Fuhrman & Zimmerman's Pediatric Critical Care

Cover
Copyright
Contributors
Preface
Section I: Pediatric Critical Care: The Discipline
Chapter 1 - History of Pediatric Critical Care
Definitions
Definition of a Pediatric Intensive Care Unit
Definition of Pediatric Intensivist
History of Critical Care
Resuscitation and Ventilation
Anesthesia
Anatomy and Physiology
History of Pediatric Critical Care
Pediatric Anesthesiology
Pediatric General and Cardiac Surgery
Neonatology
Pediatric Cardiology
Poliomyelitis
Nursing
Pediatric Critical Care
Getting Started
The Present
The Cost of Success
Around the World
Canada
Africa
Asia: Japan
India
Australia and New Zealand
Europe
Israel
Latin America
Our Heroes
Acknowledgments
Chapter 2 - The Intensivist in the New Hospital Environment: Patient Care and Stewardship of Hospital Resources
Organization and Quality Issues
Manpower Issues
Summary
Chapter 3 - The Nurse in Pediatric Critical Care
Describing What Nurses Do: The Synergy Model
Patient Characteristics of Concern to Nurses
Nurse Competencies Important to Patients and Families
Clinical Judgment
Clinical Inquiry
Caring Practices
Response to Diversity
Advocacy/Moral Agency
Facilitator of Learning
Collaboration
Systems Thinking
Optimal Patient Outcomes
Patient Level Outcomes
Provider Level Outcomes
System Level Outcomes
Nightingale Metrics
Leadership
Beacon Award
Professional Development
Staff Development
Orientation
In-Service Education
Continuing Education
Certification in Pediatric Critical Care Nursing
Summary
Chapter 4 - Research in Pediatric Critical Care
Research Areas
Wellsprings of Research
Collective Needs
Individual Motivation
Doing Research
The Null Hypothesis
Medical Research
Research Design
Independent Variable
Dependent Variable
Nuisance Variables
Design Efficacy
Randomization
Validity
Statistics: A Word
Type I and Type II Errors
Neoempiricism, Data Mining, and Knowledge Discovery in Databases
Research Funding
Obtaining Financial Support
Sources of Research Funding
Intramural Funding
Extramural Funding
National Institutes of Health
Writing the Grant Application
Hypothesis-Driven Research-Specific Aims
Significance
Preliminary Studies
Experimental Plan
Presentation
Page Limitations
Your Chances: Money
Your Chances: Cultures in Conflict
Research Ethics
Acknowledgment
Chapter 5 - Proving the Point: Evidence-Based Medicine in Pediatric Critical Care
The Evidence-Based Medicine Process
Study Types
Interventional Studies
Observational Studies
Research Summaries
Levels of Evidence
Apply the Evidence
Challenges to Evidence-Based Medicine
Conclusion
Chapter 6 - Outcomes in Pediatric Critical Care Medicine: Implications for Health Services Research and Patient Care
What Is Health Services Research?
A System of Care
Organizing Health Systems
Microsystems and Macrosystems
Microsystems
Macrosystems
The Macrosystem: Pediatric Critical Care
Access
Quality
Structure
Process
Outcomes
Neonatal Intensive Care Unit Mortality Scores.
Pediatric Intensive Care Unit Mortality Scores.
The Microsystem: Pediatric Intensive Care Unit
Patient Level
Intensive Care Unit Level
Beyond the Pediatric Intensive Care Unit
Conclusion
Chapter 7 - Safety and Quality Assessment in the Pediatric Intensive Care Unit
A Brief Consideration of the Relationship Between Safety and Quality
State of Safety and Quality in Pediatric Intensive Care Units
Fundamentals of Quality Improvement and Patient Safety: Systems Thinking
Quality Improvement and Value
Quality Improvement Methods
Variation and Display of Data over Time
Other Quality Improvement Tools
Fundamentals of Patient Safety
Errors, Injuries, Systems, and Risks
Improvement in the Pediatric Intensive Care Unit
Culture
Teams and Teamwork
Technology
Patient Safety in the Pediatric Intensive Care Unit: Past, Present, and Future
Conclusions
Chapter 8 - Information Technology in Critical Care
The Electronic Health Record
Data Acquisition
Data Access
Data Storage
Clinical Decision Support
Patient Safety
Automated Adverse Event Detection
Promises and Limitations
New Kinds of Errors
Increased Work for Clinicians
Unfavorable Alteration of Workflow
Untoward Changes in Communication Patterns
High System Demands and Frequent Changes
Persistence of Paper
Overdependence on Technology
Human Factors Engineering
Continued Promise
Design and Implementation
Health Information Exchange
Data Exchange Within a Single Health Care Organization
Data Exchange Among Multiple Health Care Organizations
Protected Health Information
Clinical Tools
Smart Infusion Pumps
Bar Coding in Health Care
Virtual Care and Telemedicine
Medical Knowledge Bases
The Internet and the Patient
Research Databases
Virtual Pediatric Intensive Care Unit ­Systems
Security
Firewalls
Wireless Networks
Virtual Private Network
Authentication
Viruses or Malware
User Privacy
Spyware
Cookies
Web Bugs
Profiles and Privacy Policies
Electronic Mail
Conclusion
Chapter 9 - Family-Centered Care in the Pediatric Intensive Care Unit
Caring and Compassion
Humanitarianism and Defining the Family
Family-Centered Care Core Concepts
Challenges for the Team and Family
Culturally Sensitive Care
Professional Boundaries
Personalizing Care
Communication
Daily Communication
Respectful Language
When English Is not the Primary Family Language
Access to Information
Technology
Rounds
Shift Report
Disclosing Medical Errors
Multidisciplinary Team
Social Worker
Chaplain/Spiritual Care
Child Life Specialist
Pet Therapist
Parent Advisory Council/Family as Consultant
Parent Support Group
Volunteers
Financial Services
Ethicist
Palliative Care
Access Concepts
Admission Process
Sibling Participation
Family Space
Participation in Care
Procedures
Resuscitation
Transferring out of the Pediatric Intensive Care Unit
Compassion Fatigue
Chapter 10 - Ethics in Pediatric Intensive Care
Moral Theory
Consequentialism
Deontology
Prevailing Principles
Beneficence
Nonmaleficence
Autonomy
Justice
Health Care Decision Making: Consent
Competency
Information
Understanding
Voluntariness
Shared Decision Making
Surrogate Decision Making: Parental Rights and Obligations
Conscientious Objection to Participation in Proposed Interventions
Pediatric Intensive Care and “Experimentation”
Chapter 11 - Ethical Issues in Death and Dying
Withholding and Withdrawing Life Support
Active Versus Passive Euthanasia
Withholding Food and Water
Competence, Incompetence, and Baby Doe
Legal Implications of Withholding or Withdrawing Life Support
Futility
Hospital Ethics Committees
Caring for the Terminally Ill
Definition of Death and Organ Retrieval
Brain Death
Organ Retrieval
Chapter 12 - Palliative Care
What Is Pediatric Palliative Care?
Issues of Concern in Palliative Care
Communication
Palliation of Symptoms or Relief of ­Suffering?
Spiritual and Environmental Needs
Support of Clinicians
Practical Aspects of Care at the End of Life
The Anticipatory Clinical Team Meeting
What Treatments May Be Withheld or Withdrawn?
Where and When Will Mechanical Ventilation Be Withdrawn?
How Should Mechanical Ventilation Be Withdrawn?
Preparation and Support of the Family
Determining Who Will Care for the Patient at This Time
Determining How Signs of Apparent Discomfort Will Be Treated
Neuromuscular Blockade and the Withdrawal of Mechanical Ventilation
Consideration of the Level of Sedation and Analgesia to Be Used
The Goal of Using Sedatives and Analgesics in This Context
Issues After Death
Essential Basic Documentation
Support of the Caregivers
Chapter 13 - The Process of Organ Donation and Pediatric Donor Management
Role of the Pediatric Intensivist and Critical Care Team in the Process of Organ Donation
Determination of Brain Death
Brain Death Physiology
Treatment of Hemodynamic Instability
Hormonal Replacement Therapy
Management of Pulmonary Issues for the Potential Pediatric Organ Donor
Fluid and Electrolyte Disturbances
Diabetes Insipidus
Oliguria
Glucose, Potassium, and Calcium Derangements
Coagulation Abnormalities and Thermoregulatory Instability
Medical Examiner/Coroner Issues and Organ Donation for Children
Donation After Circulatory Determination of Death
Summary
Chapter 14 - Pediatric Transport: Shifting the Paradigm to Improve Patient Outcome
The Problem: An Adult-Oriented Retrieval System Focused on Rapid Movement
Critical Pediatric Physiology Relevant to Transport Medicine
Rapid Transfer, Goal-Directed Therapy, and the Golden Hour
Specialized Teams Improve Outcome
The Solution: A Retrieval System Focused on Improving Outcome
Responsibility of the Retrieval System
Communications
Staffing
Equipment
Safety
Referring Hospital Responsibilities
Summary
Chapter 15 - Pediatric Vascular Access and Centeses
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
Pericardiocentesis
Indications
Contraindications
Procedure
Equipment
Technique
Maintenance
Complications
Interpretation
Summary
Umbilical Arterial Catheter and Umbilical Venous Catheter Placement
Umbilical Artery Cannulation
Supplies and Equipment
Technique
Maintenance
Complications
Summary
Umbilical Vein Cannulation
Equipment
Technique
Maintenance
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
Venous Cutdown
Peripherally Inserted Central Venous Catheters
Pulmonary Artery Catheterization
Contraindications
Procedure and Equipment
Information Acquisition
Maintenance
Interpretation
Complications
Summary
Thoracentesis and Tube Thoracostomy
Thoracentesis
Indications
Contraindications
Preparation
Procedure
Technique
Complications
Interpretation
Summary
Tube Thoracostomy
Contraindications
Supplies and Equipment
Technique
Maintenance
Complications
Summary
Paracentesis
Indications
Contraindications
Procedure
Supplies
Technique
Complications
Interpretation
Summary
Chapter 16 - Pediatric Intensive Care in Developing Countries
Why Lower Child Mortality Rates?
Expenditure on Health
Child Mortality, Infections, and Intensive Care
Role of Intensive Care
Ethical Dilemma
Causes of Death
Pneumonia
Antibiotic Treatment
Oxygen and Ventilation
Fluid Therapy
Feeding
Gastroenteritis
Shock
Fluid and Electrolyte Abnormalities
Sodium Abnormalities.
Hypokalemia.
Hypophosphatemia.
Metabolic Acidosis.
