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IAP Specialty Series on Pediatric Intensive Care
Praveen Khilnani, Krishan Chugh, Soonu Udani, Deepak Ugra
1:
Recognition and Stabilization of the Critically Ill Child
INTRODUCTION
APPROACH TO PEDIATRIC ASSESSMENT
GENERAL ASSESSMENT
Determine if Life-Threatening
APPEARANCE OF THE CHILD
AIRWAY
BREATHING
Skin Color and Temperature
CIRCULATORY STATUS
SKIN PERFUSION
ORGAN PERFUSION
BLOOD PRESSURE
Categorization
Decide
Act
Disability
Exposure
SECONDARY ASSESSMENT
TERTIARY ASSESSMENT
AIRWAY
BREATHING
CIRCULATION
CNS SUPPORT
2:
Predictors of Outcome of Critical Illness in PICU
OTHER ORGAN FAILURE SCORES
3:
Organization and Administration of Intensive Care Units
TYPE OF ICU'S
LEVEL OF ICU CARE
DESIGN OF ICU
EQUIPMENTS FOR TERTIARY LEVEL ICU
4:
Oxygen Therapy
OXYGEN TRANSPORT FROM AIR TO TISSUES
ATMOSPHERE TO ALVEOLUS
ALVEOLUS TO BLOOD
Ventilation/Perfusion Mismatch
Shunt
Diffusion Defects
OXYGEN DELIVERY
OXYGEN CONSUMPTION
INDICATIONS FOR OXYGEN SUPPLEMENTATION
CLINICAL MARKERS OF HYPOXIA
OXYGENATION INDICES
PULSE OXYMETRY
Drawbacks of Pulse Oxymetry/SpO2
Advantages of SpO2
CO-OXIMETRY
TRANSCUTANEOUS OXYGEN MONITOR (TCO2)
DETERMINATION OF TISSUE OXYGEN
HUMIDIFICATION OF OXYGEN
ADMINISTRATION OF OXYGEN THERAPY
LOW-FLOW DEVICES (TABLE 1)
Nasal Cannula
Simple Mask
Partial Rebreathing Masks
HIGH-FLOW SYSTEMS
Non-Rebreathing Mask (can Function as both, a Low- and High-Flow Device)
Air-Entrainment or Venturi Masks
Oxyhood
CPAP
MEASUREMENT OF DELIVERED OXYGEN
OXYGEN CONCENTRATOR
HYPERBARIC OXYGEN (HBO)
WEANING FROM OXYGEN THERAPY
HAZARDS OF OXYGEN
PERMISSIVE HYPOXIA
WHAT FIO2 IS TOXIC?
5:
Upper Airway Diseases
INTRODUCTION
PATHOPHYSIOLOGY
CAUSES OF UPPER AIRWAY DISEASE
HISTORY
PHYSICAL EXAMINATION
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
RADIOLOGY
X-RAYS
CT/MRI
ENDOSCOPY
Precautions
OTHERS
MONITORING
MANAGEMENT
Initial Management
Airway Management
Laryngeal Webs, Stenosis or Tumors
Vascular Impingement on Trachea
Bronchomalacia and Intrathoracic Tracheomalacia
Laryngotracheobronchitis (LTB)
Epiglottitis
Bacterial Tracheitis
Peritonsillar Abscess
Retropharyngeal Abscess
Laryngeal Papillomatosis
Vocal Cord Paralysis
Intrathoracic Mass Lesions Causing Respiratory Obstruction
TRAUMA
Postextubation Stridor
Acquired Laryngotracheal (Subglottic) Stenosis
Foreign Body Aspiration (Figures 5A and B)
Traumatic Injury to the Airway
Angioedema
6:
CPR: 2010 Guidelines
HISTORY OF CARDIOPULMONARY RESUSCITATION
THE 2010 GUIDELINES
SIMPLIFIED BLS ALGORITHM
SEQUENCE IN PEDIATRIC BLS
UNTRAINED LAY RESCUER MAY PROVIDE HANDS ONLY CPR
SYNCHRONIZED TEAM APPROACH
CONTINUED EMPHASIS FOR HIGH QUALITY CPR
PULSE CHECK: DE-EMPHASIZED
ELECTRICAL THERAPY—AUTOMATED EXTERNAL DEFIBRILLATOR (AED)
POSTCARDIAC ARREST CARE
ADDITIONAL CHANGES
DE-EMPHASIS ON DEVICES AND ADVANCED CARDIOVASCULAR LIFE SUPPORT DRUGS DURING CARDIAC ARREST
7:
Mechanical Ventilation
BASICS OF MECHANICAL VENTILATION
INTRODUCTION
BASIC MECHANICS OF VENTILATION
VENTILATION
OXYGENATION
GAS EXCHANGE
CONCEPT OF TIME CONSTANT
INDICATIONS OF MECHANICAL VENTILATION
COMMONLY USED NOMENCLATURE FOR MECHANICAL VENTILATION
MODES OF VENTILATION
Control Modes
IMV (Intermittent Mandatory Ventilation) Modes
SIMV: Ventilator Synchronizes IMV “Breath” with Patient's Effort
Support Mode
BASIC FUNDAMENTALS OF VENTILATION
VOLUME CONTROL
PRESSURE LIMITED VENTILATION
VOLUME LIMITED VENTILATION
INITIAL VENTILATOR SETTINGS
PRESSURE LIMITED
VOLUME LIMITED
ADJUSTMENTS AFTER INITIATION
GAS EXCHANGE RELATED PROBLEMS
Inadequate Oxygenation
Important guidelines
HIGH PaCO2
MEASURES TO REDUCE BAROTRAUMA AND VOLUTRAUMA
PATIENT VENTILATOR DYSYNCHRONY
SEDATION AND MUSCLE RELAXATION DURING VENTILATION
ROUTINE VENTILATOR MANAGEMENT PROTOCOL
RESPIRATORY CARE PROTOCOL
WEANING FROM MECHANICAL VENTILATION
WEANING METHODOLOGY
EXTUBATION
CLINICAL INDICATORS OF EXTUBATION READINESS
FURTHER READING
ADVANCED MODES AND MODALITIES OF VENTILATION
INTRODUCTION
INVERSE RATIO VENTILATION (IRV)
AIRWAY PRESSURE RELEASE VENTILATION (APRV)
PRESSURE SUPPORT VENTILATION (PSV)
PRESSURE-REGULATED VOLUME CONTROL (PRVC)
PROPORTIONAL ASSIST VENTILATION (PAV)
HIGH FREQUENCY VENTILATION
