Fuhrman & Zimmerman's Pediatric Critical Care

Inside Front Cover
Front Matter
Fuhrman & Zimmerman’s Pediatric Critical Care
Copyright
Contributors
Preface
Contents
Section I: Pediatric Critical Care: The Discipline
Chapter 1: History of pediatric critical care medicine
Pearls
Evolution of modern medicine
Anatomy and physiology
Resuscitation and ventilatory support
Contributions of specific disciplines
Pediatric anesthesiology
Pediatric general surgery and pediatric cardiac surgery
Neonatology
Pediatric cardiology
Early use of mechanical ventilation in neonates and children
Poliomyelitis and creation of the first intensive care units
Definitions
Pediatric intensive care unit
Pediatric intensivist
First pediatric intensive care units
Central role of critical care nursing
Role of pediatric anesthesiologists and pediatricians in founding pediatric critical care medicine
Growth of pediatric critical care medicine
Growth in numbers of pediatric intensive care units
Growth in training programs and education
Cost of success in pediatric critical care medicine
Around the world
High-mortality countries
Summary
Acknowledgments
Key references
Chapter 2: High-reliability pediatric intensive care unit: Role of intensivist and team in obtaining optimal outcomes
Pearls
Pediatric intensive care unit as a system
Models of critical care delivery
Structure
Process
Outcomes
Summary
References
Chapter 3: Critical communications in the pediatric intensive care unit
Pearls
Intensive care unit design
Medical record
Huddles
Checklists
Rounds
Closed-loop communication
Transitions of care
Medical training
Debriefing
Team training
Conclusion
Key references
Chapter 4: Professionalism in pediatric critical care
Pearls
Profession
The virtuous doctor
Stakes
Great paradox of the medical profession
Professionalism, the physician charter
Pediatric intensive care unit as a site for medical education and lifelong learning
References
Chapter 5: Leading and managing change in the pediatric intensive care unit
Pearls
National change day: A case study in leading change
History and development of change management
Change management in healthcare
Models and tools to facilitate change leadership and management
Theories of change
Bringing theory to practice
Tools for assessing readiness for change
Tools to implement change
Sustaining change
Conclusion
Key references
Chapter 6: Evolution of critical care nursing
Pearls
Early pediatric critical care nursing
Describing what nurses do: The synergy model
Patient characteristics of concern to nurses
Nurse competencies important to patients and families
Optimal patient outcomes
Patient-level outcomes
Provider-level and system-level outcomes
Nightingale metrics
Leadership
Beacon award
Professional development
Staff development
Orientation
Continuing education
Certification in pediatric nursing and pediatric critical care nursing
Evolution of advanced practice registered nurses into pediatric critical care
Clinical nurse specialists
Pediatric nurse practitioners
Nursing research
Summary
Key references
Chapter 7: Fostering a learning healthcare environment in the pediatric intensive care unit
Pearls
Learning healthcare system
Foundation predicated on professionalism
Pillars of a learning healthcare environment
Best-practice clinical care
Clinical research, including quality improvement
Interdisciplinary educational model
Benefits of a learning healthcare environment
Key references
Chapter 8: Challenges of pediatric critical care in resource-poor settings
Pearls
Child mortality rates
Current trends and health maintenance
Justification for critical care in resource-poor settings
State of critical and intensive care delivery in resource-limited settings
Approach to basic critical care in resource-limited settings
Cost considerations in critical care delivery
Ethics of intensive care in resource-poor settings
Strengthening critical care infrastructure
Healthcare systems
Pediatric critical care capacity building through education
Critical illness during public health emergencies
How to develop an ICU in low- to middle-income countries
Importance of critical care research in limited resource settings
Key references
Chapter 9: Public health emergencies and emergency mass critical care
Pearls
How many pediatric patients could be affected in a public health emergency?
What are the most likely public health emergencies?
Who will make decisions during an emergency?
What is the expected timeline of a public health emergency?
What is a surge and what can be done to meet surge needs?
How can the intensive care unit support the emergency department during a public health emergency?
How can all intensive care units work together?
What steps can be taken to maximize intensive care unit treatment in a disaster?
Patient spaces
Personnel
Mechanical ventilation
Manual ventilation
Equipment and supplies
Medications
How will the intensive care unit evacuate if needed?
How should pediatric patients be tracked?
How will limited services be ethically rationed?
What are the mental health considerations relevant to emergency mass critical care?
What is the role of medical learners in public health emergencies?
Conclusion
Key references
Chapter 10: Lifelong learning in pediatric critical care
Pearls
Adult learning theory in medical education
Graduate medical education
Accreditation council for graduate medical education core competencies, milestones, and entrustable professional activities
Methods of teaching
Bedside teaching
Procedural training
Simulation training
Beyond graduate medical education
Continuing medical education, board certification, and maintenance of certification
New methods of assessment and future challenges
Key references
Section II: Pediatric Critical Care: Tools and Procedures
Chapter 11: Essential concepts in clinical trial design and statistical analysis
Pearls
Purpose of a clinical trial
Clinical trial design
Getting started: Question and hypothesis
Target population: Minimizing variation versus generalizability
Power and sample size
Randomization
Blinding
Outcome selection
Mortality
Morbidity
Organ dysfunction
Resource use
Functional status
Quality of life
Composite end points
Outcome-free time
Surrogate end points
Common trial designs
Phases of clinical trials for new drug approval
Statistical analysis and reporting
Whom to analyze?
Hypothesis testing and determining the study result
Inference and estimate of effect
95% confidence interval
P values
Additional sources and mitigation of bias
Additional methods of exploring study results
Negative studies
Conclusions
Key references
Chapter 12: Prediction of short-term outcomes during critical illness in children
Pearls
Historical perspective
Methods
Conceptual framework
Statistical issues
Current prediction tools for assessment of mortality risk
Neonatal intensive care unit prediction methods
Pediatric intensive care unit prediction tools
Cardiac intensive care unit prediction tools
Additional algorithms in the public domain
Next generation: Morbidity and mortality prediction—trichotomous outcome
Morbidity assessment
Application of prediction tools in pediatric intensive care
Future directions: Predictive analytics and tools for decision support
Key references
Chapter 13: Pediatric critical care transport
Pearls
Pediatric transport systems
Specialized teams improve outcome
Components of a specialized interfacility transport team
Communications
Staffing
Equipment
Safety and quality improvement
Stresses of the transport environment
Referring hospital responsibilities
Summary
Key references
Chapter 14: Pediatric vascular access and centeses
Pearls
Intraosseous infusion
Indications
Contraindications
Supplies and equipment
Technique
Maintenance
Complications
Summary
Arterial catheter placement
Indications
Contraindications
Procedure
Technique
Maintenance of an arterial catheter
Complications
Summary
Central venous line placement
Indications and contraindications
Technique
Internal jugular vein cannulation
Subclavian vein cannulation
Femoral vein cannulation
Use of ultrasound for central venous line placement
Complications
Peripherally inserted central venous catheters
Ultrasound-assisted peripheral venous access
Venous cutdown
Umbilical arterial catheter and umbilical venous catheter placement
Supplies and equipment
Technique
Umbilical arterial cannulation
Umbilical venous cannulation
Proper placement of umbilical arterial and venous catheters
Maintenance
Removal
Complications
Umbilical arterial cannulation
Umbilical venous cannulation
Summary
Pulmonary artery catheterization
Contraindications
Procedure and equipment
Maintenance
Complications
Summary
Thoracentesis
Indications
Contraindications
Preparation
Technique
Complications
Interpretation
Summary
Tube thoracostomy
Contraindications
Supplies and equipment
Technique
Maintenance
Complications
Summary
Pericardiocentesis
Indications
Contraindications
Procedure
Monitoring for pericardiocentesis
Technique
Maintenance
Complications
Summary
Abdominal paracentesis
Indications
Contraindications
Procedure
Technique
Complications
Interpretation
Summary
Key references
Chapter 15: Ultrasonography in the pediatric intensive care unit
Pearls
Ultrasound physics and basics of image optimization
Transducers
Procedural guidance
Venous access
Arterial and peripheral intravenous access
Umbilical access
Drainage procedures
Lumbar puncture
Diagnostic modalities
Pulmonary ultrasound
Abdominal ultrasound
Right upper quadrant (fig. 15.18a)
Left upper quadrant (fig. 15.18b)
Pelvis (figs. 15.18c and 15.18d)
Subcostal cardiac (fig. 15.18e)
Cardiac ultrasound
Pericardiocentesis
Left ventricular function
Right ventricular function
Cardiac arrest
Neurosonology
Translation to practice
Conclusion
Key references
Section III: Pediatric Critical Care: Psychosocial and Societal
Chapter 16: Patient- and family-centered care in the pediatric intensive care unit
Pearls
Definition of “family”
Historical evolution of patient- and family-centered care
Fundamental needs of patients and families in the intensive care unit
Core principles of patient- and family-centered care1,12
Honoring differences and respecting each child and family
Maintaining flexibility in practice and procedures to deliver healthcare within the context of the family
Geography of the intensive care unit
Admission process and visiting hours
Creating a “personalized” room
Sibling participation
Parental presence during cardiopulmonary resuscitation and invasive procedures
Transition points and follow-up care, including bereavement
Sharing information using collaborative communication
Elements of high-quality communication
Family-centered rounds
Structured transdisciplinary care conferences
Providing transdisciplinary support for the family unit
Collaborating and building partnerships with patients and families
Empowering patients and families to facilitate shared medical decision-making
Patient- and family-centered care improves outcomes for all stakeholders
Overcoming barriers and challenges to patient- and family-centered care in the intensive care unit
Summary
Key references
Chapter 17: Pediatric critical care ethics
Pearls
Defining bioethics
Examples of ethical issues in the pediatric intensive care unit
Domains of bioethics
Value-based decision-making
State and national laws and legal precedence
Professional codes and healthcare organization policies and regulations
Communication, negotiation, and mediation
Prevailing ethical theories and norms
Who should address ethical issues in the pediatric intensive care unit?
Critical care team
Ethics consultant
Ethics committee
Approach to bioethics dilemmas in the pediatric intensive care unit
Recognition and clarification of ethical issues
Information gathering
Analysis of ethical issues
Consequentialism
Deontology
Principalism
Virtue-based ethics
Casuistic ethics
Care ethics
Narrative ethics
Communitarian ethics
Communication of recommendations
Support
Address staff distress
Support the patient and family
Ethics of patient and surrogate decision-making
Patient decision-making
Doctrine of informed consent
Emergency exception to informed consent
Advance directives
Child and adolescent decision-making
Shared decision-making
Surrogate decision-making
Surrogate decision-making for previously competent patients
Surrogate decision-making for never-competent patients
Parents as surrogate decision-makers
Limits of parental refusals
Limits of parental demands
Other ethical issues in the pediatric intensive care unit
Research ethics
Resource allocation
Ethical issues at the end of life
Limits to clinician refusals
Medical training
Use of unproven medical therapies
Global health
Medical errors
Relationship boundaries
Preventive ethics
Goals for the ethical practice of the intensivist
Key references
Chapter 18: Ethical issues around death and dying
Pearls
Decision-making at the end of life
Requests for potentially inappropriate treatments in the intensive care unit
Withholding and withdrawing of life-sustaining treatments
Administration of analgesics and sedatives in end-of-life care
Is there a role for neuromuscular blockade in end-of-life care?
