Ebook Paediatric intensive care: Part 1

OXFORD MEDICAL PUBLICATIONS

Paediatric
Intensive Care


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Oxford Specialist Handbooks
in Paediatrics

Paediatric
Intensive Care
Edited by

Peter Barry
Consultant in Paediatric Intensive Care,
University Hospitals of Leicester NHS Trust,
Honorary Senior Lecturer, Department of Child Health,
University of Leicester, UK

Kevin Morris
Consultant in Paediatric Intensive Care,
Birmingham Children’s Hospital,
Honorary Senior Lecturer,
University of Birmingham, UK

Tariq Ali
Consultant in Paediatric Intensive Care and Anaesthesia,
John Radcliffe Hospital,
Honorary Senior Lecturer,

Oxford University, Oxford, UK

With Special PICU Nursing Advisor Yvonne Heward

1


1

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ISBN 978–0–19–923327–4
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v

Preface
In writing this book, we have aimed to provide a comprehensive, practical

guide to the care of the critically ill child, both on an intensive care unit
and in other clinical areas—wherever children need to be stabilized and
failing organ systems need to be supported. Throughout, we have tried to
stick to the underlying principles that guide us in everyday practice—the
application of applied physiology; an understanding of disease processes; a
reckoning of what is likely and what is possible; and the provision of care
driven by compassion for our patients and their families.
The book is not just for intensivists and intensive care trainees. We hope
that it will help clinicians who provide care to sick children outside the
intensive care unit as well, in emergency departments, on paediatric wards
and adult units that are occasionally asked to support a critically ill child. Of
course, we hope that it will also prove to be a useful resource for doctors
and nurses who do work in intensive care, either as specialists or on rotation. It is a book to be picked up to find the answers to specific problems
and for guidance on how to manage specific issues. Where appropriate,
we have tried to provide more in-depth information, highlighting areas of
controversy and stimulating further reading.
The preparation of the book has been made easy by the work of the
various contributors, who delivered chapters on time and to length. They
are listed on page xv. We hope that in editing their work we have not
taken too many liberties.
Whilst writing the handbook, we were saddened by the deaths of Heinrich
Werner and David Todres, colleagues who we hoped would contribute
and comment on our work. Children’s intensive care, and this handbook,
are less without them.
We thank Julie Edge, James Greening, and David Luyt for their comments and
help with specific chapters. We would also like to thank Susan Crowhurst,
Anna Winstanley, and Helen Liepman at the Oxford University Press for
keeping us on track and seeing the project through from conception to
publication.
Finally, we thank our families for their support and forbearance.

PWB, KM, TA.
Oxford, Leicester, and Birmingham, 2009


vi

SUBJECT OF THIS PAGE

Additional disclaimer
We have checked all drugs and dosages suggested in this handbook, but
the ultimate responsibility for their use in a particular patient rests with
the prescriber.


vii

Foreword
The specialty of paediatric critical care medicine has come of age. When
it began to emerge as a specialty in its own right in the 1970s, much of
what was done was learnt from adult intensive care medicine. Paediatric
intensive care units (PICUs) were largely run by anaesthetists because
they were the experts in airway and ventilation management and understood cardiac and respiratory physiology. In those days, diseases like Reye
syndrome and Haemophilus influenzae acute epiglottitis were diseases
that presented unique challenges to those involved in paediatric critical
care, where the use of recently introduced invasive monitoring and skilful
airway management could dramatically influence survival. It also saw the
dawn of a new era in surgery for congenital heart disease which saw major
improvements in survival and the eventual evolution of paediatric cardiac
critical care as a specialty. Thirty years ago, little of the evidence for the
therapies we used was ever subjected to the rigor of clinical trials, there