BASIC CONCEPTS OF HFV (HIGH FREQUENCY VENTILATION)
TYPES OF HIGH FREQUENCY VENTILATION
HIGH FREQUENCY POSITIVE PRESSURE VENTILATION (HFPPV)
HIGH FREQUENCY JET VENTILATION (HFJV)
HIGH FREQUENCY OSCILLATOR VENTILATION (HFOV)
CLINICAL APPLICATION
NONINVASIVE VENTILATION (NIV)
ROLE OF SPONTANEOUS BREATHING IN RESPIRATORY PHYSIOLOGY
MECHANISM OF IMPROVEMENT WITH NONINVASIVE VENTILATION
ADVANTAGES OF NIPPV
INDICATIONS FOR NIPPV
Acute Diseases
Chronic Diseases
Volume Ventilation
Pressure Control Ventilation
Pressure Support Ventilation
Bi-level Positive Airway Pressure Ventilator (BIPAP)
Continuous Positive Airway Pressure (CPAP)
PRACTICAL APPLICATIONS OF NONINVASIVE (POSITIVE PRESSURE VENTILATION)
Chronic Respiratory Failure
Acute Respiratory Failure
INITIATION OF NONINVASIVE MECHANICAL VENTILATION
LIMITATIONS OF NIPPV
MONITORING DURING NIPPV
WEANING
COMPLICATIONS OF NIPPV
BRUISES AND EROSIONS
FURTHER READING
ARDS AND PNEUMONIA
GOALS OF VENTILATION IN ARDS
VENTILATION IN SEVERE ASTHMA
INDICATION OF INTUBATION AND MECHANICAL VENTILATION
STRATEGIES OF VENTILATORY SUPPORT IN CHILDHOOD ASTHMA
PERMISSIVE HYPERCAPNIA
USE OF POSITIVE END-EXPIRATORY PRESSURE
REFRACTORY HYPOXEMIA
MECHANICAL VENTILATION FOR CARDIOVASCULAR ILLNESS
CARDIORESPIRATORY INTERACTIONS: THE HEART
CARDIORESPIRATORY INTERACTIONS: THE LUNGS
VENTILATOR MANAGEMENT IN POSTOPERATIVE CARDIAC PATIENT
MECHANICAL VENTILATION IN THE NEUROLOGICALLY ILL PATIENT
BASIC PREMISES OF INTRACRANIAL PRESSURE
OXYGENATION
HYPERCARBIA AND HYPOCARBIA
TEMPERATURE
THE EFFECTS OF PEEP ON THE BRAIN
THE IMPACT OF VENTILATION MODES
NEUROMUSCULAR DISEASE: VENTILATION STRATEGY
CHRONIC /PROGRESSIVE NEUROMUSCULAR DISORDER—HOME VENTILATION
AIRWAY CLEARANCE IN CHILDREN WITH NEUROMUSCULAR WEAKNESS
MECHANICAL VENTILATORY SUPPORT IN CHRONIC NEUROMUSCULAR DISEASE
NONINVASIVE VENTILATION (NIV) AND ACUTE HYPOXIC RESPIRATORY FAILURE (AHRF): PATIENTS WITH VARYING COMORBIDITIES LIKE IMMUNE COMPROMISED AND STATUS ASTHMATICUS
ISSUES IN PROLONGED MECHANICAL VENTILATION-TRACHEOSTOMY
NEONATAL VENTILATION
CONVENTIONAL NEONATAL VENTILATION
Pressure Limited Time Cycled Ventilation
CASE: HYALINE MEMBRANE DISEASE (NEONATAL RDS)
CASE: MECONIUM ASPIRATION PPHN
8:
Respiratory Monitoring
PHYSICAL EXAMINATION
NONINVASIVE RESPIRATORY MONITORING
HISTORY
Critical Discussion on Pulse Oximetry (SpO2 = SaO2)
MASIMO PULSE OXIMETRY—A NEW PROMISING WAY OF MEASURING SPO2
What makes Masimo pulse oximetry different from conventional pulse oximetry?
CAPNOGRAPHY
WHAT IS CAPNOGRAPHY?
TYPES OF CO2 MONITORS
Mainstream
Sidestream
CLINICAL APPLICATIONS OF CO2 MONITORING
PaCO2-EtCO2 GRADIENT
OTHER USES
MICROSTREAM TECHNOLOGY
PULMONARY FUNCTION TESTS
X-RAY
INVASIVE MONITORING
BASIC INTRODUCTION OF ARTERIAL BLOOD GASES
SYSTEMATIC ANALYSIS OF ARTERIAL BLOOD GASES
STEPWISE APPROACH TO DIAGNOSING ACID-BASE DISORDERS
STEPS IN ACID-BASE ANALYSIS
9:
Acute Severe Asthma
INTRODUCTION
ASSESSMENT OF SEVERITY OF ACUTE ASTHMA
CRITERIA FOR REFERRAL TO HOSPITAL
MONITORING OF THE FOLLOWING SIGNS IS REQUIRED:
HOME MANAGEMENT
MANAGEMENT IN THE EMERGENCY DEPARTMENT
OXYGEN
INHALATION THERAPY WITH β AGONISTS
MDI VS NEBULIZERS
CORTICOSTEROIDS
ANTICHOLINERGICS
HIGH DOSE IV SALBUTAMOL IN BOLUS FORM
INTRAVENOUS TERBUTALINE IN ACUTE SEVERE ASTHMA
USE OF KETAMINE IN ACUTE ASTHMA
BTS GUIDELINES FOR USE OF AMINOPHYLLINES IN PATIENTS WITH ACUTE ASTHMA
HELIOX
MAGNESIUM SULFATE
ANTILEUKOTRIENE AGENTS
VENTILATION IN ASTHMA
SUPPORTIVE TREATMENT
PROGNOSIS
10:
Acute Respiratory Distress Syndrome
INTRODUCTION
DEFINITION
INCIDENCE AND EPIDEMIOLOGY
PATHOPHYSIOLOGY
HOST GENETIC FACTORS
INITIATING FACTORS
PHASES OF DISEASE
ALVEOLAR-CAPILLARY BARRIER DYSFUNCTION AND EDEMA FORMATION
SURFACTANT DYSFUNCTION AND ALTERATION OF PULMONARY MECHANICS
IMPAIRED ALVEOLAR FLUID CLEARANCE
ALTERATIONS IN GAS EXCHANGE
EFFECTS ON CARDIOVASCULAR FUNCTION
CLINICAL FEATURES AND INVESTIGATIONS
MANAGEMENT
POSITIVE PRESSURE VENTILATION
HIGH-FREQUENCY VENTILATION
OTHER ADJUNCTS TO THERAPY
FLUID MANAGEMENT
PRONE POSITIONING
SURFACTANT THERAPY
INHALED NITRIC OXIDE
CORTICOSTEROIDS
NUTRITIONAL SUPPORT
ROLE OF ECMO
OUTCOMES IN PEDIATRIC ARDS
FUTURE DIRECTIONS
11:
Drowning in Children
INTRODUCTION
WHAT IS DROWNING?
