BF TYPE 1T60 (Table 12.5)
3. OLYMPUS BF TYPE MP60 (Table 12.6)
4. OLYMPUS BF TYPE XP60 (Table 12.7)
5. OLYMPUS BF TYPE 3C40 (Table 12.8)
6. OLYMPUS BF TYPE N20 (Table 12.9)
THE PHYSICS OF FLEXIBLE FIBEROPTIC ENDOSCOPES
BASIC ANATOMY OF A BRONCHOFIBERSCOPE
The Handle
Insertion Cord
Light Guide Bundles
Image Transmission Bundle
Working Channel
Tip Bending Lever
Distal Tip
Universal Cord
COMPARISON OF AVAILABLE FIBERSCOPES
Diameter of Insertion Cord
Length of Insertion Cord
The Size of the Working Channel
The Field of View
The Bending Radius of the Distal Tip
The Control Mechanisms of the Bending Tip
ACCESSORY INSTRUMENTS
Light Sources
Teaching Attachments
Forceps and Brushes
CLEANING AND STERILIZATION
THE FIBEROPTIC CART
SUGGESTIONS FOR FIBERSCOPE USAGE
Do's
Don'ts
Anatomy for the Bronchoscopist
Sedation Analgesia and Monitoring During Bronchoscopy
Local Anesthesia
Sedation and General Anesthesia
Presedation assessment
Sedation
Position
Insertion of the Bronchoscope
Examination of the Lower Airways
Post Bronchoscopy Care of the Patient
Technical Problems During Bronchoscopy
Difficult Laryngeal Passage
Neonatal Flexible Bronchoscopy
CHAPTER 13:
Pediatric Thoracoscopy
HISTORY
INDICATIONS FOR PEDIATRIC THORACOSCOPY
Drainage and/or Decortication of Empyema
Anesthesia9,10
Procedure11–13
Complications2,13,14
Contraindications to Thoracoscopy2,13,15–17
Thoracoscopy for Mediastinal Masses18–20
Thoracoscopy for Pulmonary Infiltrates
Thoracoscopy for Empyemas21–24
Patent Ductus Arteriosus25–27
OTHER USES28–33
Pleural Effusion
Pneumothorax
CHAPTER 14:
Radiology for the Pediatric Intensivist
SECTION TWO: RESPIRATORY SYSTEM
CHAPTER 15:
Respiratory Physiology
APPLIED RESPIRATORY PHYSIOLOGY FOR MECHANICAL VENTILATION
Ventilation
Oxygenation
Gas Exchange
SUMMARY
CHAPTER 16:
Oxygen Therapy in Pediatrics
CONCLUSION
CHAPTER 17:
Blood Gas and Acid-Base Interpretation
ACIDOSIS
ALKALOSIS
BUFFERING SYSTEM
HOMEOSTASIS
PATHOPHYSIOLOGY
METABOLIC ACIDOSIS (FLOW CHART 17.1)
Effects of Metabolic Acidosis
TREATMENT
METABOLIC ALKALOSIS (pH > 7.44 BLOOD BICARBONATE > 26 mEq/L) (FLOW CHART 17.2)
Treatment
RESPIRATORY ACIDOSIS (pH < 7.35 WITH PRIMARY PaCO2 > 45 mmHg)
RESPIRATORY ALKALOSIS (PRIMARY DECREASE IN PaCO2 < 35 mmHg AND pH > 7.44)
Practical Tips to Approach Acid-Base Disorders
MIXED ACID-BASE DISORDERS
Mixed Metabolic and Respiratory Acidosis
Mixed Metabolic and Respiratory Alkalosis
Mixed Metabolic Alkalosis and Respiratory Acidosis
Metabolic Acidosis and Respiratory Alkalosis
Treatment
REFERENCES
CHAPTER 18:
Upper Airway Obstruction in Children
PEDIATRIC AIRWAY
Nose
Larynx and Trachea
Developmental Anatomy
Physiology
History and Physical Examination
Special Investigations
Physiology Studies
SPECIFIC DISEASES
CONGENITAL MALFORMATIONS
Malformations of the Head
Macrocephaly
Mandibular Hypoplasia
Dysfunction of Temporomandibular Joint
Malformation of Mouth and Tongue
Malformation of the Nose, Palate and Pharynx
Malformation of Larynx
Acquired Lesions of Larynx
Congenital and Acquired Subglottic Stenosis
Malformations of Trachea and Bronchi
INFECTIOUS DISEASES
SUPRAGLOTTITIS (EPIGLOTTITIS)
Clinical Presentation
Differential Diagnosis
Management
LARYNGOTRACHEOBRONCHITIS
Clinical Presentation
Management
BACTERIAL TRACHEITIS
Clinical Presentation
FOREIGN BODIES
Clinical Presentation
Management
TRAUMATIC INJURY
BURN INJURY
ANGIOEDEMA
TRACHEAL STENOSIS
Congenital Tracheal Stenosis
Acquired Tracheal Stenosis
Clinical Presentation
Management
TRACHEOMALACIA
Clinical Presentation
MEDIASTINAL MASSES
Anterior Mediastinum
Posterior Mediastinum
Anesthetic and Intensive Care Implications
CHAPTER 19:
Meconium Aspiration Syndrome and PPHN
INTRODUCTION
Pathophysiology of MAS (Fig. 19.1)
Clinical Manifestations
Management Strategies
General
Ventilatory Options
Pulmonary Vasodilators
Outcome
CHAPTER 20:
Acute Respiratory Failure
GENERAL CONSIDERATIONS
Definition
Pathophysiology
Clinical Evaluation of a Child with Impending Respiratory Failure (Flow chart 20.1)
Workup
Imaging Studies:
Diagnostic Procedures
Principles of Treatment
Airway Management
Lung and Respiratory Pump Support (Flow chart 20.2)
Indications for Admission to the PICU
Indications of Mechanical Ventilation
Adjunctive Therapies:
SPECIFIC DISORDERS LEADING TO ARF: IMPORTANT ISSUES IN DIAGNOSIS AND MANAGEMENT
CHAPTER 21:
Pediatric Tracheostomy
HISTORY (FIG. 21.1)
Indications
Airway Obstruction
Dead Space/Pulmonary Toilet
Ventilation
TYPES OF TRACHEOSTOMY TUBES (FIGS 21.2 AND 21.3)
Specific Indications for a Tracheostomy9
Tracheostomy Tubes Available in India
CHOICE OF A TUBE
TECHNIQUE
Percutaneous Technique (PT)5
Technique of Insertion of Percutaneous Tracheostomy
POSTOPERATIVE CARE
ROUTINE CARE
Tube Change
Routine Cuff Deflation
Tracheostomy Ties
Suctioning
Clean Versus Sterile Technique for Suction
Stoma Care
Humidification
Speech and Swallowing Assessment
PARENT TEACHING AND HOME CARE
Monitoring
