Paediatric Considerations

This covers principles of paediatric critical care for the adult intensivist. In general:

• Principles of adult intensive care can be safely extrapolated to children
• Involve a paediatrician early for consideration of nuances

Paediatric anaesthetic considerations, including airway management, is covered in detail under Considerations in Paediatric Anaesthesia.

Difference:

• Congenital anomalies are common

  • ~1% of children have a congenital anomaly

• Periodic breathing

  • Risk of apnoea

• Diaphragmatic reliance

  • Easily fatigued

• CO is HR dependent

  • Relatively fixed stroke volume
  • Unexplained, persistent tachycardia over 30 minutes to 4 hours is very concerning
  • Therapy that ↓ HR may precipitate profound shock
  • BP will commonly remain normal until shock is advanced

• Anticipate deterioration during intubation

• Suspect sepsis

• Suspect NAI

• Treat neonates for everything

• Sick enough for ICU referral demands a CXR

  • Mediastinal mass
  • Heart failure
  • Foreign body
  • Congenital abnormality

• 4/2/1 over-estimates fluid requirements

  • Give 50-70% of this in critically unwell

• Parental presence during resuscitation is generally helpful

Respiratory Disease

• SpO₂:
  • Normal: 90-95%
  • Pulmonary HTN: >95%
  • Chronic lung disease: 88-92%
  • Single ventricle/chronic heart: 75-85%
• CO₂:
  • Consider ventilator dead space
  • Targets as adults

Stridor

Croup:

• Acute clinical syndrome characterised by:
  • Stridor
  • Barking cough
  • Hoarseness
  • Respiratory distress
• Usually precipitated by viral infection:
  • Parainfluenza
  • RSV
  • Influenza
  • Adenovirus
• 1-5% are admitted
• Steroids
  ↓ Need for hospitalisation, intubation, and duration of admission.
  • Dexamethasone 0.6mg/kg
  • Budesonide 2mg nebuliser
• Adrenaline 5mg nebuliser
• Intubation
  • Small ETT required
  • Gas induction in OT preferable

Epiglottitis:

• Softer stridor
• Unimmunised
• Drooling
  • Painful swallowing
• Require intubation

Bacterial tracheitis:

Wheezing

Problems:

• Wheeze

  • Bronchiolitis
  • Asthma

• Inflammation vs. bronchospasm

  • Atelectasis
  • Dynamic hyperinflation

• May respond to salbutamol if <1 year of age, particularly if history of atopy

• NG feeding to 70%

• High flow oxygen 2L/kg

• Target SpO2 >90%

• Acute viral myocarditis

  • Not better with bronchiolitis treatment
  • Palpable liver
  • Deterioration with IV fluid bolus

• Pertussis

  • Apnoea common

Bronchiolitis:

• 10% of infants affected
• 2-3% admitted in first year of life
• Rare after 1 year of age
• Fever and clear nasal discharge
• INcreasing breathlessness
• Fine crepitations
• Supportive management
  • Fluid
  • Suction of nasal secretions
  • Humidified inspired gas
  • Prone positioning

Cardiac Presentations

Heart Failure:

• Left to right shunts
• Hepatomegaly
  Sensitive and specific in small children for right heart failure.
• Murmurs
• Target SpO₂ in low 90%s
  • Hyperoxia will ↓ PVR and ↑ left to right shunt

Severe cyanosis:

• Hypoxaemia non-responsive to supplemental oxygen
• No ↑ work of breathing
• “Black lungs” on CXR
  • Little pulmonary blood flow
• Need prostin
• Need atrial septostomy

Cardiogenic shock:

• Duct-dependent lesions
  • Rapid onset of poor perfusion
  • Absent femoral pulses
  • Floppy, acidotic baby
  • Intubation
  • Inotropes
  • Prostin infusion
  • Target SpO2 75-85%
  • Target palpable pulses and improved perfusion
  • Cover for sepsis
• Consider inotropes and invasive monitoring if more than 40mL/kg of resuscitation fluid is required

Neurological

Seizure:

• Secure the airway
• Check glucose
• Check calcium
• Give benzodiazepine
  • If vascular access:
    • Lorazepam
  • If no vascular access:
    • Midazolam

Metabolic Presentations

Four broad presentations:

• Hypoglycaemia:
  • Primary energy failure
• HAGMA
  • Intoxication
• Acute liver failure
• Encephalopathy and seizures

Management:

• Rule out sepsis
• NBM
• Stop catabolism
• Dextrose infusion
• Call for help

Preparation

Emergency drugs:

• Adenosine 100-200μg/kg IV
• Dextrose
  3mL/kg of 10% dextrose IV.
• Hypertonic saline
  3mL/kg of 3% NaCl.
• Mannitol
  0.25-0.5g/kg (1.25-2.5mL/kg).
• Hydrocortisone
  2-4mg/kg up to 100mg Q6H.
• Lorazepam 0.1mg/kg up to 2 doses
• Midazolam 0.15mg/kg up to 2 doses
• Levetiracetam 40mg/kg up to 3g
• Phenytoin 20mg/kg up to 2g
• Tranexamic acid 15mg/kg up to 1g

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References

1. Smith S, Advanced Life Support Group (Manchester, England), editors. Advanced paediatric life support: a practical approach to emergencies. Seventh edition. Hoboken, NJ: Wiley-Blackwell; 2023.