NEWER DEFINITIONS
PATHOPHYSIOLOGY OF THE DROWNING PROCESS
PREDISPOSING EVENTS
MANAGEMENT
EMERGENCY DEPARTMENT STRATEGIES
Active Rewarming
INVESTIGATIONS
MANAGEMENT IN PICU
PREVENTION
12:
Acute Heart Failure
ACUTE HEART FAILURE
INTRODUCTION
DEFINITION
FACTORS AFFECTING CARDIAC OUTPUT
FRANK-STARLING PRINCIPLE
PATHOPHYSIOLOGY OF SYMPTOMS IN AHF
Left Ventricle (LV) Failure
Right Ventricle (RV) Failure
ETIOLOGY OF AHF
LV failure/ RV Failure
Systolic Dysfunction/ Diastolic Dysfunction
High Output Failure/ Low Output Failure
ETIOLOGY OF AHF BASED ON PATHOPHYSIOLOGY
ETIOLOGY BASED ON AGE OF ONSET OF AHF
AHF IN POSTOPERATIVE CONGENITAL HEART DISEASE
Systemic Ventricular Failure
RV Failure
CLASSIFICATION OF AHF BY SEVERITY
CLINICAL PRESENTATION
Certain Features Deserve Mention
INVESTIGATIONS
Radiography
Electrocardiography
Echocardiography
Pulse Oximetery
Blood Gas and Electrolytes
Miscellaneous Tests
Cardiac Catheterization
MANAGEMENT
OPTIMIZE PRELOAD
INCREASE MYOCARDIAL PERFORMANCE
Dopamine
Dobutamine
Epinephrine
Isoproterenol
Digoxin
OPTIMIZE AFTERLOAD
Inodilators
Vasodilators
ACE Inhibitors
ADJUNCTIVE THERAPY
Position
Oxygen
Positive pressure ventilation
Blood Transfusion
PGE1
Diet
TREATMENT OF UNDERLYING CONDITION
RECENT ADVANCES: DRUGS
Beta-blockers
Levosimendan
Neseritide
RECENT ADVANCES: MECHANICAL AFTERLOAD REDUCTION
Intra-aortic Balloon Pump (IABP)
ECMO (Extracorporeal Membrane Oxygenation)
VAD (Ventricular Assist Device)
RECENT ADVANCES: STEM CELL THERAPY
Heart Transplantation
DRUG DOSES
OUTCOME
13:
Cardiac Arrhythmias
COMPONENTS OF A NORMAL ECG (FIGURE 1)
TACHYARRHYTHMIAS
SUPRAVENTRICULAR TACHYARRHYTHMIAS
REENTRANT ATRIOVENTRICULAR TACHYCARDIAS
Atrioventricular Reciprocating Tachycardia (AVRT)
AV Nodal (AVNRT) Re-entrant Tachycardia (Figure 3)
Atrial Flutter
Atrial Fibrillation (Figure 5)
Sinus Tachycardia
Ectopic Atrial Tachycardia
Junctional Ectopic Tachycardia
PRESENTATION AND CLINICAL FEATURES OF SVTs
MANAGEMENT OF SUPRAVENTRICULAR TACHYCARDIAS
VENTRICULAR TACHYARRHYTHMIAS
PREMATURE VENTRICULAR CONTRACTIONS
VENTRICULAR TACHYCARDIA
Ventricular Fibrillation (VF) (Figure 10)
Long QT Syndrome
BRADYARRHYTHMIAS
SINUS BRADYCARDIA
CONDUCTION ABNORMALITIES
First-Degree Atrioventricular Block
Second-Degree Atrioventricular Block: Mobitz Type I (Wenckebach) and Type II
Third-Degree Heart Block
TREATMENT OF BRADYARRHYTHMIAS
ASYSTOLE /PULSELESS ELECTRICAL ACTIVITY
COMMONLY USED DRUGS
TRANSCUTANEOUS PACING, OVERDRIVE PACING, DEFIBRILLATION AND CARDIOVERSION
14:
Hypertensive Urgency and Emergency
INTRODUCTION
DEFINITION
BLOOD PRESSURE LIMITS IN CHILDREN
ETIOLOGY
MANAGEMENT
ASSESSMENT
LABORATORY EVALUATION
MANAGEMENT
Hypertensive Urgency
Hypertensive Emergency
SPECIAL SITUATIONS
15:
Fluid and Electrolytes in the Critically Ill Child
FLUIDS IN THE CRITICALLY ILL CHILD
BODY WATER DISTRIBUTION IN CHILDREN
WATER HOMEOSTASIS
UNDERSTANDING “FLUID” CONCEPTS
FLUID THERAPY IN THE ICU
MAINTENANCE FLUID
Specific Situations (Table 3)
Using Hypotonic Solutions as Maintenance Fluids
REPLACEMENT FLUID
RESUSCITATION FLUIDS
CRYSTALLOID VS COLLOIDS IN CRITICALLY ILL CHILDREN
FURTHER READING
ELECTROLYTE DISORDERS
SODIUM
HYPONATREMIA
History
Investigations
Management
Treatment Principles
Specific Situations
HYPERNATREMIA (FIG. 2)
Causes
Specific Situations
Management of Hypernatremia
POTASSIUM
HYPOKALEMIA: K+ < 3.5 MEQ/L
Causes
Clinical Features
Treatment
HYPERKALEMIA: K+ > 5.5 MEQ/L
Causes
Clinical Features
Treatment
CALCIUM
HYPOCALCEMIA
Clinical Features
Treatment
HYPERCALCEMIA
Causes
Clinical Features
Treatment
PHOSPHORUS
HYPOPHOSPHATEMIA: S. PO4 < 2.5 MG/DL OR 0.8 MMOL/L
Clinical Features
Treatment
HYPERPHOSPHATEMIA
Causes
Clinical Features
Treatment
MAGNESIUM
HYPOMAGNESEMIA
Causes
Clinical Features
Treatment
HYPERMAGNESEMIA
Causes
Clinical Features