Artificial hydration and nutrition
Key references
Chapter 19: Palliative care in the pediatric intensive care unit
Pearls
Palliative care consults in the pediatric intensive care unit
Communication
Suboptimal communication in the intensive care unit
Families with limited english proficiency
Family meeting as an intensive care unit “procedure”
Communication pearls
Phrases to avoid
Limitation of interventions
Do not attempt resuscitation orders
Hospice support in the home
Compassionate extubation
Pain and symptom management
Medication management
Opioids
Methadone
Other pharmacologic agents
Symptom management
Pain
Dyspnea
Agitation and anxiety
Nausea and vomiting
Seizures
Bowel obstruction
Palliative sedation
Care of family and staff after a child’s death
Key references
Chapter 20: Organ donation process and management of the organ donor
Pearls
Process of organ donation
Role of the pediatric intensivist and critical care team in the process of organ donation
Determination of neurologic death
Testing for apnea
Ancillary studies
Brain death physiology
Pediatric donor management
Treatment of hemodynamic instability
Hormonal replacement therapy
Management of pulmonary issues for the potential pediatric organ donor
Fluid and electrolyte disturbances
Diabetes insipidus
Oliguria
Coagulation abnormalities
Thermoregulatory instability
Medical examiner and coroner issues and organ donation for children
Donation after circulatory death
Contraindications to organ donation
Evolving areas of transplantation
Summary
Key references
Chapter 21: Long-term outcomes following critical illness in children
Pearls
Post–intensive care syndrome
Health-related quality of life
Assessing change from baseline
Summary of outcomes in general pediatric intensive care unit populations
Hospital readmission and late mortality
Health-related quality of life
Functional status
Neurocognitive status
Mental health
Family functioning
Outcomes for common pediatric intensive care unit illness categories
Respiratory failure
Sepsis
Trauma
Extracorporeal life support
Examples of postdischarge outcomes in pediatric interventional trials
Strategies to assess long-term outcomes
Strategies to improve follow-up
Follow-up programs for intensive care unit survivors
Other initiatives
Potential targets for interventions
Conclusion
Key references
Chapter 22: Burnout and resiliency
Pearls
Burnout and compassion fatigue in pediatric critical care providers
Critical care societies work to address burnout
Strategies for building resilience
Promoting a healthy work environment
Summary
Key references
Section IV: Pediatric Critical Care: Cardiovascular
Chapter 23: Structure and function of the heart
Pearls
Anatomic development and structure
Segmental anatomy
Innervation of the heart
Ductus arteriosus
Development of the human heart
Microscopic anatomy
Cardiomyocyte
Contractile apparatus
Sarcolemma and sarcoplasmic reticulum
Cytoplasm
Cytoskeleton and extracellular matrix
Physiologic development and function
Myocardial mechanics: Cardiac sarcomere function
Excitation-contraction coupling
Sarcomere length-tension relationships
Myocardial mechanics: Myocardial receptors and responses to drugs
Myocardial mechanics: Integrated muscle function
Relationship between muscle strips and intact ventricles
Pressure-volume loops
Assessing myocardial contractility: Systolic ventricular function
Isovolumic phase indices
Ejection phase indices
Assessing myocardial relaxation: Diastolic ventricular function
Pericardial function
Ventricular interactions
Neural control of the heart
Cardiac output
Myocardial metabolism: Normal myocardial energy metabolism
Basic metabolic processes
Determinants of myocardial oxygen consumption
Myocardial oxygen demand-supply relationship
Effects of myocardial ischemia on cardiac function and metabolism
Systemic vasculature
General anatomy
Physiologic mechanisms
General features
Control of vascular tone
Autoregulation
Key references
Chapter 24: Regional peripheral circulation
Pearls
General features
General anatomy
Basic physiology
Venous return and cardiac output
Critical closing pressure
Autoregulation
Distensibility and compliance
Vascular resistance
Vascular impedance
Local regulatory mechanisms
Innervation and neural processes
Circulating endocrine and neuroendocrine mediators
Local metabolic products
Blood gas composition
Endothelial-derived factors
Myogenic processes
Regional circulations
Pulmonary circulation
Normal fetal circulation
Changes in the pulmonary circulation at birth
Regulation of postnatal pulmonary vascular resistance
Cerebral circulation
Coronary circulation
Myocardial oxygen demand-supply relationship
Gastrointestinal circulation
Renal circulation
Conflicting needs of regional circulations
Key references
References
Chapter 25: Endothelium and endotheliopathy
Pearls
Normal endothelial function
Endothelial cell heterogeneity
Endothelial progenitor cells
Coagulation and fibrinolysis
Anticoagulant mechanisms
Procoagulant mechanisms
Endothelium-derived vasodilators
Nitric oxide
Prostacyclin
Endothelium-derived hyperpolarizing factor
Endothelium-derived vasoconstrictors
Endothelins (endothelium-derived contracting factors)
Reactive oxygen species
Vasoconstrictor prostaglandins
Endothelium and blood cell interactions
Interactions of leukocytes with the vessel wall
Platelet adhesion
Endothelial permeability
Endothelial cell dysfunction
Ischemia-reperfusion injury
Sepsis
Hemolytic-uremic syndrome
Vasculitic disorders
Biomarkers of endothelial activation
Conclusions
Key references
Chapter 26: Principles of invasive cardiovascular monitoring
Pearls
Role of invasive hemodynamic monitoring
Indications for invasive hemodynamic measurements
Principles of measurement
Signal analysis
Measurement systems
Errors in measurement
Calibration
Frequency response
Impedance
Invasive techniques
Central venous catheters
Indications
Interpretation of waveforms
Mixed venous oxygen saturation
Arterial pressure catheters
Indications
Interpretation of waveforms
Pulmonary artery catheters
History and controversy
Indications
Monitoring techniques with the pulmonary artery catheter
Catheter placement
Indirectly measured variables
Measurement of cardiac output
Fick method
Thermodilution method
Calculation of oxygen delivery and consumption
Interpretation of waveforms
Resistance
Calculation of intracardiac shunt
Novel monitoring strategies
Conclusions
Key references
Chapter 27: Assessment of cardiovascular function
Pearls
Cardiovascular function
Quantity of therapy
Variables that determine tissue oxygenation
Monitoring tissue oxygenation
Qualitative assessment of cardiac output
Physical examination
Chest radiography
Quantitative assessment of cardiac output
Thermodilution technique
Fick method
Doppler echocardiography
Pulse oximetry
Other measures of oxygen delivery
Acid-base status
Blood lactate
Serum biomarkers
Gastric tonometry
Urine output
Near-infrared spectroscopy
Systemic arterial blood pressure
Invasive blood pressure monitoring
Noninvasive blood pressure monitoring
Central venous or intracardiac pressure monitoring
High-frequency physiologic data capture and streaming analytics
Assessing variables that affect the quantity of therapy
Ventricular systolic function
Ventricular diastolic function
Rhythm disturbance
Abnormal systemic vascular resistance
Increased pulmonary vascular resistance
Inefficient circulation
Vascular integrity
Pulmonary function
Physiology of the patient with a single ventricle
Key references
Chapter 28: Cardiac failure and ventricular assist devices
Pearls
Pediatric heart failure
Low cardiac output syndrome
Definitions
Assessment
Specific treatments to improve cardiac function
Broad treatment strategies
Mechanical circulatory support in pediatric patients
Extracorporeal life support
Extracorporeal membrane oxygenation indications and contraindications
Myocarditis and extracorporeal life support
Postcardiopulmonary bypass
Extracorporeal cardiopulmonary resuscitation
Bridge to transplantation
Malignant dysrhythmias
Contraindications
Critical care management during extracorporeal life support
Cardiac output
Troubleshooting
Hypovolemia
Hypertension
Cardiac stun
Echocardiography and cardiac catheterization
Single ventricle
Anticoagulation strategies
Ventilation strategies
Fluid, nutrition, and renal
Analgesia and sedation
Infection
Intrahospital transport
Ventricular assist devices
Pulsatile ventricular assist devices
Continuous-flow ventricular assist devices
Short- to medium-term ventricular assist device support
Long-term ventricular assist device support
Total artificial heart
Device selection
Indications and management
Basic management of ventricular assist device patients
Anticoagulation and antiplatelets
Antibiotic prophylaxis
Care of the drive line and cannulas
Ventricular assist device—congenital heart disease and single-ventricle physiology
Outcomes
Intraaortic balloon pump and impella device
Current perspective and future directions
Conclusions
Key references
Chapter 29: Echocardiographic imaging
Pearls
Components of the examination
Modalities
Transthoracic echocardiography
Transesophageal echocardiography
Fetal echocardiography
Intracardiac echocardiography
Cross-sectional imaging
Point-of-care ultrasound
Structural congenital heart disease and intracardiac shunting
Valve anatomy and function
Ventricular function
Assessing volume status
Assessing diastolic function
Assessing systolic function
Left ventricular systolic function
Right ventricular systolic function
Systolic function: Strain
Pulmonary hypertension
Pericardial effusion
Intracardiac vegetations and thrombi
Kawasaki disease and coronary artery anomalies
Intravascular catheters
Balloon atrial septostomy
Extracorporeal membrane oxygenation and ventricular assist devices
Key references
Chapter 30: Diagnostic and therapeutic cardiac catheterization
Pearls
Catheterization laboratory environment
Diagnostic cardiac catheterization
Oxygen saturation
Pressure assessment
Flow calculations
Estimating shunts
Resistance calculations
Angiography
Indications
Pulmonary vascular resistance and vasoreactivity testing
Therapeutic cardiac catheterization
Pericardiocentesis
Atrial septostomy
Pulmonary balloon valvuloplasty
Balloon aortic valvuloplasty
Balloon dilation of pulmonary arteries
Occlusion device insertion
Native and recurrent coarctation of the aorta
Ductal stenting
Hybrid stage I palliation for hypoplastic left heart syndrome
Transcatheter pulmonary valve replacement
Risks and complications
Preprocedural risk stratification
Cardiac catheterization and extracorporeal membrane oxygenation
Conclusion
Key references
Chapter 31: Pharmacology of the cardiovascular system
Pearls
Mechanisms of response
Adrenergic receptors
Signal transduction
β-adrenergic receptors
α-receptors
Receptor downregulation
Polymorphisms
Vasopressin receptors
V1 receptors
Phosphodiesterase regulation of cyclic adenosine monophosphate
Atpase inhibition
Developmental issues
Sympathomimetic amines
Dopamine
Basic pharmacology
Clinical pharmacology
Pharmacokinetics
Clinical role
Adverse effects
Preparation and administration
Interactions
Summary
Norepinephrine
Basic pharmacology
Clinical pharmacology
Pharmacokinetics
Clinical role
Adverse effects
Preparation and administration
Interactions
Summary
Epinephrine
Basic pharmacology
Clinical pharmacology
Pharmacokinetics
Clinical role
Preparation and administration
Adverse effects
Interactions
Summary
Isoproterenol
Basic pharmacology
Clinical pharmacology
Pharmacokinetics
Clinical role
Preparation and administration
Adverse effects
Interactions
Summary
Dobutamine
Basic pharmacology
Clinical pharmacology
Pharmacokinetics
Clinical role
Preparation and administration
Adverse effects
Interactions
Summary
Vasopressin
Basic pharmacology
Clinical pharmacology
Pharmacokinetics
Clinical role
Dosing and administration
Adverse effects
Interactions
Summary
Bipyridines
Milrinone
Clinical pharmacology
Pharmacokinetics
Clinical role
Preparation and administration
Adverse effects
Summary
Digitalis glycosides
Basic pharmacology
Clinical pharmacology
Pharmacokinetics
Clinical role
Preparation and administration
Adverse effects
Interactions
Summary
Conclusion
Key references
Chapter 32: Cardiopulmonary interactions
Pearls
Effects of ventilation on circulation
Right ventricular filling and stroke volume
Systemic venous return
Right ventricular preload and stroke volume
Positive pressure ventilation and right ventricular preload
Critical illness and the effects of positive pressure breathing on rv preload
Respiration and right ventricular afterload
Lung volume
Alveolar pressure
Regulation of pulmonary vascular resistance
Direct effects of airway pressure on pulmonary vascular tone
Respiration and left ventricular preload
Ventricular interdependence
Respiration and left ventricular afterload
Cardiac contractility
Preload dependence versus afterload dependence
Fluid responsiveness during positive pressure ventilation
Pulsus paradoxus in respiratory distress
Positive-pressure ventilation and right ventricular output in acute respiratory distress syndrome
Effects of cardiovascular function on respiration
Shock states and respiratory function
Elevated work of breathing and the circulation
Congestive heart failure/critical heart failure and shock
Cardiomyopathies and congenital heart disease
Glenn and fontan procedures
Key references
Chapter 33: Disorders of cardiac rhythm
Pearls
Classification of arrhythmias
Bradycardias
Appropriate versus normal heart rate
Sinus bradycardia and sinus pauses
Atrioventricular block
Escape rhythms and accelerated rhythms
Tachycardias
Tachycardia mechanisms
Supraventricular tachycardias
Atrioventricular reciprocating tachycardias (AV reentry)
Atrioventricular nodal reentrant tachycardia
Primary atrial tachycardias
Junctional ectopic tachycardia
Ventricular tachycardias
Approach to diagnosis
Monitoring and general assessment
Surface electrocardiogram and bedside monitoring
Bradycardias
Extrasystoles
Tachycardias with normal QRS
Tachycardias with prolonged QRS
Assessment of atrial activation
Diagnostic uses of adenosine
Treatment of rhythm disturbances
Bradycardia therapies
Pharmacologic treatment of bradycardias
Temporary and permanent pacing for bradycardias
Principles of pacing
Temporary pacing
Setting temporary pacing parameters
Permanent pacing—indications and selection
Other indications for pacing
Tachycardia therapies
Vagal maneuvers
Acute pharmacologic therapies
Adenosine
Antiarrhythmic agents
Procainamide. 
Lidocaine. 
β-blocking agents. 
Amiodarone. 
Other QT prolonging (class III) antiarrhythmic drugs
Intravenous sotalol. 
Ibutilide. 
Calcium channel–blocking agents
Magnesium sulfate
Digoxin
Dexmedetomidine
Ivabradine
Cardioversion and defibrillation
Approach to therapy
Extrasystoles
Sustained tachycardias
Unstable patients
Treatment failure
Errors in diagnosis
Unrecognized termination and reinitiation
Improper technique
Specific arrhythmias
Primary arrhythmias
Orthodromic reciprocating tachycardia in infancy
Tachycardia-induced cardiac dysfunction
Chaotic atrial tachycardia
Long QT syndromes
Idiopathic ventricular tachycardias in healthy patients
Bidirectional polymorphic ventricular tachycardias
Secondary rhythm disturbances
Postoperative arrhythmias
Postsurgical atrioventricular block
Junctional ectopic tachycardia
Late postoperative arrhythmias
Metabolic derangements
Electrolyte disturbances
Endocrine disorders (thyroid)
Central nervous system injury
Hypothermia and hyperthermia
Acute myocardial infarction
Arrhythmias resulting from drug toxicity
Digoxin
Cocaine
Tricyclic antidepressants and phenothiazine
Infections
Key references
Chapter 34: Shock states
Definition and physiology
Functional classification and common underlying etiologies
Hypovolemic shock
Cardiogenic shock or congestive heart failure
Obstructive shock
Distributive shock
Septic shock
Endocrine
Mitochondrial
Multisystem effects of shock
Respiratory
Renal
Coagulation
Hepatic
Gastrointestinal
Endocrine
Monitoring
Fick equation for oxygen consumption
Contemporary cardiac output monitoring in pediatric shock
Treatment
General principles
Intubation and mechanical ventilation
Fluid resuscitation
Vasoactive infusions
Age-related therapy concerns
Specific shock state therapy considerations
Hypovolemic shock
Cardiogenic shock
Obstructive shock
Distributive shock
Septic shock
Other therapies
Summary
Key references
Chapter 35: Pediatric cardiopulmonary bypass
Pearls
Background
History
Surgical team
Equipment and preparation for cardiopulmonary bypass
Heart-lung machine console and pumps
Cardiopulmonary bypass circuit
Oxygenators
Tubing
Hemoconcentrators
Circuit prime
Anticoagulation
Cannulation
Cardiopulmonary bypass
Pediatric VS. adult considerations
Initiation of cardiopulmonary bypass
Determining and monitoring effective perfusion flow rate
Arterial pressure
Arterial and venous oxygen saturation
Near-infrared spectroscopy
Methods to optimize physiologic management
Target hematocrit and ultrafiltration
Hypothermia
Deep hypothermic circulatory arrest VS antegrade cerebral perfusion
Ph and partial pressure of arterial carbon dioxide strategy
Myocardial protection
Inflammatory response to cardiopulmonary bypass
Termination of cardiopulmonary bypass
Key references
Chapter 36: Critical care after surgery for congenital cardiac disease
Pearls
Neonatal considerations
Preoperative care
Severe hypoxemia
Excessive pulmonary blood flow
Obstruction of left heart outflow
Ventricular dysfunction
Postoperative care
Assessment
Monitoring
Low cardiac output syndrome
Volume adjustments
Preserving and creating right-to-left shunts
Other strategies
Mechanical cardiac support
Right ventriculotomy and restrictive physiology
Diastolic dysfunction
Pharmacologic support
Managing acute pulmonary hypertension in the intensive care unit
Pulmonary vasodilators
Management of postoperative bleeding
Cardiac tamponade
Diaphragmatic dysfunction, effusions, and pulmonary issues
Chylothorax
Separating from mechanical ventilation
Central nervous system
Renal function and postoperative fluid management
Gastrointestinal issues
Infection
Hyperglycemia
Critical care management of selected specific lesions
Single-ventricle anatomy and physiology
Neonatal preoperative management
Postoperative management
Bidirectional cavopulmonary anastomosis
Fontan procedure
Complications after the fontan procedure
Pleuropericardial effusions
Rhythm disturbances
Premature closure of the fenestration
Persistent hypoxemia
Low cardiac output state
Patent ductus arteriosus
Pathophysiology
Critical care management
Atrial septal defect
Pathophysiology
Critical care management
Ventricular septal defect
Pathophysiology
Critical care management
Critical care management for late postoperative care
Atrioventricular canal defects
Pathophysiology
Critical care management
Truncus arteriosus communis
Pathophysiology
Critical care management
Critical care management for late postoperative care
Total anomalous pulmonary venous connection
Pathophysiology
Critical care management
Critical care management for late postoperative care
Transposition of the great arteries
Pathophysiology
Atrial switch procedure (mustard and senning)
Arterial switch operation (jatene procedure)
Ventricular switch (rastelli procedure)
Critical care management
Late complications
Tetralogy of fallot
Pathophysiology
Critical care management for the early postoperative course
Critical care management for late postoperative care
Pulmonary atresia
Pathophysiology
Critical care management
Critical care management for late postoperative care
Tricuspid atresia
Pathophysiology
Critical care management
Left-sided obstructive lesions
Pathophysiology
Aortic stenosis
Coarctation of the aorta
Interrupted aortic arch
Hypoplastic left heart syndrome
Pathophysiology
Critical care management
Postoperative management
Evolution of treatment strategies. 
Specific considerations for the norwood operation. 
Hybrid approach. 
