Paediatrics for the general intensivist.

1. Paediatrics for the General Intensivist
•
CICM Trainee Symposium 2017
Fiona Miles
Starship Hospital

2. What do we do differently?
What has changed?
• ABC:
– intubation, ventilation, inotropes
• Sepsis
• Cardiac
• Pertussis/ Bronchiolitis
• Head injury

3. Intubation
• Paeds airway differences
• ETT: cuffed tubes:
– reduce multiple intubations, no increase risk postextubation stridor, decreases size
• Preoxygenate/ fluid bolus
• Gas induction for airway obstruction
• Titrate drugs
– fentanyl (1-5 mcg/kg) or ketamine (1-2mg/kg)/ atracurium/ rocuronium
• Nasogastric tube, CXR
*J Anesth. 2016 Feb;30(1):3-11. doi: 10.1007/s00540-015-2062-4. Epub 2015 Aug 22
*Pediatric Anesthesia and Critical Care Journal 2014; 2(2):70-73

4. NIV: High flow
Comfort,humidification
Low PEEP (3 cm), vent ng
Fixed flow 2l/kg/min (max 50)
Adjust FiO2
Wean Fi02, then low flow
If < 5 kg, use CPAP
Paediatr Respir Rev. 2016 Sep;20:24-31

5. NIV: Bubble CPAP
• Increase alveolar volumes
• Redistribute lung water
• Recruit alveoli
• Prevent alveolar collapse
Evidence? : Effect of CPAP in
children with acute
bronchiolitis uncertain due
limited evidence
Jat et al, (CPAP) for acute bronchiolitis in children:
Cochrane Database of Systematic Reviews,
2015

6. Invasive Ventilation
• Indications:
– Arrest / Hypoxia
– GCS<8
– Shock: hypotension, acidosis
– Airway abnormalities
– Procedures
• Settings:
– PIP<30, PEEP 5-10, IT 1.O, rate <30

7. Which mode?
• Volume Control/ SIMV:
– Cardiac, head injury
• Pressure Control:
– Respiratory/ stiff lungs, paralysed, leak
• Assist Control/ Pressure support:
– LRTI/ pneumonia, spont breathing.
• Evidence: 6 modes, 421 children: no difference in duration
ventilation, mortality, weaning time
Crit Care. Jan,2011;15(1):R24..Invasive ventilation modes in children: a systematic review and
meta-analysis

8. Adjuncts:
• Lung protective strategies:
– TV 6ml/kg, PEEP, PIP<30, permissive hypercarbia
• Proning* (improves oxygenation and ?survival)
– patients with ARDS and severe hypoxemia benefit when used early and in relatively long
sessions.
• iNO**/(sildenafil) : improves outcomes in infants without CDH
• Diuretics
• *Gillies, Cochrane Database syt Rev. 11 July 2012
• *Guerin et al. Prone Positioning in Severe ARDS, May 20, 2013( Proseva trial)
• * *(Cochrane Database Syst Rev. 2017 Jan 5;1)

9. High Frequency Oscillatory Ventilation
• Acute respiratory failure
– -longer duration ventilation
– higher risk for mortality
– greater neuromuscular blockade & opioids
– Higher risk cognitive/functional impairment.
• Congenital Diaphragmatic hernia?
– Longer duration ventilation, inotropes
– Higher need for ECMO, sildenafil,
– more often failed treatment
• Not first line, but ? role in severe ARDS and
refractory hypoxemia as rescue therapy
• Am J Respir Crit Care Med Vol 193, 5, pp 471–485, 2016
• Ann Surg. 2016 May;263(5):867-74
• Curr Opin Crit Care. 2017 Feb 2

10. Fluids
• Resuscitation: Always isotonic
– glucose-free crystalloids that contain 131-154 mmol/L sodium, with a
bolus of 20 mL/kg over < 10 minutes, consider cardiac/renal disease
• Maintenance: 4:2:1 rule:
– isotonic fluids standard*
– 80% if intubated, feed < 24 hours.
• Beware hyponatraemia:
– Children at greater risk of permanent neurological complications/death due to
hyponatraemia from inappropriate use of iv fluids
• BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6388 (Published 09 December 2015)
• *Agus. (HALF-PINT Study). N Engl J Med 2017;epublished January 24th

11. ECMO
• Indications:
– cardiac surgery, cardiorespiratory failure, bridge to transplant, sepsis
• Sepsis Guidelines:
– Recommend ECMO in children with refractory septic shock or with
refractory respiratory failure associated with sepsis (2C). VA/ High flows
• Survival with ECMO:
– 73% for newborns, 39% for older children, highest VV ECMO
– 41% with respiratory failure survive to discharge
– 74% with refractory septic shock survival using VA
– 2004-2012 increasing use ECMO with improved survival
Extracorporeal therapies in pediatric severe sepsis: Crit Care. 2015; 19: 397.