DECANNULATION
COMPLICATIONS
Early Complications
Late Complications
CHAPTER 22:
Acute Severe Asthma Management in Pediatric Intensive Care Unit
REFERENCES
FURTHER READING
DIAGNOSIS OF ASTHMA IN CHILDREN
PROGNOSIS OF CHILDHOOD ASTHMA
A. FAMILY HISTORY OF ATOPY
B. CO-EXISTENCE OF ATOPIC DISEASE
C. EFFECT OF SEX
D. BRONCHIOLITIS IN INFANCY
E. PARENTAL SMOKING
F. BIRTH WEIGHT AND PREMATURITY
G. AGE AT PRESENTATION
H. SEVERITY AND FREQUENCY OF EPISODES
I. LUNG FUNCTION MEASUREMENTS
ACUTE ASTHMA IN CHILDREN AGED OVER 2 YEARS
Initial Assessment
TREATMENT OF ACUTE ASTHMA IN CHILDREN AGED OVER 2 YEARS
A. OXYGEN
B. BETA 2 AGONIST BRONCHODILATORS
C. IV SALBUTAMOL
D. STEROID THERAPY
Inhaled steroids
E. IPRATROPIUM BROMIDE
F. IV AMINOPHYLLINE
G. OTHER THERAPIES
H. INTRAVENOUS FLUIDS
I. IV MAGNESIUM SULPHATE
FURTHER INVESTIGATION AND MONITORING
ASSESSMENT OF ACUTE ASTHMA IN CHILDREN AGED LESS THAN 2 YEARS
TREATMENT OF ACUTE ASTHMA IN CHILDREN AGED LESS THAN 2 YEARS
A. beta 2 Agonist Bronchodilators
B. Steroid Therapy
C. Ipratropium Bromide
FURTHER INVESTIGATION AND MONITORING
CHAPTER 23:
Viral Pneumonias: Common Pneumonias and Recent Advances
INTRODUCTION
SPECIFIC VIRAL PATHOGENS AND THEIR CLINICAL SYNDROMES
Influenza
Adenovirus
Parainfluenza
Rhinovirus
Measles
Cytomegalovirus (CMV)
Epstein-Barr virus (EBV)
Varicella (Chicken pox)
SPECIFIC ATYPICAL PATHOGENS AND THEIR CLINICAL SYNDROMES
Mycoplasma Pneumoniae and Ureaplasma Urealyticum
Chlamydia Trachomatis, Chlamydia Pneumoniae
SUMMARY
REFERENCES
Section 1: Common viral pneumonias
COMMON VIRUSES PRODUCING PNEUMONIA
Orthomyxoviridae
Paramyxoviridae
Clinical Features
Diagnosis
Prevention
CDC Recommendation: (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm)
Chemoprophylaxis
Treatment
Prognosis and Complications
Note
REFERENCES
Section 2: Recent advances in viral pneumonias in children
CHAPTER 24:
Persistent and Recurrent Pneumonias
SUMMARY
CHAPTER 25:
Recent Advances in the Rapid Diagnosis of Respiratory Tract Infection
CONCLUSIONS
CHAPTER 26:
HIV Disease and Respiratory Infection in Children
SUMMARY (FLOW CHART 26.1)
CHAPTER 27:
Acute Respiratory Distress Syndrome (ARDS) in Children
INTRODUCTION
Pathophysiology
Physiological Derangements in ARDS
Incidence
Clinical Course
Acute Injury
Latent Period
Acute Respiratory Failure
In ARDS PaO2 /FiO2 ratio is less than or equal to 200.
In ALI (Acute lung injury) PaO2/FiO2 ratio<300.
Severe Physiological Abnormalities
Management of ARDS (Flow chart 27.1)
Ventilatory Strategies in ARDS
Conventional Ventilation
Concept of PEEP
Concept of Low Tidal Volume
Concept of Permissive Hypercapnea and Permissive Hypoxia
High Frequency Oscillatory Ventilation
Prone Position
OTHER ADJUNCTIVE THERAPIES
Inhaled Nitric Oxide
Corticosteroids
Extracorporeal Membrane Oxygenation (ECMO)22
Nutritional Support
Broad Spectrum Antibiotic Coverage
Complications
Outcome and Prognosis25–27
REFERENCES
CHAPTER 28:
Empyema Thoracic in Children: A Current Perspective
SUMMARY (FLOW CHART 28.1)
CHAPTER 29:
Air Leak Syndromes
PNEUMOTHORAX
PULMONARY INTERSTITIAL EMPHYSEMA
PNEUMOMEDIASTINUM
PNEUMOPERICARDIUM (FIG. 29.4)
CHAPTER 30:
Cystic Fibrosis: Clinical Manifestations and Treatment
CHAPTER 31:
Neonatal Congenital Lung Lesions
CONGENITAL DIAPHRAGMATIC HERNIA (CDH)
Diagnosis and Management
Prognostic Factors
Delivery
Management at Birth
Operative Repair
Results
Future Therapies
Eventration of Diaphragm
REFERENCES
PULMONARY SEQUESTRATION
Introduction
Extrapulmonary Sequestration
Intrapulmonary Sequestration
Clinical Details
Extrapulmonary Sequestration
Intrapulmonary Sequestration
Diagnosis
Chest X-ray
CT Scan
Ultrasound
Management
REFERENCES
CONGENITAL LOBAR EMPHYSEMA
Introduction
Pathophysiology
Clinical Features
Similar Congenital Lung Conditions
Intrinsic Bronchial Obstruction
Extrinsic Bronchial Obstruction
Alveolar Fibrosis
Focal Pulmonary Hypoplasia
Polyalveolar Lobe
Investigations
Chest X-ray
CT Scan
Treatment
REFERENCES
BRONCHOGENIC CYSTS1–4
Clinical Features
Surgical Management
REFERENCES
CONGENITAL CYSTIC ADENOMATOID MALFORMATION
Introduction
Pathogenesis
Types of CAM
Clinical Features
Diagnosis
Treatment
Prognosis
REFERENCES
ESOPHAGEAL ATRESIA AND TRACHEO-ESOPHAGEAL FISTULA (TEF)
Incidence
Associated Anomalies
Prognostic Classification
Current Staging
Diagnosis
Prenatal
Postnatal
Investigations
Management
PICU/NICU Problems
Preoperative
Surgical and Postoperative Complications
Long-term Complications may include:
CHAPTER 32:
Bronchodilator Therapy in Mechanically Ventilated Children
CHAPTER 33:
Basic Mechanical Ventilation
INTRODUCTION
Basic Physiology3
Ventilation
Oxygenation
Gas Exchange
Time Constant
Time constant = Resistance x Compliance
Indications of Mechanical Ventilation4 (Flow chart 33.1)
Commonly used Nomenclature
Continuous Positive Airway Pressure (CPAP)
Modes of Ventilation
Control Modes
IMV Modes
SIMV: Ventilator Synchronizes IMV “Breath” with Patient's Effort