Summary
Acknowledgment
Key references
Chapter 37: Cardiac transplantation
Pearls
Background
Indications for transplant
Transplant evaluation
Panel reactive antibody
Transplant listing
Management of the potential heart transplant recipient
Anticoagulation
Abo-incompatible listing and transplantation
Critical care management of the orthotopic heart transplant recipient
Intraoperative considerations
Early perioperative management
Management of early heart allograft dysfunction
Immunosuppression and heart allograft rejection
Complications of immunosuppression in heart transplant recipients that occur in the pediatric intensive care unit
Infection
Renal function
Diabetes mellitus
Future management strategies for critical care of infants and children with cardiopulmonary failure
Key references
Chapter 38: Physiologic foundations of cardiopulmonary resuscitation
Pearls
Mechanisms of blood flow
Cardiac versus thoracic pump mechanism
Rate and duty cycle
Chest geometry
Effects of cardiopulmonary resuscitation on intracranial pressure
Newer cardiopulmonary resuscitation techniques
Abdominal binding
Open-chest cardiopulmonary resuscitation
Cardiopulmonary bypass and extracorporeal cardiopulmonary resuscitation
Transcutaneous cardiac pacing
Pharmacology
Adrenergic agonists
Vasopressin
High-dose epinephrine
Atropine
Sodium bicarbonate
Other alkalinizing agents
Calcium
Glucose
Management of ventricular fibrillation
Defibrillation
Antiarrhythmics
Postresuscitation care
Future directions
Key references
Chapter 39: Performance of cardiopulmonary resuscitation in infants and children
Pearls
Four phases of cardiac arrest
Prearrest
No-flow/low-flow
Postarrest
Epidemiology of pediatric cardiac arrest
Optimizing blood flow during cardiopulmonary resuscitation
Pediatric cardiopulmonary resuscitation targets
Chest compression depth
Chest compression rate
Chest compression fraction/minimizing interruptions
Duty cycle
Airway and breathing management during cardiopulmonary resuscitation
Physiologic targets
Arterial blood pressure
End-tidal carbon dioxide
Medications used to treat cardiac arrest
Vasopressors
Epinephrine
Vasopressin
Antiarrhythmics
Amiodarone versus lidocaine
Other medications
Calcium
Sodium bicarbonate
Postarrest interventions
Targeted temperature management
Anticipation and prevention of hypotension
Postarrest oxygenation and ventilation management
Monitoring for and treating seizures
Other considerations
Contemporary methods to improve cardiopulmonary resuscitation quality
Intra-arrest cardiopulmonary resuscitation quality monitoring technology
Point-of-care bedside training
Extracorporeal cardiopulmonary resuscitation
Controversies in pediatric cardiac arrest management
Airway management
Ventilation during pediatric cardiopulmonary resuscitation
Ventricular fibrillation and pulseless ventricular tachycardia
Pediatric automated external defibrillators
Summary
Key references
Section V: Pediatric Critical Care: Pulmonary
Chapter 40: Structure and development of the upper respiratory system
Pearls
Developmental anatomy of the upper airway
Anatomy and physiology of the upper airway
Nasal passages
Mouth (oral cavity) and pharynx
Larynx
Trachea and bronchi
Acknowledgment
Key references
Chapter 41: Structure and development of the lower respiratory system
Pearls
Lower respiratory system
Overview of the lungs
Airways
Definitions of special lung unit and alveolar formation
Alveolar-capillary unit
Lung circulation
Pulmonary vascular system
Bronchial vascular system
Pulmonary lymphatics and bronchus-associated lymphoid tissue
Diaphragm
Summary
Key references
Chapter 42: Physiology of the respiratory system
Pearls
Physiology of the respiratory system
Boyle’s law
Equation of motion of the respiratory system
Transmural pressures
Central nervous system control
Respiratory centers and efferent nerve transmission to the respiratory muscles
Receptors and feedback to the respiratory centers
Higher states
Extrathoracic upper airways
Anatomic considerations for the pediatric upper airway
Ohm’s law and poiseuille’s law
Turbulent versus laminar flow (reynolds number)
Transmural pressure (collapse of upper airway)
Inspiratory flow limitation
Intrathoracic compartment
Flow resistance of the respiratory system
Anatomic considerations for pediatric lower airways
Reactivity of lower airways
Transmural pressure in the presence of lower airway obstruction
Identifying expiratory flow limitation
Administration of positive end expiratory pressure to prevent collapse
Time constants
Elastic properties of the respiratory system
Respiratory system and lung compliance
End-expiratory lung volume and compliance
Functional residual capacity, closing capacity, and age
Work of breathing
Extrathoracic space
Gas exchange
Ventilation-perfusion relationships
Hypoxemia
Hypercarbia
Diffusion of oxygen and carbon dioxide
Key references
Chapter 43: Noninvasive respiratory monitoring and assessment of gas exchange
Pearls
Pulse oximetry
Principles of pulse oximetry
Validation
Sources of error
Probe placement
Tissue oximetry
Near-infrared spectroscopy
Capnometry and capnography
Operating principles of capnometry
Clinical and technical issues
Gas sampling issues
Physiologic basis
Dead space ventilation
Differential diagnosis of abnormal capnograms
Gradually decreasing end-tidal carbon dioxide concentration
Sustained low end-tidal carbon dioxide concentrations without plateaus
Sustained low end-tidal carbon dioxide concentration with good plateaus
Exponential decrease in end-tidal carbon dioxide
Gradual increase in both baseline and end-tidal carbon dioxide
Clinical applications
Transcutaneous monitoring
Oxygen monitoring
Carbon dioxide monitoring
Conclusion
Key references
Chapter 44: Overview of breathing failure
Pearls
Physiology of breathing
Controls of breathing
Respiratory pump
Diaphragm
Intercostal muscles
Accessory muscles of respiration
Breathing failure
Failure of respiratory controls
Recognizing depressed respiratory drive
Failure of neural control
Structural brain lesions
Nonstructural acquired disorders
Chronic respiratory failure
Structural brain lesions
Nonstructural congenital disorders
Nonstructural acquired chronic disorders
Respiratory pump failure
Respiratory plegia, paralysis, and tetany
Muscle exhaustion
Failure of mechanics of breathing
Terminal failure of respiratory control and mechanics
Restrictive versus obstructive respiratory disease
Compensatory mechanisms in breathing failure
Compensatory mechanisms in restrictive lung disease
Compensatory mechanisms with obstructive lung disease
Special conditions
Infancy
Sleep
Thoracic dysfunction
Altered nutritional states: Malnutrition and obesity
Conclusion
Acknowledgments
Key references
Chapter 45: Ventilation/perfusion inequality
Pearls
Distribution of ventilation
Distribution of perfusion
Fractal model of pulmonary blood flow and ventilation
Va/q abnormalities in pulmonary disease
Hypoxemia
Pediatric acute respiratory distress syndrome
Pneumonia
Pleural effusion
Asthma
Pulmonary embolism
Primary pulmonary hypertension
Therapeutic considerations
Positive end-expiratory pressure
Prone positioning
Nitric oxide
Measuring pulmonary ventilation/perfusion
Key references
Chapter 46: Mechanical dysfunction of the respiratory system
Pearls
Pump dysfunction and failure
Pressures
Lung volumes and capacities
Flow/volume relationships
Equation of motion
Resistive forces
Static and dynamic compliance
Airway dynamics
Time constant
Work of breathing
Clinical manifestations of mechanical dysfunction
Effectors of the respiratory pump
Accessory muscles of respiration
Chest wall
Disease of the chest wall
Therapeutic maneuvers to improve mechanical dysfunction of the respiratory system
Positive end-expiratory pressure/continuous positive airway pressure
Rate
Tidal volume
Inspiratory and expiratory times
Inspiratory flow patterns
Key references
Chapter 47: Diseases of the upper respiratory tract
Pearls
Anatomy and physiology
Diagnosis and management
Congenital malformations of the upper airway
Choanal atresia
Laryngomalacia
Laryngeal webs and atresia
Laryngeal cysts
Laryngeal clefts
Vocal cord paralysis
Vascular compression of the trachea
Neoplasms of upper airway disease
Laryngeal papillomatosis
Hemangiomas
Other tumors of the larynx and upper airway
Croup
Epiglottitis
Bacterial tracheitis
Peritonsillar abscess
Retropharyngeal abscess
Iatrogenic and acquired disorders of the upper airway
Laryngotracheal (subglottic) stenosis
Pediatric tracheostomy
Foreign body aspiration
Burn injury to the upper airway
Airway trauma
Key references
Chapter 48: Pediatric acute respiratory distress syndrome and ventilator-associated lung injury
Key words:
Pearls
Clinical features: Pathophysiology
Definition
Epidemiology
Pathobiology
Exudative phase
Direct injury
Indirect injury
Alveolar fluid clearance
Leukocytes and inflammation
Surfactant
Coagulation
Apoptosis
Fibrosis and repair phase
Ventilator management
Considerations for ventilator mode
Tidal volume
Peak or plateau pressure
Positive end-expiratory pressure
Nonconventional ventilation strategies
Ventilator-associated lung injury
Pulmonary ancillary therapies
Exogenous surfactant
Preclinical or adult data
Pediatric data
Nitric oxide
Physiologic rationale
Preclinical and adult studies
Pediatric
Nonpulmonary therapies
Prone positioning
Physiologic rationale
Adult data
Pediatric data
Monitoring
Noninvasive support
Extracorporeal life support
Key references
Chapter 49: Acute viral bronchiolitis
Key words:
Pearls
Microbiology
Epidemiology and risk factors
Pathophysiology
Clinical features and diagnosis
Prevention
Treatment
Hypertonic saline
Inhaled bronchodilators
Corticosteroids
Hydration and nutritional support
Other inhaled therapies
Other systemic therapies
Respiratory support
High-flow nasal cannula
Continuous positive airway pressure
Invasive mechanical ventilation
Other respiratory support
Complications
Key references
Chapter 50: Asthma
Pearls
Epidemiology and risk factors
Pathophysiology
Clinical assessment
History
Physical examination
Radiography
Laboratory data
Arterial blood gas analysis
Electrolytes and complete blood cell count
Muscle enzymes
Electrocardiography
Spirometry
Treatment
Initial management in the emergency department
Admission criteria
Management in the intensive care unit
General
Oxygen
Fluids
Corticosteroids
β-agonists
Albuterol
Terbutaline
Anticholinergic agents
Magnesium sulfate
Methylxanthine agents
Helium-oxygen mixtures
Ketamine
Mechanical ventilation
Indications
Noninvasive ventilation
Intubation
Ventilator settings
Ventilatory monitoring
Analgesia, sedation, and muscle relaxation
Inhalational anesthetic agents
Antibiotics
Bronchoscopy
Extracorporeal life support
Prognosis
Key references
Chapter 51: Neonatal pulmonary disease
Pearls
Acute respiratory disorders
Transient tachypnea of the newborn
Surfactant-deficient respiratory distress syndrome
Pulmonary air leak syndromes
Pulmonary hemorrhage
Pneumonia
Meconium aspiration syndrome
Immature respiratory control
Biological maturational considerations
Apnea of prematurity
Therapeutic options
Pulmonary malformations
Pulmonary hypoplasia
Congenital diaphragmatic hernia
Congenital pulmonary airway malformation
Bronchogenic cysts
Pulmonary parenchymal cysts
Pulmonary sequestrations
Congenital lobar emphysema
Pulmonary agenesis and aplasia
Congenital defects of the lymphatics
Nonpulmonary causes of respiratory distress
Choanal atresia/stenosis
Laryngomalacia
Vocal cord paralysis
Airway vascular tumors/malformations
Tracheobronchomalacia
Tracheoesophageal fistula
Vascular compression
Phrenic nerve paralysis
Eventration of the diaphragm
Pleural effusion
Congenital anomalies of the chest wall
Persistent pulmonary hypertension of the neonate
Hyperviscosity syndrome
Congenital heart disease
Metabolic disorders
Intestinal or renal bicarbonate wasting
Neonatal chronic lung disease of prematurity: Bronchopulmonary dysplasia
Neonatal chronic lung disease: Primary ciliary dyskinesia
Acknowledgment
Key references
Chapter 52: Pneumonitis and interstitial disease
Pearls
Pathogenesis
Pathophysiology
Diagnosis
Laboratory diagnosis
Bacterial pneumonitis
Definition
Pathophysiology
Clinical features
Radiographic features
Diagnosis
Specific pathogens
Group b streptococci
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcal pneumonia
Mycoplasma pneumonia
Gram-negative bacteria
Legionella pneumophila
Anaerobic bacteria
Complications
Therapy
Viral pneumonitis
Pathophysiology
Diagnosis
Radiographic findings
Specific pathogens
Respiratory syncytial virus
Parainfluenza virus
Adenovirus
Influenza
Measles
Human immunodeficiency virus
Complications
Diagnosis
Prevention and treatment
Vaccination
Chemoprophylaxis
Therapy
Fungal pneumonitis
Primary pulmonary fungi
Pathogenesis
Histoplasmosis
Diagnosis
Complications
Treatment
Blastomycosis
Diagnosis
Complications
Treatment
Coccidioidomycosis
Diagnosis
Complications
Treatment
Opportunistic pulmonary mycoses
Pulmonary aspergillosis
Diagnosis
Complications
Treatment
Pulmonary candidiasis
Pathogenesis
Diagnosis
Complications
Treatment
Pneumocystis jirovecii pneumonia
Clinical features
Diagnosis
Complications
Treatment
Chemical pneumonitis
Aspiration pneumonia
Pathophysiology
Clinical findings
Treatment
Inhalation injury
Pathogenesis
Clinical findings
Treatment
Prognosis
Ingestion/injection of pharmacologic agents
Diagnosis/clinical findings
Idiopathic interstitial lung disease
Pediatric pulmonary hemorrhage
Definition
Pathophysiology
Etiology
Diffuse/nonimmune pulmonary hemorrhage
Diffuse/immune pulmonary hemorrhage
Focal pulmonary hemorrhage
Treatment
General
Specific
Summary
Key references
Chapter 53: Diseases of the pulmonary circulation
Pearls
Definition and classification
Pathology of pulmonary hypertension
Diagnostic evaluation of pulmonary hypertension/pulmonary vascular disease
Pharmacotherapy
Prostacyclin (pgi2) analogs
Endothelin receptor antagonists
Phosphodiesterase 5 inhibitors
Calcium channel blockers
Pulmonary hypertension in the context of specific diseases
Group 1 pulmonary arterial hypertension
Isolated pulmonary arterial hypertension
Autoimmune disorders
Infectious diseases
Group 2 pulmonary arterial hypertension (cardiac disease)
Group 3 pulmonary arterial hypertension (intrinsic pulmonary diseases)
Pulmonary arterial hypertension due to parenchymal lung disease
Pulmonary hypertension secondary to bronchopulmonary dysplasia
Diagnostic ph evaluation in BPD
Bpd-specific therapies
Congenital diaphragmatic hernia
General management of cdh
Ph-specific therapy in cdh
Cystic fibrosis
Diffuse lung disease
Pulmonary hypertension secondary to acute respiratory distress syndrome
Group 5 pulmonary hypertension
Chronic hemolytic anemia
Acute pulmonary hypertension crisis/right ventricular failure
Right ventricular dysfunction in pulmonary hypertension
Adaptive versus maladaptive right ventricular hypertrophy
Sympathetic activation in pulmonary arterial hypertension
Right ventricle ischemia
Metabolism in right ventricular hypertrophy
Right ventricle inflammation and fibrosis
Recent advances in molecular mechanisms and novel therapeutic targets in pulmonary hypertension
Genetic predisposition
Growth factors and apoptosis resistance
Inflammation
Noncalcium ion channels
Transcription factors and transcriptional coregulators
Metabolic reprogramming and mitochondrial dysfunction
Epigenetic modifications
Long-term outcomes of patients with pulmonary vascular disease
Future directions and perspectives
Key references
Chapter 54: Mechanical ventilation and respiratory care
Pearls
Applied respiratory physiology
Lung volumes and capacities
Lung inflation and deflation
Time constant
Work of breathing
Determinants of gas exchange
Indications for mechanical ventilation
Respiratory failure
Other indications for mechanical ventilation
Design and functional characteristics of ventilators
Phases of a breath
Initiating breaths
Patterns of gas flow
Limit
Cycling of breaths
Continuous positive airway pressure and positive end-expiratory pressure
Ventilator modes and phase variables
Selection of parameters for mandatory breaths
Dual-control modes
Automatic tube compensation
Nontraditional modes of ventilation
Airway pressure release ventilation
Proportional assist ventilation
Neurally adjusted ventilatory assist
Ventilation for selected underlying pathophysiology
Primary respiratory muscle failure (“respiratory pump failure”)
Obstructive lung diseases
Restrictive lung diseases
Unilateral lung disease or severely differential lung disease
Heart failure and postoperative management of congenital heart disease
Diseases with abdominal distention
Neurologic and neuromuscular diseases
Patient-ventilator asynchrony
Asynchrony associated with breath triggering
Asynchrony during inspiration (flow asynchrony)
Asynchrony during cycling
Use of neuromuscular blockade
High-frequency ventilation
Mechanism of gas flow in high-frequency ventilation in the normal lung
High-frequency jet ventilation
High-frequency oscillatory ventilation
High-frequency percussive ventilation
Adverse effects of mechanical ventilation
Airway injury
Effects on the lung
Effects on the circulatory system
Specialty gases
Inhaled nitric oxide
Helium-oxygen mixture
Altering pulmonary vascular resistance with adjusted inspired oxygen and carbon dioxide concentrations
Respiratory care during mechanical ventilation
Pulmonary hygiene
Humidification systems
Aerosol therapy
Weaning from mechanical ventilation and extubation
Extubation readiness trial
Extubation
Key references
Chapter 55: Noninvasive ventilation in the pediatric intensive care unit
Pearls
Epidemiology
Physiology and application of noninvasive ventilation
High-flow nasal cannula
Noninvasive positive-pressure ventilation
Negative-pressure ventilation
Negative-pressure ventilation use in chest physiotherapy and secretion clearance
Vibration mode
Cough mode
Neurally adjusted ventilatory assist
Patient selection
Bronchiolitis
Asthma
Pediatric acute respiratory distress syndrome
Immunocompromised patients
Neuromuscular disease
Patient monitoring and complications
Sedation during noninvasive ventilation
Failure of noninvasive ventilation
Long-term use of noninvasive ventilation
Key references
Chapter 56: Extracorporeal life support
Pearls
A trip around the extracorporeal membrane oxygenation circuit
Cannulation techniques
Venoarterial extracorporeal membrane oxygenation (fig. 56.1a)
Venous cannulation
Arterial access
Left heart decompression
Venovenous extracorporeal membrane oxygenation
Venoarteriovenous extracorporeal membrane oxygenation
Arteriovenous
Percutaneous cannulation
Extracorporeal membrane oxygenation circuit
Venous reservoir and venous saturation monitor
Priming
Types of pumps and oxygenators
Roller head pumps
Centrifugal pumps
Negative inlet pressure
Membrane lung
Hollow-fiber membrane lung
Patient populations treated with extracorporeal life support
Neonatal cardiopulmonary failure
Pediatric patients
Trauma patients
Extracorporeal membrane oxygenation and high-risk diseases
Poisonings
Bridge to lung transplant
Why use extracorporeal membrane oxygenation?