Management
16:
Hemodynamic Monitoring
CLINICAL EXAMINATION
BLOOD PRESSURE
Pressure versus Flow
PRELOAD ASSESSMENT
Static Preload Measurements
Dynamic Indices of Preload
PASSIVE LEG RAISING (FIGURE 3)
CARDIAC OUTPUT (CO) ASSESSMENT
Assessment of Tissue Oxygenation
VENOUS O2 SATURATION
INTERPRETING ScvO2
17:
Inotropic and Vasopressor
DEFINITIONS
ADRENERGIC RECEPTORS
NORADRENERGIC RECEPTORS
INDIVIDUAL INOTROPE MEDICATIONS
DOPAMINE
Clinical Usage
ADRENALINE
Clinical Usage
DOBUTAMINE
Clinical Usage
MILRINONE
Clinical Usage
LEVOSIMENDAN
Clinical Usage
INDVIDUAL VASOPRESSOR MEDICATIONS
NORADRENALINE
Clinical Usage
VASOPRESSIN
Clinical Usage
PHENYLEPHRINE
Clinical Usage
INDIVIDUAL VASODILATOR MEDICATIONS
SODIUM NITROPRUSSIDE (SNP)
Clinical Usage
NITROGLYCERIN (NTG)
Clinical Usage
PHENOXYBENZAMINE
Clinical Usage
OTHERS
ISOPRENALINE (ISOPROTERENOL)
Clinical Usage
PHARMACOKINETICS
ADVERSE REACTIONS
Cardiovascular Effects
Central Nervous System
Metabolic Effects
Skin Necrosis
Renal and Splanchnic Blood Flow
Hematologic
Endocrine and Immunosuppression
Dosing and Administration
GOALS OF VASOACTIVE THERAPY
PRACTICAL TIPS TO THE USE OF INOTROPE AND VASOPRESSORS
NURSING ISSUES REGARDING VASOACTIVE MEDICATION ADMINISTRATION
18:
Septic Shock and MODS
INTRODUCTION
DEFINITIONS
MANAGEMENT
EARLY AND GOAL DIRECTED THERAPY IMPROVE OUTCOMES
First Hour of Resuscitation (Emergency Room)
Vasoactive Drugs
PICU MANAGEMENT
TITRATION OF VASOACTIVE DRUGS
REFRACTORY SHOCK
MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)
THERAPY
RENAL SUPPORT
HEPATIC DYSFUNCTION
19:
Acute Liver Failure
ETIOLOGY (TABLE 1)
INFECTIONS
METABOLIC DISEASES
TOXINS/DRUGS
AUTOIMMUNE
VASCULAR
PATHOGENESIS
MANAGEMENT
TRANSPORT OF A CHILD WITH ENCEPHALOPATHY
INVESTIGATIONS AND MONITORING
FLUID AND ELECTROLYTES
RENAL
HEMODYNAMIC SUPPORT
NUTRITION
INFECTIONS
SUPPORTIVE THERAPY
BLOOD AND BLOOD PRODUCTS
PROPHYLAXIS FOR GI BLEEDING
MANAGEMENT OF HEPATIC ENCEPHALOPATHY
SEDATION
EARLY ENCEPHALOPATHY
SEIZURES
RAISED INTRACRANIAL PRESSURE
LIVER TRANSPLANT
20:
Acute Kidney Injury in Children
INTRODUCTION
DEFINITION
INCIDENCE
CRITERIA FOR DEFINING AKI
ETIOLOGY
ASSESSMENT AND INVESTIGATIONS
MANAGEMENT
MONITORING
FLUID MANAGEMENT
ELECTROLYTE MANAGEMENT
HYPERTENSION
NUTRITION
TREATMENT OF THE UNDERLYING DISEASE
DRUG DOSE MODIFICATION
PHARMACOLOGICAL THERAPY
RENAL REPLACEMENT THERAPY (RRT)
OUTCOME
Follow-up of acute kidney injury :
PREVENTION OF ACUTE KIDNEY INJURY
21:
Antimicrobials in the PICU
COMMON MICROORGANISMS ASSOCIATED WITH INFECTIONS IN THE PICU
22:
Infection Control
INFECTION CONTROL
STANDARD PRECAUTIONS
PERSONAL PROTECTIVE EQUIPMENT (PPE)
ADMINISTRATIVE RESPONSIBILITY
SURVEILLANCE
BLOOD STREAM INFECTIONS
RISK FACTORS
ETIOLOGICAL AGENTS
DIAGNOSTIC CRITERIA
MANAGEMENT
VENTILATOR-ASSOCIATED PNEUMONIA
VAP
RISK FACTORS
NON- MODIFIABLE FACTORS
PATIENT-RELATED
TREATMENT–RELATED
PATHOGENESIS
DIAGNOSIS
NNIS (NATIONAL NOSOCOMIAL INFECTION SURVEILLANCE SYSTEM) CRITERIA FOR THE DIAGNOSIS OF HAP/VAP
ROLE OF ANTIMICROBIALS
TREATMENT
PREVENTION: BUNDLE APPROACH TO PREVENT VAP
RECOMMENDATIONS FOR THE PREVENTION OF PEDIATRIC VAP: (THE VAP BUNDLE)
URINARY TRACT INFECTIONS (UTI)
Risk Factors
Prevention of CA-UTI
Prevention of Microburia in Indwelling Urinary Catheters
Preventive Measures of Doubtful Effectiveness
ORGANIZATION OF INFECTION CONTROL PROGRAM
23:
Head Injury in Children
WHAT IS THE LEVEL OF COMA?
CLASSIFICATION OF HEAD INJURY USING THE GCS FROM 3–15 POINTS 13–15 MILD 9–12 MODERATE 3–8 SEVERE
RADIOLOGICAL CRITERIA FOR MINOR HEAD INJURY
BLOOD PRESSURE IN HEAD INJURY
CERVICAL SPINE IMMOBILIZATION
OTHER ASSOCIATED INJURIES
SURGICALLY AMENABLE LESIONS
INTRACRANIAL PRESSURE (ICP)
WHAT IS THE TREATMENT THRESHOLD FOR ICP
PROPOSED MODEL FOR THE PATHOLOGICAL CASCADE OF ICP WAVES
TARGET FOR CPP?