Support Mode
Pressure Support5
BASIC FUNDAMENTALS OF VENTILATION
Pressure vs Volume Control6
Pressure Limited Ventilation (Fig. 33.1)
Volume Limited Ventilation (Fig. 33.2)
Trigger/Sensitivity
Advanced Modes
Pressure Regulated Volume Control (PRVC)7 (Fig. 33.3)
Initial Ventilator Settings
Choose the Mode
Pressure Limited
Volume Limited
Adjustments after Initiation
Gas Exchange Related Problems
Inadequate Oxygenation
High PaCO2
Measures for High PaCO2
Guidelines
Measures to Reduce Barotrauma and Volutrauma
Sedation and Muscle Relaxation during Ventilation
Routine Ventilator Management Protocol
Respiratory Care Protocol (See Chapter on Respiratory Care)
Disease Specific Ventilation
Status asthmaticus10,11
Initiation of Ventilation
Ventilation Strategies
Controlled Hypoventilation using SIMV or Assist Control
Support Modes: Volume or Pressure Support
Use of PEEP
Controlled Hypercapnia9
CASE SCENARIO 1
Ventilation for Acute Respiratory Distress Syndrome (ARDS)
Goals of Ventilation in ARDS
CASE SCENARIO 2
Airleak Syndrome
Pneumothorax, Bronchopleural Fistula
Ventilation Strategies
Other Modes useful in Airleak Syndrome
Postoperative Ventilation following Open Heart Surgery
General Principles
CASE SCENARIO 3
Raised ICP (Intracranial Pressure)
Neonatal Ventilation18
Conventional Neonatal Ventilation20,21
Pressure Limited Time Cycled Ventilation
Disadvantages
CASE SCENARIO 4
Alternative Modes of Neonatal Ventilation
Rescue Strategies for Management of Neonatal Ventilatory Failure
CASE SCENARIO 5
Inhaled Nitric Oxide (INO)
Summary
CHAPTER 34:
Structure and Function of a Conventional Ventilator
CHAPTER 35:
Commonly Available Ventilators
VELA VENTILATOR: VIASYS HEALTH CARE (USA)
Features (as listed by the manufacturer)
NEONATAL VENTILATOR MODEL BEARCUB 750 PSV–VIASYS HEALTH CARE (USA)
Listed Features (from the manufacturer)
VENTILATOR MODEL AVEA- VIASYS HEALTH CARE (USA)
Drager Babylog 8000
Drager Babylog 8000 Plus, Evita XL, Evita 2 Dura
Siemens Servo 900C Ventilator
Siemens Servo 300/300A Ventilator
Sechrist Ventilator (Old and Newer Versions)
VIP Bird Ventilators
Transport Ventilator (BIRD AVIAN)
Newport Ventilators: E lOOM, Breeze E150 and Wave E120 Ventilators
Infant Star 500/950 Ventilator System
Siemens Servo-I (Maquet)
Listed Features (from the manufacturer)
Product Benefits
Sensormedics 3100A
Respironics BIPAP and Non-invasive Ventilator
Author's Comments
CHAPTER 36:
Advanced Mechanical Ventilation: Newer Modes and Modalities
CHAPTER 37:
Ventilator Graphics and Clinical Applications
LOOPS
ABNORMAL WAVEFORMS
Auto-PEEP or Air Trapping
Increased Airway Resistance (Raw)
PIP vs. Pplat.
Decreased Lung Compliance during Volume Ventilation
Alveolar Overdistension
Modes of Ventilation
Scalar Waveforms of Pressure and Volume Controlled Ventilation
Scalar Waveforms during Common Modes of ventilation in Volume-Targeted Ventilation
Controlled Mode
Assisted Mode
SIMV (Synchronized Intermittent Mandatory Ventilation)
SIMV with Pressure Support (PS)
Clinical Applications and Significance
Conclusions
REFERENCES
FURTHER READING
CHAPTER 38:
Care of the Ventilated Patient
CHAPTER 39:
Weaning from Mechanical Ventilation
EXTUBATION
Common Causes of Extubation Failure:
DONT'S
Summary
Conclusion
CHAPTER 40:
Complications of Mechanical Ventilation
COMPLICATIONS RELATED TO ADJUNCTIVE THERAPIES
Mechanical Misadventures
SUMMARY
CHAPTER 41:
Noninvasive Ventilation
MECHANISM OF IMPROVEMENT WITH NONINVASIVE VENTILATION
Advantages of NIPPV
Indications for NIPPV
Acute Diseases
Chronic Diseases
Volume Ventilation
Pressure Control Ventilation1,4
Pressure Support Ventilation1,4
Bilevel Positive Airway Pressure Ventilator (BIPAP)1,3,20
Continuous Positive Airway Pressure (CPAP)
Practical Applications of Noninvasive Positive Pressure Ventilation (Flow chart 41.1)
Chronic Respiratory Failure
Acute Respiratory Failure
Initiation of Noninvasive Mechanical Ventilation
Limitations of NIPPV
Monitoring during NIPPV1,3,4,20
Weaning
Complications of NIPPV
Bruises and Erosions
CONCLUSIONS
REFERENCES
CHAPTER 42:
High Frequency Ventilation
VENTILATOR INDUCED LUNG INJURY
PROTECTIVE STRATEGIES OF CONVENTIONAL MECHANICAL VENTILATION
BASIC CONCEPTS OF HFV (HIGH FREQUENCY VENTILATION)
TYPES OF HIGH FREQUENCY VENTILATION
High Frequency Positive Pressure Ventilation (HFPPV)
High Frequency Jet Ventilation (HFJV) (Fig. 42.1)
High Frequency Oscillatory Ventilation (HFOV) (Fig. 42.2)
CLINICAL APPLICATION (FLOW CHART 42.1)
SUMMARY
REFERENCES
WHERE IS THE EVIDENCE?
Initiation of High Frequency Oscillation
WHY IS THIS IMPORTANT?
When Preparing to Change from Conventional to High Frequency Ventilation, What Preparations must be Made?
Monitoring
Settings
Amplitude
Frequency
What Steps are to be Taken if the Blood Pressure is not Adequate?
Mean Airway Pressure
FiO2
Case Presentations
Case 1
What would be Appropriate Initial Oscillator Settings? Why?