Low Birth Weight
Neonatal Asphyxia
Malaria
Diagnosis
Initial Treatment
Antimalarial Drugs
Other Treatment
Measles
Diagnosis
Infection Control
General Measures
Human Immunodeficiency Virus
Pertussis
Diagnosis
Treatment
Tetanus
Treatment
Tuberculosis
Pathophysiology
Diagnosis
Presentation to the Intensive Care Unit
Lower Airway Obstruction
Bronchoesophageal Fistula
Laryngeal Tuberculosis
Tuberculous Meningitis
Tuberculous Pericarditis
Miliary and Abdominal Tuberculosis
Treatment Regimens
Diphtheria
Course During the First Week
Subsequent Course
Diagnosis
Antibiotics
Antitoxin
Supportive Care
Cardiac
Prevention of the Spread of Disease
Dengue
Fluid Therapy
Other Treatment
Malnutrition
Conclusion
Chapter 17 - Educating the Intensivist
Requirements
The American Board of Pediatrics
The Accreditation Council for Graduate Medical Education
ACGME Core Competencies
Duty Hours
Adult Learning
The Dreyfus and Dreyfus Model of Skill Acquisition
Methods of Teaching
Teaching at the Patient’s Bedside
Procedural Training
Simulation Training
Web-Based Education
Evaluation and Assessment of Competency
Milestones
Education in Research, Scholarship, and Leadership
Mentorship
Establishing and Maintaining Competency
Chapter 18 - Critical Care in Public Health Emergencies
Basic Concepts
National Response Framework and Incident Command System
Ordinary Surge and Mass Critical Care
Pediatric Critical Care Needs and Resources in a Public Health Emergency
When the PICU Is Notified of a Sudden-Impact Public Health Emergency
Emergency Department Phase
Triage
Decontamination
Infection Control
Keeping Families Together, Identifying and Tracking Children, Child Safety
Intensive Care Unit Phase
PICU Operations in a Gradual Onset and Sustained Public Health Emergency
Space
Personnel
Mechanical Ventilation
Manual Ventilation
Equipment and Supplies
Medications
Critical Care in Specific Types of Public Health Emergencies
Rationing
Section II: Cardiovascular System
Chapter 19 - Structure and Function of the Heart
Anatomic Development and Structure
Gross Anatomy
Microscopic Anatomy
Myocyte
Contractile Apparatus
Sarcolemma and Sarcoplasmic Reticulum
Cytoplasm
Cytoskeleton and Extracellular Matrix
Nerves and Receptors
Ductus Arteriosus
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
Isovolumic Phase Indices.
Ejection Phase Indices.
Ventricular Function Curves
Pericardial Function
Ventricular Interaction
Diastolic Ventricular Function
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
Autoregulation
Chapter 20 - Regional Circulation
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
Chapter 21 - Principles of Invasive Monitoring
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 Pressure Catheters
Indications
Interpretation of Waveforms
Continuous Mixed Venous Oxygen Saturation
Arterial Pressure Catheters
Indications
Interpretation of Waveforms
Pulmonary Artery Catheters
History and Controversy
Indications
Catheter Ports
Measurement of Cardiac Output
Fick Method
Thermodilution Method
Calculation of Oxygen Delivery and Consumption
Interpretation of Waveforms
Resistance
Calculation of Intracardiac Shunt
Directly and Indirectly Measured Variables
Conclusions
Chapter 22 - Assessment of Cardiovascular Function
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 DO2
Acid-Base Status
Blood Lactate
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
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
Chapter 23 - Echocardiography and Noninvasive Diagnosis
Diagnosis of Congenital Heart Disease
Cardiac Function Assessment
Structure-Oriented Approach
Segmental Analysis: Situs Diagnosis
Segmental Analysis: Atrioventricular Connection
Segmental Analysis: Ventriculoarterial Connection
Ventricular and Atrial Septa
Atrial Septum
Ventricular Septum
Segmental Analysis: Valves
Atrioventricular Valves
Semilunar Valves
Segmental Analysis: Veins
Systemic Venous Connections
Systemic Venous Anomalies
Pulmonary Veins
Segmental Analysis: Coronary Arteries
Segmental Analysis: Aorta
Systemic Arteriovenous Fistulas
Pulmonary Arteries
Ventricular Function Assessment and Hemodynamics
Contrast Echocardiography
Transesophageal Echocardiography
Specific Lesions
Shunts
Complex Heart Defects
Left Heart Lesions
Right Heart Lesions
Special Considerations after Chest Trauma
Safety of Ultrasound
Costs and Benefits
Trends
Chapter 24 - Diagnostic and Therapeutic Cardiac Catheterization
Catheterization Laboratory Environment
Hemodynamic and Oxygen Saturation Data
Assessment of Critical Illness
Transcatheter Radiofrequency Ablation
Congenital Heart Disease
Therapeutic Interventions in the Newborn
Atrial Communication Procedures
Pulmonary Balloon Valvotomy
Aortic Balloon Valvotomy
Perioperative Interventional Procedures
Risks and Complications
Balloon Dilation of Pulmonary Arteries
Occlusion Device Insertion
Cardiac Catheterization and Extracorporeal Membrane Oxygenation
Chapter 25 - Pharmacology of the Cardiovascular System
Mechanisms of Response
Adrenergic Receptors
Signal Transduction
β-Adrenergic Receptors
α Receptors
Receptor Downregulation
Polymorphisms
Vasopressin Receptors
V1 Receptors
Receptor Downregulation
Polymorphisms
Phosphodiesterase Regulation of cAMP
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
Adverse Effects
Preparation and Administration
Adverse Effects
Interactions
Summary
Vasopressin
Basic Pharmacology
Clinical Pharmacology
Pharmacokinetics
Clinical Role
Preparation and Administration
Adverse Effects
Interactions
Summary
Terlipressin
Basic Pharmacology
Clinical Pharmacology and Adverse Effects
Bipyridines
Inamrinone
Clinical Pharmacology
Pharmacokinetics
Clinical Role
Preparation and Administration
Adverse Effects
Interactions
Milrinone
Clinical Pharmacology
Pharmacokinetics
Clinical Role
Preparation and Administration
Adverse Effects
Summary
Nesiritide
Basic Pharmacology
Clinical Pharmacology
Pharmacokinetics
Preparation and Administration
Adverse Effects
Drug Interactions
Clinical Role
Digitalis Glycosides
Basic Pharmacology
Clinical Pharmacology
Pharmacokinetics
Clinical Role
Preparation and Administration
Adverse Effects
Interactions
Summary
Conclusion
Chapter 26 - Cardiopulmonary Interactions
Effects of Ventilation on Circulation
Right Ventricular Filling and Stroke Volume
Venous Return
Right Ventricular Preload and Stroke Volume
Positive Pressure Mechanical Ventilation and Right Ventricular Preload
Critical Illness and Effects of Positive Pressure Breathing on the Right Heart
Pulmonary Circulation
Lung Volume
Alveolar Pressure
Regulation of Pulmonary Vascular Resistance
Direct Effects of Airway Pressure on Pulmonary Vascular Tone
Left Ventricular Preload
Decreased Venous Return
Ventricular Interdependence
Cardiac Crowding
Left Ventricular Afterload
Cardiac Contractility
Preload Dependence Versus Afterload Dependence
Fluid Responsiveness During Positive ­Pressure Ventilation
Elevated Work of Breathing and the Circulation
Pulsus Paradoxicus in Respiratory Distress
Effects of Breathing on Measurement of Hemodynamic Parameters
Effects of Cardiovascular Function on Respiration
Shock States and Respiratory Function
Congestive Heart Failure
Cardiac Disease as a Cause of Blood Gas Abnormalities
Hypercyanotic Spells
Glenn and Fontan Procedures
Pulmonary Hypertension
Vascular Impingement on the Lungs
Effect of Initiating Mechanical Ventilation
Chapter 27 - Myocardial Dysfunction, Ventricular Assist Devices, and Extracorporeal Life Support
Myocardial Dysfunction
Low Cardiac Output Syndrome
Therapeutic Considerations
Decreasing Oxygen Consumption
Increasing Oxygen Delivery
Pharmacologic Treatment of Pediatric Heart Failure
Mechanical Circulatory Support
Historical Perspective
Mechanical Support Devices
Short-Term Mechanical Support Devices
Extracorporeal Life Support
Extracorporeal Life Support Circuit
Extracorporeal Life Support Physiology
Extracorporeal Life Support Indications and Contraindications
Myocarditis
Postcardiopulmonary Bypass
Extracorporeal Cardiopulmonary Resuscitation
Myocardial Failure: Bridge to Transplantation
Malignant Dysrhythmias
Refractory Respiratory Failure
Contraindications
Critical Care Management During Extracorporeal Life Support
Cardiac Output
Troubleshooting
Cardiac Stun
Diagnostic and Therapeutic Uses of Cardiac Catheterization
Patients with a Single Ventricle
Anticoagulation Strategies
Ventilation Strategies
Fluid, Nutrition, and Renal Strategies
Analgesia and Sedation
Infection
Intrahospital Transport
Ventricular Assist Devices
Centrifugal Ventricular Assist Devices
Intraaortic Balloon Pump
Long-Term Mechanical Support Devices
Pulsatile-Type Devices
Berlin Heart Ventricular Assist Device or EXCOR
The Medos Ventricular Assist Device
Thoratec Ventricular Assist System
The Abiomed BVS 5000 VAD
Rotary/Axial-Type Devices
MicroMed DeBakey and HeartAssist 5
Jarvik 2000
HeartMate II
Total Artificial Heart
Next Generation Levitated Devices
Ethics
Future Directions
Conclusion
Chapter 28 - Disorders of Cardiac Rhythm
Classification of Arrhythmias
Bradycardias
Appropriate Versus Normal Heart Rate
Sinus Bradycardia and Sinus Pauses
Conduction Abnormalities
Escape Rhythms
Tachycardias
Classification by Mechanism
Classification by Site
Supraventricular Tachycardias
Atrioventricular Reciprocating Tachycardias
Atrioventricular Nodal Reentrant Tachycardia
Primary Atrial Tachycardias
Junctional Ectopic Tachycardia
Ventricular Tachycardias
Approach to Diagnosis
Monitoring and General Assessment
Surface Electrocardiogram
Bradycardias
Extrasystoles
Tachycardias with Normal QRS
Tachycardias with Prolonged QRS
Monitoring of Atrial Depolarization
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
Newer Indications for Pacing
Tachycardia Therapies
Vagal Maneuvers
Acute Pharmacologic Therapies
Antiarrhythmic
Procainamide.
Lidocaine.
β-Blocking Agents.
Amiodarone.
Calcium Channel–Blocking Agents.
Magnesium Sulfate.
Digoxin.