MONITORING DEVICES
HYPERTONIC SALINE
24:
The Comatose Child
INVESTIGATIONS
MANAGEMENT
25:
Neuromuscular Diseases in Critically Ill Children
INTRODUCTION
ANTERIOR HORN CELL DISORDERS
PERIPHERAL NERVE DISORDERS
GUILLIAN BARRE SYNDROME
CLINICAL CONSIDERATIONS
ATYPICAL VARIANTS
LABORATORY DIAGNOSIS
TREATMENT
ICU MANAGEMENT—WHEN TO TRANSFER/WHEN TO INTUBATE
PROGNOSIS
NEUROMUSCULAR JUNCTION DISORDERS (NMJ)
WHEN TO SUSPECT?
MYASTHENIC DISORDERS
TYPES OF DISEASE
MUSCLE DISEASE
ICU RELATED NEUROMUSCULAR DISORDERS
RISK FACTORS OF CINM
CRITICAL ILLNESS MYOPATHY (CIM)
CRITICAL ILLNESS POLYNEUROPATHY (CIP)
DIFFERENTIAL DIAGNOSIS OF CINM
TREATMENT, PROGNOSIS AND PREVENTION OF CINM
PROLONGED NEUROMUSCULAR JUNCTION BLOCKADE
SUMMARY
26:
Status Epilepticus
NEWER DEFINITION OF SE
ETIOLOGICAL CLASSIFICATION
Cryptogenic (Idiopathic)
Remote symptomatic
FEBRILE STATUS
ACUTE SYMPTOMATIC
PROGRESSIVE ENCEPHALOPATHY
MECHANISM OF SE
SYSTEMIC MANIFESTATIONS ASSOCIATED WITH SE
EARLY SE
LATE SE
MANAGEMENT OF SE-PREHOSPITAL SETTING
EARLY INSTITUTION OF FIRST LINE MEDICATIONS
MANAGEMENT OF SE IN THE HOSPITAL SETTING
INITIAL STABILIZATION
PHARMACOLOGIC INTERVENTION
STAGED MANAGEMENT
NONCONVULSIVE STATUS EPILEPTICUS
DIAGNOSTIC TESTING
OUTCOMES
RISK OF EPILEPSY
FUNCTIONAL DISABILITIES
27:
Blood and Blood Component Therapy: Issues and Guidelines
INTRODUCTION
BLOOD COMPONENTS
ANTICOAGULANT AND PRESERVATIVE SOLUTIONS
STORAGE LESIONS
SHELF LIFE
WHOLE BLOOD
DESCRIPTION
INDICATIONS
ADMINISTRATION
DOSAGE
RED BLOOD CELLS (RBC)
DESCRIPTION
INDICATIONS
TRANSFUSION IN CHRONIC ANEMIA
ADMINISTRATION
FRESH FROZEN PLASMA (FFP)
DESCRIPTION
INDICATIONS
ADMINISTRATION
DOSE
ADVERSE EFFECTS
PLATELET CONCENTRATES (PC)
DESCRIPTION
INDICATIONS
PROPHYLACTIC PCS
Administration
Dose
CCI (Corrected Platelet Count Increment) and Platelet Refractoriness
CRYOPRECIPITATE
Description
Indications
Dose
Administration
HAZARDS OF TRANSFUSION
MEASURES AVAILABLE TO REDUCE OR MINIMIZE ADVERSE TRANSFUSION SIDE EFFECTS
28:
Management of a Child with Polytrauma
INTRODUCTION
MECHANISM OF INJURY
MEASUREMENT OF PEDIATRIC INJURY SEVERITY
UNIQUE ASPECTS OF PEDIATRIC TRAUMA
MANAGEMENT OF A CHILD WITH POLYTRAUMA
TEAM APPROACH
IN THE FIELD
INITIAL ASSESSMENT (FIGURE 1)
AIRWAY
CIRCULATION AND CONTROL OF HEMORRHAGE
DISABILITY OR QUICK NEUROLOGICAL SURVEY
EXPOSURE
RESUSCITATION
FLUID THERAPY IN HEMORRHAGIC SHOCK
MONITORING OF RESUSCITATION
SECONDARY SURVEY
TERTIARY SURVEY
ANCILLARY LABORATORY STUDIES
USEFUL IMPORTANT INVESTIGATIONS INCLUDE
RADIOLOGICAL SURVEY
USG ABDOMEN-FOCUSED ABDOMINAL ULTRASOUND IN TRAUMA (FAST)
FURTHER MANAGEMENT
MANAGEMENT OF NONNEUROLOGICAL INJURIES
ABDOMINAL TRAUMA
THORACIC TRAUMA
GENITO-URINARY TRAUMA
SUMMARY
29:
Endocrine Emergencies in Critically Ill Children
HYPERGLYCEMIA
TIGHT GLYCEMIC CONTROL
HYPOGLYCEMIA
CAUSES
INVESTIGATIONS
TREATMENT
ADRENAL INSUFFICIENCY (AI)
CAUSES
DYSFUNCTION OF THE HPA AXIS DURING CRITICAL ILLNESS
SYMPTOMS
INVESTIGATIONS
TREATMENT
DOSE
Corticosteroids in Septic shock
NONTHYROIDAL ILLNESS SYNDROME(NTIS) (SICK EUTHYROID SYNDROME)
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
TREATMENT
THYROTOXIC CRISIS
CLINICAL PRESENTATION
TREATMENT
PHEOCHROMOCYTOMA (HYPERCATECHOLAMINE CRISIS)
INVESTIGATIONS
TREATMENT
CAUSES
HYPOCALCEMIA IN CRITICAL ILLNESS (1MMOL/L OF CALCIUM = 4 MG/DL)
VITAMIN D DEFICIENCY IN CRITICAL ILLNESS
SYMPTOMS
TREATMENT
INVESTIGATIONS
HYPERCALCEMIA (LEVELS ABOVE 3MMO/L OR 12MG/DL)
CAUSES
TREATMENT
THE SALT / WATER SYNDROMES
CEREBRAL SALT WASTING (CSW)
SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)
DIABETES INSIPIDUS
30:
Diabetic Ketoacidosis in Children
INTRODUCTION
DEFINITION
CLASSIFICATION
CAUSES OF DKA (PRECIPITANTS)
PATHOPHYSIOLOGY OF DKA
SIGNS AND SYMPTOMS
LABORATORY EVALUATION (TABLE 1)
MANAGEMENT
FLUID THERAPY
CALCULATION OF FLUID DEFICIT
GUIDELINES FOR FLUID THERAPY
INSULIN THERAPY
GUIDELINES OF INSULIN THERAPY
POTASSIUM
GUIDELINES
BICARBONATE