was little formalized training, and paediatric critical care was a part-time
specialty. Much has changed. Many countries have established formalized
training schemes with specialty examinations, full-time career intensivists
with academic positions are being appointed, and the specialty has its own
journal. There are also a number of published textbooks in paediatric
critical care medicine. Do we need another and, if so, how is Paediatric
Intensive Care different? The answer is yes, we do, if it presents knowledge
in a different and more accessible format. I particularly appreciate the way
it deals with the important issues in an abbreviated arrangement which
presents knowledge in an easily accessible layout. It has a comprehensive
coverage of the important physiological principles and, as someone from
the previous era where anaesthesia was the entry into PICU, I am pleased
to see that prominence is given to airway management and the use of
anaesthetic drugs.
We are entering a new era in the specialty where what we do will be
judged by our results. The public and profession are rightly less tolerant
of errors and less than optimal care. At the same time the intensive care
specialist is dealing with increasing amounts of new knowledge which he
or she has to absorb in a very demanding clinical specialty. Having access
to a reference source such as Paediatric Intensive Care which gives them
vital information presented in such an easy to navigate format will make
that task less burdensome.
Desmond Bohn MB MRCP FRCPC FFARCS
Professor of Anaesthesia and Paediatrics
University of Toronto;
Chief, Department of Critical Care Medicine
The Hospital for Sick Children, Toronto, Canada


This page intentionally left blank

ix

Acknowledgement
We would like to thank Mr David Barron for providing the illustrations for
the cardiac lesions described in Chapter 20.


This page intentionally left blank


xi

Contents
Contributors xv
Symbols and abbreviations xix

4
5
6
7

Section 1 General introduction to
paediatric intensive care
An introduction to paediatric intensive care
Epidemiology and outcome of paediatric
intensive care
Paediatric resuscitation and critical
care outreach

Clinical assessment
Physics and clinical measurement
Vascular access and clinical monitoring
Applied physiology and bedside assessment

8
9
10
11
12
13
14
15
16
17

Section 2 Organ system support and
related practical procedures
Airway management and ventilation
Anaesthesia
Analgesia and sedation
Circulatory support
Cardiopulmonary bypass
Managing fluids, electrolytes, and acid–base
Renal replacement therapies
Nutrition
Heat-related illness
Prescribing

1

2
3

3
13
19
39
45
61
103

129
175
185
199
221
229
257
275
289
295


xii

SUBJECT OF THIS PAGE

CONTENTS

18 Transport and retrieval

19 Imaging in paediatric intensive care

20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

Section 3 Specific specialties
Cardiac disorders and postoperative care
Respiratory disease
Neurocritical care
Trauma and burns
Infection control policies and PICU
Immunity and infection

Sepsis and multiple organ failure
Laboratory investigations for infectious disease
Antimicrobial use on the PICU
Neonatology
Gastroenterology and hepatology
Nephrology
Diabetes and endocrinology
Metabolic disorders
Haematology
Brain death, organ donation, and
transplantation
Poisoning
Technology-dependent children
Genetic syndromes
Paediatric intensive care medicine in
the developing world

309
331

347
407
451
493
531
535
569
585
589
603

625
645
669
693
709
723
741
755
761
779


CONTENTS

40
41
42
43

Section 4 Compassionate and
family-orientated care
The child and family in PICU
Aspects of the law in paediatric
intensive care
Clinical governance, audit, and
risk management
Child protection
Appendix 859

Index 881

xiii

821
833
843
849


This page intentionally left blank


xv

Contributors
Tariq Ali

Steven Cray

Consultant in Paediatric
Anaesthesia and Intensive Care,
John Radcliffe Hospital,
Honorary Senior Lecturer,
Oxford University, Oxford, UK

Consultant in Paediatric
Anaesthesia and Intensive Care,
Birmingham Children’s
Hospital, UK

Oliver Bagshaw

Consultant in Paediatric
Intensive Care,
Bristol Royal Hospital for
Children, UK

Consultant in Paediatric
Anaesthesia and Intensive Care,
Birmingham Children’s
Hospital, UK

Paul Baines
Consultant in Paediatric Intensive
Care, Alder Hey Hospital,
Honorary Lecturer, Department of
Medical Microbiology, University
of Liverpool, UK

Peter Barry
Consultant in Paediatric Intensive
Care, University Hospitals of
Leicester NHS Trust,
Honorary Senior Lecturer,
Department of Child Health,
University of Leicester, UK