Extracorporeal membrane oxygenation for cardiac dysfunction
Extracorporeal membrane oxygenation for resuscitation
Extracorporeal membrane oxygenation and septic shock
Patient selection criteria
Physiology of extracorporeal life support: Gas exchange and oxygen delivery
Oxygenation
Carbon dioxide exchange
Oxygen delivery
Recirculation
Transport
Patient management on extracorporeal membrane oxygenation
Initiation of extracorporeal life support
Patient management during extracorporeal life support
General principles
Anticoagulation monitoring
Nutritional support
Fluid and renal replacement therapy
Ventilator management
Sedation and analgesia
Weaning from extracorporeal membrane oxygenation
Decannulation
When to stop extracorporeal membrane oxygenation support
Complications from extracorporeal membrane oxygenation
Bleeding
Infection
Vascular injury
Other management tidbits
Right ventricular failure
Outcomes from extracorporeal life support
Medical outcomes
Neurodevelopmental outcomes
Long-term neurologic implications
Future of extracorporeal membrane oxygenation
Key references
Chapter 57: Pediatric lung transplantation
Pearls
Indications
Contraindications
Survival and outcomes
Evaluation of the donor
Surgical approach
Presurgical management in the intensive care unit
Postsurgical management
Immunosuppression
Immunobiology
Rejection
Antibody-mediated rejection
Chronic lung allograft dysfunction
Treatment options for clad
Summary
Key references
Section VI: Pediatric Critical Care: Neurologic
Chapter 58: Structure, function, and development of the nervous system
Pearls
Major cell types
Intercellular communication in the nervous system
Electrical synapses
Chemical synapses
Neuromuscular junction
Chemical synapses in the central nervous system
Neurotransmitter systems
Neurotransmitters
Acetylcholine
Catecholamines
Serotonin
Amino acids
Adenosine, peptides, and nitric oxide
Neurotransmitter receptors
Nicotinic acetylcholine receptors
Muscarinic acetylcholine receptors
Glutamate receptors
Gabaa and gabab receptors
Major anatomic organization of the nervous system
Central nervous system
Spinal cord
Medulla
Pons
Midbrain
Reticular formation
Cerebellum
Diencephalon
Basal ganglia
Cerebral hemispheres
Peripheral nervous system
Somatic peripheral nervous system
Visceral or autonomic peripheral nervous system
Sympathetic nervous system
Parasympathetic autonomic nervous system
Meninges
Blood-brain barrier
Anatomy
Selectivity
Blood-brain barrier–deficient areas
Ventricles and cerebrospinal fluid
Ventricular system
Cerebrospinal fluid production and flow
Cerebrospinal fluid composition and function
Vasculature in the central nervous system
Brain vasculature
Spinal cord vasculature
Regulation of cerebral blood flow
Perfusion pressure–related autoregulation
Oxygen-related autoregulation
Hydrogen ion–related autoregulation
Metabolic coupling
Emerging characterization of the “lymphatic” circulation in the central nervous system
Developmental processes relevant to pediatric critical care medicine
Cell origin and differentiation
Synaptogenesis and synaptic pruning
Neurotransmitter system maturation
Myelination
Development of cerebrovasculature and blood-brain barrier
Developmental aspects of cerebral blood flow, autoregulation, and cerebral metabolism
New insights in neurodevelopment relevant to pediatric critical care
Excitatory amino acid inhibition and neurodevelopmental apoptosis
Microbiome and neurodevelopment and function
Conclusion
Key references
Chapter 59: Critical care considerations for common neurosurgical conditions
Pearls
Hydrocephalus
Background
Pathophysiology
Clinical presentation
Causes
Diagnosis
Management
Arachnoid cysts
Background
Clinical presentation
Diagnosis
Management
Chiari malformations
Chiari I malformation
Chiari II malformation
Other chiari malformations
Dandy-walker complex
Encephalocele and meningocele
Spinal dysraphism
Conclusions
Key references
Chapter 60: Neurologic assessment and monitoring
Pearls
Nursing role in the recognition of neurologic complications of critical illness
Anticipatory planning for new neurologic deficits
History and assessment of risk factors
Iatrogenic complications of pharmacotherapy
Vital signs
General physical exam
Importance of observation in the neurologic exam
Assessment of level of consciousness and mental status
Fundoscopic examination
Cranial nerve examination
Approach to the motor exam
Reflexes
Cerebellar function and gait evaluation
Sensory examination
Abnormal movements or altered sensorium in the child with static encephalopathy
Distinguishing functional deficits from nonorganic pathology in the pediatric intensive care unit
Goals of the neurologic examination in the pediatric intensive care unit
Neuroimaging
Intracranial pressure monitoring
Electroencephalography monitoring
Transcranial doppler measurement of cerebral blood flow
Near infrared spectroscopy
Brain tissue oxygen monitoring
Optic nerve sheath diameter measurement
Tympanometry
Cerebral microdialysis
Integrating neurologic monitoring data
Key references
Chapter 61: Neuroimaging
Pearls
Imaging modality overview
Radiography
Ultrasound
Computed tomography
Magnetic resonance imaging
Advanced magnetic resonance imaging techniques
Magnetic resonance angiography
Catheter angiograms
Myelography
Nuclear medicine
Hypoxic ischemic injury and germinal matrix hemorrhage in the neonate
Imaging of neurovascular disorders
Ischemic stroke
Vasculopathy/vasculitis
Intracranial hemorrhage and vascular malformations
Venous infarct
Posterior reversible encephalopathy syndrome
Central nervous system infection
Demyelinating disease
Trauma
Hydrocephalus
Tumor
Seizures
Conclusion
Key references
Chapter 62: Coma and depressed sensorium
Pearls
Definitions
Epidemiology
Relevance
Physiology/pathophysiology
Etiology
Initial treatment of the comatose child
Prehospital care
Initial stabilization
Airway
Breathing
Circulation
History
Timing of the onset of symptoms
Antecedent events
Associated signs or symptoms
Preexisting conditions and comorbidities
Physical examination
Focused neurologic examination
Respiratory pattern
Eye examination
Cranial nerve examination
Motor examination
Herniation syndromes
Diagnostic evaluation
Laboratory tests
Imaging and other studies
Treatment goals: Initial and ongoing
Prognosis and outcomes
Key references
Chapter 63: Intracranial hypertension and monitoring
Pearls
Clinical background
Physiology of the intracranial vault
Intracranial pressure
Utility of hydrodynamic and electrical analog models of intracranial pressure
Cerebral vasodilation and cerebral spinal fluid pressure
Cerebral perfusion pressure and cerebral autoregulation
Measurement of intracranial pressure
Invasive monitoring devices
Noninvasive diagnostic tests of intracranial pressure
Pressure gradients and compartments
Clinical analysis of intracranial pressure
Normal values in intracranial pressure
Choice of type of invasive intracranial pressure monitoring
Choice of whether to use intracranial pressure monitoring
Clinical targets in intracranial pressure and cerebral perfusion pressure levels
Supplementing intracranial pressure monitoring with other monitoring modalities
Mechanism of brain injury in intracranial hypertension
Intracranial pressure monitoring and the postinsult natural history of injury
Key references
Chapter 64: Status epilepticus
Pearls
Definition of status epilepticus
Outcome of status epilepticus
Status epilepticus classification
Seizure types and classification
Febrile seizures and febrile status epilepticus
Seizures in the pediatric intensive care unit
Chemically induced seizures
Dialysis disequilibrium syndrome
Hepatic mechanisms
Hypertensive encephalopathy
Posttraumatic epilepsy
Renal failure
Transplantation
Autoimmune status epilepticus
Neurophysiology and pathology
Cardiorespiratory failure in status epilepticus
Other organ systems
Evaluation and electroencephalography in status epilepticus
Management of status epilepticus
General supportive care
Monitoring and termination of status epilepticus
First- and second-line pharmacotherapy
Current practice protocols
First-line benzodiazepines: Diazepam, lorazepam, or midazolam
Second-line fosphenytoin and phenobarbital
Other therapies
Medications for established status epilepticus
Management of refractory status epilepticus and other forms of treatment-resistant status epilepticus
Super-refractory status epilepticus
Fever-induced refractory epileptic encephalopathy and febrile infection-related epilepsy syndrome
Therapeutic strategies in the rse-srse-norse-fires spectrum
Immunotherapies
Infusions and anesthesia for seizure control
Midazolam
Midazolam infusions for refractory status epilepticus
Ketamine
Ketamine infusions for refractory status epilepticus
High-dose barbiturates
Treatment and dosing strategy with pentobarbital
Ceeg monitoring
Complications of pentobarbital
Concurrent antiseizure medications with pentobarbital
Inhalational anesthetics for (super) refractory status epilepticus
Hypothermia for (super) refractory status epilepticus
Ketogenic diet for (super) refractory status epilepticus
Surgical options
Changing goals of therapy in prolonged srse/fires
Key references
Chapter 65: Hypoxic-ischemic encephalopathy
Pearls
Epidemiology
Mechanisms of hypoxic-ischemic brain injury
Energy failure
Selective vulnerability
Cell death mechanisms
Neuronal death pathophysiology
Reperfusion injury
Anoxia, ischemia, reperfusion pathophysiology
Excitotoxicity and calcium accumulation
Protease activation
Oxygen radical formation
Membrane phospholipid hydrolysis and mediator formation
Endogenous defenses
Clinical pathophysiology
Cerebral blood flow and metabolism after resuscitation
Histopathology of hypoxic-ischemic encephalopathy
Clinical outcome and prognostication after pediatric cardiac arrest
Response of the immature brain to cardiac arrest
Treatment after cardiac arrest
Field interventions
Supportive care in the intensive care unit
Current and novel therapies and interventions
Postresuscitative targeted temperature management
Improving quality of cardiopulmonary resuscitation
Achieving high-quality cardiopulmonary resuscitation
Therapies optimizing postresuscitative cerebral blood flow
Phenotype-directed management
Cognitive rehabilitation after the intensive care unit
Futuristic approaches
Mitochondria targeting strategies
Targeted temperature management in a syringe
Erythropoietin
Stem cell therapy
Extracorporeal life support
Summary
Acknowledgment
Key references
Chapter 66: Pediatric stroke and intracerebral hemorrhage
Pearls
Significance
Arterial ischemic stroke
Etiologies and risk factors
Cerebral arteriopathy
Sickle cell disease
Congenital and acquired heart disease
Hypercoagulable states
Pathophysiology
Presentation
Neuroimaging
Laboratory evaluation
Initial laboratory studies in child with possible acute stroke
Other tests of hypercoagulability (etable 66.1)
Treatment
Supportive therapy
Recanalization therapies
Antithrombotic therapy
Cerebral sinus venous thrombosis
Etiologies and risk factors
Neuroimaging
Laboratory evaluation
Treatment
Prognosis
Spontaneous intracranial hemorrhage
Arteriovenous malformations
Aneurysms
Cavernous malformation
Coagulation disorders
General care of the child with intracerebral hemorrhage
Prognosis
Conclusion
Key references
Chapter 67: Central nervous system infections and related conditions
Pearls
Bacterial meningitis
Epidemiology
Epidemiology of common organisms causing pediatric meningitis
Pathogenesis
Clinical manifestations
Laboratory diagnosis
Treatment
Supportive care
Adjunctive therapy
Outcomes
Prevention
Subdural empyema
Brain abscess
Viral meningoencephalitis
Epidemiology
Pathophysiology/pathogenesis of viral meningoencephalitis
Clinical evaluation
Laboratory manifestations
Neuroimaging
Clinical presentation and course
Treatment
Prognosis
Acute disseminated encephalomyelitis
Key references
Chapter 68: Acute neuromuscular disease and disorders
Pearls
Guillain-barré syndrome
Myasthenia gravis
Congenital and transient neonatal myasthenia gravis
Tick paralysis
Periodic paralyses
Botulism
Diphtheria
Acute intermittent porphyria
Spinal muscular atrophy
Poliomyelitis
Polio-like syndromes
Organophosphate and carbamate poisoning
Key references
Chapter 69: Acute rehabilitation and early mobility in the pediatric intensive care unit
Pearls
Rehabilitation team members in the pediatric intensive care unit
Role of physical therapy in the pediatric intensive care unit
Role of occupational therapy in the pediatric intensive care unit
Role of speech-language pathology in the pediatric intensive care unit
Important considerations for mobility in the pediatric intensive care unit
Pediatric intensive care unit environment
Cardiac and pulmonary status and complications
Sedation
Intensive care unit–acquired weakness
Facilitating infant neurodevelopment during critical illness
Communication
Acute rehabilitation across the intensive care unit continuum
Patient selection: Age-based factors
Patient selection: Acuity of illness
Equipment
Positioning equipment
Sitting equipment
Standing or ambulation equipment
Other equipment
Resource utilization
Implementation of acute rehabilitation in the pediatric intensive care unit: Evidence and strategies
Evidence in support of early mobilization in the pediatric intensive care unit
Early mobilization: The “e” in the abcdef ICU liberation bundle
Implementation of a pediatric intensive care unit early mobility program: Strategies for success
Step 1: Form an interdisciplinary team
Step 2: Summarize the evidence
Step 3: Identify local barriers to implementation
Step 4: Establish performance measures
Step 5: Ensure that all patients receive the intervention—the 4 e’s
Summary
Key references
Section VII: Pediatric Critical Care: Renal
Chapter 70: Renal structure and function
Pearls
Renal anatomy
Renal development
Renal vasculature
Vascular anatomy
Vascular function
Vascular development
The nephron
Nephron development
Glomerulus
Glomerular anatomy
Glomerular function
Tubular anatomy
Proximal tubule
Loop of henle
Distal nephron
Tubular function
Proximal tubule
Loop of henle
Distal tubule
Collecting duct
Interstitium
Development
Structure and function
Summary
Key references
Chapter 71: Fluid and electrolyte issues in pediatric critical illness
Pearls
Sodium
Hyponatremia
Pathophysiology and etiology
Decreased total body sodium
Renal sodium losses
Cerebral salt wasting
Increased total body sodium
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Renal failure
Normal total body sodium
Signs and symptoms
Treatment
Prevention
Therapy
Hypernatremia
Pathophysiology and etiology
Low total body sodium
Normal total body sodium
Increased total body sodium
Signs and symptoms
Treatment
Potassium
Causes of hypokalemia
Hypokalemia without potassium deficit
Hypokalemia with potassium deficit
Renal losses
Gastrointestinal losses
Signs and symptoms
Treatment
Hyperkalemia
Causes
Artifactual
Redistribution
Increased load
Impaired elimination
Manifestations of hyperkalemia
Treatment
Magnesium
Hypomagnesemia
Causes
Signs and symptoms
Treatment
Hypermagnesemia
Cause
Signs and symptoms
Treatment
Calcium
Regulation of calcium
Hormonal regulation of calcium
Hypocalcemia
Clinical and laboratory concerns
Treatment
Hypercalcemia
Treatment
Phosphorus
Hypophosphatemia
Causes of severe hypophosphatemia
Signs and symptoms
Treatment
Hyperphosphatemia
Causes of hyperphosphatemia
Signs and symptoms
Treatment
Key references
Chapter 72: Acid-base disorders
Pearls
Overview of acid-base physiology
Defining acids and bases
Role of water
Principles of electroneutrality
Acids, bases, and buffers
Tools for interpreting acid-base disorders
Henderson-hasselbalch equation
Base excess and standard base excess
Bicarbonate-based approach
Anion gap and corrected anion gap
Serum osmolar gap
Strong ion difference
Urinary anion gap
Summary
Clinical approach to disorders of acid-base balance
Is abnormal ph dangerous?
