دانلود کتاب Pediatric Critical Care Medicine: Volume 1: Care of the Critically Ill or Injured Child

فهرست مطالب :

Foreword to the First Edition
Preface to the Second Edition
Preface to the First Edition
Promises to Keep
Acknowledgements
Contents
Contributors
Part I: The Practice of Pediatric Critical Care Medicine
1: Pediatric Critical Care: A Global View
Introduction
What Is Required to Provide Critical Care?
What Is Required to Provide Intensive Care?
Critical Care in Mass Disaster Situations
Ethical Considerations
Conclusions
References
2: Pediatric Critical Care and the Law: Medical Malpractice
Introduction
Medico-legal Civil Liability for Pediatric Critical Physicians
Steps to Minimize Medico-legal Liability for the Pediatric Critical Care Physician
Legal Standards for Admissibility of Medical Evidence and Expert Testimony
Unique Issues in the Pediatric Intensive Care Unit Setting
Emerging Medico-legal Issues Resulting from the Availability of Electronic Data from EHR
References
3: Architectural Design of Critical Care Units: A Comparison of Best Practice Units and Design
Introduction
A Little History and Statistics
Advances in Health Design and Sources for Inspiration
Case Studies, Comparisons and Practice
Construction Types
Functional Types
Layout Types
Unit Circulation
Departmental Areas
Patient Room Design and Bed Number
Space Allocation by Category
Discussion and Exemplary Designs
Patient Care
Patient Toilet Facilities and Waste Disposal
Patient Bed Location and Medical Utilities
Patient Room and Technology
Staff and Material Support
Degree of Nursing Centralization
Staff Facilities
Staff Access to Nature
Diagnostic and Therapeutic
Proximity to Diagnostic and Treatment Support
Administration and Education
Proximity to Administration and Education Spaces
Public and Family
Family Space
Outdoor Space
Green Space
Conclusion and Future Trends
References
4: PICU Administration
Introduction
Pediatric Intensive Care Unit Structure
Historical Perspective
Levels of Care
Patient Population
Subspecialty Care
Team Structure
Medical Director
Physician Team
Nursing Team
Respiratory Therapy
Ancillary Staff
Multidisciplinary Approach
Roles of the Leadership Team
Quality and Safety Assurance
Team Development
Family Centered Care
Hospital Relations
Education and Training
Conclusion
References
5: Nursing Care in the Pediatric Intensive Care Unit
Role of the Pediatric Critical Care Nurse
Education
Orientation of New Staff
Clinical Preceptorship
Senior Staff Development
Administration
Structure
Staffing
Innovation and Research
Conclusion
References
6: Scoring Systems in Critical Care
Introduction
History
Use of Scoring Systems
Elements of a Scoring System
Reliability
Validity
Types of Scoring Systems
Intervention Specific Scoring Systems
Physiology Specific Scoring Systems
Adult Mortality Scores
Pediatric Mortality Scores
Pediatric Morbidity Scores
Disease or Condition Specific Scoring Systems
Trauma
Congenital Heart Disease
Other
Functional Outcome Scores
The Future of Scoring Systems
Conclusion
References
7: Pharmacology in the PICU
Principles of Pharmacokinetics and Pharmacodynamics
Pharmacokinetics
Absorption
Drug Distribution
Drug Metabolism
Drug Elimination
Developmental Effects on Pharmacokinetics and Pharmacodynamics
Pharmacogenomics
Bedside Application of Pharmacokinetic Principles
Bioavailability
Volume of Distribution
Clearance
Elimination Half-Life
Target-Effect Versus Target-Concentration Strategies
Drug Interactions
Drug-Drug Interactions
Pharmacokinetic Interactions
Absorption
Distribution
Metabolism
Elimination
Pharmacodynamic Interactions
Herbal-Drug Interactions
Pharmaceutical Interactions
Drug-Food and Drug-Enteral Formula Interactions
Drug-Disease Interactions
Drug Safety
References
8: Telemedicine in the Pediatric Intensive Care Unit
Introduction
The Use of Telemedicine in Emergency Departments
The Use of Telemedicine During Transport of Critically Ill Children
The Use of Telemedicine for Children Hospitalized in Intensive Care Units
Consultative Model
Continuous Oversight Model
Telemedicine Technologies
The Future of Telemedicine in the PICU
References
9: Quality Improvement Science in the PICU
What Is Health-Care Quality?