Case 2
Take Home TIPS
STANFORD Hospital and Clinics Recommendations and Guidelines for Implementation of High Frequency Oscillatory Ventilation (HFOV)
Indications and Patient Selection
Patient Preparation
Initial HFOV Settings
Guidelines for Initial HFOV Settings
Weaning from HFOV
Potential Complications
CONCLUSION
REFERENCES
FURTHER READING
I. INITIAL SETTINGS
II. MANAGEMENT STRATEGIES FOR THE SENSORMEDICS 3100
III. WEANING
IV. COMPLICATIONS ASSOCIATED WITH HFOV
CHAPTER 43:
Inhaled Nitric Oxide (INO)
CHAPTER 44:
Neonatal Ventilation
CHAPTER 45:
Surfactant Therapy in the Newborn
CONCLUSION
CHAPTER 46:
Extracorporeal Membrane Oxygenation (ECMO)
CONCLUSIONS
ACKNOWLEDGEMENT
CHAPTER 47:
Pediatric Heart and Lung Transplantation
HEART TRANSPLANTATION
Indications for Transplant
Waiting List
Status 1A
Status 1B
Status 2
Status 7
Contraindications
Surgical Techniques
LUNG AND HEART-LUNG TRANSPLANTATION
Indications
Selection of Candidates and Waiting List
Surgical Considerations
PHYSIOLOGY OF THE TRANSPLANTED HEART
Hemodynamics
PHYSIOLOGY OF THE TRANSPLANTED LUNG
Perioperative Care of Infants and Children after Thoracic Organ Transplant
Initial Assessment
Critical Care Issues after Thoracic Organ Transplantation
Cardiovascular Issues
Improvement of Cardiac Function
Pulmonary Dysfunction
After Heart Transplant
After Lung Transplantation
Perioperative Pain and Sedation
Metabolic Demands and Nutritional Support
Immunosuppression
Post-transplant Problems
Diagnosis and Management of Rejection
Types of Rejection
Rejection after Cardiac Transplants
Diagnosis
Histologic Grades of Rejection
Noninvasive Assessment of Acute Rejection
Acute Rejection after Lung Transplantation
Acute Rejection
Management of Acute Rejection
CHRONIC REJECTION AND PROBLEMS AFTER TRANSPLANTATION
Common to all Transplants
Infection
Malignancy
Side Effects of Drugs
PROBLEMS SPECIFIC TO EACH ORGAN TRANSPLANT
Heart Transplant
Allograft Arteriopathy
Lung Transplant
Chronic Rejection
Outcomes from Heart Transplants in Children
Graft and Patient Survival
Growth and Development
Quality of Life
Psychologic Functioning
Outcomes from Lung Transplantation
Survival
Outcomes from Heart-lung Transplantation
Psychosocial Issues Before and After Transplantation
Important Differences between Adult and Pediatric Heart Transplants
SECTION THREE: CIRCULATORY SYSTEM
CHAPTER 48:
Shock: Management of Shock in PICU
DEFINITIONS
PATHOPHYSIOLOGY
PHASES OF SHOCK
Compensatory Mechanisms
Clinical Presentation
CLASSIFICATION OF SHOCK
ASSESSMENT AND RECOGNITION OF SHOCK
Laboratory Investigations
MONITORING OF SHOCK
TREATMENT OF SHOCK
Respiratory Support (Ventilation)
Cardiovascular Support
Rate and Rhythm
Preload and Volume Replacement
Choice of Fluid for Volume Replacement10–14
MYOCARDIAL CONTRACTILITY
Inotropic and Vasoactive Agents
Afterload Reduction
SUPPORTIVE THERAPY
SUMMARY
CHAPTER 49:
Inotropes and Vasopressors in the Pediatric Intensive Care Unit
DIGOXIN
Mechanism(s) of Action
Digoxin: Practical Aspects1,2
Adverse Effects
THE CHOICE OF INOTROPES AND VASOPRESSORS
DOPAMINE
Clinical Pharmacology
Therapeutic Use
Pharmacokinetics
Preparation and Administration
Adverse Effects and Contraindications
Drug Interactions
DOBUTAMINE
Clinical Pharmacology
Therapeutic Uses
Septic Shock
Pharmacokinetics
Preparation and Administration
Adverse Effects
Drug Interactions
EPINEPHRINE
Clinical Pharmacology
Cardiac Effects
Blood Pressure
Vascular Effects
Effects on Smooth Muscles
Respiratory Effects
Metabolic Effects
Therapeutic Use
Pharmacokinetics
Preparation and Administration
Adverse Effects
Central Nervous System
Cardiovascular System
Metabolic Effects
Drug Interactions
MILRINONE
Mechanism of Action
Clinical Pharmacology
Therapeutic Use
Use After Cardiac Surgery
Use in Septic Shock
Use in CHF
Pharmacokinetics
Preparation and Administration
Dose
Adverse Effects
Drug Interactions
NOREPINEPHRINE
Clinical Pharmacology
Therapeutic Use
Pharmacokinetics
Preparation and Administration
Adverse Effects
Drug Interactions
VASOPRESSIN
Clinical Pharmacology
Clinical Use
Pharmacokinetics
Dosing, Preparation and Administration
Drug Interactions
Adverse Effects
SUMMARY
Guideline
REFERENCES
CHAPTER 50:
Cardiogenic Shock
CLINICAL FINDINGS
INITIAL TREATMENT
SPECIFIC CONDITIONS
Congenital Heart Disease in the Neonate
Left Heart Obstructive Lesions
Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA)
Cardiac Muscle Disorders
Myocardial Asphyxia
Myocarditis
Dysrhythmias
Metabolic Causes
Hypoglycemia
Adrenal Insufficiency
Miscellaneous Causes of Cardiac Failure
SUMMARY
CHAPTER 51:
Pediatric Septic Shock
INTRODUCTION
DEFINITIONS
Rapid Cardiopulmonary Assessment and Clinical Examination of a Patient in Shock
Emergency Management (Golden Hour of Sepsis Management)
Speed is Essential
Priorities of Treatment
Approach or Management of Severe Sepsis or Septic Shock: (Time frames may overlap depending on hemodynamic status)
i. 0 min-5 min
ii. 5 min to 40 min
iii. 40 min to 60 min
iv. 60 min and beyond
DISCUSSION OF FLOW CHART 51.1
0–5 min
5–40 min
Initial Resuscitation
Choice of Fluid for Volume Replacement
Crystalloids
Albumin
Method of Fluid Administration
Hypocalcemia and Hypoglycemia
Early Antibiotics
Inotropic and Vasoactive Agents
40–60 min
Dopamine
Dobutamine
Adrenaline (Epinephrine)
Noradrenaline (Norepinephrine)
Beyond 60 min
Recognize Catecholamine Resistant Shock
Further Management in PICU
Cold shock with Normal Blood Pressure
Clinical Significance of Mixed Venous Oxygen Saturation (ScVO2)
Levosimendan28–32
Cold Shock with Low Blood Pressure
Enoximone33,34
Warm Shock with Low Blood Pressure
Vasopressin (VP)
Dosing, Preparation and Administration
THERAPEUTIC END-POINTS
CONCLUSIONS
ACKNOWLEDGEMENTS
CHAPTER 52:
Multiorgan Failure in Critically Ill Children
CONCLUSIONS
CHAPTER 53:
Viral Hemorrhagic Fever: Management in Pediatric Intensive Care Unit