Blood gases: Arterial, central venous, or capillary samples?
Evaluation of acid-base disorders
Metabolic acidosis
Elevated anion gap acidoses
Lactic acidosis
Ketoacidosis
Toxic compounds that directly provoke acidosis
Other forms of metabolic acidosis with an increased anion gap
Hyperchloremic acidosis: Nonanion gap metabolic acidosis
Exogenous chloride load
Postpyloric gastrointestinal fluid losses
Renal tubular acidosis and drug-mediated tubulopathies
Urinary reconstruction using bowel segments
Treating metabolic acidosis
Sodium bicarbonate
Alternative alkalinizing agents
Dialysis management of metabolic acidosis
Metabolic alkalosis
Treating metabolic alkalosis
Respiratory acid-base derangements
Respiratory acidosis
Treating respiratory acidosis
Respiratory alkalosis
Mixed acid-base derangements
Summary
Key references
Chapter 73: Tests of kidney function in children
Pearls
Assessment of glomerular function and injury
Renal clearance techniques
Renal inulin clearance compared with other glomerular filtration rate measurement techniques
Plasma markers
Creatinine
Cystatin c
Estimating equations
Summary of recommendations regarding use of glomerular filtration rate estimating equations
Neonatal renal function
Biomarkers of acute kidney injury and the next generation
Tubular function
Urine
Urine electrolytes (sodium and chloride)
Urine concentration capacity
Serum blood urea nitrogen/creatinine ratio
Urine microscopy
Proteinuria
Renal acidification
Potassium regulation
Generalized proximal tubulopathy
Integration of kidney function assessment in critical care
Key references
Chapter 74: Glomerulotubular dysfunction and acute kidney injury
Key words:
Pearls
Physiology of glomerular filtration
Normal renal physiology and response of the kidney during stress
Pathogenesis of reduced glomerular filtration rate in acute kidney injury
Morphologic changes in renal injury
Mechanisms of renal cell injury
Alterations in cell membranes
Cellular calcium homeostasis
Production of free radicals
Tubular cell energy metabolism
Glomerulotubular dysfunction
Hemodynamically mediated acute kidney injury
Treatment of acute kidney injury
Prevention/attenuation of acute kidney injury
Diuretics
Calcium entry blockers
Prostaglandins
Renin-angiotensin antagonists
Adenosine and adenosine triphosphate
Atrial natriuretic factor
Free radical scavengers
Thyroxine
Glycine and alanine
Acute kidney injury: Clinical impact
Hyperkalemia
Severe hypertension
Plasma and extracellular volume expansion
Severe metabolic acidosis
Hypocalcemia/hyperphosphatemia
Uremia
Renal disposition of endogenous and exogenous compounds
Specific kidney diseases that may lead to acute kidney injury
Hemolytic uremic syndrome
Pathophysiology
Clinical signs
Complications
Therapy
Prognosis
Acute glomerulonephritis
Acute postinfectious (streptococcal) glomerulonephritis
Clinical signs
Laboratory findings
Treatment
Prognosis
Systemic lupus erythematosus
Clinical signs
Treatment
Prognosis
Other glomerulonephritides
Nephrotic syndrome and acute kidney failure
Tubulointerstitial disease
Acute tubulointerstitial nephritis
Cardiorenal syndrome
Cardiac surgery–related acute kidney injury
Tumor lysis syndrome
Management
Rasburicase
Role of renal replacement therapy
Pigment nephropathy
Pathophysiology
Hypocalcemia
Drug-induced nephrotoxicity
Aminoglycoside nephrotoxicity
Amphotericin b
Vancomycin
Calcineurin inhibitors
Nonsteroidal antiinflammatory drugs
Contrast-induced nephropathy
Acute renal failure after stem cell transplantation
Urinary tract obstruction
Conclusions
Key references
References
Chapter 75: Pediatric renal replacement therapy in the intensive care unit
Pearls
Basic physiology of dialysis and ultrafiltration
Peritoneal dialysis
Physiology
Indications
Technique
Disadvantages and complications
Intensive care unit issues
Intermittent hemodialysis
Physiology
Indications
Technique
Disadvantages and complications
Intensive care unit issues
Continuous renal replacement therapy
Physiology
Indications
Technique
Anticoagulation
Dialysate and infused fluids
Clearance
Disadvantages and complications
Intensive care unit issues
Extended dialysis
Outcomes of renal replacement in critically ill children
Advances in pediatric renal replacement therapies
Summary
Key references
Chapter 76: Pediatric renal transplantation
Pearls
Donor source: Living donor versus deceased donor
Living donor transplantation
Deceased donor transplantation
Timing of transplantation
Histocompatibility
Abo blood group considerations
Hla matching
Pretransplantation crossmatch testing
Sensitized recipient
Surgical procedure
Multiorgan transplantation
Immediate arrival to the pediatric intensive care unit (boxes 76.1, 76.2, and 76.3)
Posttransplantation monitoring
Hemodynamics and tissue perfusion
Fluid and electrolytes
Urine output
Recovery of renal function
Immunosuppression
Infection surveillance and prevention
Posttransplantation complications
Acute kidney injury
Vascular complications
Urologic complications
Rejection
Urinary tract infection
Other infections
Recurrence of primary renal disease
Focal segmental glomerulosclerosis
References
Chapter 77: Renal pharmacology
Pearls
Kidney function and drug disposition
Drug dosing in kidney disease
Drug dosing in dialysis
Kidney as a therapeutic target: Diuretics and agents regulating renal excretion
Carbonic anhydrase inhibitors
Mechanism and sites of action
Efficacy on urinary excretion and therapeutic uses
Adverse effects
Osmotic diuretics
Mechanism and sites of action
Efficacy on urinary excretion and therapeutic uses
Adverse effects
Loop diuretics
Mechanism and site of action
Pharmacokinetics
Effects on urinary excretion and adverse effects
Therapeutic uses
Thiazide and thiazide-like diuretics
Mechanism and site of action
Pharmacokinetics
Effects on urinary excretion and therapeutic uses
Adverse effects
Potassium-sparing diuretics
Mechanism and site of action
Effects on urinary excretion and therapeutic uses
Adverse effects
Vasopressin antagonists
Mechanism of action and therapeutic uses
Adverse effects
Diuretic resistance
Medications for the prevention/reversal of acute kidney injury
Key references
Chapter 78: Acute severe hypertension
Pearls
Terminology
Etiology
Pathophysiology
Endothelial homeostasis
Sympathetic nervous system activation
Renin-angiotensin-aldosterone system
Nitric oxide
Volume overload
Clinical presentation
Patient evaluation and monitoring
Blood pressure measurement and other monitoring
Diagnostic evaluation
Pharmacologic therapy
General considerations
Clonidine
Esmolol
Hydralazine
Isradipine
Labetalol
Nicardipine
Sodium nitroprusside
Other available agents
Special situations
Preeclampsia
Pheochromocytoma
Summary
Key references
Section VIII: Pediatric Critical Care: Metabolic and Endocrine
Chapter 79: Cellular respiration
Pearls
Pathways of cellular respiration
Glycolysis (anaerobic respiration)
Fatty acid β-oxidation
Protein catabolism
Krebs cycle
Mitochondrial oxidative phosphorylation
Oxygen toxicity
Impaired cellular respiration in critical illness
Clinical assessment of oxygen utilization
Lactate
Venous oxygen saturation
Microdialysis
Near-infrared spectroscopy
Optical spectroscopy
Tissue oxygen tension
Magnetic resonance spectroscopy
Blood mitochondrial DNA
Mitochondrial- and bioenergetic-targeted therapy in critical illness
Antioxidants
Glycemic control
Substrate provision
Mitochondrial biogenesis and mitophagy
Membrane stabilizers
Hibernation
Mitochondrial transplantation
Conclusions
Key references
Chapter 80: Biology of the stress response
Key words:
Pearls
Definitions and background
Stress system primary elements
Stress response
Central activation and integration
Peripheral responses
Cellular responses
Stress response in critical illness
Recommendations and conclusions
Key references
Chapter 81: Inborn errors of metabolism
Pearls
Pathophysiology of inborn errors of metabolism
Inheritance of inborn errors of metabolism
Signs and symptoms of inborn errors of metabolism
Laboratory evaluation of suspected inborn errors of metabolism
Postmortem evaluation of a child with suspected inborn errors of metabolism
Emergency treatment of children with suspected inborn errors of metabolism
Classification of inborn errors of metabolism by clinical presentation
Group 2 inborn errors of metabolism: Impaired energy production
Group 3 inborn errors of metabolism: Intoxication
Summary
Metabolic acidosis
Hypoglycemia
Cardiomyopathy and inborn errors of metabolism
Metabolic myopathies and rhabdomyolysis
Neonatal screening
Conclusions
Key references
Chapter 82: Progress towards precision medicine in critical illness
Pearls
Genetic variation and critical illness
Genetic variation and sepsis
Genetic variation and acute respiratory distress syndrome
Transcriptomics and critical illness
Plasma biomarkers and critical illness
Plasma biomarkers and sepsis
Plasma biomarkers and acute respiratory distress syndrome
Summary
Key references
Chapter 83: Molecular foundations of cellular injury
Pearls
Caspase-dependent forms of regulated cell death
Apoptosis
Animal studies on apoptosis
Pyroptosis
Caspase-independent forms of regulated cell death
Necroptosis
Animal studies—necroptosis
Autophagy
Mitochondrial permeability transition–mediated regulated necrosis
Ferroptosis
Parthanatos
Netosis
Cell death as a therapeutic target
Key references
References
Chapter 84: Endocrine emergencies
Pearls
Hypothalamic-pituitary-adrenal axis
Cortisol biochemistry and biology
Actions of cortisol
Immunity
Metabolism
Hemodynamics
Assessing the cortisol stress response
Free cortisol
Adrenal insufficiency in the intensive care unit
Primary adrenal insufficiency
Secondary adrenal insufficiency
Treatment of adrenal insufficiency
Corticosteroid side effects
Alterations of glucose homeostasis
Glucose homeostasis in health
Hyperglycemia
Stress hyperglycemia and outcomes
Pathophysiology of stress hyperglycemia
Mechanisms of stress hyperglycemia adverse outcomes
Clinical trials examining management of critical illness hyperglycemia
Glucose measurement
Hypoglycemia
Clinical manifestations
Pathogenesis
Fasting adaptation
Hypoglycemia treatment
Alterations of thyroid hormone in critical illness
Thyroid biochemistry
Thyroid hormone actions
Hyperthyroidism
Hypothyroidism
Euthyroid sick syndrome in critical illness
Thyroid hormone supplementation in the picu
Key references
Chapter 85: Diabetic ketoacidosis
Pearls
Etiology, definition, and presentation
Epidemiology
Frequency of diabetic ketoacidosis at diagnosis
Frequency of diabetic ketoacidosis in children and adolescents after diagnosis
Morbidity and mortality associated with diabetic ketoacidosis
Management guidelines (fig. 85.1)
Fluids
Insulin
Electrolytes
Correction of acidosis
Monitoring
Diabetic ketoacidosis–associated complications
Hyperglycemic hyperosmolar syndrome
Thrombotic complications
Other complications
Neuropsychologic sequelae
Healthcare costs associated with diabetic ketoacidosis
Key references
Section IX: Pediatric Critical Care: Hematology and Oncology
Chapter 86: Structure and function of the hematopoietic organs
Pearls
Normal peripheral blood values
Structure of the bone marrow
Function of the bone marrow: Hematopoiesis
Regulators of hematopoiesis: Growth factors
Erythropoiesis
Granulopoiesis
Megakaryocyte and platelet production
Lymphopoiesis
Spleen
Key references
Chapter 87: The erythron
Pearls
Oxygen transport
Carbon dioxide transport
Biophysical factors influencing gas transport
Blood rheology
Red blood cell aggregation and adhesion
Red blood cell deformability
Regulation of blood flow distribution by red blood cells
Role of red blood cell–nitric oxide interactions in vasoregulation
Metabolism of endothelium-derived nitric oxide by red blood cells: Historical view
Metabolism of endothelium-derived nitric oxide by red blood cells: Contemporary view
Processing and export of s-nitrosothiols by red blood cells
Metabolism of nitrite by red blood cells
Vasoregulation by red blood cell-derived adenosine triphosphate
Red blood cell energetics and consequences of antioxidant system failure
Acquired red blood cell injury, eryptosis, and clearance
Influence of red blood cells on hemostasis
Summary
Key references
References
Chapter 88: Hemoglobinopathies
Pearls
Globin gene loci
Sickle cell disease
Molecular description and epidemiology
Sickle cell trait
Spectrum of sickle cell disease genotypes and natural history
Laboratory and diagnostics
Pathophysiology
Hemoglobin polymerization
Red cells, inflammation, hemolysis, and the endothelium
Clinical manifestations
Pain
Pathophysiology, diagnosis, and presentation
Management
Sepsis. 