Engaging Healthcare Providers in Quality Improvement
The Case for Health-Care Quality as a Priority for Pediatric Critical Care
Models for Understanding Quality
The Science of Quality Improvement
Understanding Variation Through Statistical Process Control
A Few Key Tools and Change Concepts for Quality Improvement
Summary
References
10: Patient Safety in the PICU
Introduction
The Challenge of Measurement of the Patient Safety Events
What Harm and Risk Exists in PICUs
Systems, Systems Thinking and Patient Safety in PICUs
Improving Safety in the PICU: A Systems Approach
Special Safety Topics
Patient Safety in the PICU
References
11: Outcomes Research in the PICU
Introduction
Rationale for Pediatric Critical Care Outcomes Research
Definition of Outcome Measures
Survival Status
Functional Health Status
Health-Related Quality Of Life
Severity of Illness as an Important Mediator of Outcomes
Methods of Outcome Assessment: Pathways to Studying Outcomes
Structure-Process-Outcomes Model
HRQOL Model
Types of Outcome Research
Health Resource Utilization and Costs
The Future of Outcomes Research in Pediatric Intensive Care
References
12: Resident and Nurse Education in Pediatric Intensive Care Unit
Introduction
Uniqueness of Pediatric Intensive Care Units
Resident Education Techniques
Resident Education in Pediatric Critical Care
Evaluation of Residents
Educating New Graduate Nurses
Use of Simulators in Medical Education
Conclusion
References
13: Epidemiology of Critical Illness
Challenges of Defining a Population in Critical Care
Epidemiology of Children Receiving Critical Care Services
Epidemiology of Mechanical Ventilation and ARDS/ALI
Epidemiology of Sepsis
Epidemiology of Status Asthmaticus
Conclusion
References
14: Ethics in the Pediatric Intensive Care Unit: Controversies and Considerations
Introduction
Informed Consent/Parental Permission
Informed Consent
Parental Permission
Assent
Emancipated Minor and Mature Minor Exceptions
Communication in the Pediatric Intensive Care Unit
Provision of End of Life Care in the Pediatric Intensive Care Unit
Use of Medication at the End of Life
Withholding Artificially Provided Fluids and Nutrition
Unilateral Decision Making and Futility
Conflict Resolution
Declaring Death and Organ Donation
Declaration of Death
Organ Donation
Ethical Issues Related to Donation After Cardiac Death
Research in the Pediatric Intensive Care Unit
Caring for the Caregiver
References
15: Palliative Care in the PICU
Introduction
The Definition of Palliative Care
Epidemiology of Palliative Care Patients in the PICU
Integration of Palliative Care in the Critical Care Setting
The Interdisciplinary Palliative Care Team
Family-Centered Communication
Goals of Care and Decision Making
Symptom Management
Spiritual Distress
Attention to Siblings
Practical Considerations During the Peri- death Period in the PICU
Bereavement
Caring for Healthcare Professionals
Conclusion
References
16: Evidence-based Pediatric Critical Care Medicine
A Clinical Scenario Raises Important Clinical Questions
The Need for EBM
The EBM Process and Approaching the EBM Core Topics
Evidence-Based Clinical Practice in Pediatric Critical Care: Challenges and Next Steps
References
17: Simulation Training in Pediatric Critical Care Medicine
Adverse Events and Medical Error in the Intensive Care Unit: Rationale for a Robust Training Model
Heritage of Medical Simulation as a Tool to Mitigate Human Error
Simulation-Based Teamwork Training in Pediatric Critical Care
Curriculum
Delivery Modes
Outcomes of CRM Training
Simulation as a Teaching Tool: Principles of Practice
Simulation-Based Curricula Founded on Principles of Adult Learning Theory
Simulation Scenario Design
Debriefing
Applications of Simulation-Based Skills Training in Critical Care Training
Resuscitation Training
Procedural Training
Airway Management
Other Applications of Simulation to the Pediatric Critical Care Environment
Conclusion
References
18: Career Development in Pediatric Critical Care Medicine
Introduction
Developing “Mastery” in Clinical Pediatric Critical Care Medicine