Cardioversion and Defibrillation
Approach to Therapy
Extrasystoles
Sustained Tachycardias
Unstable Patients
Treatment Failure
Errors in Diagnosis
Unrecognized Reinitiation
Improper Technique
Specific Arrhythmias
Primary Arrhythmias
Orthodromic Reciprocating Tachycardia in Infancy
Tachycardia-Induced Cardiac Dysfunction
Congenital Atrioventricular Block
Chaotic Atrial Tachycardia
Long QT Syndromes
Genetic Arrhythmias
Ventricular Tachycardia in Ostensibly Healthy Patients
Secondary Rhythm Disturbances
Postoperative Arrhythmias
Junctional Ectopic Tachycardia. JET immediately following cardiac surgery may be mistaken for third-degree AV block, but on rewa...
Late Postoperative Arrhythmias
Metabolic Derangements
Endocrine Disorders (Thyroid).
Central Nervous System Injury.
Hypothermia and Hyperthermia.
Acute Myocardial Infarction.
Arrhythmias Resulting from Drug Toxicity
Cocaine.
Tricyclic Antidepressants and Phenothiazine.
Infections
Chapter 29 - Shock States
Definition and Physiology
Recognition and Assessment of the Shock State
Treatment of Shock
General Principles
Intubation and Mechanical Ventilation
Fluid Resuscitation
Vasoactive Infusions
Other Therapies
Multisystem Effects of Shock
Respiratory
Renal
Coagulation
Hepatic
Gastrointestinal
Endocrine
Functional Classification and Common Underlying Etiologies
Hypovolemic Shock
Etiology and Pathophysiology
Therapy
Cardiogenic Shock or Congestive Heart Failure
Etiology and Pathophysiology
Clinical Assessment
Therapy
Myocardial Contractility: Inotropic Agents
Afterload Reduction: Vasoactive Drugs
Surgical Intervention
Specific Etiologies
Cardiomyopathy
Hypoxic-Ischemic Injury
Cardiac Injury in Trauma
Obstructive Shock
Etiology and Pathophysiology
Specific Etiologies
Cardiac Tamponade
Coarctation/Interrupted Arch
Distributive Shock
Etiology and Pathophysiology
Septic Shock
Etiology and Pathophysiology
Therapy
Cardiovascular Support
Nutrition
Experimental/Unproved Therapies
Summary
Chapter 30 - Cardiac Bypass for Repair of Congenital Heart Disease in Infants and Children
Cardiopulmonary Bypass in Infants Versus Adults
Physiology of Cardiopulmonary Bypass
Hypothermia
Pulsatile Versus Nonpulsatile Flow
Strategies for Blood Gas Management: Alpha-Stat and pH Stat
Neurologic Injury and Protection
Preoperative Factors
Postoperative Factors
Neuromonitoring and ­Neuroprotection
Myocardial Protection
Pulmonary Effects of Cardiopulmonary Bypass
Renal Function and Protection on Cardiopulmonary Bypass
Endocrine Response to Cardiopulmonary Bypass
Systemic Inflammation
Management of Cardiopulmonary Bypass
Hemodilution
Circuit Miniaturization
Biocompatible Circuits
Circuit Design
Oxygenators
Initiation of Cardiopulmonary Bypass
Anticoagulation
Termination of Cardiopulmonary Bypass
General Principles
Anatomical Considerations and the Use of Transesophageal Echocardiography
Hypothermia
Bleeding
Modified Ultrafiltration
Delayed Sternal Closure
Conclusions
Chapter 31 - Critical Care After Surgery for Congenital Cardiac Disease
Newborn Considerations
Preoperative Care
Physical Examination and Laboratory Data
Echocardiographic and Doppler Assessment
Cardiac Catheterization
Magnetic Resonance Imaging and Angiography
Assessment of Patient Status and Predominant Pathophysiology
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
Right Ventriculotomy and Restrictive Physiology
Pharmacologic Support
Catecholamines
Type III Phosphodiesterase Inhibitors
Thyroid Hormone
Other Afterload-Reducing Agents
Other Strategies
Diastolic Dysfunction
Managing Acute Pulmonary Hypertension in the Intensive Care Unit
Pulmonary Vasodilators
Cardiac Tamponade
Mechanical Support of the Circulation
Preoperative Stabilization
Failure to Wean from Cardiopulmonary Bypass
Postcardiotomy
Bridge to Transplantation
Resuscitation
Extracorporeal Membrane Oxygenation Cannulation, Stabilization, and Evaluation
Daily Management
Weaning from Extracorporeal Membrane Oxygenation
Cardiovascular Interactions with Other Organs
Respiratory Function and Heart-Lung Interaction
Special Respiratory Problems for the Cardiac Patient
Weaning from Mechanical Ventilation
Central Nervous System
Renal Function and Postoperative Fluid Management
Gastrointestinal Issues
Infection
Hyperglycemia
Critical Care Management of Specific Lesions
Single-Ventricle Anatomy and Physiology
Preoperative Management
Bidirectional Cavopulmonary Anastomosis
Fontan Procedure
Specific Complications After the Fontan Procedure
Rhythm Disturbances. Atrial flutter and/or fibrillation; heart block; and, less commonly, ventricular dysrhythmia may have a sig...
Premature Closure of the Fenestration. Not all patients require a fenestration for a successful, uncomplicated Fontan operation....
Persistent Hypoxemia. Arterial O2 saturation levels may vary substantially after a modified Fontan procedure. Common causes of p...
Low Cardiac Output State. An elevated LA pressure after a modified Fontan procedure may reflect poor ventricular function from d...
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
Transposition of the Great Arteries
Pathophysiology
Critical Care Management
Atrial Baffle Procedure (Mustard and Senning).
Arterial Switch Operation (Jatene Procedure).
Ventricular Switch (Rastelli Procedure).
Late Postoperative Care
Total Anomalous Pulmonary Venous Connection
Pathophysiology
Critical Care Management
Critical Care Management for Late Postoperative Care
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
Patent Ductus Arteriosus
Pathophysiology
Critical Care Management
Truncus Arteriosus
Pathophysiology
Critical Care Management
Critical Care Management for Late Postoperative Care
Left-Sided Obstructive Lesions
Pathophysiology
Aortic Stenosis
Coarctation of the Aorta
Interrupted Aortic Arch
Hypoplastic Left Heart Syndrome
Evolution of treatment strategies
Specific considerations for the Norwood operation.
Summary
Chapter 32 - Cardiac Transplantation
Critical Care of the Pediatric Patient Waiting for Heart Transplantation
Management of the Potential Heart ­Transplant Recipient
Inotropic Support
Mechanical Support
Anticoagulation
Management of the Potential Heart Donor
Critical Care Management of the Orthotopic Heart Transplant Recipient
Intraoperative Considerations
Early Perioperative Management
Management of Early Heart Allograft ­Dysfunction
Heart Allograft Rejection and Immune ­Suppression
Complications of Immune Suppression in Heart Transplant Recipients Occurring in the Pediatric Intensive Care Unit
Infection
Renal Function
Diabetes Mellitus
Future Management Strategies for Critical Care of Infants and Children with Cardiopulmonary Failure
Chapter 33 - Physiologic Foundations of Cardiopulmonary Resuscitation
Mechanisms of Blood Flow
Cardiac Versus Thoracic Pump Mechanism
Rate and Duty Cycle
Chest Geometry
Effects of Cardiopulmonary Resuscitation on Intracranial Pressure
Simultaneous Compression Ventilation Cardiopulmonary Resuscitation
Interposed Abdominal Compression ­Cardiopulmonary Resuscitation
Active Compression-Decompression ­Cardiopulmonary Resuscitation and ­Impedance Threshold Valve Interposition
Vest Cardiopulmonary Resuscitation
Abdominal Binding
Open-Chest Cardiopulmonary Resuscitation
Cardiopulmonary Bypass
Transcutaneous Cardiac Pacing
Pharmacology
Adrenergic Agonists
Vasopressin
High-Dose Epinephrine
Atropine
Sodium Bicarbonate
Other Alkalinizing Agents
Calcium
Glucose
Management of Ventricular Fibrillation
Defibrillation
Amiodarone
Postresuscitation Care
Future Directions
Chapter 34 - Performance of Cardiopulmonary Resuscitation in Infants and Children
Four Phases of Cardiac Arrest
Prearrest
No Flow/Low Flow
Postresuscitation
Epidemiology of Pediatric Cardiac Arrest
Interventions During the Low-Flow Phase: Cardiopulmonary Resuscitation
Airway and Breathing
Circulation
Optimizing Blood Flow During Low-Flow Cardiopulmonary Resuscitation: Push Hard, Push Fast
Chest Compression Depth
Compression/Ventilation Ratios
Duty Cycle
Circumferential Versus Focal Sternal Compressions
Open-Chest Cardiopulmonary Resuscitation
Medications Used to Treat Cardiac Arrest
Vasopressors
Calcium
Buffer Solutions
Postresuscitation Interventions
Temperature Management
Glucose Control
Blood Pressure Management
Postresuscitation Myocardial Dysfunction
Other Considerations
Quality of CPR
Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation
Ventricular Fibrillation and Ventricular Tachycardia in Children
Antiarrhythmic Medications: Lidocaine and Amiodarone
Pediatric Automated External Defibrillators
Summary
Section III: Respiratory System
Chapter 35 - Structure and Development of the Upper Respiratory System in Infants and Children
Developmental Anatomy of the Upper Airway
Anatomy and Physiology of the Upper Airway
Nasal Passages
Mouth and Pharynx
Larynx
Trachea and Bronchi
Chapter 36 - Structure of the Respiratory System: Lower Respiratory Tract
Lower Respiratory System
Lungs
Airways and Bronchus-Associated Lymphoid Tissue
Definitions of Special Lung Unit and Alveolar Formation
Alveolar-Capillary Unit
Lung Circulation
Pulmonary Vascular System
Bronchial Vascular System
Pulmonary Lymphatics
Diaphragm
Summary
Chapter 37 - Physiology of the Respiratory System
Physiology of the Respiratory System
Physiology of the Respiratory System