Pathophysiology and etiology
Management
Acute chest syndrome
Presentation
Management
Stroke. 
Natural history
Diagnosis
Management
Aplastic crisis
Splenic sequestration
Pulmonary hypertension
Pathophysiology and etiology
Diagnosis
Management
Multiorgan failure 
Renal conditions
Iron overload
Sleep conditions and depression and suicide in sickle cell disease
Surgery and anesthesia
Disease-modifying and curative therapies for sickle cell disease
Hydroxyurea
Transfusion
Choice of product
Type and goals of transfusion
Transfusion reactions and hyperhemolysis
Hematopoietic stem cell transplantation, gene therapy, and novel therapies for sickle cell disease
Thalassemia
Molecular description and epidemiology
Laboratory and diagnostics
Pathophysiology
Forms and variations
α-thalassemia
β-thalassemia
Hbe/β0-thalassemia
Natural history
Assessment of iron overload
Spectrum of disease
Anemia
Transfusion-related complications
Cardiac complications
Assessments
Management
Hepatic and renal dysfunction in thalassemia
Thrombosis and pulmonary emboli
Pulmonary hypertension
Endocrine
Hematopoietic stem cell transplantation, gene therapy, and novel therapies for thalassemia
Key references
Chapter 89: Coagulation and coagulopathy
Pearls
Overview of hemostasis
Role of platelets and von willebrand factor in hemostasis
Role of endothelial cells in hemostasis
Crosstalk between coagulation and inflammation
Hypercoagulability and thrombophilia
Approach to the patient with an identified or suspected coagulation disorder
Clinical history
Physical examination
Basic tests of hemostasis
Platelet function testing
Thromboelastography and thromboelastometry
Abnormal hemostasis in critical illness
Disseminated intravascular coagulation and other microangiopathic consumptive disorders
Pathogenesis
Clinical presentation and diagnosis
Meningococcal purpura fulminans
Management
Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome
Thrombocytopenia associated multiorgan failure
Abnormal hemostasis in liver disease and hepatic insufficiency
Presentation
Management
Vitamin k deficiency
Management
Circulating anticoagulants
Iatrogenic coagulopathy
Massive transfusion syndrome
Management
Anticoagulant overdose
Warfarin
Management
Heparin
Management
New oral anticoagulants
Management
Platelet disorders
Quantitative platelet disorders
Heparin-induced thrombocytopenia
Qualitative platelet disorders
Management
Defects associated with acquired vwf defects
Uremia
Thrombocytopenia-associated multiorgan failure
Cardiac-induced hemostatic disorders
Systemic diseases associated with factor deficiencies
Thrombophilia and immunothrombosis
Summary
Key references
Chapter 90: Thrombosis in pediatric critical care
Pearls
Developmental hemostasis
Etiology and epidemiology
Central venous access devices
Arterial access
Cardiac surgery
Thrombophilia
Heparin-induced thrombocytopenia
Clinical features
Diagnosis
Venous thrombosis
Pulmonary embolus
Arterial thrombosis
Intracardiac thrombosis
Management
Unfractionated heparin in children
Thromboprophylaxis in the pediatric intensive care unit
Conclusions
Key references
Chapter 91: Transfusion medicine
Pearls
Red blood cells
Red blood cell transfusion: Why and why not
Anemia and oxygen delivery
Oxygen delivery in the critically ill
Adaptive mechanisms with anemia
Oxygen kinetics in the critically ill
Regulation by red blood cells of oxygen delivery to tissue
Risks of anemia
Transfusion of red blood cells: Indications (when)
Hemorrhagic shock or severe bleeding (node 1)
Picu patients with severe anemia without severe bleeding (node 2)
Hemoglobin less than 5 or between 5 and 7 g/dl (node 2)
Hemodynamically unstable patients without serious bleeding (node 3)
Hemodynamically stable noncardiac patients (node 4)
Cardiac patients (node 5)
Prevention of anemia and red blood cell transfusion
Pre–pediatric intensive care unit anemia
Pediatric intensive care unit–associated anemia
Post–pediatric intensive care unit anemia
Types of red blood cell units
Standard red blood cell units
Other types of red blood cell units
Leukocyte-reduced red blood cell units
Washed red blood cell units
Irradiated red blood cell units
Cytomegalovirus-negative red blood cell units
Directed red blood cell units
Autologous red blood cell units
Transfusion of red blood cells: How
Blood types
Volume and number of red blood cell units
Length of storage
Perfusion, warming, and filtration
Plasma
Types of plasma
Transfusion of plasma: Indications (when)
Transfusion of plasma: How
Platelets
Types of platelet products
Standard platelet products
Special platelet concentrates
Leukocyte-reduced platelets
Irradiated platelets
Cytomegalovirus-negative platelets
Cryopreserved platelets
Pathogen-reduced platelets
Platelet transfusion (why)
Transfusion of platelets: Indications (when)
Transfusion of platelets: How
Whole blood
Whole blood: Type of product
Whole blood: Indications
Whole blood: How
Cryoprecipitate
Transfusions reactions and complications
Transfusion reactions
Immediate transfusion reactions
Other acute transfusion reactions
Delayed transfusion reactions
Complications related to massive transfusion
Transfusion-transmitted infections
Transfusion-related immunomodulation
Other transfusion-related complications
Reactions and complications more frequent with plasma transfusion
Reactions and complications more frequent with platelet transfusion
Treatment of transfusion reactions and complications
Conclusion
Key references
Chapter 92: Hematology and oncology problems
Pearls
Hematologic emergencies
Anemia
Hemorrhagic anemia
Anemia secondary to decreased production
Hemolytic anemia
Thrombocytopenia related to decreased platelet production
Thrombocytopenia-related immune-mediated consumption
Thrombocytopenia related to nonimmune consumption
Bleeding in uremia
Oncologic emergencies
Tumor lysis syndrome
Hyperkalemia
Hyperphosphatemia/hypocalcemia
Hyperuricemia
Hyperleukocytosis
Spinal cord compression
Acute airway compromise in anterior mediastinal tumors
Superior vena cava syndrome
Hemophagocytic lymphohistiocytosis
Anthracycline-induced cardiac dysfunction
Posterior reversible encephalopathy
Chimeric antigen receptor t cell–mediated toxicity
Key references
Chapter 93: Critical illness in children undergoing hematopoietic progenitor cell transplantation
Pearls
Sources of hematopoietic progenitor cells and identification of donors
Indications and outcomes
Transplant procedure
Conditioning regimen
Stem cell harvesting/collection/cryopreservation
Reinfusion
Recovery period
Complications
Cardiac complications
Pulmonary complications
Early pulmonary complications
Periengraftment respiratory distress syndrome
Pulmonary cytolytic thrombi
Diffuse alveolar hemorrhage
Idiopathic pneumonia syndrome
Late pulmonary complications
Bronchiolitis obliterans syndrome/bronchiolitis obliterans organizing pneumonia
Pulmonary venoocclusive disease
Critical care for pulmonary complications
Mechanical ventilatory support
Adjunctive therapies
Conclusion
Dilemmas in the diagnosis of pulmonary complications
Hepatic complications
Colitis and other gastrointestinal complications
Myelosuppression and hematologic complications
Myelosuppression and immune dysregulation
Infectious complications
Graft failure
Hematologic complications
Iron overload
Graft-versus-host disease
Neurologic complications
Chimeric antigen receptor t cells
Key references
Section X: Pediatric Critical Care: Gastroenterology and Nutrition
Chapter 94: Gastrointestinal structure and function
Pearls
Intestinal structure, digestion, absorption of nutrients, water, and electrolytes
Water and solute transport across intestinal epithelium
Digestion of carbohydrates
Digestion of proteins
Digestion of lipids
Fat digestion
Intestinal lymphatics
Regulation of electrolyte and water movement
Electrolyte transport
Gastric acid
Intestinal motility
Pancreas
Pancreatic exocrine secretory function
Hepatobiliary system
Examination
Anatomy, structure, and function
Portal circulation
Hepatic function
Degradation and elimination by the liver
Enterohepatic circulation
Hepatic regulatory function
Storage function
Host-defense mechanisms of the gut: Immunology and microbiology
Immunologic processing in the gut
Gastrointestinal and hepatobiliary testing in the intensive care unit
Key references
References
Chapter 95: Disorders and diseases of the gastrointestinal system
Pearls
Gastrointestinal evaluation of the critically ill child
Abdominal examination
Gastrointestinal endoscopy
Gastroesophageal reflux monitoring
Use of colorants to identify aspiration in the intensive care unit
Radiologic procedures
Plain films
Contrast radiography
Ultrasonography, computed tomographic scanning, and magnetic resonance scanning
Radionuclide scanning
Testing for occult blood loss
Stool ph and reducing substances
Intensive care unit as a satellite laboratory facility
Life-threatening complications of gastrointestinal disorders
Systemic
Central line–associated bloodstream infection
Esophagus
Congenital esophageal anomalies
Caustic injury to the esophagus
Esophageal foreign bodies
Gastroesophageal reflux
Stomach and duodenum
Gastric volvulus
Gastric ulcer
Duodenal ulcers
Small intestine and colon
Malrotation
Necrotizing enterocolitis
Low cardiac output syndrome
Food allergy
Hemolytic uremic syndrome
Inflammatory bowel disease
Distal intestinal obstruction syndrome
Hirschsprung disease
Acute colonic pseudo-obstruction
Abdominal compartment syndrome
Acute and chronic pancreatitis
Acute and chronic liver failure
Key references
Chapter 96: Acute liver failure
Pearls
Acute liver failure
Background, definitions, etiology, outcomes
Etiologies
Prognostic assessment
Diagnosis and workup
Specific treatments for particular causes of pediatric acute liver failure
Acetaminophen toxicity
Amanita poisoning
Autoimmune hepatitis
Wilson disease
Metabolic disease
Pediatric intensive care unit complications and management
Neurologic complications: Hepatic encephalopathy and cerebral edema
Cerebral edema
Management of hepatic encephalopathy and cerebral edema
Ventilation
Glucose, electrolytes, and fluid balance
Ascites
Renal function
Coagulopathy
Infection prophylaxis and treatment
Liver support
Decision-making for liver transplantation for acute liver failure
Key references
Chapter 97: Hepatic transplantation
Pearls
Current state of pediatric liver transplantation
Indications for liver transplant
Liver transplant evaluation
Pretransplant considerations
Transplant considerations
Donor considerations
Liver transplant procedure
Complications of liver transplantation
Primary graft nonfunction
Vascular complications
Bleeding
Biliary complications
Rejection
Infection
Posttransplant lymphoproliferative disorder
Posttransplant management in the intensive care unit
Drains and vascular access
Fluid and electrolytes
Graft function
Anticoagulation
Respiratory support
Sedation
Infection prophylaxis
Immunosuppression
Liver transplant outcomes
Patient and graft survival
Retransplantation
Key references
References
Chapter 98: Acute abdomen
Pearls
Anatomic and physiologic considerations
Peritoneum
Visceral blood flow
Physical examination of the abdomen
Laboratory tests
Imaging options
Ultrasonography
Abdominal plain radiographs
Computed tomography
Magnetic resonance imaging
Abdominal conditions requiring treatment in the intensive care unit
Perforated viscera
Ischemia
Neutropenic enterocolitis
Pancreatitis
Hemorrhage
Other specific conditions
Cholecystitis
Spontaneous bacterial peritonitis
Abdominal compartment syndrome
Intraabdominal abscess
Intestine as a source of sepsis
Surgical intervention
Key references
Chapter 99: Nutrition of the critically ill child
Pearls
Malnutrition in the pediatric critically ill patient
Assessment of nutritional status
Body composition
Biochemical assessment
Metabolic consequences of critical illness
Underfeeding and overfeeding in the pediatric intensive care unit
Indirect calorimetry
Protein requirements
Lipid requirements
Micronutrient requirements
Refeeding syndrome
Enteral nutrition in critically ill children
Parenteral nutrition
Carbohydrates
Amino acids
Lipids
Electrolytes/minerals and trace elements
Biochemical monitoring
Obese critically ill children
Revised guidelines for pediatric critical care nutrition
Conclusions
Key references
References
Section XI: Pediatric Critical Care: Immunity and Infection
Chapter 100: Innate immunity
Pearls
Components of innate immune system
Innate immune stimulus: Danger hypothesis
Signal recognition
Signal transduction
Effector pathways
Soluble mediator response
Cellular response
Crosstalk between systems
Regulation of the innate immune response
Clinical manifestations of the innate immune response in the intensive care unit
Therapeutic targets of the innate immune system
Therapeutic questions arising from the innate immune system
Conclusion
Key references
References
Chapter 101: Adaptive immunity
Pearls
Lymphocytes develop to recognize specific antigens
B-cell activation leads to antibody secretion: The humoral immune response
Effector t cells direct cell-mediated immunity
T-cell activation requires interaction with innate immune cells
T-cell activation requires a second signal
Cd8+ t cells differentiate into cytotoxic t cells
Cd4+ t cells differentiate into multiple t helper cell subtypes
Th1 cells
Th2 cells
Th17 cells
T follicular helper (tfh) cells
Th9 cells
Regulatory t cells (treg)
Additional t-cell subtypes
Adaptive immunity in the intensive care unit
Summary
Key references
Chapter 102: Critical illness and the microbiome
Pearls
General concepts in the field of microbiome science
Commensal, pathogenic, and keystone species
Site specificity
Dysbiosis
Studying the microbiome
Development of the microbiome in children
Development of intensive care unit dysbiosis in children
Known and potential clinical consequences of intensive care unit dysbiosis
Microbiome-based therapeutics in the intensive care unit
Probiotics
Fecal microbiota transplantation
Selective gut decontamination
Supplementing/repleting microbial metabolites
Targeted interventions against enterobacteriaceae
Monitoring the intensive care unit microbiome
Future of microbiome science
Key references
Chapter 103: Congenital immunodeficiency
Pearls
Basic framework for understanding the immune system
Compartment 1: Complement
Clinical presentations
Compartment 2: Phagocytes
Clinical presentations
Compartment 3: B cells and antibodies
Clinical presentations
Compartment 4: T cells
Clinical presentations
Specific disorders likely to be encountered in the pediatric intensive care unit