Workforce and Career Development
Maintenance of Workforce
Leadership and Team Science in Pediatric Critical Care
Job Activity and Career Development in Pediatric Critical Care
Intensivist as Educator
RESEARCH…research…Translational Research and Implementation Science…and Mentoring
Career Development…beyond Pediatric Critical Care Medicine
References
Part II: The Science of Pediatric Critical Care Medicine
19: Genetic Polymorphisms in Critical Illness and Injury
Introduction
Genetic Polymorphisms
Techniques Involved in Genotyping of Polymorphic Sites
Influence of Genetic Polymorphisms in Sepsis
Genetic Variation in Genes Involved in the Recognition of Pathogens
Genetic Variation in Genes Involved in the Response to Pathogens and Other Stimuli
Influence of Genetic Polymorphisms in Respiratory Failure and Lung Injury
Influence of Genetic Polymorphisms in Cardiopulmonary Bypass
Influence of Genetic Polymorphisms and Risk of Thrombosis
Pharmacogenomics: The Study of the Genomics of Drug Response and Adverse Effects
Limitations and Study Design Issues in Genetic Association Studies
Conclusion
References
20: Genomics in Critical Illness
Introduction
Gene Association Studies
Genome-Wide Expression Profiling
Proteomics
Comparative Genomics
Epigenetics
Pharmacogenomics
Other Branches of “Omics”
Conclusion
References
21: Signal Transduction Pathways in Critical Illness and Injury
Introduction
Historical Perspective of Signal Transduction
Basic Overview of Signal Transduction
Stimuli Triggering Signal Transduction
General Strategies for Signal Propagation
Specific Pathways
Nuclear Factor-k B Pathway
Mitogen-Activated Protein Kinase Pathways
p38 Mitogen-Activated Protein Kinase Pathway
JNK Mitogen-Activated Protein Kinase Pathway
ERK Mitogen-Activated Protein Kinase Pathway
Regulation of Signal Transduction Pathway
Phosphatases as Regulators
Intracellular Protein Modulators
Epigenetic Mechanisms as Regulators
Histone Modifications
microRNA
Conclusion
References
22: Pro-inflammatory and Anti- inflammatory Mediators in Critical Illness and Injury
Introduction
Cellular Elements
Innate Immunity
Adaptive Immunity
Cytokines and Chemokines
The Inflammatory Response in Critical Illness
Circulating Cytokine Levels
Gene Expression Profiling
Immunoparalysis
Innate Immunity
Adaptive Immunity
Reversal of Immunoparalysis
Tipping the Scales
Conclusion
References
23: Oxidative and Nitrosative Stress in Critical Illness and Injury
Introduction
Reactive Oxygen Species and Reactive Nitrogen Species
Antioxidants
Redox Homeostasis and Physiologic Function
Endothelial Relaxation and Adherence Properties
Immune Responses
Regulation of Mitochondrial Respiration
The Role of Reactive Oxygen Species and Reactive Nitrogen Species in Critical Illness
Sepsis
Vascular Dysregulation in Sepsis
Cytopathic Hypoxia and Mitochondrial Dysfunction in Sepsis
ROS and Nuclear Factor kappa-B in Sepsis
Antioxidants in Sepsis
Therapies Targeting Oxidative and Nitrosative Stress in the Treatment of Sepsis
Traumatic Brain Injury and Epilepsy
Therapies for Traumatic Brain Injury and Epilepsy
References
24: Ischemia-Reperfusion Injury
Introduction
Metabolic Derangements of Ischemia
Alteration of Oxygen Supply
Energy Failure and Calcium Overload During Ischemia
The Reperfusion Injury
Oxidative and Nitrosative Stress
Direct Oxidative and Nitrosative Injury: Damage of Macromolecules, DNA and Activation of Poly (ADP-ribose) Polymerase-1 (PARP-1)
Indirect Oxidative and Nitrosative Injury: The Interactive Role of Oxidants with Protein Kinases, Phosphatases and Transcription Factors
Sources of Reactive Oxygen and Nitrogen Species
Mitochondrial Production
Xanthine Oxidase
Oxidative Burst from the Infiltrated Neutrophils: The NAD(P)H Oxidase
Nitric Oxide and Nitrosative Stress
Other Sources
Alteration of Anti-oxidant Mechanisms
The Endothelial Dysfunction and Neutrophil Infiltration
Expression of Adhesion Molecules on Endothelial Surface: Loss of Endothelial Barrier Function
Loss of Endothelial Barrier: The Injury Vicious Cycle