SUMMARY
REFERENCES
INTRODUCTION
RISK FACTORS REPORTED FOR DHF
PATHOGENESIS OF DENGUE AND DHF (FIG. 53.2)
Mechanism of Thrombocytopenia
CLINICAL CLASSIFICATION
DENGUE FEVER
DENGUE HEMORRHAGIC FEVER (DHF)
DENGUE SHOCK SYNDROME (DSS) (FLOW CHART 53.2)
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Diagnosis – Dengue Fever
Diagnostic Value of Signs
Diagnosis of DHF: Clinical Criteria
Unusual Manifestations—Complications
Acute Hepatic Failure (AHF)
Renal Failure
Myocardial Dysfunction
Causes of Death in DHF
LABORATORY METHODS FOR DIAGNOSIS
MANAGEMENT: FEBRILE PHASE
High Risk Dengue Patients that Need Special Attention
Indication for Admission
MANAGEMENT: CRITICAL PHASE
A. General Measures
B. Monitoring of children DHF/ DSS
C. Obtain Laboratory Tests
D. Intravenous (IV) Fluids
E. Blood and Platelet Transfusion
F. Treatment of Complications
SIGNS OF RECOVERY
CRITERIA FOR DISCHARGING PATIENTS
WHAT NOT TO DO
PREVENTION AND CONTROL OF DENGUE FEVER
Dengue Vaccine
Acknowledgement
CHAPTER 54:
Role of Echocardiography in the Pediatric Intensive Care Unit
SUMMARY
CHAPTER 55:
Cardiac Failure
DEFINITION
PROCESSES CAUSING CARDIAC FAILURE
CLINICAL PRESENTATION
Newborns
Infants
Children and Young Adults
Radiographic Findings
THE ELECTROCARDIOGRAM
Echocardiography (See Chapter on Pediatric Echocardiography)
Management
FLUID MANAGEMENT
DIGOXIN
MODULATORS OF RENIN-ANGIOTENSIN-ALDOSTERONE AXES
ACE Inhibitors
Aldosterone Antagonists
Beta Blockers
CONCLUSION
CHAPTER 56:
Cardiac Dysrhythmias in Pediatric Intensive Care
REFERENCES
CHAPTER 57:
Hypertension in Children
CHAPTER 58:
Postoperative Management of Pediatric Cardiac Patients after Open Heart Surgery
INTRODUCTION
BASIC PHYSIOLOGIC PRINCIPLES FACTORS AFFECTING CARDIAC OUTPUT
Factors Affecting Myocardial Performance
Pathophysiology of Low Cardiac Output Based on Etiology (Flow chart 58.1)
Pathophysiology of Left Ventricle (LV) Dysfunction
Pathophysiology of Right Ventricle (RV) Dysfunction
Cardiopulmonary Bypass
Myocardial Effects
CNS Effects
Pulmonary Effects
Renal Effects
Electrolyte Abnormalities
GI/ Nutritional Effects
Postoperative Management
Evaluation
Invasive Hemodynamic Monitoring
Laboratory Tests
Specific Cardiac Issues
Management of Inotropes
Ventilation
Effects of Ventilation on Heart Rate
Effects of Ventilation on Right Ventricular Function
Effects of Ventilation on Left Ventricular Function
Ventilatory Settings
Sedation, Analgesia and Paralysis
Fluids and Electrolytes
Nutrition
Renal Issues
Coagulation Issues
Acyanotic Heart Defects (Flow chart 58.6)
Left to Right Shunts
Cyanotic Heart Defects (Flow chart 58.7)
CHAPTER 59:
Pediatric Pacemaker and Implantable Cardioverter Defibrillator (ICD) Therapy
CHAPTER 60:
Interventional Pediatric Cardiology: An Overview
VASCULAR ANGIOPLASTIES
Mechanism of Dilation
Dilation of Pulmonary Artery Stenosis
Dilation of Coarctation of the Aorta
Dilation of Systemic and Pulmonary Obstructions
Dilation of Miscellaneous Vascular Lesions
DILATION OF VALVULAR LESIONS
Morphology
Dilation of the Pulmonary Valve
Dilation of the Aortic Valve
Dilation of Bioprosthetic Valves
CLOSURE OF EXTRACARDIAC AND INTRACARDIAC COMMUNICATIONS
Materials
Detachable Balloons
Ivalon Plus for Occlusion of the Patent Ductus Arteriosus
Rashkind Double-umbrella Occluder
Gianturco Steel Coils
Septal Occluders
PROCEDURES
Closure of Aortopulmonary Collaterals
Closure of Arteriovenous Malformations
Closure of Surgical Systemic to Pulmonary Shunts
Ventricular Septal Defects
The Fenestrated Fontan
Endovascular Stents
COMPLICATIONS
SUMMARY
SECTION FOUR: METABOLIC RENAL ISSUES
CHAPTER 61:
Electrolyte Abnormalities in Critically Ill Children
DISORDERS OF WATER HOMEOSTASIS
Diabetes Insipidus
Management of Diabetes Insipidus
Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
Management of SIADH
Sodium
Hyponatremia (Serum Sodium < 135 mmol/L)
Management of Hyponatremia (Flow chart 61.1)
Hypernatremia (Serum Sodium >150 mmol/L)
Clinical Manifestations
Management of Hypernatremia (Flow chart 61.2)
POTASSIUM DISORDERS
Hypokalemia (Serum Potassium < 3.5 mmoles/L)
Clinical Manifestations
Management of Hypokalemia (Flow chart 61.3)
Hyperkalemia (Serum Potassium > 5 mmoles/L)
Clinical Manifestations
Management of Hyperkalemia (Flow chart 61.4)
CALCIUM DISORDERS
Hypocalcemia
Clinical Manifestations
Management of Hypocalcemia (Flow chart 61.5)
Emergency Treatment
Hypercalcemia
Management of Hypercalcemia (Flow chart 61.6)
MAGNESIUM
Hypomagnesemia
Clinical Features
Management of Hypomagnesemia
Hypermagnesemia
SUMMARY
CHAPTER 62:
Inborn Errors of Metabolism
PATHOPHYSIOLOGY
LABORATORY INVESTIGATIONS
TREATMENT
CHAPTER 63:
Diabetic Ketoacidosis
CLASSIFICATION
DEFINITION OF DIABETIC KETOACIDOSIS(DKA)
Severity of Acidosis
Pathogenesis
Clinical Manifestations of DKA
Laboratory Findings
Leukocytosis is common
Cerebral obtundation and coma ultimately ensue
PICU Management (Flow chart 63.1)
Treatment of Ketoacidosis
Potassium
Phosphate
SUMMARY
CHAPTER 64:
Acute Renal Failure in Pediatric Intensive Care Unit
CHAPTER 65:
Renal Replacement Therapy in the Pediatric Intensive Care Unit
PHYSIOLOGICAL PRINCIPLES OF DIALYSIS
SELECTION OF MODALITY
INDICATIONS OF DIALYSIS
PERITONEAL DIALYSIS (FIG. 65.2)
Insertion of Catheter
Advantages of PD
Disadvantages of PD
HEMODIALYSIS (Fig. 65.5)
Advantages of HD
Disadvantages of HD
CONTINUOUS VENOVENOUS HEMOFILTRATION AND HEMODIAFILTRATION (CVVH/CVVHD)
Advantages and Disadvantages of CVVH/CVVHD
CHAPTER 66:
Pediatric Renal Transplantation
SECTION FIVE: GASTROENTEROLOGICAL ISSUES
CHAPTER 67:
Gastrointestinal Bleeding: Diagnosis and Management
LOWER GI BLEEDING
Further Diagnostic Evaluation
MANAGEMENT
Stabilization in the PICU
Therapeutic Modalities
SUMMARY
CHAPTER 68:
Nutrition in the Pediatric Intensive Care Unit
MODES OF NUTRITIONAL REPLETION
Enteral, Parenteral or Both?