Specific disorders: Complement
C1 inhibitor deficiency
Early pathway defects (c1, c2, c3, c4)
Late pathway components: Membrane attack complex defects (c5, c6, c7, c8, c9)
Complement regulatory protein defects (factor h, factor I, mcp)
Specific disorders: Phagocytes
Severe congenital neutropenia
Leukocyte adhesion deficiency
Whim syndrome
Chronic granulomatous disease
Specific disorders: B cells and antibodies
X-linked agammaglobulinemia
Hyperimmunoglobulin m syndromes
B-cell activation
Pneumocystis jirovecii and cryptosporidium parvum infections among patients with hyperimmunoglobulin m and cd40l mutations
Common variable immunodeficiency syndromes
Genetic defects associated with a common variable immunodeficiency phenotype
Selective immunoglobulin a deficiency
Specific disorders: T cells
22q11 deletion syndrome (digeorge syndrome)
Severe combined immunodeficiency
X-linked severe combined immunodeficiency
Pathogenesis of selected genotype/phenotypes of scid
Adenosine deaminase– and purine nucleotide phosphorylase–deficient severe combined immunodeficiency
Specific disorders: Other complex or combined immunodeficiencies
Wiskott-aldrich syndrome
Genotype/phenotype correlations of mutations in wiscott aldrich syndrome
Cartilage-hair hypoplasia
Radiation-sensitive disorders: Ataxia telangiectasia and nijmegen breakage syndrome
Susceptibility to hemophagocytic lymphohistiocytosis and severe epstein-barr virus infection
Toll-like receptors and innate signaling pathway defects
Chronic mucocutaneous candidiasis syndromes
Autoimmune lymphoproliferative syndrome
Laboratory evaluation of the immune system
Diagnostic testing: Complement
Diagnostic testing: Phagocytes
Diagnostic testing: B cells and antibodies
Diagnostic testing: T cells
Treatment of immune system disorders
Treatment: Complement
Treatment: Phagocytes
Treatment: B cells and antibodies
Immunoglobulin replacement
Prophylactic antibiotics
Treatment: T cells
Key references
References
Chapter 104: Acquired immune dysfunction
Pearls
Immune dysfunction during sepsis, malnutrition, hiv/aids, and other critical illness states
Sepsis and immune dysfunction
Immunosuppression in sepsis
Malnutrition and immune dysfunction
HIV infection and AIDS
Pulmonary complications and respiratory failure
Pneumocystis jirovecii pneumonia
Cytomegalovirus pneumonitis
Other viral pathogens
Mycobacterial pathogens
Fungal infections
Lymphocytic interstitial pneumonitis
Upper airway obstruction
Cardiovascular complications
Abdominal complications
Hematologic and malignancy complications
Central nervous system complications
Occupational human immunodeficiency virus exposure
Other selected causes of secondary immune dysfunction
Immunosuppressive medications
Transfusions
Uremia
Neonatal period
Key references
Chapter 105: Immune balance in critical illness
Pearls
Innate and adaptive immunity
Innate immunity
Adaptive immunity
Proinflammatory and antiinflammatory responses
Systemic inflammatory response syndrome in critical illness
Compensatory antiinflammatory response syndrome in critical illness
Temporal aspects of the systemic inflammatory response syndrome/compensatory antiinflammatory response syndrome response
Cars and clinical outcomes
Immunomodulation in the pediatric intensive care unit
Targeted innate immunostimulation
Targeted adaptive immunostimulation
Unintended immunomodulation
Immune monitoring in the intensive care unit
Conclusion
Key references
Chapter 106: Pediatric rheumatologic disease
Pearls
Rheumatologic diseases: Overview
Rheumatologic diseases: Clinical presentation, diagnosis, and treatment
Juvenile idiopathic arthritis
Systemic juvenile idiopathic arthritis
Key points
Clinical presentation
Laboratory studies
Management
Systemic lupus erythematosus
Key points
Clinical presentation
Mucocutaneous manifestations
Musculoskeletal manifestations
Pulmonary manifestations
Pleuritis and pleural effusion
Pulmonary hemorrhage
Pulmonary embolism
Interstitial lung disease
Pulmonary hypertension
Cardiovascular manifestations
Pericarditis and pericardial tamponade
Myocarditis
Valvular disease
Arrhythmias
Acute coronary syndrome
Renal manifestations
Central nervous system manifestations
Hematologic involvement
Thrombotic thrombocytopenic purpura
Immune dysfunction
Acute abdominal manifestations: Peritonitis, serositis, pancreatitis, and intestinal perforation
Laboratory studies
Auto-antibody testing
Management
Neonatal systemic lupus erythematosus
Raynaud phenomenon
Antiphospholipid syndrome
Key points
Clinical presentation
Laboratory studies
Management
Juvenile dermatomyositis
Key points
Clinical presentation
Laboratory studies
Imaging
Management
Systemic vasculitis
Key points
Small-vessel vasculitis
Immune-complex small-vessel vasculitis
Henoch-schönlein purpura
Treatment of hsp
Pauci-immune small-vessel vasculitis (antineutrophil cytoplasmic antibody–associated vasculitis)
Granulomatosis with polyangiitis
Microscopic polyangiitis
Eosinophilic granulomatosis with polyangiitis
Treatment of anca-associated vasculitis
Medium-vessel vasculitis
Kawasaki disease
Treatment of kd
Polyarteritis nodosa
Large-vessel vasculitis
Takayasu arteritis
Primary vasculitis of the central nervous system
Autoinflammatory syndromes
Key points
Rheumatologic diseases: Conditions and complications in the intensive care unit
Macrophage activation syndrome
Key points
Airway compromise
Organ-specific complications
Treatment-related complications of rheumatologic diseases
Corticosteroids
Gastrointestinal side effects
Infectious side effects
Summary
Key references
Chapter 107: Bacterial and fungal infections
Pearls
Bacterial infections in the intensive care unit
Gram-positive bacteria
Gram-negative bacteria
Anaerobic infections
General considerations for antibiotic therapy
Antibiotic classes
β-lactam antibiotics
β-lactam antimicrobial plus β-lactamase inhibitor combination
Cephalosporins
Carbapenems
Monobactams
Aminoglycosides
Glycopeptides
Macrolides
Fluoroquinolones
Miscellaneous
Clindamycin
Linezolid
Metronidazole
Colistin
Doxycycline
Trimethoprim-sulfamethoxazole
Tigecycline
Daptomycin
Antibiotic resistance and treatment of multidrug-resistant pathogens
Antibiotic resistance mechanisms
Treatment of multidrug-resistent pathogens
Fungal infections and antifungal agents
Candida
Aspergillus and other invasive molds
Antifungal agents
Amphotericin
Triazoles
Echinocandins
Flucytosine
Combination antifungals
Infection diagnostics
Antimicrobial stewardship
Summary
Key references
Chapter 108: Life-threatening viral diseases and their treatment
Pearls
Myocarditis
Epidemiology and etiology
Clinical presentation
Diagnosis and management
Acute liver failure
Epidemiology and etiology
Clinical presentation
Diagnosis and management
Viral pneumonia/pneumonitis
Epidemiology and etiology
Clinical presentation
Diagnosis and management
Central nervous system infections
Epidemiology and etiology
Clinical presentation
Diagnosis and management
Emerging viral diseases
Key references
Chapter 109: Healthcare-associated infections
Pearls
Epidemiology
Risk factors
Pathogen transmission and isolation practices
Infection prevention strategies
Care bundles
Hand hygiene
Personal protective equipment
Antimicrobial resistance and antimicrobial stewardship
Visitation policies
Specific healthcare-associated infections in the pediatric intensive care unit
Bloodstream infections
Hospital-acquired lower respiratory tract infections (lrtis)
Viral lower respiratory tract infections
Ventilator-associated pneumonia
Urinary tract infections
Surgical site infections
Ventriculostomy-related infections
Healthcare-associated diarrhea
Key references
Chapter 110: Pediatric sepsis
Pearls
Epidemiology
Definitions
Clinical presentation
Pathogenesis
Pathogen recognition and signal transduction
Cytokines as principal mediators of the sepsis response
Adhesion molecules
Nitric oxide
Coagulation cascade
Peroxisome proliferator-activated receptor-γ pathway
Myeloid-derived suppressor cells
Paradigm of sepsis as an adaptive immune problem
Genomic medicine and sepsis
Genetic influence and septic shock
Genome-wide expression profiling in children with septic shock
Treatment strategies
Initial resuscitation
Invasive monitoring
Elimination of pathogens
Maintenance of oxygen delivery
Additional management considerations
Immunomodulation
The case for more effective stratification in pediatric septic shock
Conclusion
Key references
References
Chapter 111: Multiple-organ dysfunction syndrome
Pearls
Pathophysiology and targeted therapies
Mitochondrial dysfunction
Innate and adaptive immune response
Microcirculatory dysfunction, ischemia-reperfusion injury
Epithelial dysfunction
Neurohumoral response
Multiple-organ dysfunction syndrome phenotypes
Multiple-organ dysfunction syndrome definitions
Multiple-organ dysfunction syndrome scoring
Epidemiology
Time course and outcomes
Conclusions and research perspectives
Key references
Section XII: Pediatric Critical Care: Environmental Injury and Trauma
Chapter 112: Bites and stings
Pearls
Snakebites
Epidemiology
Venomous snakes in the united states
Pathophysiology and clinical presentation
Emergency and critical care
Prehospital care
Assessment, stabilization, and disposition
Antivenin considerations
Antivenin administration
Other supportive care
Recurrence and therapeutic complications
Follow-up
Prognosis
Pitfalls
Resources
Spider bites
Epidemiology
Widow spiders
Recluse spiders
Pathophysiology and clinical presentation
Widow spider envenomation (latrodectism)
Recluse spider envenomation (loxoscelism)
Emergency and critical care
Latrodectism management
Loxoscelism management
Therapeutic complications
Follow-up
Prognosis
Pitfalls
Future directions
Resources
Scorpion stings
Epidemiology
Clinical presentation
Emergency and critical care
Hymenoptera stings (bees, wasps, and ants)
Massive envenomation
Emergency and critical care
Prognosis
Key references
Chapter 113: Hyperthermic injury
Pearls
Definitions
Epidemiology
Pathophysiology of heat-related illnesses
Acclimatization
Acute-phase response
Clinical features of heat stroke
Central nervous system
Cardiovascular
Pulmonary
Renal
Gastrointestinal
Metabolic
Hematologic
Infectious
Treatment
Key references
References
Chapter 114: Accidental hypothermia
Pearls
Physiology
Central nervous system
Cardiovascular
Respiratory
Renal
Coagulation
Treatment
Resuscitation
Rewarming
Outcome
Key references
Chapter 115: Drowning
Pearls
Definitions
Epidemiology
Pathophysiologic considerations
Type of aspirated fluid
Pulmonary effects
Cardiovascular effects
Central nervous system effects
Effects on other organ systems
Mammalian diving reflex
Preexisting associated conditions
Cold water drowning
Management
Management at the scene
Emergency department evaluation and stabilization
Management in the intensive care unit
Prognosis
Key references
Chapter 116: Burn and inhalation injury
Pearls
Types of burns
Flame burn
Scald burn
Electrical burn
Chemical burn
Normal skin anatomy
Depth and size of burn
Superficial burns
Superficial partial-thickness burns
Deep partial-thickness burns
Full-thickness burns
Zones of injury
Estimating the extent of the burn
Prehospital and early management
Transfer to burn centers
Pain management
Resuscitation
Colloid resuscitation
Complications of resuscitation
Treatment of burn wounds
Topical therapy
Surgery (excision and grafting)
Inhalation injury
Pathophysiology of inhalation injury
Diagnosis of inhalation injury
Management of inhalation injury
Ventilator support
Airway clearance and extubation criteria
Therapeutic adjuncts
Nutrition
Calculating and monitoring nutritional requirements
Enteral support
Parenteral support
Nutritional adjuncts
Rehabilitation
Reconstructions
Prevention
Key references
Chapter 117: Evaluation, stabilization, and initial management after trauma
Pearls
Prehospital care and trauma team activation
Trauma resuscitation
Primary survey
Overview
Establish an airway with cervical spine stabilization (a)
Breathing (b)
Circulation (c)
Disability (d)
Exposure/environment (e)
Secondary survey
Diagnostic assessment
Laboratory studies
Radiographic imaging
Emergency department thoracotomy
Stabilization and definitive care
Conclusions
Key references
Chapter 118: Traumatic brain injury
Pearls
Epidemiology
Pathophysiology
Posttraumatic ischemia
Excitotoxicity
Delayed neuronal death cascades
Cerebral swelling
Cerebral blood volume
Edema
Axonal injury
History
Signs and symptoms
Initial resuscitation
Rapid-sequence induction and intubation
Circulatory stabilization
Herniation
Transition from the emergency department to the pediatric intensive care unit: Computed tomographic scan and intracranial ...
Diagnostic studies and monitoring modalities
Computed tomography
Magnetic resonance imaging
Intracranial pressure monitoring
Advanced monitoring techniques
Monitoring cerebral blood flow
Monitoring cerebral metabolism
Treatment in the pediatric intensive care unit
Intracranial pressure and cerebral perfusion pressure thresholds
Baseline care
Treatment of intracranial hypertension: First-tier therapies
Ventricular cerebrospinal fluid drainage
Osmolar therapy
Sedation analgesia and neuromuscular blockade
Head position
Treatment of intracranial hypertension: Second-tier therapies
Barbiturates
Hyperventilation
Hypothermia
Decompressive craniectomy
Other therapies for refractory intracranial hypertension
Miscellaneous
Linking rehabilitation and acute care
Outcomes
Conclusion
Key references
Chapter 119: Pediatric thoracic trauma
Pearls
Epidemiology and prevention
Anatomic and physiologic considerations
Initial resuscitation and diagnosis
Chest wall injury
Lung and airway injury
Traumatic asphyxia
Cardiac injuries
Esophageal injury
Chylothorax
Diaphragmatic injury
Conclusions
Key references
Chapter 120: Pediatric abdominal trauma
Key words:
Pearls
Mechanisms and patterns of injury
Penetrating abdominal trauma
Recreational and sports injury
Wartime trauma
Evaluation and resuscitation
Physical examination
Laboratory tests
Radiographic assessment
Computed tomography
Sonography
Additional assessment tools
Diagnostic peritoneal lavage
Diagnostic laparoscopy
Management of specific abdominal injuries
Nonoperative management of solid-organ injuries
Embolization of solid-organ injuries
Injury to the spleen
Injury to the liver
Injury to the small bowel
Injury to the duodenum
Injury to the pancreas
Blunt abdominal aortic injury
Renal trauma
Bladder injuries
Pelvic fractures
Key references
Chapter 121: Child abuse
Pearls
Case example
Abuse VS. accident?