Complement Activation
Toll-Like Receptors and Damage Associated Molecular Patterns
Matrix Metalloproteinases
Cellular and Molecular Defenses Against Cell Injury
The Hypoxia-Inducible Factor-1 (HIF-1)
The Heat Shock Response
The Reperfusion Injury Salvage Kinase (RISK) Pathway
Autophagy
Endogenous Hydrogen Sulfide Production
The Ischemic Preconditioning Response
Conclusion
References
Part III: Resuscitation, Stabilization, and Transport of the Critically Ill or Injured Child
25: Post-resuscitation Care
Introduction
Post-cardiac Arrest Syndrome
Pathophysiology of the Post-arrest Reperfusion State
Post-resuscitation Care of the Respiratory System
Post-resuscitation Care of the Cardiovascular System
Post-resuscitation Neurologic Management
Pathophysiology
Clinical Manifestations
Management
Prognosis
Blood Glucose Management
Acid-Base and Electrolyte Management
Immunologic Disturbances and Infection
Coagulation Abnormalities
Gastrointestinal Management
Acute Kidney Injury
Endocrinologic Abnormalities
Conclusion
References
26: Predicting Outcomes Following Resuscitation
Introduction
Out-of-Hospital Cardiac Arrest
In-Hospital Cardiac Arrest
Classifying Outcomes Following Resuscitation
Predicting Outcomes Following Resuscitation
List of Predictors (Pre-arrest, Arrest, Post-arrest)
Neurological Diagnostic Studies for Prognostification
Neurologic Exam
Neurophysiologic Studies
Biomarkers
Neuroimaging
Other Important Considerations
Conclusion
References
27: Basic Management of the Pediatric Airway
Introduction
Developmental Anatomy and Physiology of the Pediatric Airway
Basic Airway Management
Positioning
Airway Adjuncts
Tracheal Intubation
Indications
Assessment and Preparation
Equipment
Airway Pharmacology
Pre-induction Agents
Induction Agents
Neuromuscular Blocking Agents (NMBs)
Oral Tracheal Intubation
Nasal Tracheal Intubation
Rapid Sequence Intubation (RSI)
Complications of Tracheal Intubation
Tracheal Extubation
References
28: Pediatric Difficult Airway Management: Principles and Approach in the Critical Care Environment
Introduction
What Is a Difficult Airway?
Principles of Difficult Airway Management: The ASA Difficult Airway Algorithm
Basic Management Problems
Difficult Ventilation
Difficult Intubation
Difficult Supraglottic Airway Insertion/Placement
Difficulty with Patient Cooperation
Difficult Tracheostomy
Basic Management Choices
Awake Intubation vs. Anesthetized Intubation
Non-invasive vs. Invasive Technique for Initial Approach to Intubation
Preservation vs. Ablation of Spontaneous Ventilation
Preparation
Venue
Pharmacologic Management
Sedation for Intubation with Spontaneous Ventilation Maintained
Benzodiazepine and Opiates
Dexmedetomidine
Ketamine
Neuromuscular Blockade
Succinylcholine
Airway Management Equipment
Ventilation Adjuncts
Oral Airways
Nasopharyngeal Airways
Modified Nasopharyngeal Airway
Two-Person, Two-Handed Ventilation
Laryngeal Mask and Supraglottic Airways
Tracheal Intubation Tools
Direct Laryngoscopy
Flexible Bronchoscope
Video/Indirect Laryngoscopes
Bullard Laryngoscope
Glidescope Cobalt
Storz Video Laryngoscope
Airtraq
Optical Stylets
Laryngeal Masks as Intubation Conduits
The Unanticipated Difficult Airway
Systems Management
Tracheal Extubation in the Child with a Difficult Airway
Conclusion
References
29: Central Venous Vascular Access
Introduction
Choice of Sites and Type of Catheter
Femoral Venous Catheterization
Demographic and Historical Data
Indications and Contraindications for Placement
Anatomy
Insertion Technique
Confirmation of Placement
Complications and Risks
Subclavian Vein Catheterization
Demographic and Historical Data
Indications
Anatomy
Insertion Technique
Confirmation of Placement
Complications
Internal Jugular Vein Catheterization
Demographic: Historical Data: Indications for Placement
Anatomy
Insertion Technique
Confirmation of Placement
Complications
Axillary Vein Catheterization
Demographic and Historical Data: Indications for Use
Anatomy
Technique
Complications
Ultrasound-Guided Central Vein Catheterization: The New Standard?