Conducting Airways
Model of the Respiratory System
Elastic Properties of the Respiratory System
Compliance and Elastance
Elastic Recoil of the Respiratory System
Flow Resistance of the Respiratory System
Dynamic Change in Airway Caliber During Respiration
Applied Forces
Interactions Between Lungs and Chest Wall
Time Constant of Emptying
Physiology of Positive Pressure Mechanical Ventilation
Gas Exchange
Ventilation Perfusion Relationships
Alveolar Ventilation
Diffusion of Oxygen and Carbon Dioxide
Chapter 38 - Control of Breathing and Acute Respiratory Failure
Normal Regulation of Breathing
Failure of Respiratory Controls
Acute Disorders of Respiratory Controls
Acute Life-Threatening Events
Chronic Disorders of Respiratory Controls
Structural Brain Disorders
Nonstructural Congenital Disorders
Nonstructural Acquired Chronic Disorders
Recognition and Treatment
The Deteriorating Patient
Evaluation During Recovery
Measuring Respiratory Drive
Therapy Related to Respiratory ­Controls
Chapter 39 - Assessment and Monitoring of Respiratory Function
Physical Examination of the Respiratory System
Radiography
Evaluation of Gas Exchange
Noninvasive Respiratory Monitoring
Transcutaneous Oxygen and Carbon Dioxide Monitoring
Pulse Oximetry
Capnography
Arterial Blood Gas Monitoring
Respiratory Mechanics
Endoscopy
Summary
Chapter 40 - Overview of Breathing Failure
Physiology of Breathing
Diaphragm (Structure and Function)
Intercostal Muscles
Accessory Muscles of Respiration
Integrated Control of Breathing
Neural Automatic Control of Breathing
Chemoregulation in the Physiology of Breathing
Breathing Failure
Final Common Pathways to Breathing Failure
Failure of Neural Control
Failure of Muscles of Breathing
Failure of Mechanics of Breathing
Breathing Failure from Lung Disease
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
Thoracic Dysfunction
Altered Nutritional States: Malnutrition and Obesity
Conclusion
Chapter 41 - Ventilation/Perfusion Inequality
Distribution of Ventilation
Distribution of Perfusion
Fractal Model of Pulmonary Blood Flow and Ventilation
Fractal Model of the Pulmonary Ventilation
VA/Q Abnormalities in Pulmonary Disease
Hypoxemia
Acute Respiratory Distress Syndrome
Pneumonia
Asthma
Pulmonary Embolism
Primary Pulmonary Hypertension
Therapeutic Considerations
Positive End-Expiratory Pressure
Prone Positioning
Nitric Oxide
Chapter 42 - Mechanical Dysfunction of the Respiratory System
Work, Power, and Energy Expenditure in the Respiratory System
Determinants of Respiratory Work
Volume-Pressure Relationships
Nature of the Mechanical Forces Acting on the Respiratory Pump
Nondissipative Phenomena: Elastic Behavior of the Respiratory System
Lungs/Chest Wall Interactions
Dissipative Forces
Dynamic Volume-Pressure Relationships
Effect of Flow Rate and Pattern on the Dynamics of the Gas Stream
Airway Dynamics
Airway Muscle and Compliance of the ­Airways
Airway Obstruction
A Specific Case Study in Airway Mechanics: Mechanical Ventilation
Determinants of Regional Gas Flow Distribution in the Lungs
Restrictive and Obstructive Respiratory Disease
Determinants of Respiratory Efficiency
Power of Breathing and Breathing Frequency
Alterations in Chest Wall Configuration
Diaphragmatic Configuration
Rib Cage Distortion
Alterations in Contractile State of the Respiratory Muscles
Conclusion
Chapter 43 - Noninvasive Monitoring in Children
Vital Signs
Electrocardiographic Monitoring
Blood Pressure Measurement
Temperature Monitoring and Routine ­Temperature Management
Temperature Monitoring Sites
Pulse Oximetry
Principles of Pulse Oximetry
Validation
Sources of Error
Probe Placement
Cerebral Oximetry
Somatic Regional Oximetry
Muscle Oximetry
Capnometry and Capnography
Physiologic Basis
Operating Principles of Capnometry
Clinical and Technical Issues
Gas Sampling Issues
Dead-Space Ventilation
Differential Diagnosis of Abnormal Capnograms
Gradually Decreasing End-Tidal CO2 Concentration
Sustained Low End-Tidal CO2 Concentrations Without Plateaus
Sustained Low End-Tidal CO2 Concentration with Good Plateaus
Exponential Decrease in End-Tidal CO2
Gradual Increase in both Baseline and End-Tidal CO2
Transcutaneous Monitoring
Oxygen Monitoring
Carbon Dioxide Monitoring
Cerebral Function Monitoring
Bispectral Index Monitoring
Historical Perspective and Development of the Electroencephalogram
Age-Related Maturation of the Electroencephalogram
Validation Studies
Utility Studies
Summary of Bispectral Index–Related Studies in Critical Care
Conclusion
Chapter 44 - Specific Diseases of the Respiratory System: Upper Airway
Initial Management
Congenital Malformations
Choanal Atresia
Laryngomalacia
Laryngeal Webs, Stenosis, and Tumors
Vascular Impingement on the Trachea
Bronchomalacia and Intrathoracic ­Tracheomalacia
Infectious Processes
Laryngotracheobronchitis
Epiglottitis
Peritonsillar Abscess
Retropharyngeal Abscess
Bacterial Tracheitis
Laryngeal Papillomatosis
Vocal Cord Paralysis
Intrathoracic Mass Lesions Causing Respiratory Obstruction
Trauma
Postextubation Stridor
Laryngotracheal (Subglottic) Stenosis
Foreign Body Aspiration
Traumatic Injury to the Airway
Burn Injury to the Upper Airway
Angioedema
Tracheostomy
Postoperative Nursing Care
Complications
Decannulation
Chapter 45 - Asthma
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 (Salbutamol)
Terbutaline
Anticholinergic Agents
Magnesium Sulfate
Methylxanthine Agents
Helium-Oxygen Mixtures
Ketamine
Mechanical Ventilation
Indications
Intubation
Ventilator Settings
Ventilatory Monitoring
Analgesia, Sedation, and Muscle Relaxation
Inhalational Anesthetic Agents
Antibiotics
Bronchoscopy
Extracorporeal Life Support
Prognosis
Chapter 46 - Neonatal Respiratory Disease
Acute or Early-Onset Respiratory Disorders
Delayed Clearance of Fetal Lung Liquid
Pulmonary Air Leak Syndromes
Pulmonary Hemorrhage
Pneumonia
Meconium Aspiration Syndrome
Surfactant-Deficient Respiratory Distress Syndrome
Surfactant Protein B Deficiency
Congenital Malformations of the Lung
Pulmonary Hypoplasia
Congenital Diaphragmatic Hernia
Cystic Adenomatoid Malformation
Bronchogenic Cysts
Pulmonary Parenchymal Cysts
Pulmonary Sequestrations
Congenital Lobar Emphysema
Pulmonary Agenesis and Aplasia
Special Treatment Considerations for Acute Respiratory Failure
Surfactant Replacement
High-Frequency Ventilation
Extracorporeal Membrane Oxygenation
Nitric Oxide Inhalation
Liquid Ventilation
Chronic Pulmonary Disease
Chronic Lung Disease (Bronchopulmonary Dysplasia)
Congenital Defects of the Lymphatics
Nonpulmonary Conditions that Result in Respiratory Disease
Apnea of Prematurity
Choanal Atresia/Stenosis
Laryngomalacia
Vocal Cord Paralysis
Subglottic Hemangioma
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 and/or Renal Bicarbonate ­Wasting
Chapter 47 - Pneumonitis and Interstitial Disease
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
Miscellaneous Etiologic Agents
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 Carinii 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
Chapter 48 - Diseases of Pulmonary Circulation
Etiology and Treatment of Pulmonary Hypertension
Embryology
Vascular Smooth Muscle
Hemodynamic Features of Fetal Circulation
Regulation of Pulmonary Vascular Tone in Utero
Transitional Circulation
Factors Responsible for Decrease in Pulmonary Vascular Resistance at Birth
Persistent Pulmonary Hypertension of the Newborn
Pathophysiology
Clinical Presentation
Treatment
General Measures
Hyperventilation and Alkali Infusion
Oxygen
Lung Recruitment Strategies
High-Frequency Ventilation.
Nitric Oxide.
Phosphodiesterase Inhibitors
Extracorporeal Membrane Oxygenation
Pulmonary Arterial Hypertension in Children
Pathophysiology
Pulmonary Vascular Histopathology
Congenital Heart Disease
Clinical Presentation
Diagnostic Approach
Acute Vasodilator Testing
Treatment
General Measures
Pulmonary Vasodilators
Prostanoids.
Epoprostenol.
Treprostinil.
Iloprost.
Beraprost.
Endothelin Receptor Antagonists.
Bosentan.
Selective ETA Receptor Antagonists.
Nitric Oxide.
Phosphodiesterase Inhibitors
Combination Therapy
Pulmonary Thromboendarterectomy
Atrial Septostomy
Lung and Combined Heart/Lung Transplantation
Prognosis and Survival in Pulmonary Arterial Hypertension
Chapter 49 - Mechanical Ventilation and Respiratory Care
Applied Respiratory Physiology
Lung Volumes and Capacities
Physiology of Inflation and Deflation
Work of Breathing
Determinants of Gas Exchange
Indications for Mechanical Ventilation
Respiratory Failure
Cardiovascular Dysfunction
Neurologic and Neuromuscular Disorders
Design and Functional Characteristics of Mechanical Positive-Pressure Ventilators
Ventilator as a Machine
Modes of Ventilation
Mandatory Mechanical Ventilation
Volume-Regulated Mandatory Breaths
Pressure-Regulated Mandatory Breaths
Continuous Flow Versus Demand Flow
Intermittent Mandatory Ventilation
Continuous Positive Airway Pressure/Positive End-Expiratory Pressure
Selection of Parameters for Mandatory Breaths
Assisted Mechanical Ventilation
Pressure-Support Ventilation
Other Modes of Ventilation
Airway Pressure Release Ventilation
Mandatory Minute Volume Ventilation
Dual Control Modes
Mandatory Dual-Control Breath-to-Breath Modes.
Assisted Dual-Control Breath-to-Breath Mode.
