Critical Care in Infants and Children: The Basics

Copyright 2008 Society of Critical Care Medicine

Critical Care in Infants and Children: The Basics

1Copyright 2008 Society of Critical Care Medicine

ObjectivesReview physiologic differences between pediatric and adult patients in terms of critical illnessEvaluate the differences in the incidence of conditions, consequences, and complicationsIdentify general differences in therapy


Case Study3-month-old with prematurity (4 kg)1 week of nasal congestion, cough, wheezing, tachypnea, and feverHeart rate 182/min, respirations 72/min, SpO2 89% (room air), temperature 101.7°F (38.7°C)Grunting, retractions, cyanotic

What is the most important initial intervention?


Acute Respiratory FailureMost common cause of arrestReduced respiratory reserve− Decreased bellows effect of thorax− Horizontal diaphragm draws

thorax inward during inspiration− Abdominal distension

compromises diaphragmatic excursion

− Smaller airways, fewer alveoli

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Airway ManagementHead position− Sniffing positionSuction airway (nostrils in infants)Supply 100% oxygenGentle bag-mask ventilationEndotracheal intubation


Case Study3-month-old with prematurity (4 kg)Grunting, retractions, cyanoticNostrils suctioned, 100% oxygen suppliedRespirations 60/min, SpO2 93%

What interventions are now needed?


IntubationBlind nasal intubation discouragedTongue may cause obstructionAnterior and cephalad position of larynxCricoid pressureStraight bladeTube size: (16 + age in years)/4 Airway narrowest at cricoid ringShort trachea

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Case StudySuccessfully intubated with3.5 mm uncuffed tubeEqual breath soundsRespirations 40/min with bag-mask ventilation, SpO2 100%Hyperinflated chest

What ventilator settings should be chosen? What assessments should be performed?


Mode Time-cycled, pressure-limited

Peak inspiratory pressure

Start at 18–20 cm H2O and titrate to tidal volume

Tidal volume ~8 mL/kg

Respiratory rate 20–30 breaths/min

PEEP 3–5 cm H2O

Oxygen 100%

Ventilator Settings Weight <5 kg


Mode SIMV (pressure or volume)

Inspiratory time

0.5–0.6 sec (baby), 0.6–0.8 sec (toddler), 0.8–1 sec (older child)

Tidal volume 8–10 mL/kg (6 mL/kg in ARDS)

Respiratory rate Adjust for acceptable PaCO2

PEEP 3-5 cm H2O

Oxygen 100%

Pressure support 5–10 cm H2O

Ventilator SettingsWeight >5 kg


Case Study4-month-old with prematurityVomiting and diarrhea for 3 daysFed water and herbal tea for 48 hoursUnresponsive, tonic-clonic activityHeart rate 165/min, blood pressure 68/47 mm Hg, respirations 56/min

What is the possible diagnosis?

What interventions are appropriate?


ShockSame classification as adultsCardiac output dependent on changes in heart rate in childrenHypotension is late finding in children Pulmonary vasculature is reactive to hypoxia, hypothermia, hypercapnia− Increased right ventricular

afterload


Hypovolemic ShockCardiopulmonary monitoringFluid resuscitation as initial therapy− Isotonic crystalloids 20 mL/kg− Repeated volumes up to 60 mL/kg− Smaller volumes in suspected

myocardial dysfunctionReplace blood when 5–10% circulating volume lostEvaluate volume status


Case Study2-year-old with recurrent urinary infectionsAbdominal pain, vomiting, and fever for 4 daysLethargic, cool extremitiesHeart rate 152/min, blood pressure 68/26 mm Hg, respirations 42/min, temperature 39.2°C



Septic ShockFluid resuscitation Vasopressor support− Dopamine (5–10 µg/kg/min) as first

choice− Norepinephrine or epinephrine if

unresponsive− Dobutamine if low cardiac outputHydrocortisoneGlucose determination

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Other ShockCardiogenic shock− Ductal-dependent lesions− Non-ductal dependent lesionsObstructive shock

Ductal-dependent lesion


Case Study6-month-old with diarrhea for 6 daysDrank water, rice water, and juiceTonic-clonic seizure activityUnresponsive, cyanotic and apneic

What is the possible diagnosis?



Metabolic ConditionsHigher insensible water loss in children− Require greater amount of fluid/kg− Absolute amount is smallLimited ability to maintain body temperatureHypoglycemia common during stressHyponatremia, hypernatremia, and hypocalcemia are common

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Case Study4-month-old found unresponsive by babysitterFell out of bed when rolling overUnresponsive, tonic-clonic activityBruises on forehead and chestHeart rate 88/min, respirations 8/min

What are the possible diagnoses?



Neurologic IssuesAirway maintenanceGCS difficult to applyConsider occult trauma (child abuse)Consider metabolic, infectious, and toxic etiologiesTreatment of seizures− Rectal diazepam if no IV access− IV midazolam, lorazepam, or

diazepam− Phenytoin or fosphenytoin load

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Questions


Key PointsIrritability is an early sign of mental status changesEarly signs of respiratory distress are tachypnea, grunting, and nasal flaringConsider anatomic features of the pediatric airway when intubatingTidal volume is 8-10 mL/kg in normal lungs and 6 mL/kg in acute lung injury


Key PointsPerfusion status is best assessed with capillary refill and extremity temperatureHypovolemic shock may require 40-60 mL/kg of isotonic fluidsVasopressor support with dopamine is indicated in vasodilatory shock after volumeObstructive shock is commonly caused by congenital lesions


Key PointsIntracranial hemorrhage can cause significant blood lossHypoglycemia is common during stressBody temperature is not well maintainedImmature immune systems increase the risk of infectionDiazepam can be administered rectally for seizures

Critical Care in Infants and Children: The Basics

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