Complications Associated With Central Venous Catheter Placement
Pneumothorax
Arterial Puncture
Catheter Malposition: Femoral Catheters
Catheter Malposition and Post Procedure Chest Radiographs: Cervicothoracic Catheters
References
30: Shock
Historical Perspective
A Brief Overview of Cellular Respiration and the Cellular Basis of Shock
Differences Between Pediatric Shock and Adult Shock
Pathophysiology of Shock
Hemodynamic Relationships in Shock
Compensatory Mechanisms in Shock
Functional Classification of Shock
Hypovolemic Shock
Obstructive Shock
Tension Pneumothorax
Pulmonary Embolism
Cardiac Tamponade
Left Ventricular Outflow Tract Obstruction
Right-sided Obstructive Lesions
Cardiogenic Shock
Distributive Shock
Diagnosis of Shock
Therapeutic Endpoints of Resuscitation in Pediatrics
Traditional Endpoints
Cardiac Filling Pressures
Venous Oximetry and Near-Infrared Spectroscopy
AVDO 2
Lactate
Management of Shock
Fluid Therapy
Blood Products
Vasoactive Medications
Inotropes
Dopamine
Dobutamine
Epinephrine
Norepinephrine
Phosphodiesterase Inhibitors
Other Agents
Vasodilators
Vasopressors
Phenylephrine
Vasopressin
Hydrocortisone
Extra-Corporeal Life Support (ECLS)
Conclusion
References
31: Acute Respiratory Failure
Introduction
Definition
Etiologies of Respiratory Failure
Upper Airway Obstruction
Lower Airway Obstruction
Hypoventilation
Respiratory Muscle Insufficiency
Ventilation/Perfusion (V/Q) Inequality
Shunting
Diffusion Impairment
Evaluation of Respiratory Failure
Oxygenation
Carbon Dioxide Retention
Treatment of Respiratory Failure
References
32: The Multiply Injured Child
Introduction
Trauma Related Mortality and Morbidity
Age Distribution
Injury Patterns and Mechanisms of Injury
Incidence of Multiple Trauma and Trauma Scoring
Pathophysiology of Major Trauma and Mechanisms of Secondary Damage
Hypoperfusion, Hypoxemia and Tissue Hypoxia
Reperfusion Injury
Pathophysiologic Responses to Major Trauma
Neuroendocrine and Metabolic Stress Response
The Systemic Inflammatory Response to Trauma
Multi-Organ Dysfunction Syndrome (MODS) and Multiple Organ Failure (MOF) Following Trauma in Children
Clinical Implications of Multiple Trauma
Pre-hospital Care of the Multiply Injured Child
Pre-hospital Airway Management
Emergency Department Management of the Multiply Injured Child
Role of the PICU Physician
Primary Survey, Resuscitation and Initial Stabilization
Airway
Breathing and Mechanical Ventilation
Circulation
Vascular Access
Fluid Resuscitation
Blood and Coagulation Factors Transfusion
Imaging of the Multiply Injured Child
Management of the Multiply Injured Child in the Intensive Care Unit
Triad of Death
Damage Control in the Unstable Injured Child
Blunt Abdominal Trauma in the Multiply Injured Child
Thoracic Injury in the Multiply Injured Child
References
33: Coma and Altered Mental Status
Introduction
Epidemiology
Consciousness and Coma and Altered Mental Status Definitions
Anatomy of the Brain in Relation to Coma
Causes of Coma
Evaluation of the Comatose Child
History
Physical Examination
Neurologic Examination
Glasgow Coma Score (GCS)
Response to Stimuli
Cranial Nerve Examination
Fundoscopic Examination
Pupillary Exam
Eye Position and Motility
Oculocephalic and Oculovestibular Reflexes
Gag Reflex
Other Brainstem Reflexes
Diagnostic Testing
Associated Problems
Intracranial Hypertension
Seizures
Outcome Prediction
General Considerations
Scoring Tools
Adjunct Tools
Neurologic Exam
Neurophysiology
Neuroimaging
Conclusion
References
34: Interfacility Transport
Introduction
Historical Perspective
The Transport Team
Medical Director
Transport Coordinator
Transport Team Personnel
Training and Education
Equipment
Communications Center
Mode of Transport
Aeromedical Transport Considerations
Altitude Physiology
Safety in Transport
Medicolegal Issues
Clinical Care Stabilization of the Critically Ill or Injured Child for Transport
Airway and Respiratory Care
Sepsis
Vascular Access
Family Centered Care and Interfacility Transport
Unique Transport Situations
Scene Flights
Organ Procurement
Extracorporeal Membrane Oxygenation (ECMO)
Burns
Quality Improvement in Transport
Future of Pediatric Transport