GUIDELINES
PHOSPHATE
GUIDELINES
MONITORING AND POST HYPERGLYCEMIC CARE
THERAPY RELATED COMPLICATIONS OF DIABETIC KETOACIDOSIS
HYPOGLYCEMIA
HYPOKALEMIA
CEREBRAL EDEMA
ACUTE RESPIRATORY DISTRESS SYNDROME
HYPERCHLOREMIC ACIDOSIS
PREVENTION OF DKA
31:
Clinical Utility of Ultrasound and Echocardiography in Pediatric Intensive Care
INTRODUCTION
ECHOCARDIOGRAPHY AND USG OF VESSELS
USE IN TRAUMA PATIENTS
NEUROLOGICAL MONITORING
AIRWAY MANAGEMENT
LUNG ULTRASOUND
SYSTEMATIC APPROACH—CLINICAL CORRELATION BLUE PROTOCOL
LIMITATIONS OF ULTRASOUND
32:
Acute Surgical Abdomen
INTRODUCTION
GENERAL APPROACH TO A CHILD WITH ACUTE ABDOMEN
INVESTIGATIONS
DIAGNOSIS TO CONSIDER
INFANTS: LESS THAN 2 YEARS (TABLE 1)
MALROTATION AND MIDGUT VOLVULUS
INTUSSUSCEPTION
INGUINAL HERNIA
HIRSCHSPRUNG'S DISEASE
PRE-SCHOOL CHILDREN (2–5 YEARS) (TABLE 1)
APPENDICITIS
SCHOOL-AGE CHILDREN (> 5 YEARS) (TABLE 1)
APPENDICITIS
MECKEL'S DIVERTICULUM
PANCREATITIS
PRIMARY ACUTE PERITONITIS
INFLAMMATORY BOWEL DISEASE
TESTICULAR PATHOLOGY
OVARIAN PATHOLOGY
COMMON NON-SURGICAL CAUSES OF ABDOMINAL PAIN
CONSTIPATION
URINARY TRACT
CONCLUSION
33:
Severe Acute Pancreatitis
ETIOLOGY
CLINICAL FEATURES
DIAGNOSIS
RELEVANT LABORATORY INVESTIGATIONS
PROGNOSTIC INDICATORS
MANAGEMENT
FLUID RESUSCITATION
ANALGESIA
ORGAN SUPPORT
CORRECTION OF METABOLIC DERANGEMENTS
NUTRITION
PREVENTION OF INFECTIOUS COMPLICATIONS
INTERVENTIONS FOR PANCREATIC NECROSIS
34:
Burn Injuries
INTRODUCTION
PREVENTION
FIRST AID
HOSPITAL MANAGEMENT
INHALATION INJURY
Upper Airway Obstruction
Carbon Monoxide (CO) Poisoning
Lung Parenchymal Dysfunction
EVALUATION OF BURN WOUND
Estimating Burn Size
ESTIMATING BURN DEPTH
ADMISSION CRITERIA AND MANAGEMENT
FLUID AND ELECTROLYTE MANAGEMENT
SYSTEMIC ANTIBIOTICS
NUTRITION
MANAGEMENT OF THE BURN WOUND
FACTORS AFFECTING MORTALITY IN BURNS
SUMMARY
35:
Pain and Sedation
INTRODUCTION
NON-PHARMACOLOGICAL TREATMENT
SEDATION
GOALS OF SEDATION
SEDATIVE DRUGS
BENZODIAZEPINE
PROPOFOL
ETOMIDATE
BARBITURATES
ANALGESIA
MORPHINE
FENTANYL
REMIFENTANIL
NSAID'S
ANALGESIC AND SEDATIVE DRUGS
KETAMINE
ADRENERGIC ALPHA-2-AGONISTS
ASSESSMENT OF PAIN AND SEDATION
NEUROMUSCULAR BLOCKING AGENTS
WITHDRAWAL SYNDROME
36 A:
Envenomation 1
SNAKE BITE
VENOM COMPOSITION
VENOM ENZYMES
QUANTITY OF VENOM INJECTED AT A BITE, “DRY BITES”
SYMPTOMS AND SIGNS OF SNAKE BITE
WHEN VENOM HAS NOT BEEN INJECTED
WHEN VENOM HAS BEEN INJECTED
Local Symptoms and Signs in the Bitten Part
Generalized (systemic) Symptoms and Signs
General
Cardiovascular (Viperidae)
Bleeding and clotting disorders (Viperidae)
Neurological (Elapidae, Russell's viper)
Skeletal muscle breakdown (sea snakes, some krait species)
Renal (Viperidae, sea snakes)
Endocrine (acute pituitary/adrenal insufficiency from infarction of the anterior pituitary)
Locked in syndrome
Long-term complications (sequelae) of snake-bite
Symptoms and signs of cobra-spit ophthalmia (eye injuries from spitting cobras)
FIRST AID TREATMENT PROTOCOL
RECOMMENDED METHOD FOR INDIA
“DO IT R.I.G.H.T.”
MOST TRADITIONAL FIRST AID METHODS SHOULD BE DISCOURAGED: THEY DO MORE HARM THAN GOOD!
PATIENT ASSESSMENT PHASE: ON ARRIVAL
DIAGNOSIS PHASE: GENERAL PRINCIPLES (TABLE 2)
PAIN
Clinical Situations in which Snake bite Victims Might Require Urgent Resuscitation
Signs of Severe Envenomation (Table 3)
INVESTIGATIONS/LABORATORY TESTS
20-minute Whole Blood Clotting Test (20WBCT)
OTHER TESTS
ANTIVENOM TREATMENT
WHAT IS ANTIVENOM?
Indications for Antivenom (Table 4)
Local Envenomation
How long after the bite can antivenom be expected to be effective?
ANTIVENOM REACTIONS
CONTRAINDICATIONS TO ANTIVENOM: PROPHYLAXIS OF HIGH RISK PATIENTS
TREATMENT OF ANTIVENOM REACTIONS
SELECTION, STORAGE AND SHELF LIFE OF ANTIVENOM
ADMINISTRATION OF ANTIVENOM
Local administration of antivenom at the site of the bite is not recommended:
Antivenom must never be given by the intramuscular route if it could be given intravenously.