“When the Gut Works Use It'
NUTRITIONAL ASSESSMENT
Basal Metabolic Rate (BMR)
Catabolic Index
NUTRITIONAL SUPPORT
Carbohydrates
Proteins
Lipids
NUTRITION IN SPECIAL CIRCUMSTANCES
Nutrition in Liver Failure
Nutritional Management of Acute Renal Failure30,31
Nutritional Supplements
Vitamins
Electrolytes and Minerals
Trace Elements (Table 68.4)
Immunonutrition
Glutamine
Ornithine Ketoglutarate
Prebiotics
Fiber and Probiotic Bacteria
Omega-3 Fatty Acids
CONCLUSION
SUMMARY
CHAPTER 69:
Parenteral Nutrition for the Pediatrician
CHAPTER 70:
Fulminant Hepatic Failure
CLINICAL FEATURES
Diagnosis
Management (Flow chart 70.1)
Hepatic Encephalopathy and Cerebral Edema
Specific Therapies in FHF
Hepatic Support in FHF
Orthotopic Liver Transplantation in FHF
Auxiliary Orthotopic Liver Transplantation (APOLT)
Hepatocyte Transplantation
SUMMARY
CHAPTER 71:
Liver Transplantation
INDICATIONS
Preoperative Evaluation
Recipient Hepatectomy
Implantation of Donor Liver
Immunosuppressive Therapy
Postoperative Complications
Primary Nonfunction (PNF)
Hepatic Complications
Hepatic Artery Thrombosis
Portal Vein Thrombosis
Biliary Tract
EXTRAHEPATIC COMPLICATIONS
Post-transplant Lymphoproliferative Disease (PTLD)
OUTCOME OF LIVER TRANSPLANTATION
CHAPTER 72:
Liver Transplantation in Children: Indian Scenario
INDICATIONS
End Stage Liver Disease
Fulminant Hepatic Failure
Metabolic Disorders
Assessment
Preparation for LT
Critical Care Issues in Management
Indian Scenario
SECTION SIX: HEMATOLOGICAL ISSUES
CHAPTER 73:
Disseminated Intravascular Coagulation
CHAPTER 74:
Blood Transfusion in Neonatal and Pediatric Intensive Care
INTRODUCTION
Physiological Principles
ANEMIA IN THE INTENSIVE CARE UNIT
Pathophysiology of Anemia (Flow chart 74.1)
Impairment in Adaptive Mechanisms in Newborns and Pediatric Population9–11
Risk vs Benefits12–14
Guidelines for Blood Transfusion
Transfusion Reactions
Hemolytic Transfusion Reactions
Nonhemolytic Febrile Reactions
Anaphylactic Reactions
Massive Transfusion Complications
Graft versus host Disease
Transfusion-related Acute Lung Injury
Fresh Frozen Plasma25
Guidelines for Transfusion of Fresh Frozen Plasma
Platelet Transfusion25
Irradiated Blood Components
Indications
Granulocyte Transfusion
Cryoprecipitate (Table 74.3)
Apheresis of Blood Components
Blood Transfusion Practices in Neonates
Whole Blood or Packed Red Cells
Volume of RBCs to be Transfused
WEIGHT IN KG × BLOOD VOLUME PER KG × (DESIRED HEMATOCRIT – OBSERVED HEMATOCRIT)
Hematocrit of the Blood to be Transfused
Exchange Transfusion
Indications
Criteria for Exchange Transfusion in Rh-HDN
Selection of Blood for Exchange Transfusion in Rh-HDN:
Volume and Hematocrit of Blood for Exchange Transfusion
Newer Directions
Blood Salvage and Autologous Transfusion
Blood Substitutes
SUMMARY
REFERENCES
FURTHER READING
SECTION SEVEN: PEDIATRIC SURGICAL ISSUES
CHAPTER 75:
Postoperative Care in Pediatric Surgical Patients
SUMMARY
CHAPTER 76:
Multiple Trauma: Stabilization and Management in Pediatric Intensive Care Unit
INTRODUCTION
Outline of the Chapter
Prehospital Care of an Injured Child
Management at the Accident Site
Primary Survey
Initial Wound Care
First Aid for Fracture
Hospital Management
A. Airway
B. Breathing
C. Circulation
(i) Vascular Access
(ii) Intraosseous Access
(iii) Choice of Resuscitation Fluid
Secondary Survey
Head Injury
External Examination
Fractures
Intracranial Hematoma
Boney Injuries
Thoracic Injuries8
Abdominal Trauma9
Pediatric Intensive Care Unit (PICU) Management Protocol (Flow chart 76.1)
PICU Monitoring of a Trauma Patient
CHAPTER 77:
Child Abuse and Shake Injuries
DEFINITION AND ETIOLOGY
DIAGNOSIS
EXAMINATION
Shake Injuries
Examination
Retina
Head
Initial Stabilization
CT Scan of Head
Treatment
HEAD INJURIES
ABDOMINAL INJURIES
LABORATORY AND DIAGNOSTIC IMAGING STUDIES
Laboratory Evaluation
Biochemical
Toxicological
Urinalysis
DIAGNOSTIC IMAGING EVALUATION
Skeletal Survey
CT Scan and MRI
Ultrasonography
MANAGEMENT
LEGAL IMPLICATIONS
CHAPTER 78:
Pediatric Anesthesia—for the Pediatrician
TRIAD OF ANESTHETIC RISK
Are there Terms ‘Mild Anesthesia’ or ‘Short General Anesthesia (GA)’?
How Long Should the Child Fast ?
What Monitoring is Commonly Employed in Routine Pediatric Anesthetic Practice?
Common pediatric Problems Faced by the Pediatric Anesthesiologist
Asthma
Anemia
Seizures (Fits)
Cardiac Murmurs
Former Preterm Infant
Do the Children Feel Pain?
Old Nurses Tales (MYTHS)
Why do you Treat Pain?
Adverse Effects of Pain on Various Systems
How to Treat Postoperative Pain?
What are the Special Methods Administering Narcotics?
What are the Common Regional Analgesics Techniques Empolyed in Children?