AutoMode
Automatic Tube Compensation
Proportional Assist Ventilation
High-Frequency Ventilation
Definitions
Mechanism of Gas Flow in High-Frequency Ventilation in the Normal Lung
Parameters to Be Selected
High-Frequency Jet Ventilation
High-Frequency Oscillatory Ventilation
High-Frequency Percussive Ventilation
Clinical Uses of High-Frequency Ventilation
Approach to Mechanical Ventilation Based on Underlying Pathophysiology
Primary Respiratory Muscle Failure (“Respiratory Pump Failure”)
Disorders with Airway Obstruction
Parenchymal Lung Disease
Alveolar Recruitment and Derecruitment
Prone Positioning
Unilateral Lung Disease or Severely ­Differential Lung Disease
Heart Failure
Postoperative Management After Repair of Congenital Heart Disease
Diseases with Abdominal Distention
Neurologic and Neuromuscular Diseases
Patient-Ventilator Asynchrony
Use of Neuromuscular Blockade
Special Techniques of Respiratory Support
Altering Inspired Oxygen and Carbon Dioxide Concentration
Helium-Oxygen Mixture
Inhaled Nitric Oxide
Adverse Effects of Mechanical Ventilation
Yin-Yang of Mechanical Ventilation
Airway Injury from Mechanical Ventilation
Effects on the Lung
Effects on the Circulatory System
Respiratory Care During Mechanical Ventilation
Pulmonary Hygiene
Humidification Systems
Aerosol Therapy
Weaning from Mechanical Ventilation
Traditional Method of Weaning
“Modern” Method of Weaning
Readiness to Extubate Trial
Extubation
Weaning Problems
Tracheostomy and Weaning
Home Respiratory Care
Indications for Home Respiratory Care
Logistics of Home Care
Chapter 50 - Noninvasive Ventilation: Concepts and Practice
Historical Perspective
Indications
Short-Term Noninvasive Ventilation
Adult Studies on the Short-Term Use of Noninvasive Ventilation
Pediatric and Neonatal Studies
Interfaces
Oral-Nasal Masks
Nasal Masks
Total Face Mask
Adam’s Circuit
Head Hood
Equipment
Optimizing Patient‑Ventilator Interaction
Ventilator Settings
Complications and Concerns During Short-Term Noninvasive Ventilation
Circuit and Carbon Dioxide Rebreathing
Long-Term Noninvasive Ventilation
Physiologic Effects and Outcomes of Long-Term Noninvasive Ventilation
Ventilator Settings
Monitoring of Patients with Long-Term Noninvasive Ventilation
Negative-Pressure Ventilation
Design and Modes of Negative-Pressure Ventilators
Clinical Applications
Respiratory Dysfunction and Failure
Cardiovascular Disorders
Summary
Chapter 51 - Ventilator-Induced Lung Injury
Evidence for Ventilator-Induced Lung Injury
Ventilation of Intact Lungs
High Lung Volume Ventilator-Induced Lung Injury
Low Lung Volume Ventilator-Induced Lung Injury
Ventilation of Damaged Lungs
High-Volume Lung Injury
Low-Volume Lung Injury
Roles of Tidal Volume, Positive End-Expiratory Pressure, and Overall Lung Distention
Effects of Positive End-Expiratory Pressure When Tidal Volume Is Kept Constant
Effects of Positive End-Expiratory Pressure when Tidal Volume Is Reduced
Importance of Overall Lung ­Distention
Possible Mechanisms of Ventilator-Induced Lung Injury
Mechanisms of Increased Vascular Transmural Pressure
Mechanisms of Altered Permeability
Effects of Surfactant Inactivation
Participation of Inflammatory Cells and Mediators
Role of Inflammatory Mediators. The role of inflammatory cytokines in the course of VILI has been the subject of recent studies ...
New Insights in ­­Ventilator-Induced Lung Injury
Cellular Response to Mechanical Strain
Influence of Carbon Dioxide Tension on Ventilator-Induced Lung Injury
Strategies to Reduce Ventilator-Induced Lung Injury: Use of the Pressure-Volume Curve
Imaging Ventilator-Induced Lung Injury
Conclusion and Clinical Applications
Chapter 52 - Acute Respiratory Distress Syndrome in Children
Pathogenesis
Endothelial and Epithelial Injury
Role of Cytokines
Role of Ventilator-Induced Lung Injury
Resolution of Lung Injury
Fibrosing Lung Injury
Clinical Features
Incidence and Etiology
Clinical Course
Oxygenation and Ventilator Strategy
Permissive Hypercapnia
Adjunct Therapies
Noninvasive Ventilation
Conclusion
Chapter 53 - Extracorporeal Life Support
Materials and Methods
Cannulation Techniques
Venoarterial Extracorporeal Membrane Oxygenation
Arterial Access.
Venovenous Extracorporeal Membrane Oxygenation
Percutaneous Cannulation
Decannulation
Venous Reservoir and Venous Saturation Monitor
Types of Pumps and Oxygenators
Roller-Head Pumps
Centrifugal Pumps
Membrane Oxygenator
Hollow-Fiber Oxygenator
Other Points
Patient Populations Treated with Extracorporeal Life Support
Neonatal Cardiopulmonary Failure
Pediatric and Adult Patients
Extracorporeal Membrane Oxygenation in Adults
Extracorporeal Membrane Oxygenation for Myocardial Dysfunction
Extracorporeal Membrane Oxygenation for Resuscitation
Trauma Patients
Patient Selection Criteria
Gas Exchange and Oxygen Delivery
Oxygenation
Carbon Dioxide Exchange
Oxygen Delivery
Patient Management
Screening
Cannulation and Initiation of Extracorporeal Life Support
Priming
Patient Management During Extracorporeal Life Support
Weaning from Extracorporeal Membrane Oxygenation
Complications
Bleeding
Infection
Long-Term Outcome
The Future
Section IV: Central Nervous System
Chapter 54 - Pediatric Neurocritical Care
Historical Context
Rationales for Development of Pediatric Neurocritical Care
Rationale 1
Rationale 2
Rationale 3
Future of Pediatric Neurocritical Care
Chapter 55 - Pediatric Neurologic Assessment and Monitoring
Overview and Basic Principles of Pediatric Intensive Care Unit Neurology
Recognition of Neurologic Complications in the PICU Patient
Establishing a Baseline Neurologic Examination and Anticipatory Planningfor New Deficits
History and Assessment of Risk Factors
Iatrogenic Complications of Pharmacotherapy
Approach to the Physical Exam
Vital Signs
General Physical Exam
Importance of Observation in the Neurologic Exam
Nonorganic Pathology in the Pediatric Intensive Care Unit
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
Goals of the Neurologic Examination in the Pediatric Intensive Care Unit
Neuromonitoring
Neuroimaging
Intracranial Pressure Monitoring
Brain Tissue Oxygen Monitoring
Cerebral Microdialysis
Near-Infrared Spectroscopy
Electroencephalographic Monitoring
Integrating Neurologic Monitoring Data
Chapter 56 - Neuroimaging
Imaging Modality Overview
Ultrasound
Computerized Tomography
Magnetic Resonance Imaging
Advanced Magnetic Resonance Imaging Techniques
Magnetic Resonance Angiography
Catheter Angiograms
Myelography
Nuclear Medicine
Preterm and Term Neonate Imaging
Stroke in the Older Infant/Child
Posterior Reversible Encephalopathy ­Syndrome
Venous Infarct
Vasculopathy/Vasculitis
Vascular Malformations
Central Nervous System Infection
Demyelinating Disease
Trauma
Hydrocephalus
Tumor
Seizures
Conclusion
Chapter 57 - Structure, Function, and Development of the Nervous System
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
Developmental Processes Relevant to Pediatric Critical Care Medicine
Cell Origin and Differentiation
Synaptogenesis and Synaptic Pruning
Neurotransmitter System Maturation
Myelination
Development of the Cerebrovasculature and Blood-Brain Barrier
Developmental Aspects of Cerebral Blood Flow, Autoregulation, and Cerebral Metabolism
Conclusion
Chapter 58 - Coma and Depressed Sensorium
Pathophysiology
Anatomy of Arousal and Ascending Reticular Activating System
States of Impaired Sensorium
Identification of Cause
Initial Assessment and Immediate Resuscitation
Focused Neurologic Examination
Respiratory Pattern
Eye Examination
Motor Examination
Focal Neurologic Lesions Could Be Supratentorial or Subtentorial
Presentation of Nonfocal Neurologic Lesions
Herniation Syndromes
Diagnostic Evaluation
Therapeutic Intervention
Immediately Treatable Forms of Coma
Rapidly Progressive Reversible Lesions
States Amenable to Prolonged Therapy
Outcome
Ethical Considerations
Chapter 59 - Intracranial Hypertension and Brain Monitoring
Clinical Background
Physiology of the Intracranial Vault
Intracranial Pressure
Hydrodynamic Model of Intracranial ­Pressure
Cerebral Vasodilation and Cerebrospinal Fluid Pressure
Cerebral Perfusion Pressure and ­Autoregulation
Measurement of Intracranial Pressure
Monitoring Devices
Noninvasive Inference of Intracranial ­Pressure
Pressure Compartments
Analysis of Intracranial Pressure
Normal Values in Intracranial Pressure Monitoring
Normal Trends in Intracranial Pressure and Waveform Analysis
Assessment of Pressure-­Volume ­Compensatory Reserve and ­Cerebrovascular Pressure Reactivity
Monitoring Optimal Cerebral Perfusion Pressure Derived from Intracranial Pressure Parameters
Quantifying the Cumulative Intracranial Pressure/Cerebral Perfusion Pressure Insult to the Brain
Clinical Utility of Intracranial Pressure Monitoring with Other Monitoring Modalities
Mechanism of Brain Injury Where ­Intracranial Hypertension Occurs
Monitoring and the Postinsult Natural History
Newer Modalities: Supplementary Monitoring of Intracranial Pressure
Neurochemical Protein Markers of Injury
Brain Oxygenation
Microdialysis and Brain Tissue Biochemistry
Transcranial Doppler Ultrasonography and Assessment of Autoregulation
Clinical Neurophysiology
Chapter 60 - Status Epilepticus
Definition
Classification of Status Epilepticus
Epidemiology of Status Epilepticus
Incidence
Cause
Outcome
Mortality
Subsequent Development of Epilepsy
Pathophysiology
Diagnosis
Refractory Status Epilepticus
Treatment of Status Epilepticus
General Supportive Measures
Initial Management
Benzodiazepines
Barbiturates
Phenytoin
Fosphenytoin
Paraldehyde
Treatment of Refractory Status Epilepticus
Goals of Therapy
High-Dose Barbiturates
High-Dose Benzodiazepines
Propofol
Valproic Acid
Inhalational Anesthetics
Ketamine and Lidocaine
Pyridoxine
Surgical Treatment
Investigations
Acknowledgment
Chapter 61 - Severe Traumatic Brain Injury in Infants and Children
Epidemiology
Pathophysiology
Posttraumatic Ischemia
Excitotoxicity
Apoptosis 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 Pressu...
Diagnostic Studies and Monitoring Modalities
Computed Tomography
Magnetic Resonance Imaging
Intracranial Pressure Monitoring
Advanced Monitoring Techniques
Monitoring Cerebral Metabolism
Treatment in the Pediatric Intensive Care Unit
Intracranial Pressure and Cerebral ­Perfusion Pressure Thresholds
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
Lumbar Cerebrospinal Fluid Drainage
Controlled Arterial Hypertension
Is Rigorous Intracranial Pressure Control the Common Denominator in Studies with Exceptionally Good Outcome?