References
35: Multiple Organ Dysfunction Syndrome
Introduction
Definition of Pediatric Multiple Organ Dysfunction Syndrome (MODS)
Pediatric MODS Scoring Systems
Epidemiology
Etiology
Sepsis
Congenital Heart Diseases
Multiple Trauma
Solid Organ or Bone Marrow Transplantations
Pathogenesis
Evolutionary Ties Between Sepsis and Tissue Injury
Inflammation and Immune System
Adaptive Immunity and Immune Suppression
Coagulation and Fibrinolysis
Capillary Leak Syndrome
Neuroendocrine Response
Hyper and Hypometabolism
Cellular Dysoxia
Organ Dysfunctions in Critically Ill Children
Cardiovascular Dysfunction and Septic Shock
Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS)
Gut Mucosal Barrier Dysfunction
Neuromuscular Syndromes
Outcome of Pediatric MODS
Treatment of Pediatric MODS
General Supportive Care
Organ Therapeutic Management
Hemodynamic Management
Lung Protective Ventilation
Renal Failure Management
Nutritional Support
Withdrawal of Curative Care
References
36: Withdrawal of Life Support
Introduction
Ethical Framework
Autonomy
Beneficence and Nonmaleficence
Justice
Family Centered Care and Conflict
Providing Care During Withdrawal of Life Support
Providing Care Around the Time of Death
References
37: Brain Death
History of the Brain Death Concept
The Neurological Determination of Death: Concept, Terminology and Clinical Relevance
Whole-Brain Versus Brainstem Death
Brain Death Versus Brain Arrest
End-of-Life Care and the Obligations of the PICU
Demographics and Etiology
Pathophysiology
Minimum Clinical Criteria
Brainstem Reflexes
Etiology and Coma
Absent Motor Response
Absent Brainstem Reflexes
Apnea Testing
Confounding Factors
Physician Expertise
Subsequent Clinical Examinations and Time Intervals
Age Related Adjustments
Legal Time of Death
Ancillary Testing
Electroencephalography (EEG)
Tests of Intracerebral Blood Flow
4-Vessel Cerebral Angiography
Nuclear Medicine Imaging Techniques
Transcranial Doppler Ultrasonography
Magnetic Resonance Angiography with Magnetic Resonance Imaging (MRA with MRI)
Computed Tomographic Angiography (CTA)
Other Tests of Interest
Variability and Practice Controversies
References
38: The Physiology of Brain Death and Organ Donor Management
Introduction
The Physiology of Brain Death
Neurogenic Myocardial Dysfunction
Neurogenic Pulmonary Edema
Inflammatory State
Donor Management: General
Cardiovascular Performance and Monitoring
Hemodynamic Targets and Supports
Preload
Contractility
Systemic Vascular Resistance
Vasopressin and Catecholamine Sparing in Brain Death
Oxygenation and Ventilation Strategies
Metabolic and Endocrine
Glycemia and Nutrition
Diabetes Insipidus and Hypernatremia
Thyroid Hormone
Corticosteroids
Combined Hormonal Therapy
Transfusion Thresholds
Invasive Bacterial Infections
Donor Management: Organ Specific
Heart
Lungs
Bronchoscopy and Bronchopulmonary Infections
Liver
Kidney
Intestine
Logistics of Organ Donation
Donor Management Protocols and Education
Optimal Time of Organ Procurement
Decisions Regarding Transplantability
References
Part IV: Monitoring the Critically Ill or Injured Child
39: Respiratory Monitoring
Introduction
Monitoring Gas Exchange
Monitoring Oxygenation
Arterial Blood Gas Monitoring
Pulse Oximetry
Monitoring Ventilation
Arterial Blood Gas Analysis
End-Tidal CO 2 Monitoring
Transcutaneous CO 2 (TcCO 2) Measurements
Monitoring the Mechanics of the Respiratory System
Scalars
Flow-Time Scalars
Pressure-Time Scalar
Volume-Time Scalar
Loops
Pressure-Volume (PV) Loops
Recruitment/Derecruitment
Overdistention
Flow-Volume (FV) Loops
Conclusion
References
40: Hemodynamic Monitoring
Introduction
Vascular Pressure Measurement
Cardiac Output
Indicator Dilution Techniques
Pulmonary Thermodilution (Swan-Ganz Catheters)
Transpulmonary Thermodilution
Transpulmonary Ultrasound Dilution
Dye Dilution
Lithium Dilution
The Fick Principle
Oxygen Consumption Measurement
Arterial and Mixed Venous Oxygen Content
Presence of Anatomical Shunt
Indirect Fick Principle
Doppler Ultrasound
Impedance/Conductance Methods
Thoracic Impedance
Intracardiac Impedance
Arterial Pulse Contour Analysis
Other Methods
Measuring the Adequacy of Flow