Ten Commandments of Pediatric Anesthesia
SECTION EIGHT: TOXIC INGESTION
CHAPTER 79:
Poisoning and Bites
TOXICITY OF SPECIFIC AGENTS
HYDROCARBONS EXPOSURE
CLINICAL FEATURES
Pulmonary
Gastrointestinal
CNS
Cardiac
Fever
Emergency Management (Flow chart 79.2)
ORGANOPHOSPHATES
Clinical Features
TREATMENT (FLOW CHART 79.3)
Specific Treatment
CARBAMATES
PARACETAMOL
Clinical Features
Laboratory Features
TREATMENT (FLOW CHART 79.4)
Gastrointestinal Decontamination
N-Acetyl Cysteine (NAC)
IRON
Clinical Features
Management (Flow chart 79.5)
Serum Iron Level
Decontamination
Iron Chelation Therapy
Intensive Care Management
SALICYLATE POISONING
Clinical Manifestations
Investigation
Treatment (Flow chart 79.6)
Gastrointestinal Tract Decontamination
Urinary Alkalinization
Hemodialysis
METHANOL AND ETHYLENE GLYCOL
Treatment
CALCIUM CHANNEL BLOCKERS
Treatment
ANTIDEPRESSANTS
CARBON MONOXIDE POISONING
SMOKE INHALATIONAL INJURY AND CARBON MONOXIDE POISONING
Thermal Injury
Asphyxia
Carbon Monoxide Poisoning
Mechanism of Toxicity
Clinical Effects
Diagnosis
Management
Cyanide Toxicity
SUMMARY
ALUMINIUM PHOSPHIDE POISONING
Epidemiology
Mode of Action
Structure and Reactions
Mechanism of Action
Clinical Presentation
Systemic Effects
Diagnosis
Management in the Pediatric Intensive Care Unit
Prevention
POISONING BITES
Pathophysiology
Clinical Features
Systemic Effects Snake Evenomation
Factors which Indicate Poor Prognosis
Identifying Common Venomous Snakes of India
Investigations
Management (Flow chart 79.7)
Pre-hospital Management (First aid)
Rapid Assessment and Resuscitation in the Emergency Ward
Anti Snake Venom (ASV)
Indications
Indications for ASV for Local Envenomation
Indications for ASV for Systemic Envenomation
Sensitivity Testing
Neostigmine
Local Wound Management
Other Supportive Measures
SCORPION STING
Pathophysiology
Clinical Features
Local Pain
Investigations
Management (Flow chart 79.8)
Pain Relief
Fluid Therapy
Scorpion Antivenom
Prazosin
Management of Complications
Harmful Therapies to be Avoided
Prognosis
CHAPTER 80:
Methemoglobinemia
SECTION NINE: INFECTIONS AND INFECTION CONTROL
CHAPTER 81:
Antibiotic Therapy in the Pediatric Intensive Care Unit
CARBAPENEM
Meropenem
Pharmacokinetics
Microbiology
Spectrum of Activity
Aerobic and Facultative Gram-positive Microorganisms
Aerobic and Facultative Gram-negative Microorganisms
Anerobic Microorganisms
Indications
Skin and Skin Structure Infections
Intra-abdominal Infections
Bacterial Meningitis
Febrile Neutropenia
Use in Critically Ill Children
Contraindications
Dosage and Administration
Use in Renal Failure
Adverse Effects
Therapeutic Utility in Intensive Care Setting
LINEZOLID
Mechanism of Action
Pharmacokinetics
Indications
Linezolid Dosing Recommendations
Adverse Effects
Drug-Drug Interactions
Incompatibilities
Clinical use
TEICOPLANIN
Spectrum of Activity
Pharmocokinetics
Comparison of Vancomycin and Teicoplanin
Side Effects
Therapeutic Uses
Dosage and Formulation
TIGECYCLINE
Microbiology
Tigecycline Antibacterial Spectrum
Not Good For Pseudomonas
Dose
SUMMARY RECOMMENDATIONS
SUMMARY
CHAPTER 82:
Nosocomial Infection and its Management
CHAPTER 83:
The Immunocompromised Child in the Pediatric Intensive Care Unit
CHAPTER 84:
Pediatric HIV Infections
AIDS
Definition
Identification of Perinatal HIV Exposure
Diagnosis of HIV Infection in Infants (Flow chart 84.1)
MONITORING PEDIATRIC HIV INFECTION
Immunologic Parameters in Children
HIV RNA in Children
Pneumocystis Carinii Pneumonia (PCP)
Pathogenesis of Pneumocystis Carinii Infection
Clinical and Radiological Presentation of PCP
Currently Available Antiretroviral Agents (Table 84.3)
General Features of Antiretroviral Agents
HIV Counselling
Pre and Post Test Counseling
Pre Test Counseling
Post Test Counseling
Negative Test
Equivocal Test
Positive Test
Counseling the Mother of an HIV Infected Baby
NUCLEOSIDE/NUCLEOTIDE ANALOGUE REVERSE TRANSCRIPTASE INHIBITORS (NRTIS/NNRTIS)*†
Abacavir (GW 1592U89, ABC, ZiagenTM)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Didanosine (Dideoxyinosine, ddI, Videx®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Lamivudine (3TC, Epivir®, Epivir HBV®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Stavudine (d4T, Zerit®, Zerit XR®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Tenofovir (Viread®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Zalcitabine (ddC, HIVID®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Zidovudine (ZDV, AZT, Retrovir®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIS)*
Delavirdine (DLV, Rescriptor®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Efavirenz (DMP-266, EFV, SustivaTM)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Nevirapine (NVP, Viramune®)
Dosage
Drug Interactions
Special Instructions
Protease Inhibitors (PIs)*
Amprenavir (APV, AgeneraseTM)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Indinavir (IDV, Crixivan®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Nelfinavir (NFV, Viracept®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Ritonavir (RTV, Norvir®)
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Dosage
Major Toxicities
Drug Interactions
Special Instructions
Fusion Inhibitors
Dosage
Major Toxicities
Drug Interactions
Special Instructions
SECTION TEN: NEUROLOGICAL ISSUES
CHAPTER 85:
Pediatric Head Injury
CLINICAL EVALUATION AND MANAGEMENT IN EMERGENCY
Cushings Triad
Indices of Good Outcome9–12
Indices of Poor Outcome
External Examination13,14
Types of Injuries
Injuries to Scalp
Fractures15–17
Intracranial Hematoma
Epidural Hematoma19 (Figs 85.2 and 85.3)
Subdural Hematoma (SDH) (Fig. 85.4)
Intracerebral Hematoma and Contusions (Fig. 85.5)
Diffuse Brain Injury
Other Injuries
Radiological Investigations
Neurosurgical Management
NONSURGICAL MANAGEMENT
Management in the PICU (Figs 85.6, 85.7 and Flow chart 85.1)