Miscellaneous
Outcomes
Conclusion
Chapter 62 - Hypoxic-Ischemic Encephalopathy: Pathobiology and Therapy of the Post-Resuscitation Syndrome in Children
Epidemiology
Cellular and Molecular Pathobiology
Mechanisms of Hypoxic-Ischemic Brain Injury
Energy Failure
Selective Vulnerability
Cell Death Mechanisms
Reperfusion Injury
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 After Pediatric Cardiopulmonary Arrest
Response of the Immature Brain to Cardiopulmonary Arrest
Treatment of Cardiopulmonary Arrest
Field Interventions
Supportive Care in the Intensive Care Unit
Current and Novel Therapies
Postresuscitative Hypothermia
Inhibition of PostischemicExcitotoxicity
Voltage-Operated Calcium Channel Antagonists
Inhibitors of Oxygen Radical Mediated Injury
Phospholipid-Derived Mediator Manipulation and Antiinflammatory Therapies
Futuristic Approaches
Anti–Cell Death Strategies
Neuronal Regeneration and Replacement
Extracorporeal Support
Summary
Acknowledgment
Chapter 63 - Stroke and Intracerebral Hemorrhage
Arterial Ischemic Stroke
Pathophysiology
Epidemiology
Etiologies and Risk Factors
Sickle Cell Disease
Moyamoya Disease and Syndrome
Arterial Dissection
Congenital and Acquired Heart Disease
Focal and “Transient” Cerebral Arteriopathy
Vasculitis
Hypercoagulable States
Metabolic Disorders and Toxins
Clinical Manifestations
Imaging and Laboratory Evaluation
Treatment
Supportive Measures
Thrombolytic Therapy
Antithrombotic Therapy: General Principles
Antiplatelet Therapy
Anticoagulant Therapy
Special Circumstances
Moyamoya Syndrome.
Rehabilitation
Cerebral Venous Sinus Thrombosis
Pathophysiology
Epidemiology
Clinical Manifestations
Imaging and Laboratory Evaluation
Treatment
Prognosis
Spontaneous Intracranial Hemorrhage
Epidemiology
Clinical Manifestations
Evaluation
Treatment
Prognosis
Chapter 64 - Acute Neuromuscular Diseases and Disorders
Guillain-Barré Syndrome
Myasthenia Gravis
Congenital and Transient Neonatal Myasthenia Gravis
Tick Paralysis
Periodic Paralyses
Hypokalemic Periodic Paralysis
Hyperkalemic Periodic Paralysis
Normokalemic Periodic Paralysis
Botulism
Diphtheria
Acute Intermittent Porphyria
Spinal Muscular Atrophy
Poliomyelitis
Polio-like Syndromes
Organophosphate and Carbamate Poisoning
Rhabdomyolysis
Malignant Hyperthermia
Neuroleptic Malignant Syndrome
Inflammatory Myopathies
Dermatomyositis and Polymyositis
Benign Acute Childhood Myositis
Chapter 65 - Central Nervous System Infections Presenting to the Pediatric Intensive Care Unit
Bacterial Meningitis
Epidemiology
Pathogenesis
Clinical Manifestations
Diagnosis
Treatment
Supportive Care
Adjunctive Therapy
Prevention
Outcomes
Subdural Empyema
Meningoencephalitis
Epidemiology
Pathophysiology/Pathogenesis of Viral Meningoencephalitis
Clinical Evaluation
Laboratory Manifestations
Neuroimaging
Clinical Presentation and Course
Treatment
Prognosis
Acute Disseminated Encephalomyelitis
Brain Abscesses
Primary and Granulomatous Amoebic Central Nervous System Infections
Conclusions
Section V: Renal, Endocrine, and Gastrointestinal Systems
Chapter 66 - Renal Structure and Function
Renal Development
Renal Anatomy
Renal Vasculature
Vascular Development
Vascular Anatomy
Vascular Function
The Nephron Unit
Nephron Development
Glomerular Anatomy
Glomerular Function
Tubular Anatomy
Proximal Tubule
Loop of Henle
Distal Nephron
Tubular Function
Proximal Tubule
Loop of Henle
Distal Tubule
Collecting Duct
The Interstitium
Development
Structure and Function
Summary
Chapter 67 - Fluid and Electrolyte Issues in Pediatric Critical Illness
Fluids Update
Albumin
Starch
Fluid Balance
Diabetic Ketoacidosis/Cerebral Edema
Sodium
Hyponatremia
Pathophysiology and Etiology
Decreased Total Body Sodium.
Increased Total Body Sodium.
Congestive Heart Failure
Cirrhosis
Nephrotic Syndrome
Renal Failure
Normal Total Body Sodium
Signs and Symptoms
Treatment
Hypernatremia
Low Total Body Sodium Level
Normal Total Body Sodium Level
Increased Total Body Sodium Level
Signs and Symptoms
Treatment
Potassium
Hypokalemia
Hypokalemia with Potassium Deficit.
Renal Losses.
Gastrointestinal Losses.
Signs and Symptoms
Treatment
Hyperkalemia
Causes of Hyperkalemia
Artifactual.
Redistribution.
Increased Potassium Load.
Decreased Excretion.
Manifestations of Hyperkalemia
Treatment
Magnesium
Hypomagnesemia
Causes of Hypomagnesemia
Signs and Symptoms
Treatment
Hypermagnesemia
Causes of Hypermagnesemia
Signs and Symptoms
Treatment
Phosphorus
Hypophosphatemia
Cause of Severe Hypophosphatemia
Signs and Symptoms
Treatment
Hyperphosphatemia
Causes of Hyperphosphatemia
Signs and Symptoms
Treatment
Disorders of Calcium Homeostasis
Regulation of Extracellular Calcium
Hormonal Regulation of Calcium
Hypocalcemia
Clinical and Laboratory Diagnosis
Treatment
Hypercalcemia
Clinical and Laboratory Diagnosis
Treatment
Chapter 68 - Acid-Base Balance and Disorders
Understanding Acid-Base Physiology: Traditional and Newer Approaches
Acids, Bases, Buffers: The Traditional Understanding
Acid Production in the Body
The Classic Paradigm: H+ Depends on CO2, H2CO3, and HCO3−
Base Excess and Standard Base Excess
Bicarbonate Rules
Anion Gap and Corrected Anion Gap
Water as the Main Source of Hydrogen Ions: The Stewart Approach
CO2 and Bicarbonate in Stewart’s Approach
The Strong Ion Difference
Strong Ion Gap
Nonvolatile Weak Acids (Albumin and Phosphate)
Merging Traditional and Newer Approaches: Is an Integrated Approach Ready for the Bedside?
Corrected Anion Gap
New Insights for Old Problems
The Clinical Problem: Does Abnormal pH Harm?
Blood Gases: Arterial, Central Venous, or Capillary Samples?
Metabolic Acidosis
Elevated Anion Gap Acidoses
Lactic Acidosis
Ketoacidosis
Toxic Compounds that Directly Provoke Acidosis
Other Forms of Metabolic Acidosis ­Associated with an Increased Anion Gap
Hyperchloremic Acidoses: The Non–Anion Gap Metabolic Acidoses
Exogenous Chloride Load
Postpyloric Gastrointestinal Fluid Losses
Renal Tubular Acidoses and Drug-Mediated Tubulopathies
Urinary Reconstruction Using Bowel Segments
Treating Metabolic Acidosis
Sodium Bicarbonate
Carbicarb
Tris(hydroxymethyl)aminomethane
Dichloroacetate
Dialysis Management of Metabolic Acidosis
Metabolic Alkalosis
Treating Metabolic Alkalosis
Respiratory Acid-Base Derangements
Respiratory Acidosis
Treating Respiratory Acidosis
Permissive Hypercapnia
Respiratory Alkalosis
Pseudorespiratory Alkalosis
Mixed Acid-Base Derangements
Acid-Base Balance in Special Situations
Hypothermia
Alpha-Stat and pH-Stat
Summary
Chapter 69 - Tests of Kidney Function in Children
Assessment of Glomerular Function and Injury
Renal Clearance Techniques
Inulin
Iothalamate
Creatinine Clearance
Plasma Disappearance Techniques
Radioisotopes
Iohexol
Plasma Markers
Creatinine
Cystatin C
Estimating Equations
Other Novel Biomarkers of Acute Kidney Injury Under Investigation
Tubular Function
Urine Electrolytes (Sodium and Chloride)
Urine Concentration Capacity
Serum Blood Urea Nitrogen/Creatinine Ratio
Urine Microscopy
Proteinuria
Renal Acidification
Potassium Regulation
Generalized Proximal Tubulopathy
Chapter 70 - Renal Pharmacology
Kidney Function and Drug Disposition
Drug Dosing in Kidney Disease
Dialysis
The Kidney as a Therapeutic Target: Diuretics
Diuretic Resistance
Prevention/Reversal of Acute Renal Failure
Chapter 71 - Glomerulotubular Dysfunction and Acute Kidney Injury
Acute Kidney Injury Pathophysiology
Physiology of Glomerular Filtration
Morphologic Changes in Renal Injury
Pathogenesis of Reduced Glomerular Filtration Rate in Acute Kidney Injury
Mechanisms of Renal Cell Injury
Alterations in Cell Membranes
Cellular Calcium Homeostasis
Production of Free Radicals
Tubular Cell Energy Metabolism
Classification of Acute Glomerulotubular Dysfunction
Hemodynamically Mediated Acute Kidney Injury
Treatment of Acute Kidney Injury
Prevention/Attenuation of Acute Renal Failure
Dopamine
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
Clinical Signs
Complications
Therapy
Prognosis
Acute Glomerulonephritis
Acute Postinfectious (Streptococcal) Glomerulonephritis
Clinical Signs.
Laboratory Findings.
Treatment.
Prognosis.
Systemic Lupus Erythematosus
Clinical Signs. T
Treatment.
Prognosis.
Other Glomerulonephritides
Nephrotic Syndrome and Acute Kidney Failure
Tubulointerstitial Disease
Acute Tubulointerstitial Nephritis
Cardiorenal Syndrome
Basis for Deteriorating Renal Function
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
Sirolimus
Nonsteroidal Antiinflammatory Drugs
Contrast-Induced Nephropathy
Role of Renal Replacement Therapy.