Epidemiology
Medical VS. forensic assessment
Sentinel injuries
Case example
Specific syndromes
Abusive head trauma
Presentation
Diagnosis
Retinal hemorrhage
Imaging
Intensive care unit/surgical considerations
Abdominal trauma
Alternative explanations of injuries
Birth
Subdural hematoma or retinal hemorrhage with valsalva
Brief resolved unexplained event
Cerebral venous sinus thrombosis
Benign enlargement of subarachnoid space
Other alternatives: Lumbar puncture, vaccines, bleeding, or bone mineralization disorders
Mandated reporting
Approach to parents
Case example
Multidisciplinary diagnosis
Coroner cases
Conclusions
Key references
Section XIII: Pediatric Critical Care: Pharmacology and Toxicology
Chapter 122: Principles of drug disposition
Pearls
Clinical pharmacokinetics
Clearance
Volume of distribution
Half-life
Bioavailability
Applied pharmacokinetics
Clinical pharmacodynamics
Determinants of effective therapy
Pharmacokinetic processes
Absorption
Enteral absorption
Sublingual/buccal absorption
Transdermal absorption
Intramuscular and subcutaneous absorption
Rectal absorption
Distribution
Age-dependent maturation in protein binding
Age-dependent maturation in body composition
Disease-dependent changes affecting drug distribution
Metabolism
Hepatic phase I metabolism
Cyp3a
Cyp2c
Cyp2d6
Cyp2b6
Other
Hepatic phase II metabolism
Intestinal metabolism
Elimination
Renal excretion
Biliary excretion
Pharmacodynamics changes
Critical care therapeutics
Antimicrobials
Analgesics and sedatives
Cardiovascular agents
Pulmonary agents
Anticoagulants
Steroids
Neuromuscular blockers
Conclusion
Key references
Chapter 123: Molecular mechanisms of drug actions
Pearls
Targets for drug action
Receptors
Ion channels
Enzymes
Carrier proteins
Receptor type and regulation
G protein–coupled receptors
Channel-linked receptors
Enzyme-linked receptors
Nuclear receptors
Receptor regulation
Signal transduction mechanisms: Intracellular messengers and effectors
Second messengers
Cyclic adenosine monophosphate
Cyclic guanosine monophosphate
Arachidonic acid and its metabolites
Diacylglycerol and inositol triphosphate
Calcium ions
Phosphorylation of proteins
Protein kinases
Calcium-binding proteins
Multiple drug targets within an organ system: The myocardium
Drug response and genetic polymorphisms
Genetic polymorphisms and drug disposition
Genetic polymorphisms, drug targets, and signaling mechanisms
Drug response and development
Drug response and disease
Conclusion
Key references
Chapter 124: Adverse drug reactions and drug-drug interactions
Pearls
Adverse drug reactions by organ system
Renal
Hepatic
Cardiovascular
Central nervous system
Hematologic
Endocrine and metabolic
Dermatologic
Drug-drug interactions
Pharmacodynamic drug-drug interactions
Drug-drug interactions by therapeutic class
Cardiovascular agents
Vasopressors
Antiarrhythmics
β-blockers
Calcium channel blockers
Angiotensin-converting enzyme inhibitors
Nitrates
Anticonvulsant medications
Antiinfective and antimicrobial agents
Anesthetic agents and sedatives
Analgesic agents
Anticoagulants
Immunosuppressive agents
Antineoplastic agents
Key references
Chapter 125: Principles of toxin assessment and screening
Pearls
Common agents involved in serious pediatric poisonings
Resources for the clinician
General assessment of the poisoned patient
History
Physical examination
Laboratory tests and toxin screens
Additional investigations
Radiographic studies
Diagnostic trials
Summary
Key references
Chapter 126: Toxidromes and their treatment
Pearls
Opioids
Sedative hypnotics
Sympathomimetic agents
Anticholinergic agents
Cholinergic agents
Methemoglobinemia
Xenobiotic-induced hyperthermia
Metabolic acidosis with increased anion gap
Toxin-induced seizures
Cardiovascular agents
Acetaminophen (paracetamol)
Key references
Section XIV: Pediatric Critical Care: Anesthesia Principles in the Pediatric Intensive Care Unit
Chapter 127: Airway management
Pearls
Anatomic considerations
Basic airway management
Nasopharyngeal airway
Oropharyngeal airways
Oxygen delivery devices
Nasal cannulas
Masks
Noninvasive positive-pressure ventilation
Establishing a functional airway
Endotracheal intubation
Indications
Respiratory failure
Hemodynamic instability
Neuromuscular dysfunction
Failure of central nervous system to regulate ventilatory drive and airway reflexes
Other indications
Physiologic effects of intubation
Recognition of a difficult airway
Process of intubation
Pharmacologic agents to facilitate intubation
Anticholinergic agents
Sedative and analgesic agents
Neuromuscular blocking agents
Preoxygenation
Orotracheal intubation
Nasotracheal intubation
Adjunctive airway approaches
Laryngeal mask airway
Video laryngoscopy
Flexible fiberoptic bronchoscopy
Cricothyrotomy, tracheostomy, and retrograde intubation
Extubation
Complications of endotracheal intubation
Prolonged intubation
Tracheostomy
Special circumstances
Full stomach
Increased intracranial pressure and neurologic dysfunction
Cervical spine instability
Upper airway obstruction
Facial and laryngotracheal injury
Open-globe injury
Key references
Chapter 128: Anesthesia effects on organ systems
Pearls
Anesthetic agents and regional anesthesia methods
Neurologic effects
Cardiovascular effects
Respiratory, gastrointestinal, and renal effects
Key references
Chapter 129: Anesthesia principles and operating room anesthesia regimens
Pearls
Preoperative evaluation
Nothing-by-mouth guidelines
Preoperative medication
Monitoring
Pharmacology of anesthetic agents
Local anesthetic agents
Intravenous anesthetic agents
Opioids
Volatile anesthetic agents and nitrous oxide
Neuromuscular blocking agents
Intraoperative anesthetic care
Maintenance anesthesia
Intraoperative fluid management
Postoperative care
Postoperative analgesia
Conclusions
Key references
Chapter 130: Malignant hyperthermia
Pearls
Pathophysiology
Genetics
Clinical recognition of malignant hyperthermia
Differential diagnosis
Course of malignant hyperthermia
Potential systemic complications
Management of an episode of malignant hyperthermia
Initial steps: Discontinue trigger agents and administer dantrolene
Further management: Expert consultation and symptomatic treatment
Urine and blood tests in malignant hyperthermia
Testing for malignant hyperthermia susceptibility
Muscle contracture testing
Less invasive tests of malignant hyperthermia susceptibility
Disorders associated with malignant hyperthermia
Muscular diseases and malignant hyperthermia
Heat illness and malignant hyperthermia susceptibility
Neuroleptic malignant syndrome
Malignant hyperthermia association and registry
Key references
Chapter 131: Neuromuscular blocking agents
Pearls
Neuromuscular junction
Neuromuscular blocking agents: Depolarizing agents
Neuromuscular blocking agents: Nondepolarizing agents
Pancuronium
Vecuronium
Rocuronium
Rapacuronium
Mivacurium
Atracurium
Cis-atracurium
Reversal of neuromuscular blockade
Acetylcholinesterase inhibitors
Sugammadex
Monitoring neuromuscular blockade
Adverse effects of neuromuscular blockade
Summary: Neuromuscular blocking agents in the picu
Key references
Chapter 132: Sedation and analgesia
Pearls
Posttraumatic stress disorder
Sedation scoring and assessment
Opioids and analgesia in the pediatric intensive care unit
Specific opioid agonists
Morphine
Meperidine
Fentanyl
Sufentanil
Alfentanil
Remifentanil
Codeine
Hydromorphone
Tramadol
Opiate antagonists
Incidental pain syndromes in the pediatric intensive care unit
Sickle cell crisis
Opiate tolerance
Rapid opiate detoxification
Benzodiazepines
Specific benzodiazepines
Diazepam
Midazolam
Lorazepam
Tolerance for and dependence on benzodiazepines
Flumazenil
Other agents for sedation in the pediatric intensive care unit
Chloral hydrate
Butyrophenones and phenothiazines
Haloperidol
Droperidol
Chlorpromazine
Lytic cocktail
Neuroleptic malignant syndrome
Baclofen
Cannabis
Dexmedetomidine
Propofol
Special issue regarding long-term infusion of propofol
Propofol infusion syndrome
Propofol tolerance and withdrawal
Ketamine
Etomidate
Inhalational anesthetic agents
Inhalation agent withdrawal syndrome
Sedation for children with preexisting cognitive impairment
Apoptosis and neurocognitive effects of anesthetic agents
Sedation-related complications
Pharmacoeconomics of analgesia and sedation in the pediatric intensive care unit
Key references
Chapter 133: Tolerance, dependency, and withdrawal
Pearls
History of tolerance and withdrawal in medical practice
Clinical signs and symptoms of withdrawal
Limitation of the development of tolerance and physical dependency
Incidence of tolerance and physical dependency
Scoring systems to identify withdrawal
Weaning from sedative and analgesic agents
Summary
Key references
Chapter 134: Pediatric delirium
Pearls
Background
Etiology
Epidemiology
Risk factors
Outcomes
Clinical presentation
Diagnosis
Treatment
Underlying illness
Iatrogenic factors
Environment
Pharmacotherapy
Prevention
Conclusion
Key references
Chapter 135: Procedural sedation for the pediatric intensivist
Differences between outpatient and inpatient sedation
Outpatient procedural sedation training during pediatric critical care fellowship
Sedation team structure
Classification of sedation
Equipment, monitoring, and rescue drugs
Sedation prescreening
Considerations in choosing commonly used medications
Nonpharmacologic approach to outpatient sedation
Sedation adverse events
Key references
Section XV: Pediatric Critical Care: Board Review Questions
Chapter 136: Board review questions
Chapter 1: History of pediatric critical care medicine
Chapter 2: High-reliability pediatric intensive care unit: role of intensivist and team in obtaining optimal outcomes
Chapter 3: Critical communication in the pediatric intensive care unit
Chapter 4: Professionalism in pediatric critical care
Chapter 5: Leading and managing change in the pediatric intensive care unit
Chapter 7: Fostering a learning healthcare environment in the pediatric intensive care unit
Chapter 8: Challenges of pediatric critical care in resource-poor settings
Chapter 9: Public health emergencies and emergency mass critical care
Chapter 10: Lifelong learning in pediatric critical care
Chapter 11: Essential concepts in clinical trial design and statistical analysis
Chapter 12: Prediction tools for short-term outcomes following critical illness in children
Chapter 13: Pediatric critical care transport
Chapter 14: Pediatric vascular access and centeses
Chapter 15: Ultrasonography in the pediatric intensive care unit
Chapter 16: Patient- and family-centered care in the pediatric intensive care unit
Chapter 17: Pediatric critical care ethics
Chapter 18: Ethical issues around death and dying
Chapter 19: Palliative care in the pediatric intensive care unit
Chapter 20: Organ donation process and management of the organ donor
Chapter 21: Long-term outcomes following critical illness in children
Chapter 22: Burnout and resiliency
Chapter 23: Structure and function of the heart
Chapter 24: Regional and peripheral circulation
Chapter 25: Endothelium and endotheliopathy
Chapter 26: Principles of invasive cardiovascular monitoring
Chapter 27: Assessment of cardiovascular function
Chapter 28: Cardiac failure and ventricular assist devices
Chapter 29: Echocardiographic imaging
Chapter 30: Diagnostic and therapeutic cardiac catheterization
Chapter 31: Pharmacology of the cardiovascular system
Chapter 32: Cardiopulmonary interaction
Chapter 33: Disorders of cardiac rhythm
Chapter 34: Shock states
Chapter 35: Pediatric cardiopulmonary bypass
Chapter 36: Critical care after surgery for congenital cardiac disease
Chapter 37: Cardiac transplantation
Chapter 38: Physiologic foundations of cardiopulmonary resuscitation
Chapter 39: Performance of cardiopulmonary resuscitation in infants and children
Chapter 40: Structure and development of the upper respiratory system
Chapter 41: Structure and development of the lower respiratory system
Chapter 42: Physiology of the respiratory system
Chapter 43: Noninvasive respiratory monitoring and assessment of gas exchange
Chapter 44: Overview of breathing failure
Chapter 45: Ventilation/perfusion inequality
Chapter 46: Mechanical dysfunction of the respiratory system
Chapter 47: Diseases of the upper respiratory tract
Chapter 48: Pediatric acute respiratory distress syndrome and ventilator-associated lung injury
Chapter 49: Acute viral bronchiolitis
Chapter 50: Asthma
Chapter 51: Neonatal pulmonary disease
Chapter 52: Pneumonitis and interstitial disease
Chapter 53: Diseases of the pulmonary circulation
Chapter 54: Mechanical ventilation and respiratory care
Chapter 55: Noninvasive ventilation in the pediatric intensive care unit
Chapter 56: Extracorporeal life support
Chapter 57: Pediatric lung transplantation
Chapter 58: Structure, function, and development of the nervous system
Chapter 59: Critical care considerations for common neurosurgical conditions
Chapter 60: Neurologic assessment and monitoring
Chapter 61: Neuroimaging
Chapter 62: Coma and depressed sensorium
Chapter 63: Intracranial hypertension and monitoring
Chapter 64: Status epilepticus
Chapter 65: Anoxic ischemic encephalopathy
Chapter 66: Pediatric stroke and intracerebral hemorrhage
Chapter 67: Central nervous system infections and related conditions
Chapter 68: Acute neuromuscular disease and disorders
Chapter 70: Renal structure and function
Chapter 71: Fluid and electrolyte issues in pediatric critical illness
Chapter 72: Acid-base balance in critical illness
Chapter 73: Tests of kidney function in children
Chapter 74: Glomerulotubular dysfunction and acute kidney injury
Chapter 75: Pediatric renal replacement therapy in the intensive care unit
Chapter 76: Pediatric renal transplantation
Chapter 77: Renal pharmacology
Chapter 78: Hypertensive urgencies and emergencies
Chapter 79: Cellular respiration
Chapter 80: Biology of the stress response
Chapter 81: Inborn errors of metabolism
Chapter 82: Genetic variation in health and disease
Chapter 83: Molecular foundations of cellular injury
Chapter 84: Endocrine emergencies
Chapter 85: Diabetic ketoacidosis
Chapter 86: Structure and function of the hematopoietic organs
Chapter 87: The erythron
Chapter 88: Hemoglobinopathies
Chapter 89: Coagulation and coagulopathy
Chapter 90: Thrombosis in pediatric critical care
Chapter 91: Transfusion medicine
Chapter 92: Hematology and oncology problems
Chapter 93: Critical illness in children undergoing hematopoietic progenitor cell transplantation
Chapter 94: Gastrointestinal structure and function
Chapter 95: Disorders of the gastrointestinal system
Chapter 96: Acute liver failure
Chapter 97: Hepatic transplantation
Chapter 98: Acute abdomen
Chapter 99: Nutrition of the critically ill child
Chapter 100: Innate immunity
Chapter 101: Adaptive immunity
Chapter 102: Critical illness and the microbiome
Chapter 103: Congenital immunodeficiencies
Chapter 104: Acquired immune dysfunction
Chapter 105: Immune balance in critical illness
Chapter 106: Pediatric rheumatologic disease
Chapter 107: Bacterial and fungal infections
Chapter 108: Life-threatening viral diseases and their treatment
Chapter 109: Healthcare-associated infections
Chapter 110: Pediatric sepsis
Chapter 111: Multiple organ dysfunction syndrome
Chapter 112: Bites and stings
Chapter 113: Hyperthermic injury
Chapter 114: Hypothermic injury
Chapter 115: Drowning
Chapter 116: Burn and inhalation injuries in children
Chapter 117: Evaluation, stabilization, and initial management after trauma
Chapter 118: Traumatic brain injury
Chapter 119: Pediatric thoracic trauma
Chapter 120: Pediatric abdominal trauma
Chapter 121: Child abuse
Chapter 122: Principles of drug disposition
Chapter 123: Molecular mechanisms of drug action
Chapter 124: Adverse drug reactions and drug-drug interactions
Chapter 125: Principles of toxin assessment and screening
Chapter 126: Toxidromes and their treatment
Chapter 127: Airway management
Chapter 128: Anesthesia effects on organ systems
Chapter 129: Anesthesia principles and operating room anesthesia regimens
Chapter 130: Malignant hyperthermia
Chapter 131: Neuromuscular blocking agents
Chapter 132: Sedation and analgesia
Chapter 133: Tolerance, dependency, and withdrawal
Chapter 134: Pediatric delirium
Chapter 135: Procedural sedation for the pediatric intensivist
Inside Back Cover