Sarah Bowdin
Staff Physician, Division of
Clinical and Metabolic Genetics,

The Hospital for Sick Children,
Toronto,
Assistant Professor, Paediatrics,
University of Toronto, Canada

Joe Brierley
Consultant in Paediatric and
Neonatal Intensive Care Unit,
Great Ormond Street Hospital for
Children, London, UK

Ashish A Chikermane
Consultant Paediatric Cardiologist,
Birmingham Children’s
Hospital, UK

Peter Davis

Edward Doyle
Consultant Paediatric Anaesthetist
Royal Hospital for Sick Children,
Edinburgh, UK

Heather Duncan
Consultant in Paediatric Intensive
Care
Birmingham Children’s
Hospital, UK

Mark L Duthie

Consultant in Paediatric Intensive
Care,
University Hospitals of Leicester
NHS Trust, UK

Linda Edwards
Consultant in Paediatric Intensive
Care,
Birmingham Children’s Hospital, UK

C Helen Fardy
Consultant in Paediatric Intensive
Care,
Lead Clinician,
PICU, The University Hospital of
Wales, Cardiff, UK

Peter-Marc Fortune
Consultant in Paediatric Intensive
Care,
Clinical Director of Critical Care,
Royal Manchester Children’s
Hospital, UK


xvi

CONTRIBUTORS

Clive Graham

Consultant Microbiologist,
West Cumberland Hospital,
Whitehaven, UK

Professor, Pediatric and Surgery
(EM), BC Children’s Hospital,
University of British Columbia,
Vancouver, Canada

Jean Harkin

Rakesh Lodha

Solicitor and Assistant Deputy
Coroner,
Harkin Lloyd Solicitors,
Liverpool, UK

Department of Pediatrics,
All India Institute of Medical
Sciences, New Delhi, India

Ben Harvey

Consultant in Paediatric
Intensive Care,
Medical Director,
Southampton University Hospital
Trust, UK

Education & Practice Development
Charge Nurse, PICU,
Glenfield General Hospital,
University Hospitals of
Leicester, UK

Kay C Hawkins
Consultant in Paediatric
Intensive Care,
Royal Manchester Children’s
Hospital, UK

Chris Hendriksz
Consultant in Clinical Inherited
Metabolic Disorders,
Birmingham Children’s
Hospital, UK

Yvonne Heward
Lecturer Practitioner, Paediatric
Intensive Care and PEWS
Birmingham Children’s Hospital,
Birmingham City University, UK

David Inwald
Senior Lecturer and Honorary
Consultant in Paediatric
Intensive Care,
Imperial College London, UK

Rhian Isaac
Pharmacy Clinical Lead,
Birmingham Children’s
Hospital, UK

Niranjan Kissoon
Senior Medical Director, Acute
and Critical Care Programs
Associate Head, Department
of Pediatrics,

Michael J Marsh

Jane Martin
Consultant in Paediatric
Intensive Care,
John Radcliffe Hospital,
Oxford, UK

Jillian McFadzean
Consultant in Paediatric
Anaesthesia and Intensive Care,
Royal Hospital for Sick Children,
Edinburgh, UK

Paul McVittie
Resuscitation Service Manager,
Birmingham Children’s Hospital,
UK

Reinout J Mildner
Consultant in Paediatric Intensive
Care,
Birmingham Children’s Hospital,
UK

Kevin Morris
Consultant in Paediatric
Intensive Care,
Birmingham Children’s
Hospital,
Honorary Senior Lecturer,
University of Birmingham, UK

Simon Nadel
Consultant in Paediatric
Intensive Care,
Imperial College Healthcare NHS
Trust, London, UK


CONTRIBUTORS

Sanjiv Nichani

Fiona Reynolds

Lead Consultant, Paediatric
Intensive Care and High
Dependency Care,

University Hospitals of
Leicester, UK

Consultant in Paediatric Intensive
Care,
Birmingham Children’s,
Hospital, UK

Andrew Nyman

Consultant in Paediatric Intensive
Care and Respiratory Medicine,
Cambridge University Hospitals
NHS Foundation Trust, UK