Seizure Control
Management of Intracranial Hypertension and Cerebral Perfusion Pressure (CPP)
Mechanical Ventilation
Sedation and Muscle Relaxation
Fluid Therapy
Mannitol
Induced Hypothermia
Steroids
Nutrition
Rehabilitation
Complication and Sequelae of Head Injury
Early
Late
Outcome after pediatric head injury9
Child outcome score
SUMMARY
GUIDELINES FOR ACUTE MEDICAL MANAGEMENT OF SEVERE TRAUMATIC BRAIN INJURY IN INFANTS AND CHILDREN1
Evidence Highlights
CONCLUSION
CHAPTER 86:
Coma: Encephalitis and Cerebral Malaria
ENCEPHALITIS
Herpes Encephalitis
Japanese Encephalitis
CHAPTER 87:
Bacterial, Viral and Fungal Meningitis
BACTERIAL MENINGITIS
Introduction
Etiology
Clinical Presentation
Patients at Risk of Neurological Injury
Pathogenesis
Brain Injury
Critical Period
Lumbar Puncture
Indications for Admission to the PICU
Treatment
Cardiorespiratory Management
Dexamethasone
Antibiotics
Fluid Therapy
Severe Meningitis
Novels Therapies
Complications
Control Measures
FUNGAL MENINGITIS
INTRODUCTION AND INCIDENCE
Candida
Diagnosis
Clinical Presentation
Laboratory Diagnosis
Radiologic Findings
Treatment
HERPES SIMPLEX ENCEPHALITIS
Introduction and Incidence
Diagnosis
Clinical Presentation
Laboratory Diagnosis
Radiological Findings
Treatment
TUBERCULAR MENINGITIS
Introduction and Incidence
Diagnosis
Clinical Presentation
Laboratory Diagnosis
Radiologic Findings
Treatment
CHAPTER 88:
Sedation, Analgesia and Neuromuscular Blockade
CLINICAL PHARMACOLOGY OF COMMONLY USED SEDATIVES AND ANALGESICS
Benzodiazepines
Midazolam
Diazepam
Lorazepam
Opiates
Morphine
Fentanyl
Pethidine (Meperidine)
Ketamine
Propofol
Chloral Hydrate
Newer Agents
PRACTICAL APPROACH TO SEDATION IN THE PICU
SUMMARY
NEUROMUSCULAR BLOCKADE
Goals
Things to Consider when Choosing a NMBA
Speed of Onset
Duration of Paralysis
Mechanism of Action
Side Effects
Physiology of the Neuromuscular Junction
Monitoring Adequacy or Depth of Muscular Blockade
NON-DEPOLARIZING AGENTS
Short-acting
Mivacurium (Mivacron)
Intermediate-acting
Vecuronium (Norcuron)
Atracurium (Tracurium)
Long-acting Nondepolarizing Muscle Relaxants
Pancuronium (Pavulon)
Metocurine (Metubine)
d-Tubocurarine
Pipecuronium (Arduan)
Reversal of NDPA
Depolarizing Agents
Succinylcholine
CHAPTER 89:
Hydrocephalus
SUMMARY
CHAPTER 90:
Status Epilepticus
TREATMENT OF STATUS EPILEPTICUS
Immediate Resuscitative Measures in the Emergency Room (ER)
Anticonvulsant Therapy for SE
Alternative Therapy
Treatment of NCSE
New Antiepileptic Drugs
Felbamate
Gabapentin
Lamotrigine
Tiagabine
Prognosis and Outcome
SUMMARY
CHAPTER 91:
Near-drowning
ASSESSMENT AND MANAGEMENT
Management at the Scene
Management in the Emergency Room
Management in the PICU
Monitoring
HYPOTHERMIA
RESPIRATORY MANAGEMENT
Role of Diuretics and Corticosteroids
Infection Control
Cardiovascular Management
Neurological Management
Outcome
PROGNOSIS
CONCLUSION
CHAPTER 92:
Brain Death in Children
HISTORY
Physical Examination
Observation Period According to Age
Corroborative Studies
Apnea Test
CONCLUSION
CHAPTER 93:
Care of Terminally Ill Children
INTRODUCTION
A Child's Reaction to Illness and Hospitalization
Stress in PICU Team Members
ISSUES RELATED TO A CRITICALLY ILL CHILD DYING (OR LIKELY TO DIE) IN PICU AND END OF LIFE CARE
End of Life Care Definitions5
Medical Futility
Do not Resuscitate Orders (DNR)
ENDSTAGE PALLIATIVE CARE9
Nutritional Support
Pain Management
Psychological Support
Bereavement and Grief10,11
Process of Grieving
INTERVENTIONS
Presence of the Family While Withdrawing Life Support Systems
Spiritual Beliefs, Rites and Rituals
Strategies to Enhance Communication
Breaking Bad News16
HELPING PARENTS FACE THE DEATH OF THEIR CHILD17,18
Communicate
Facilitate Family Grieving
Rights of Parents When a Baby Dies
SUPPORTING GRIEVING FAMILIES19,20
General
At the Time of Death
After the Death
SUMMARY
CHAPTER 94:
Limitation of Life Support in the Pediatric Intensive Care Unit: Ethical Issues Relating to End of Life Care
CONCLUSIONS
ABSTRACT
Guidelines
INTRODUCTION
Ethical Principles
GUIDELINES FOR LIMITING LIFE-SUPPORT INTERVENTIONS
Guideline 1
Guideline 2
Guideline 3
Guideline 4
Guideline 5
Guideline 6
Guideline 7
Guideline 8
Medical Futility and Unilateral Decisions by Physicians
What Constitutes Medical Futility?
CONCLUSIONS
CHAPTER 95:
Psychological Issues in PICU
CHILD'S REACTION TO HOSPITALIZATION
Developmental Sphere
Biological Sphere
Psychological Sphere
EFFECTS OF HOSPITALIZATION ON THE FAMILY OF THE CHILD
Social Sphere
Developmental Dimension
Biological Dimension
Psychological Dimension
Social Dimension
SOURCES OF STRESS IN A HOSPITAL SETTING
Unfamiliar Hospital Environment
Losing the Parental Role
Costs of Staying in a Hospital
Physical Health of the Child
1. Unexpected and Sudden Admission
2. Treatment Complications
3. Dying Child
ROLE OF NURSE IN HELPING CHILD AND FAMILY IN COPING WITH STRESS OF HOSPITALIZATION AND ILLNESS
CONCLUSION
SECTION ELEVEN: ENVIROMENTAL INJURIES
CHAPTER 96:
Thermal Burns
CHAPTER 97:
Heat Disorders
THERMOREGULATION
ENVIRONMENTAL HYPERTHERMIA
MINOR HEAT ILLNESSES
HEATSTROKE
Management
MALIGNANT HYPERTHERMIA
Pathophysiology16
Clinical Syndrome
Management16
Some Clinicians Recommend Steroids
SUDDEN UNEXPECTED CARDIAC ARREST IN CHILDREN
Postacute Phase
CHAPTER 98:
Electrical Shock
SUMMARY
SECTION TWELVE: MISCELLANEOUS
CHAPTER 99:
Research in the Pediatric Intensive Care Unit
CHAPTER 100:
Quality in Pediatric Intensive Care Unit
SUMMARY
CHAPTER 101:
Training in Pediatric Critical Care Medicine
SKILLS
Respiratory
Cardiovascular
Neurologic
Metabolic and Nutritional
Hematologic
Renal
Psychosocial
General
SYLLABUS
CHAPTER 102:
Medicolegal Aspects in Intensive Care
CHAPTER 103:
Useful Information and Equations in the PICU
CHAPTER 104:
Drugs Used in the Pediatric Intensive Care Unit
INDEX
TOC
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