Pediatric Intensive Care

Abstract

Anesthetists will find themselves treating critically ill children as part of their responsibilities. This requires fundamental skills such as recognizing the child who is seriously ill or deteriorating, and then quickly intensifying treatment. Critically ill children are tachypneic, tachycardic and have signs of respiratory and cardiac failure. The critically ill infant may have an undiagnosed congenital disorder. Advice from on-call pediatric intensivists in specialized centers will help with escalation of therapy. Common problems during transfer to intensive care are hypoventilation and hypoxemia, hypotension, hypoglycemia, hypothermia, unrecognized seizures, and inadequate cerebral perfusion pressure. The decision to intubate and ventilate before transfer can be difficult, and depends on the likelihood of deterioration in transit. Well secured intravenous access and tracheal tube are basic to safe transfer, and a nasotracheal tube usually allows better fixation than oral. A frequent reason for ICU admission of infants is croup or bronchiolitis, with epiglottitis being rare now. Children with fulminant sepsis caused by streptococcus or meningococcus are often among the most ill in the intensive care, and children with these conditions can benefit the most from early recognition and aggressive resuscitation.

Review Questions

• 1. You are called to the emergency department to assist in the assessment and resuscitation of an unwell 2 year old boy. He has had a fever for 24 h and has become increasingly lethargic. This morning he has developed a non-blanching rash. On examination he is pale, poorly perfused and is disinterested in his surrounds. His heart rate is 195 bpm and blood pressure 120/50 mmHg with an appropriate size cuff. A lactate obtained by an arterial stab before your arrival is 8 mmol/L. The resident has not been able to obtain intravenous access.

  • (a) Discuss your approach to this situation, in particular outlining priorities of management.

  • (b) Comment on the blood pressure measurement.

• 2. The ward resident asks you to attend to a 4 year old child currently an inpatient on the pediatric ward. She had been admitted to the ward earlier in the evening with a 2 day history of a barking cough and a 6 h history of increasing stridor. She was admitted with a diagnosis of croup and was given a dose of oral steroids before admission to the ward 8 h ago. She has become increasingly agitated with a biphasic stridor. She is working hard to breathe. Her oxygen saturation before oxygen therapy was 92%, but now is fully saturated with a Hudson mask at 6 L/min.

  • (a) Outline your approach to management of this child’s airway issues.

  • (b) Comment on the use of oxygen therapy in this child.

• 3. You have intubated a child for ongoing ICU care. Where is the best position for the tip of the ETT— not too high and not too low, but where? What is the best method to ensure correct depth of the ETT?