Specialist Registrar in Paediatric
Intensive Care, John Radcliffe
Hospital,
Oxford, UK

Hitesh Pandya

Rob Ross Russell

Helen Rowlands

Consultant in Paediatric
Intensive Care,
Leicester Royal Infirmary, UK

Consultant Paediatric Cardiac
Intensivist,
Great Ormond Street Hospital,
London, UK

Josep Panisello

David Rowney

Consultant in Paediatrics,
John Radcliffe Hospital,
Oxford, UK

Consultant in Paediatric
Anaesthesia and Intensive Care,
Royal Hospital for Sick Children,
Edinburgh, UK

Giles J Peek
Consultant in Cardiothoracic
Surgery & ECMO,
Glenfield Hospital, Leicester, UK

Mark Peters
Consultant in Paediatric and
Neonatal Intensive Care,
Great Ormond Street Hospital for
Children, London, UK

Christine M Pierce

Consultant in Paediatric and
Neonatal Intensive Care,
Great Ormond Street Hospital for
Children, London, UK

Stephen Playfor
Consultant in Paediatric Intensive
Care,
Royal Manchester Children’s
Hospital, UK

Jane Radcliffe
Consultant in Paediatric
Intensive Care,
Alder Hey Children’s NHS
Foundation Trust, Liverpool, UK

Phil Sargent
Senior Staff Specialist,
Paediatric Intensive Care Unit,
Mater Childrens Hospital, Brisbane,
Queensland, Australia

Andrew Selby
Consultant in Paediatric Intensive
Care and Long Term Ventilation,
Alder Hey Children’s NHS
Foundation Trust, Liverpool, UK

Alison Shefler

Consultant in Paediatric Intensive
Care,
John Radcliffe Hospital,
Oxford, UK

Sunit Singhi
Head, Department of Pediatrics,
Advanced Pediatric Centre,
Postgraduate Institute of
Medical Education and Research,
Chandigarh, India

xvii


xviii

CONTRIBUTORS

Megan Smith

James Whitelaw

Consultant in Paediatric Intensive
Care,
Nottingham University Hospitals
NHS Trust, UK

Consultant in Paediatric Intensive
Care, University Hospitals of

Leicester NHS Trust, UK

Charles G Stack
Consultant in Paediatric
Anaesthesia and Intensive Care,
Sheffield Children’s Hospital, UK

Reader in Paediatric
Gastroenterology and Nutrition,
Child Life and Health, University of
Edinburgh, UK

JE Stevens

Peter Wilson

Consultant in Paediatric
Anaesthesia and Intensive Care,
John Radcliffe Hospital,
Oxford, UK

Director, Paediatric Intensive
Care Unit,
Southampton University Hospital
NHS Trust, UK

Robert C Tasker
University Senior Lecturer in
Paediatrics,
Cambridge University School of

Clinical Medicine, UK

Harish Vyas
Professor in PICU and Respiratory
Medicine,
Paediatric Intensivist and Head of
Service, Children & Young People,
Nottingham University
Hospitals, UK

David C Wilson


xix

Symbols and abbreviations
b
1
X
i
d
>
<
7
4
5
M
A–a
ABC
ABG

ACS
ACT
ADH
ADR
AET
ALI
ALTE
ANP
ANZICS
AP
APRV
aPTT
AR
ARB
ARDS
ARF
ASD
ATN
AV
AVP
AVSD
AXR

cross reference
warning
controversial
increased
decreased
greater than
less than

approximately
male
female
website
alveolar–arterial
airway, breathing, and circulation
arterial blood gas
abdominal compartment syndrome
activated clotting time
antidiuretic hormone
adverse drug reaction
atrial ectopic tachycardia
acute lung injury
apparent life-threatening event
atrial natriuretic peptide
Australian and New Zealand Intensive Care Society
aortopulmonary
airway pressure release ventilation
activated partial thromboplastin time
aortic regurgitation
angiotensin receptor blocker
acquired respiratory distress syndrome
acute renal failure
atrial septal defect
acute tubular necrosis
atrioventricular
arginine vasopressin
atrioventricular septal defect
abdominal X-ray