Recurrence of systemic envenoming
Criteria for repeating the initial dose of antivenom
Treatment of neurotoxic envenoming
36 B:
Envenomation 2
SCORPION STING
EPIDEMIOLOGY
ECO-BIOLOGICAL ASPECTS OF SCORPION
COMPONENTS OF VENOM AND MECHANISMS OF ACTION
CLINICAL COURSE
TREATMENT
TRADITIONAL METHODS
PHARMACOLOGICAL ASPECTS OF PRAZOSIN
37:
Management of Poisonings in Children
INTRODUCTION
EPIDEMIOLOGY
CLINICAL APPROACH TO THE POISONED CHILD
PATIENT HISTORY
PHYSICAL EXAMINATION
LABORATORY EVALUATION
MANAGEMENT
INITIAL STEPS IN TREATING THE POISONED PATIENT
ADMISSION IN PICU. Any child with
SPECIFIC POISONINGS – MOST COMMONLY SEEN IN INDIAN CHILDREN
SUMMARY
38:
Nutrition in Critically Ill Children
INTRODUCTION
GOALS OF NUTRITION
ENERGY EXPENDITURE IN CRITICALLY ILL CHILDREN
TO CALCULATE ENERGY REQUIREMENTS IN CRITICALLY ILL CHILDREN
RECOMMENDATION FOR FEEDING IN PICU
FEEDING IN SPECIAL SITUATIONS
OVERFEEDING AND UNDERFEEDING
ENTERAL VS PARENTERAL NUTRITION
NUTRITIONAL ASSESSMENT
CLINICAL EXAMINATION
LABORATORY EXAMINATION
METHODS OF ESTABLISHING ENTERAL NUTRITIONAL SUPPORT
NASOGASTRIC VS POST-PYLORIC
CONTINUOUS VS INTERMITTENT
HURDLES IN ESTABLISHING ENTERAL NUTRITION
CONTRAINDICATIONS
IDEAL ENTERAL FEED
PREDIGESTED FORMULAE
IMMUNONUTRITION
TOTAL PARENTERAL NUTRITION (TPN
REFEEDING SYNDROME
39:
Inborn Errors of Metabolism
INTRODUCTION
TYPES OF IEM
INCIDENCE
INHERITANCE
PRESENTATION
INVESTIGATIONS
DIAGNOSIS
TREATMENT
EMERGENCY TREATMENT
MANAGEMENT OF HYPERAMMONEMIA
MANAGEMENT OF SUSPECTED ORGANIC ACIDEMIA
MANAGEMENT OF CONGENITAL LACTIC ACIDOSIS
TREATMENT OF NEWBORN WITH REFRACTORY SEIZURES WITH NO OBVIOUS AETIOLOGY
MANAGEMENT OF THE ASYMPTOMATIC NEWBORN WITH A HISTORY OF SIBLING DEATH WITH SUSPECTED IEM
LONG TERM TREATMENT OF IEM
PREVENTION-GENETIC COUNSELLING AND PRENATAL DIAGNOSIS
NEONATAL MASS SCREENING
IN SUMMARY
40:
Immunological Problems and Critical Illness
INTRODUCTION
THREE LEVELS OF DEFENSE
BALANCE OF INFLAMMATION AND ANTIOINFLAMMATION
IMMUNE DEFICIENCY
PRIMARY IMMUNODEFICIENCY (PID)
SECONDARY IMMUNODEFICIENCY
IMMUNOLOGY IN SEPSIS
MALNUTRITION AND IMMUNODEFICIENCY
TYPES OF PRIMARY IMMUNEDEFICIENCY
WHEN TO SUSPECT IMMUNEDEFICIENCY IN THE CRITICAL CARE SETTING
HISTORY OF PRESENT ILLNESS
SPECIAL SENARIOS
PEDIATRIC ONCOLOGY
CHILDREN WITH HIV
ORGAN TRANSPLANT RECIPIENTS
CERTAIN DICTUMS FORM GREAT CLINICAL SENSE:
SUMMARY
41:
Oncologic Emergencies
METABOLIC EMERGENCIES
TUMOR LYSIS SYNDROME (TLS)
Features of Tumor Lysis Syndrome
MANAGEMENT
Fluids and Hydration
Allopurinol
Recombinant Urate Oxidase (Rasburicase)
Additional Management
HYPERCALCEMIA
SYNDROME OF INAPPROPRIATE SECRETION OF ANTI-DIURETIC HORMONE (SIADH)
HEMATOLOGIC EMERGENCIES
HYPERLEUKOSTASIS
Risk Factors
Therapy
FEBRILE NEUTROPENIA
Risk Factors for Serious Bacterial Infections
Laboratory Factors
VIRUSES
Diagnosis
Management
Mediastinal Masses/Superior Vena Cava Syndrome (SVCS)
Diagnosis
Evaluation of the Child with Suspected Mediastinal Mass
Management
SPINAL CORD COMPRESSION
Clinical Presentation
Diagnosis
Therapy
42:
Dengue
INTRODUCTION
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
FEBRILE PHASE
CRITICAL PHASE
LAB DIAGNOSIS
MANAGEMENT OF CHILDREN WITH DENGUE WITHOUT WARNING SIGNS
MANAGEMENT OF DENGUE WITH WARNING SIGNS WITHOUT SHOCK
MANAGEMENT OF SEVERE DENGUE
Shock
Fluid Overload or Respiratory Distress
MANAGEMENT OF SHOCK
Normotensive Shock
MANAGEMENT OF FLUID OVERLOAD
Prevention
Management
ABDOMINAL COMPARTMENT SYNDROME (ACS)
ENCEPHALOPATHY
RENAL FAILURE
CARDIAC COMPLICATIONS
NOSOCOMIAL SEPSIS
43:
Malaria
INTODUCTION
LIFE CYCLE (FIGURE 2)
CLINICAL DISEASE AND EPIDEMIOLOGY
DIAGNOSIS OF MALARIA
CLINICAL DIAGNOSIS
PARASITOLOGICAL DIAGNOSIS
Definition of Uncomplicated Malaria
SEVERE P. FALCIPARUM MALARIA
Definition
Clinical Features
Laboratory Findings
TREATMENT OBJECTIVES
Clinical Assessment
DIFFERENTIAL DIAGNOSES
SPECIFIC ANTIMALARIAL TREATMENT
ADJUNCTIVE TREATMENT
CONTINUING SUPPORTIVE CARE
TREATMENTS NOT RECOMMENDED