Mixed Venous Oxygen Saturation
Near Infrared Spectroscopy (NIRS)
Blood Lactate
Regional Perfusion
Tissue PCO 2 Monitoring Using Tonometry
Optical Monitoring Methods
Capillary Refill
Assessing the Components of Cardiac Output
Heart Rate
Preload Versus Volume Responsiveness
Contractility
Afterload
Diastolic Function
References
41: Neurological Monitoring of the Critically-Ill Child
Physical Examination
Intracranial Pressure (ICP) Monitoring
Electrophysiological Monitoring
Bispectral (BIS) Index Monitoring
Electroencephalography (EEG)
Evoked Potentials
Assessments of Blood Flow and/or Metabolism
Xenon Cerebral Blood Flow Determination
Transcranial Doppler Ultrasonography: (TCD)
Jugular Venous Oxygen Saturation: (SjvO 2)
Near-Infrared Spectroscopy: NIRS
Brain Oxygen Monitoring and Cerebral Microdialysis
MR Spectroscopy: MRS
Serum Markers of Neurological Injuries: Neuromarkers
Conclusion
References
42: Nutrition Monitoring in the PICU
Introduction
Assessing Nutritional Status
Subjective Global Nutritional Assessment (SGNA)
Anthropometrics
Obesity
Malnutrition
Monitoring Biochemical Markers
Plasma Proteins
Nutritional Indices
Nitrogen Balance
Creatinine Height Index- Body Protein Turnover
Monitoring Resting Energy Expenditure
Indirect Calorimetry
The Standard Metabolic Monitor
Recent Advances in Monitoring REE in the Critically Ill
The Short Douglas Bag Protocol
Alternative Methods Used to Predict Energy Expenditure
Bicarbonate Dilution Kinetics
Indirect Estimations of REE
Predictive Equations
Lessons Learned From Adult Studies
The Pediatric Experience
Body-Composition Tests
Dual-Energy X-Ray Absorptiometry
Bioelectrical Impedance: Magnetic Resonance Spectroscopy
Doubly Labeled Water Technique
Whole-Body Counting/Neutron Activation
Miscellaneous Tests Indicating Nutritional Status/Stress Response
Comparison with Recommended Dietary Allowances
Routine Laboratory Tests
Glucose Control
Cell-Mediated Immunity and Lymphopenia
Functional Tests of Malnutrition
Clinical Data Impacting Nutrition and Metabolic Response Monitoring
Cytokines
Counter-Regulatory Stress Hormones
Drugs Influencing Monitoring
Critical Illness
Nutrition Monitoring
Early Nutrition Monitoring
The Immunonutrition Question
Protocols in the Role of Monitoring
Monitoring the Metabolic Response
Conclusions
References
43: Monitoring Kidney Function in the Pediatric Intensive Care Unit
Introduction
Defining the Problem
Classic Parameters of Acute Kidney Injury
Glomerular Filtration Rate (GFR)
Serum Creatinine
Serum Urea
Urine Output
Fluid Overload
Urinalysis and Microscopy
Urine Chemistry and Similarly Derived Indices
The Need for Better Markers of AKI
Emerging Biomarkers
NGAL
Cystatin C
IL-18
KIM-1
L-FABP
AKI Biomarker Combinations
Renal Angina: Risk Stratification to Optimize AKI Biomarker Utility
Future Perspectives in AKI Biomarkers
References
Part V: Special Situations in Pediatric Critical Care Medicine
44: Principles of Mass Casualty and Disaster Medicine
Introduction
Disaster Types, Preparedness, and Management
Hospital Emergency Preparedness
Community and/or Local Government Emergency Preparedness
State Government Emergency Preparedness
Federal Government Emergency Preparedness
Public Health Emergency Preparedness
Mass Casulaty Incidents
Incident Command System (ICS)
Casualties’ Flow within the Hospital
Patient Triage
Principles of Initial Hospital Management
Use of Radiology
Operating Room
Secondary Transport
Re-Assessment Phase
Communication and Manpower Control
Information Center and Public Relations
Personal Protective Equipment
Hospital Based Decontamination and Pediatric Considerations
Crisis (or Disaster) Standards of Care
Alternate Care Sites
Communication and Information Technology Issues
Unique Aspects of Children Related to Terrorism and Disasters
Biologic, Chemical, Radiologic and Trauma Vulnerabilities
Mental Health Vulnerabilities
Children with Special Health Care Needs
Pediatric Disasters Preparedness
Epidemics and Pandemics Preparedness
Terrorism Preparedness
Conclusion
References
45: Care in an Austere Environment
Introduction
Provider Opportunities and Readiness
Cultural Sensitivity
Patient Care
Conclusion
References