xx

PRELIM
SYMBOLS
RUNNING
AND ABBREVIATIONS
HEAD

BAL
BE
BIPAP
BIS
BMR
BOOP
BP
BPA
BSD
BT
Ca
CAP
CARS
CCAM
CIPNM
CN
CNEP
CNS
CO
CO2
CoA

COHb
CPAP
CPB
CPP
CRBSI
CRP
CSF
c-spine
CSW
CVP
CVVH
CVVHDF
CXR
DF
DHCA
DHF
DI
DIC
DNAR

bronchoalveolar lavage
base excess
bilevel positive airway pressure
bispectral index
basal metabolic rate
bronchiolitis obliterans organizing pneumonia
blood pressure
British Paediatric Association
brainstem death
Blalock–Taussig

calcium
community acquired pneumonia
counterinflammatory acute response syndrome
congenital cystic adenomatoid malformation
critical illness polyneuropathy and myopathy
cranial nerve
continuous negative extrathoracic pressure
central nervous system
carbon monoxide
carbon dioxide
coarctation of the aorta
carboxyhaemoglobin
continuous positive airway pressure
cardiopulmonary bypass
cerebral perfusion pressure
catheter-related blood stream infection
C-reactive protein
cerebral spinal fluid
cervical spine
cerebral salt wasting
central venous pressure
continuous veno-venous haemofiltration
continuous veno-venous haemodiafiltration
chest X-ray
dengue fever
deep hypothermic circulatory arrest
dengue haemorrhagic fever
diabetes insipidus
disseminated intravascular coagulation
Do Not Attempt Resuscitation [order]

SYMBOLS AND ABBREVIATIONS

DO2
DSS
ECF
ECG
Echo
ECLS
ECMO
ECPR
EEG
EFW
EHS
ET
EtCO2
ETS
ETT
FAO
FFP
FFS
FHF
FiO2
FISH
FOB
FRC
GABA
GALT
GBS

GFR
GI
GVHD
h
HAART
Hb
HbCO
HBOT
HCAI
HDU
HE
HELLP
HFJV
HFOV

oxygen delivery
dengue shock syndrome
extracellular fluid
electrocardiogram
echocardiogram
extracorporeal life support
extracorporeal membrane oxygenation
extracorporeal cardiopulmonary resuscitation
electroencephalogram
electrolyte free water
exertional heat stroke
endotracheal
end-tidal carbon dioxide
endotracheal secretions
endotracheal tube

fatty acid oxidation
fresh frozen plasma
flexible fibrescope
fulminant hepatic failure
fraction of inspired oxygen
fluorescent in situ hybridization
fibreoptic bronchoscopy
functional residual capacity
gamma-amino butyric acid
gut-associated lymphoid tissue
Guillain–Barré syndrome
glomerular filtration rate
gastrointestinal
graft-versus-host disease
hour/s
highly active antiretroviral therapy
haemoglobin
carboxyhaemoglobin
hyperbaric oxygen therapy
healthcare associated infection
high dependency unit
hepatic encephalopathy
haemolytic anaemia, elevated liver enzymes, low platelets
high frequency jet ventilation
high frequency oscillatory ventilation

xxi


xxii

SYMBOLS AND ABBREVIATIONS

HFV
HIT
HIV
HR
HRG
HUS
I:E
IBD
ICPM
ICTPICM
ICU
IF
IM
IMD
IO
IOA
IPPV
IRDS
iTBI
ITP
IV
IVC
IVIG
J
JET
K
kg

L
LA
LCOS
LIP
LVEDP
LVOTO
m
MAC
MAP
MAPCA
MARS
mcg
Mg

high frequency ventilation
heparin-induced thrombocytopenia
human immunodeficiency virus
heart rate
Healthcare Resource Group
haemolytic uraemic syndrome
inspiration:expiration [ratio]
inflammatory bowel disease
intracranial pressure monitoring
Intercollegiate Committee for Training in Paediatric
Intensive Care Medicine
intensive care unit
intestinal failure
intramuscular
inherited metabolic disorders
intraosseous