FLUID THERAPY
BLOOD TRANSFUSION
EXCHANGE BLOOD TRANSFUSION
USE OF ANTICONVULSANTS
CONCOMITANT USE OF ANTIBIOTICS:
MIXED MALARIA INFECTIONS
SEVERE MALARIAL ANEMIA (SMA)
ETIOLOGICAL BASIS OF SEVERE MALARIAL ANEMIA
CEREBRAL MALARIA
44:
Drugs in PICU
I. ANTIBIOTICS
ANTIMALARIALS
ANTIVIRAL AND ANTIFUNGAL
II. CARDIOVASCULAR
IIA. CARDIAC DRUGS
IIB. INOTROPES
IIC. DIURETICS
IID. VASODILATORS
III. CNS DRUGS
IIIA. ANTICONVULSANT
IIIB. ANALGESICS
IIIC. SEDATIVES AND ANXIOLYTIC
IIID. AGENT REDUCING RAISED ICP
IV. INTUBATION DRUGS
IVA. INDUCTING AGENT
IVB. PARATYTIC AGENT
IVC. REVERSAL AGENTS
V. GIT DRUGS-ANTIEMETICS & ANTACIDS
VI. RESPIRATORY SYSTEM-BRONCHODILATORS
VII. MISCELLANEOUS
VIIA. ANTIDOTES IN POISONING
VIIB. ANTICOAGULANTS & LOCAL HEMOSTATIC AGENTS
VIIC. ELECTROLYTE SOLUTIONS
VIID. STEROIDS
VIIE. VITAMINS & HARMONES
VIII. INFUSION PREPARATION GUIDELINE OF COMMONLY USED DRUGS
IX. PREPARATION OF DESIRED DEXTROSE CONCENTRATION
45:
Transport of Sick Children
INTRODUCTION
ROLE AND RESPONSIBILITIES OF THE PHYSICIAN OF THE REFERRING HOSPITAL
TRANSPORT TEAM COMPOSITION
TRANSPORT TEAM DIRECTOR
TRANSPORT COORDINATORS
TRANSPORT TEAM (THE TEAM PARTICIPATING IN ACTUAL TRANSPORTS)
TRAINING AND PERSONAL ATTRIBUTES OF TRANSPORT TEAM MEMBERS
TRANSPORT TEAM RESPONSIBILITIES
EQUIPMENT, SUPPLIES, AND MEDICATIONS
MODE OF TRANSPORT
POINT OF COMMUNICATION
STABILIZATION OF THE CRITICALLY III OR INJURED CHILD FOR TRANSPORT
MANAGEMENT OF THE AIRWAY
RESPIRATORY CARE AND VENTILATORY SUPPORT
MONITORING DURING TRANSPORT
CALCULATING THE OXYGEN REQUIREMENT DURING TRANSPORT
SPECIAL CONSIDERATION DURING AIR TRANSPORT
REGULATORY AND MEDICOLEGAL ISSUES
INTRAHOSPITAL TRANSPORT
46:
Procedures in Pediatric Intensive Care Unit (PICU)
INTUBATION
INTRODUCTION
Step 1: When to Intubate a Child
Step 2: What are the Contraindications
Step 3: Preparation
Step 4: Confirm Tube Palcement
Step 5: Post-intubation Care
Step 6: Complications
CENTRAL LINE PLACEMENT
INTRODUCTION
Stepwise Approach
ARTERIAL LINE PLACEMENT
INTRODUCTION
INTRACRANIAL PRESSURE MONITORING
INTRODUCTION
Step 1: Indication for Monitoring
Step 2: Monitoring Techniques of ICP
Step 3: Preparation for Invasive Intracranial Pressure Monitoring
Step 4: Preperation for ICP Catheter Insertion
Step V: Procedure
Step VI: Documentation of Insertion and Post-Insertion
Step VII: Interpretation of ICP Monitoring
Step 8 : EVD Removal
CHEST TUBE PLACEMENT
INTRODUCTION
Step 1: Understand Some Terms
Step 2: Indications for Insertion (Table 9)
Step 3: Rule Out Contraindications
Step 4: Pre-drainage Assessment
Step 5: Preparation
Step 6: Consent & premedication
Step 7: Prepare drainage system and drain size
Step 8: Patient Position (Figure 25)
Step 9: Site Selection
Step 10: Procedure
B. Trocar tube thoracostomy
INTRA-ABDOMINAL PRESSURE MONITORING
INTRODUCTION
Step I : Understand the Definition, Cause, Classification of Intra-abdominal Pressure
Step 2: Measurement of Intra-abdominal Pressure
Step 3: Preparation
Step 4 : Different Methods
Step 5: Interpreting the Result
47:
End-of-Life Care
INTRODUCTION
THE GOALS OF CARE
DELIVERING BAD NEWS
DO–NOT–RESUSCITATE ORDERS
WITHHOLDING AND WITHDRAWING LIFE SUPPORT
THE WITHHOLDING/WITHDRAWING DISTINCTION
MEDICAL NUTRITION AND HYDRATION
SEDATIVES AND ANALGESICS IN THE CARE OF THE DYING
SPECIAL TOPICS IN END-OF-LIFE CARE
FUTILITY
HOSPITAL ETHICS COMMITTEES (EC)
THE USE OF NEUROMUSCULAR BLOCKING AGENTS DURING WITHDRAWAL OF LIFE SUPPORT
INTERNATIONAL PERSPECTIVES OF END-OF-LIFE CARE
SUMMARY
48:
Postoperative Care in Children
POSTOPERATIVE CARE IN CHILDREN
MANAGEMENT OF IMMEDIATE POSTOPERATIVE ISSUES
49:
Nursing Issues in the PICU
INTRODUCTION
PATIENT POPULATION
LEVELS OF PICU CARE
DESCRIBING WHAT NURSES DO: THE SYNERGY MODEL
PATIENT CHARACTERISTICS OF CONCERN TO NURSES
NURSE COMPETENCIES IMPORTANT TO THE PATIENT
OPTIMAL PATIENT OUTCOMES
CURRENT ENVIRONMENT
ISSUES/CHALLENGES
CONCLUSION
INDEX
TOC
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