12. Sepsis Guidelines: differences
• Airway: Intubation, lung protective ventilation
• Fluids:
– 20 ml/kg crystalloid (adults 30) No difference mortality crystalloid vs colloid,
– Hb: similar outcomes 7g/dL cf 9.5g/dL, Aim 7-9 g/dl,
– IVIG: reduced mortality neonates only
• Antibiotics:
<3/12 : cefotaxime/ amoxycillin, >3/12: cefotax / gent
• Sedation protocols:
– morphine, chloral, diazepam,
– not propofol, dexametatomidine, etomidate

13. Vasopressors/Inotropes
• Noradrenaline/adrenaline
Now noradrenaline then vasopressin/adrenaline
• Dobutamine/Milrinone : low CO/high SVR
• Calcium: <6 mths
• Vasopressin: low SVR
Titrate to end point reflecting perfusion, reduce or discontinue in face
of worsening hypotension or arrhythmias
• Hydrocortisone 1 mg/kg 6h
If stability not achievable with adequate fluid resuscitation/ pressors

14. CHD
• Primary: shock, cyanosis, CHF, arrhythmia
• Secondary: rheumatic, cardiomyopathy, adult CHD
• Lactate disproportionate
• ABC:
– Oxygen unless single ventricle physiology
– ?Duct dependent: Prostaglandin
– ?pulmonary hypertension: diuretics, iNO,
– Cardiomyopathy : afterload reduction, milrinone,
levosimenden
– Tetralogy: avoid dehydration, Aim high Hct

15. Single ventricle Physiology
• Balance systemic and pulmonary circulations QP/QS.
– Lactate (<2) vs saturations, (75-85%)
• Shunt dependent circulations:
– adequate filling/Hct>0.45, anticoagulation
– Spontaneous ventilation BDG/Fontan
• Circulation unbalanced:
a) Excessive Pulmonary blood flow/ Shock QP>QS  acidosis, hypotension, shock, MOF
• minimise SVR - afterload reduction
• Minimise oxygen requirements – ventilate, sedate
• Increase PVR: hypoventilate to PaCO2 = 5.3 to 6.6 kPa
b) Inadequate Pulmonary blood flow: QP,QS: Hypoxia
• Prostaglandin, Septostomy
• Increase SVR to “force” more blood into pulmonary circulation
• Reduce PVR -FiO2, alkalinise, iNO, oxygen

16. Seizures
• Management:
– Most respond to simple measures: cooling
– Intubate >60 mins
– Antibiotics: cefotaxime/vancomycin, acyclovir if focal
• Drugs:
• Benzo: Diazepam: (0.3mg/kg iv, 0.7mg/kg pr) , lorazepam 0.1 mg/kg
• Phenytoin (20 mg/kg) +/- 10 mg/kg)
• Phenobarbitone (20 mg/kg)
• Midazolam infusion (1-4 mcg/kg/min, up to 10)
– (leviteracetam) , topiramate, propofol, valproate with caution/ advice
• Imaging:
• CT : history, prolonged, focal
• MRI: NAI/ ADEM?
• Wilfong, Management of convulsive status epilepticus in children, UpToDate, Sept, 2016

17. Bronchiolitis
• Common < 2years, most RSV, beware adenovirus
• High risk: premature, CLD, cardiac disease
• Concern if HR>180, RR>80, exhaustion, apnoea
• Treatment:
– NIV, chloral hydrate, nasogastric
– Avoid bronchodilators, stimulants, ABG
• Current DAB* trial: underway
– *Dexamethasone and Adrenaline for Bronchiolitis, ANZ CTG

18. Pertussis
• High risk: <6 weeks, prem, unimmunised, wcc>40
• Malignant: HR>180, wcc> 25 x 109/L, N/L > 1.0
– Pneumonia, leukocytosis, pulmonary hypertension
– death in 75% of cases
• Management:
– a) respiratory: intubate for severe apnoea
– b) cardiac: filling, constrictors, milrinone)
– c) neurological: anticonvulsants
– d) azithromycin five days
– ? exchange transfusion: ?wcc >70-90
Pediatr Crit Care Med. 2016 Nov 1.

19. Head injury
• C Spine injuries : rare but high cervical/ SCIWORA
• TBI mechanism: Shearing, DAI common
cerebral swelling (loss of autoregulation from anoxia and impact)
axonal shearing from deceleration
Focal: haemorrhage: less common
• Management:
<6 years: ICP <18, CPP >45, `>6 years ICP <20, CPP >50
Cool to normothermia only
• Decompressive Craniectomy :
DECRA but few trials in children
Selected cases where good motor score and acute change with pupils,
?effective in reversing early neurological deterioration or herniation,
improving outcomes with refractory intracranial hypertension
Kochanek et al.: Pediatr Crit Care Med 13:Suppl 1S1–S82, 2012

20. Non- Accidental Injury
• Risk factors:
age<1, premature, disability, FH abuse, mental illness, poor support networks
• Presentation:
–subdural haemorrhage/ DAI, retinal haemorrhages, skull fracture,
–Ruptured viscera, Genital trauma, Long bone fractures <3 years old
–Unusual injuries: bites, cigarette burns, rope marks, bruises
–Neglect: malnutrition, poor hygiene, emotional disturbance
• Management:
–Clinical examination: centiles, sexual abuse, Te Pua, Medical Photography
–Skeletal survey: healed fractures
–FBC, coagulation studies (+ vWf)
–Fundoscopy by opthalmologist
–Imaging: CT <2 years if history of concern, MRI shake injury

21. Other issues in PICU:
• Tight glucose control not adopted*
– hypoglycaemia, need 4-6mg/kg/min
• Increasing use clonidine, dexmedetomidine
• Concern with benzodiazepines in neonates
• Family present throughout
• **Cochrane Database Syst Rev. 2014 Dec 18;(12)

23. Resources:
Starship Paediatric Intensive Care Clinical Guidelines
http://www.adhb.govt.nz/picu/Protocols/protocols.htm