46: Agents of Biological and Chemical Terrorism
Introduction
Historical Context of Biological and Chemical Agents
Pediatric Unique Factors
Specific Chemical and Biological Agents of Terrorism
Chemical Agents
Nerve Agents (Tabun (GA), Sarin (GB), Soman (GD), and VX
Mechanism of Action
Signs/Symptoms
Diagnosis
Decontamination/Isolation
Treatment
Cyanide
Mechanism of Action
Signs/Symptoms
Diagnosis
Treatment
Biologic Agents
Inhalational Anthrax (Bacillus Anthracis)
Signs/Symptoms
Diagnosis
Infection Control
Treatment
Pneumonic Plague ( Yersinia pestis)
Signs/Symptoms
Diagnosis
Decontamination/Infection Control
Treatment
Tularemia ( Francisella tularensis)
Signs/Symptoms
Diagnosis
Infection Control
Treatment
Smallpox (Variola)
Symptoms/Signs
Diagnosis
Decontamination and Infection Control
Treatment
Botulinum Toxin
Symptoms/Signs
Diagnosis
Decontamination/Infection Control
Treatment
Conclusion
References
47: Pandemic Influenza
Introduction
Molecular Description of the Influenza Virus
Government Planning for Pandemic Influenza
Critical-Care Planning for Pandemic Influenza
Pediatric-Specific Issues
2009 H1N1 Experience
Ethics
Conclusion
References
48: Pediatric Drowning
Introduction
Epidemiology
Associated Conditions
Associated Medical Conditions
Associated Injuries
Pathophysiology
Immersion
Submersion
Hypothermia
Effects on End-Organs
Respiratory System
Cardiovascular System
Central Nervous System
Clinical Evaluation and Decision Making
Treatment
Scene
Emergency Department
Intensive Care Unit
Predicting Long-Term Outcome
Clinical Neurologic Examination
Neuroradiology
Neurophysiology
References
49: Heat Illness and Hypothermia
Thermoregulation
Heat Illnesses
Classification
Pathophysiology
Biochemical and Cellular Alterations
Systemic Alterations
Epidemiology
Clinical Manifestations
CNS Manifestations
Cardiovascular Manifestations
Respiratory Manifestations
Skin Manifestations
Gastrointestinal Manifestations
Renal Manifestations
Diagnosis and Clinical Evaluation
Treatment
Cooling
End-Organ Support
Prognosis
Cold Injury
Classification
Pathophysiology
Molecular and Cellular Alterations
Systemic Alterations
Epidemiology
Clinical Manifestations
CNS Manifestations
Cardiovascular Manifestations
Respiratory Manifestations
Renal Manifestations
Hematologic Manifestations
Diagnosis and Clinical Evaluation
Treatment
Prognosis
References
50: Toxic Ingestions
Introduction
Evaluation
Antidotes
Decontamination
Surface Decontamination
Gastric Decontamination
Activated Charcoal (AC)
Whole Bowel Irrigation (WBI)
Cathartics
Enhanced Elimination
Forced Diuresis
Urine Alkalinization
Hemodialysis
Hemoperfusion
Intravenous Lipid Emulsion (ILE)
Specific Toxic Ingestions
Recreational Drugs
Cocaine
Gamma-hydroxybutyrate (GHB)
3,4-Methylenedioxymethamphetamine (MDMA)
“Bath Salts”
Ketamine
Dextromethorphan
2-C Phenethylamines
Alcohols
Ethylene Glycol
Methanol
Isopropyl Alcohol (Isopropanol)
Ethanol
Psychoactive Drugs
Antipsychotics
Selective Serotonin Reuptake Inhibitors (SSRIs)
Tricyclic Antidepressants (TCAs)
Antihypertensives
Calcium Channel Blockers (CCBs)
Beta-blockers (β-blockers)
Clonidine
Analgesics, Analgesics, Sedatives, and Antipyretics
Opioids
Benzodiazepines
Acetaminophen
Salicylates
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Organophosphates and Carbamates
Iron
Hydrocarbons and Inhalation Abuse
Caustic Agents
Smoke Exposure, Cyanide (CN) and Carbon Monoxide (CO)
Cyanide
Carbon Monoxide
Antihistamines
Anticonvulsants
Barbiturates
Phenytoin
Valproic Acid (VPA)
Carbamazepine
Oxcarbazepine
Levetiracetam
Methemoglobinemia
References
51: Envenomations
Introduction
Venomous Snakes
Snake Venoms and Toxins
Clinical Manifestations of Envenomation
Identification of the Snake
Initial Management: Resuscitation and Stabilization (Fig. 51.8)
Management: Antivenom (Antivenin) Therapy
Monitoring
Secondary Management and Follow-Up Care
Sea-Snake Bite
Uncommon and Exotic Snake Bites
Spiders
Funnel-Web Spiders
Red-Back Spider
Black Widow Spiders
Brown Recluse Spiders
Scorpions
Bees, Wasps, and Ants
Venomous Marine Animals
Jellyfish
Blue-Ringed Octopus
Stinging Fish
Venomous Cone Shells
Shark Attacks
References
Index