intraosseous access
intermittent positive pressure ventilation
infant respiratory distress syndrome
inflicted traumatic brain injury
idiopathic thrombocytopenic purpura
intravenous
inferior vena cava
intravenous immunoglobulin
joule/s
junctional ectopic tachycardia
potassium
kilogram/s
litre/s
left atrial
low cardiac output state
lymphoid interstitial pneumonitis
left ventricular end diastolic pressure
left ventricular outflow tract obstruction
metre/s
minimum alveolar concentration
mean arterial pressure or mean airway pressure
major aortopulmonary collateral artery
molecular adsorbent recirculating system
microgram/s
magnesium


SYMBOLS AND ABBREVIATIONS

MH

min
mL
mm
MR
MRA
MRI
MRS
MUF
MVB
N
NAHI
NAI
NCSE
NEC
NEPV
NHS
NI
NIBP
NICE
NIRS
NIV
NMBA
NNRTI
NO
NRTI
NSAID
OER
O2
OI
OSA

P
Pa
PA
PAC
PAOP
PBF
PCA
PCCMDS
PCT
PD

malignant hyperthermia
minute/s
millilitre/s
millimetre/s
mitral regurgitation
magnetic resonance angiography
magnetic resonance imaging
magnetic resonance spectroscopy
modified ultrafiltration
manual ventilation bag
newton/s
non-accidental head injury
non-accidental injury
non-convulsive status epilepticus
necrotizing enterocolitis
negative extrathoracic pressure ventilation
National Health Service [UK]
nosocomial infection
non-invasive blood pressure

National Institute for Health and Clinical Excellence
near infrared spectroscopy
non-invasive ventilation
neuromuscular blocking agent
non-nucleoside reverse transcriptase inhibitor
nitric oxide
nucleoside reverse transcriptase inhibitor
non-steroidal anti-inflammatory drug
oxygen extraction ratio
oxygen
oxygenation index
obstructive sleep apnoea
pressure
pascal
pulmonary artery
pulmonary artery catheter
pulmonary artery occlusion pressure
pulmonary blood flow
patient-controlled analgesia
paediatric critical care minimum dataset
primary care trust
peritoneal dialysis

xxiii


xxiv

SYMBOLS AND ABBREVIATIONS

PDA
PDEI
PEA
PEEP
PEF
PEP
PH
PI
PIC
PICANet
PICM
PICS
PICU
PIE
PIP
PN
PP
PPHN
PPV
PR
PTH
PV
PVR
PVRi
RAD
RBC
RCPCH
RCT
RH
RMSF

rpm
RSE
RSI
RSV
RTA
RVEDP
RVOTO
s
SBE

patent ductus arteriosus
phosphodiesterase inhibitors
pulseless electrical activity
positive end-expiratory pressure
peak expiratory flow
post exposure prophylaxis
pulmonary hypertension
protease inhibitor
paediatric intensive care
Paediatric Intensive Care Audit Network
paediatric intensive care medicine
Paediatric Intensive Care Society
paediatric intensive care unit
pulmonary interstitial emphysema
peak inspiratory pressure or positive inspiratory
pressure
parenteral nutrition
pulsatile perfusion
persistent pulmonary hypertension of the newborn
positive-pressure ventilation

pulmonary regurgitation
parathyroid hormone
pressure–volume
pulmonary vascular resistance
pulmonary vascular resistance index
reactive airway disease
red blood cell
Royal College of Paediatrics and Child Health
randomized control trial
relative humidity
Rocky Mountain spotted fever
revolutions per minute
refractory status epilepticus
rapid sequence induction
respiratory syncytial virus
road traffic accident
right ventricular end diastolic pressure
right ventricular outflow tract obstruction
second/s
standard base excess