Acute Renal Failure After Stem Cell Transplantation
Urinary Tract Obstruction
Chapter 72 - Pediatric Renal Replacement Therapy in the Intensive Care Unit
Renal Failure and Other Indications for Renal Support
Acute Kidney Injury
Acute Intoxication and Metabolic Disorders
Renal Support
Conservative Management
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
Dialysis Fluid and Infused Fluids
Clearance
Disadvantages and Complications
Intensive Care Unit Issues
Extended Daily Dialysis
Outcomes of Renal Replacement in Critically Ill Children
Summary
Chapter 73 - Hypertension in the Pediatric Intensive Care Unit
Definition of Terms
Etiology and Evaluation
Pathophysiology
Endothelial Homeostasis
Hemodynamics of the Kidney
The Autonomic System: Sympathetic Activation
Renin-Angiotensin System
Nitric Oxide
Hypervolemia
Clinical Symptoms
Management Strategy
Monitoring
Pharmacotherapy
Sodium Nitroprusside
Nitroglycerin
Nicardipine
Esmolol
Labetalol
Hydralazine
Clonidine
Enalaprilat
Fenoldopam
Isradipine
Summary
Chapter 74 - Cellular Respiration
Metabolism of Respiration
Oxygen Chemistry
Mitochondria
Adenosine Triphosphate
Respiration, Metabolic Pathways
Glycolysis
Krebs Cycle
Electron Transport Chain
Monitoring of Tissue Oxygenation
Blood Lactate Monitoring in Critically Ill Patients
Anaerobic Hyperlactatemia
Aerobic Hyperlactatemia
Continuous Central Venous Oxygen Saturation Monitoring
Functional Magnetic Resonance Imaging
Magnetic Resonance Spectroscopy
Near-Infrared Spectroscopy
Optical Spectroscopy
Carbomyl Phosphate Synthase—A Marker of Mitochondrial Damage
Clinical Correlations in Altered Cellular Respiration
Substrate Deficiency (Hypoglycemia)
The Four Dysoxias
Anemic Dysoxia
Hypoxemic Dysoxia
Ischemic Dysoxia
Cytopathic Dysoxia
Drug Effects on Cellular Respiration
Cyanide
Aspirin
2,4-Dinitrophenol
Propofol
Sepsis and Dysoxia
Hibernation Physiology in Sepsis
Chapter 75 - Nutrient Metabolism and Nutrition Therapy During Critical Illness
Malnutrition in the Critically Ill Pediatric Patient
Assessment of Nutritional Status
Body Composition
Biochemical Assessment
Nutritional Requirements During Critical Illness
Metabolic Consequences of the Stress Response
Underfeeding and Overfeeding in the Pediatric Intensive Care Unit
Assessing Energy Expenditure in Critically Ill Patients
Indirect Calorimetry
Protein Requirements
Lipid Requirements
Micronutrient Requirements
Enteral Nutrition in Critically Ill Children
Immune-Enhancing Diets for the Critically Ill Child
Parenteral Nutrition
Carbohydrates
Amino Acids
Lipids
Electrolytes/Minerals and Trace Elements
Biochemical Monitoring
Refeeding Syndrome
Nutritional Support of Obese Critically Ill Children
Guidelines for Pediatric Critical Care Nutrition
Conclusions
Chapter 76 - Inborn Errors of Metabolism
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
Group 3 Inborn Errors of Metabolism
Summary
Metabolic Acidosis
Hypoglycemia
Cardiomyopathy and Inborn Errors of Metabolism
Metabolic Myopathies and Rhabdomyolysis
Neonatal Screening for Inborn Errors of Metabolism
Conclusion
Chapter 77 - Common Endocrinopathies in the Pediatric Intensive Care Unit
Functional Elements of the Stress Response
Hypothalamic-Pituitary-Adrenal Axis
Cortisol Biochemistry
Actions of Cortisol
Inflammation
Hemodynamics
Metabolism
Assessing Adequacy of the Cortisol Stress Response
Free Cortisol
Adrenal Insufficiency in the Intensive Care Unit
Primary Adrenal Insufficiency
Secondary Adrenal Insufficiency
Cortisol Replacement Studies
Adult Investigations
Pediatric Investigations
Current Guidelines for Corticosteroid Prescription in the Pediatric Intensive Care Unit
Septic Shock
Bronchopulmonary Dysplasia
Neonatal Hypotension
Acute Lung Injury/Acute Respiratory ­Distress Syndrome
Postextubation Stridor
Corticosteroid Adverse Effects
Alterations of Glucose Homeostasis
Normal Glycemic Regulation
Glucose Uptake and Metabolism
Hyperglycemia
Etiology of Critical Illness Hyperglycemia
Hyperglycemia and Outcomes
Hyperglycemia Pathogenesis
Management of Critical Illness Hyperglycemia
Clinical Trials
The Ideal Glycemic Target
Summary
Hypoglycemia
Definition
Pathogenesis
Clinical Manifestations
Fasting Adaptation
Diagnostic Approach
Defects of Gluconeogenesis
Defective Glycogen Storage and Mobilization
Ketotic Hypoglycemia
Hormonal Deficiencies
Fatty Acid Oxidation Disorders
Hyperinsulinism
Hypoglycemia and Critical Illness
Hypoglycemia Treatment
Summary
Alterations of Thyroid Hormone in Critical Illness
Classic Thyroid Endocrinology
Thyroid Hormone Biochemistry
Thyroid Hormone Actions
Hyperthyroidism
Hypothyroidism
Sick Euthyroid Syndrome in Critical Illness
Thyroid Hormone Supplementation in the Pediatric Intensive Care Unit
Chapter 78 - Diabetic Ketoacidosis
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
Fluids
Insulin
Electrolytes
Correction of Acidosis
Monitoring
Diabetic Ketoacidosis–Associated Complications
Cerebral Edema
Neuropsychologic Sequelae
Thrombotic Complications
Other Complications
Hyperglycemic Hyperosmolar Syndrome
Health Care Costs Associated with Diabetic Ketoacidosis
Chapter 79 - Structure and Function of Hematopoietic Organs
Structure and Function of the Bone Marrow
Hematopoiesis
Erythropoiesis
Granulopoiesis
Megakaryocyte and Platelet Production
Lymphopoiesis
The Spleen
Lymph Nodes
Chapter 80 - Thrombosis in Pediatric Intensive Care
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
Conclusions
Chapter 81 - Hematology and Oncology Problems in the Intensive Care Unit
Hematologic Emergencies
Anemia
Hemorrhagic Anemia
Anemia Secondary to Bone Marrow Failure
Hemolytic Anemia
Thrombocytopenia
Immune Thrombocytopenia
Nonimmune Thrombocytopenia
Bleeding in Uremia
Oncologic Emergencies
Tumor Lysis Syndrome
Pathophysiology
Therapy
Hyperleukocytosis
Spinal Cord Compression
Acute Airway Compromise in Anterior Mediastinal Tumors
Superior Vena Cava Syndrome
Septic Shock in Pediatric Oncologic Patients
Hemophagocytic Lymphohistiocytosis
Anthracycline-Induced Cardiogenic Shock
Chapter 82 - Transfusion Medicine
Red Blood Cells
Red Blood Cell Transfusion: Why and Why Not
Anemia and O2 Delivery
Adaptive Mechanisms to Anemia
O2 Kinetics in the Critically Ill
Regulation by Red Blood Cells of DO2 to Tissue
Transfusion of Red Blood Cells: Indications (When)
Evidence-Based Medicine: Clinical Studies
Red Blood Cell Transfusion: Current Recommendations
Prevention of Red Blood Cell Transfusion
Types of Packed Red Blood Cell Units
Standard Packed RBC Units
Other Types of Packed Red Blood Cell Units
Leukocyte-Reduced Packed Red Blood Cell Units.
Washed Packed Red Blood Cell Units.
Irradiated Packed Red Blood Cell Units.
Cytomegalovirus-Negative Packed Red Blood Cell Units.
Directed Packed Red Blood Cell Units.
Autologous Packed Red Blood Cell Units.
RBC substitutes and other alternatives to RBC transfusion
Transfusion of Packed Red Blood Cells: How
Blood Types
Volume and Number of Units
Length of Storage
Perfusion, Warming, and Filtration
Monitoring and Reporting Adverse Events
Plasma
Transfusion of Plasma: Indication (When)
Transfusion of Plasma: How
Platelets
Standard Platelet Concentrates
Special Platelet Concentrates
Leukocyte-Reduced Platelets
Irradiated Platelets
Cytomegalovirus-Negative Platelets
Platelets Substitutes
Transfusion of Platelets: Indication (When)
Transfusion of Platelets: How
Cryoprecipitate
Transfusion Reactions and Complications
Red Blood Cells, Plasma, and Platelets
Immediate Transfusion Reactions
Respiratory System
Cardiovascular System
Other Acute Transfusion Reactions
Delayed Transfusion Reactions
Complications Related to Massive Red Blood Cell Transfusion
Transfusion Transmitted Infections
Transfusion-Related Immunomodulation
Complications Specific to Plasma Transfusion
Complications Specific to Platelet Transfusion
Treatment of Transfusion Reactions
Conclusion
Chapter 83 - Critical Illness Involving Children Undergoing Hematopoietic Progenitor Cell Transplantation
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
Engraftment Syndrome
Diffuse Alveolar Hemorrhage
Idiopathic Pneumonia Syndrome
Etiology of Idiopathic Pneumonia Syndrome.
Treatment of Idiopathic Pneumonia Syndrome.
Late Pulmonary Complications
Bronchiolitis Obliterans/Bronchiolitis Obliterans Organizing Pneumonia
Pulmonary Veno-occlusive Disease
Dilemmas in the Diagnosis of Pulmonary Complications
Hepatic Complications
Myelosuppression and Hematologic Complications
Myelosuppression and Immune Dysregulation
Infectious Complications
Graft Rejection
Hematologic Complications
Iron Overload
Graft-Versus-Host Disease
Neurologic Complications
Late Effects
Nutritional Support in the Critically Ill Hematopoietic Progenitor Cell Transplantation Patient
Chapter 84 - Hemoglobinopathies
Perspective
The Globin Gene Loci
Sickle Cell Disease
Molecular Description and Epidemiology
Sickle Cell Trait
Spectrum of Sickle Cell Disease Genotypes
Natural History
Laboratory and Diagnostics
Pathophysiology
Hemoglobin Polymerization
Red Cells, Inflammation, and the Endothelium
Hemolysis and Nitric Oxide Homeostasis
Clinical Manifestations
Pain
Pathophysiology, Diagnosis, and Presentation.
Management.
Sepsis
Pathophysiology and Etiology.
Management
Acute Chest Syndrome
Presentation.
Management
Stroke
Natural History.
Diagnosis. S
Management.
Aplastic Crisis
Splenic Sequestration
Pulmonary Hypertension
Pathophysiology and Etiology.
Diagnosis.
Management
Multiorgan Failure
Priapism
Skin Ulcers
Cholelithiasis
Renal Conditions
Ocular Conditions
Avascular Necrosis
Iron Overload
Sleep Conditions
Depression and Suicide
Surgery and Anesthesia
Therapies and Interventions
Hydroxyurea
Transfusion
Choice of Product.
Type and Goals of Transfusion.
Indications
Hematopoietic Stem Cell Transplantation
Gene Therapy
Nitric Oxide
Induction of β-like Chains
Antioxidants
Endothelial Protectants
Thalassemia
Molecular Description and Epidemiology
Laboratory and Diagnostics
Pathophysiology
Forms and Variations
α-Thalassemia
β-Thalassemia
HbE/β0-Thalassemia
Combined Mutations
Natural History
Assessment of Iron Overload
Spectrum of Disease
Anemia
Transfusion-Related Complications
Cardiac Failure
Assessments
Management
Hepatic Dysfunction
Endocrine Abnormalities
Growth, Osteoporosis, Osteopenia, and Fractures
Thrombosis and Pulmonary Emboli
Pulmonary Hypertension
Therapies and Interventions
Hematopoietic Stem Cell Transplantation
Gene Therapy
Inducers of Other β-like Genes
Acknowledgment
Chapter 85 - Gastrointestinal Structure and Function
Intestinal Structure, Digestion, and Absorption of Nutrients, Water, and Electrolytes
Water and Solute Transport Across the Intestinal Epithelium
Digestion of Carbohydrates
Digestion of Proteins
Digestion of Lipids
Digestion of Fat
Intestinal Lymphatics
Regulation of Electrolyte and Water Movement
Electrolyte Transport
Zinc
Hydrogen Ions
Pancreas
Pancreatic Exocrine Secretory Function
Hepatobiliary System
Examination
Anatomy: Microanatomy, Structure, and Function
Portal Circulation
Hepatic Function
Enterohepatic Circulation
Host-Defense Mechanisms of the Gut: Immunology and Microbiology
Gastrointestinal and Hepatobiliary Testing in the Intensive Care Unit
Chapter 86 - Disorders and Diseases of the Gastrointestinal Tract and Liver
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
The Intensive Care Unit as a Satellite ­Laboratory Facility
Breath Hydrogen Testing
Life-Threatening Complications of Gastrointestinal Disorders
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
Hirschsprung Disease
Acute Colonic Pseudo-obstruction
Abdominal Compartment Syndrome
Acute Pancreatitis
Acute and Chronic Liver Failure
Chapter 87 - Gastrointestinal Pharmacology
Nausea and Vomiting
Introduction and Definitions
Pathophysiology
Chemotherapy-Induced Nausea and ­Vomiting: Types of Emesis
Treatment Guidelines
Postoperative Nausea and Vomiting
Diarrhea
Introduction and Definition
Treatment
Constipation
Introduction and Definition
Treatment
Gastroesophageal Reflux Disease
Histamine-2 Receptor Antagonists
Proton Pump Inhibitors
Antacids
Surface Agents
Prokinetic Therapy
Gastroesophageal Reflux Disease and Acute Life-Threatening Event
Stress-Induced Mucosal Damage: Ulcer ­Prophylaxis
Gastrointestinal Hemorrhage
Proton Pump Inhibitors
Octreotide and Somatostatin
Vasopressin
Helicobacter Pylori Infection
Drug-Induced Liver Injury
Cause
Treatment
Cerebral Edema and Hepatic Encephalopathy
Ascites
Coagulopathy and Hemorrhagic Complications
Pruritus
Cholangitis
Miscellaneous
Dose Adjustments for Hepatic Dysfunction
Rectal Administration of Medication
Chapter 88 - Acute Liver Failure, Liver Transplantation, and Extracorporeal Liver Support
Definition
Epidemiology
Clinical Presentation by Etiology
Family Support
Management
Initial Assessment and Care
Fluid Balance
Nonspecific Adjunctive Therapy
Antibiotic Therapy
Nutritional Support
Central Nervous System Monitoring
Prevention and Management of Complications
Hypoglycemia
Coagulopathy and Hemorrhage
Prevention of Gastrointestinal Hemorrhage
Encephalopathy
Management of Hepatic Encephalopathy
Cerebral Edema
Renal Dysfunction
Ascites
Secondary Bacterial and Fungal Infections
Hemofiltration for Hepatic Support
Extracorporeal Hepatic Support
Liver Transplantation
Technical Aspects of Liver Transplantation
Immune Suppression
Postoperative Management Issues of Concern to the Intensivist
Primary Nonfunction
Bleeding
Monitoring Vascular Anastomotic Patency
Infection
Biliary Complications
Rejection
Complications of Immune Suppressive Medications
Chapter 89 - Acute Abdomen
Anatomic and Physiologic Considerations
The Peritoneum
Visceral Blood Flow
Physical Exam of the Abdomen
Laboratory Tests
Imaging Options
Ultrasonography
Abdominal Plain Radiographs
Computed Tomography
Magnetic Resonance Imaging
Abdominal Conditions Requiring Intensive Care Unit Care
Perforated Viscera
Ischemia
Neutropenic Enterocolitis
Pancreatitis
Hemorrhage
Other Specific Conditions
Cholecystitis
Abdominal Compartment Syndrome
The Intestine as a Source of Sepsis
Surgical Intervention
Section VI: Immunity and Infection
Chapter 90 - The Innate Immune System
Components of the Innate Immune System
Circulating Pattern Recognition Receptors: Complement, Lectins, and Defensins
Neutrophils
Cellular Pattern Recognition Receptors
Signaling
Crosstalk
Hypoxic-ischemic injury
Complex System
Predisposition to an (in)Appropriate Response
Cytokines
Therapeutic Interventions
Chapter 91 - Infection and Host Response
Historical Perspectives
Innate Immune Versus Adaptive Immune Response
Pattern Recognition Receptors
Toll-Like Receptors
Endogenous Antimicrobials
Soluble Components of Immunity
C-Reactive Protein
Complement System
Immunoglobulin
Contact Activation System
Lipid-Derived Mediators of Inflammation
Cytokines
Interleukin-1 and Tumor Necrosis Factor
Interferons and Other Soluble Products
Cellular Components of Immunity
Platelets
Leukocyte Localization
Host Response to Infection: A Summary
Chapter 92 - Congenital Immunodeficiencies
The Immune System and the Classification of the Primary Immunodeficiency Diseases
Laboratory Diagnosis of Congenital Immunodeficiencies
Clinical Presentations of Congenital Immunodeficiency Syndromes
Combined T- and B-Lymphocyte Defects
Severe Combined Immunodeficiency
Clinical Presentations and Laboratory Findings in SCID.
Therapy for Patients with Clinical Suspicion or Diagnosis of SCID.
Other Combined Immunodeficiency Disorders
Hyper Immunoglobulin M Syndrome
Clinical and Laboratory Presentation of X-Linked Hyper Immunoglobulin M.
Antibody Deficiency Syndromes
Clinical Presentations and Laboratory Findings in Antibody Defects.
Congenital Defects of Phagocytes
Chronic Granulomatous Disease
Complement Deficiencies
Other Well-Defined Immunodeficiency Syndromes
Wiskott-Aldrich Syndrome
Clinical and Laboratory Presentation of Wiskott-Aldrich Syndrome.
DiGeorge Syndrome
Clinical and Laboratory Presentation of DiGeorge Syndrome.
DNA Repair Defects with Immunodeficiency
Hyper Immunoglobulin E Syndrome
Diseases of Immune Dysregulation
Familial Hemophagocytic Lymphohistiocytosis.
Summary
Chapter 93 - Acquired Immune Dysfunction
Immune Function and Critical Illness
Malnutrition and Immune Deficiency
Human Immunodeficiency Virus Infection and Acquired Immune Deficiency Syndrome
Epidemiology
Antiretroviral Therapy
Pulmonary Complications and Respiratory Failure
Pneumocystis Jirovecii Pneumonia
Cytomegalovirus Pneumonitis
Other Viral Pathogens
Mycobacterial Pathogens
Fungal Infections
Lymphoid Interstitial Pneumonitis
Upper Airway Obstruction
Cardiovascular Complications
Septic Shock
Vasculitis
Myocardial Dysfunction
Dysrhythmias
Pericardial Disease
Renal Failure
Abdominal Complications
The Acute Abdomen
Pancreatitis
Hepatobiliary Failure
Hematologic Complications
Malignancies
Neurologic Complications
Human Immunodeficiency Virus Encephalopathy
Cerebrovascular Disease
Central Nervous System Malignancy
Infections of the Central Nervous System
Ethical Issues
Occupational Human Immunodeficiency Virus Exposure
Summary
Chapter 94 - Bacterial Infection, Antimicrobial Use, and Antibiotic-Resistant Organisms in the Pediatric Intensive Care Unit
Antibiotic Classes
β-Lactam Antibiotics
Penicillins
β-Lactam Antimicrobial plus β-Lactamase Inhibitor Combination
Cephalosporins
Carbapenems
Monobactams
Aminoglycosides
Glycopeptides
Macrolides
Fluoroquinolones
Miscellaneous
Clindamycin
Linezolid
Metronidazole
Colistin
Tigecycline
Daptomycin
Antibiotic Resistance
Antibiotic Resistance Mechanisms
Antibiotic Resistance and Infections in the Pediatric Intensive Care Unit
An Approach to Therapy in the Pediatric Intensive Care Unit
General Considerations for Antibiotic Therapy
Antibiotic Therapy for Specific Pathogens
Antimicrobial Stewardship
Summary
Chapter 95 - Life-Threatening Viral Diseases and Their Treatment
Myocarditis
Background
Pathogenesis
Cause
Clinical Presentation
Acute Liver Failure
Background
Cause
Clinical Presentation
Viral Pneumonia/Pneumonitis
Background
Cause
Clinical Presentation
Central Nervous System Infections
Background
Cause
Clinical Presentation
Exotic Viral Diseases
Diagnosing Viral Disease
Myocarditis
Acute Liver Failure
Pneumonia/Pneumonitis
Meningitis/Encephalitis
Treatment for Viral Infections
Myocarditis
Acute Liver Failure
Pneumonitis
Encephalitis
Chapter 96 - Infectious Syndromes in the Pediatric Intensive Care Unit
Meningococcus
Etiology and Epidemiology
Clinical Presentation
Diagnosis
Management
Conventional Therapy
Novel Therapy
Prevention and Vaccines
Prognosis
Staphylococcus Toxic Shock Syndrome
Etiology and Epidemiology
Clinical Presentation
Diagnosis
Management
Prognosis
Invasive Group A β-Hemolytic Streptococcus
Etiology and Epidemiology
Clinical Presentation
Diagnosis
Management
Prognosis
Invasive Pneumococcus
Etiology and Epidemiology
Clinical Presentation
Diagnosis
Management
Prevention and Vaccination
Prognosis
Lyme Disease
Etiology and Epidemiology
Clinical Presentation
Diagnosis
Management
Prognosis
Rocky Mountain Spotted Fever
Etiology and Epidemiology
Clinical Presentation
Diagnosis
Management
Prognosis
Hantavirus
Etiology and Epidemiology
Clinical Presentation
Diagnosis
Management
Prognosis
Chapter 97 - Health Care–Associated Infection in the Pediatric Intensive Care Unit: Epidemiology and Control—Keeping Patients Safe
Burden of Illness and Scope of the Problem
Epidemiologic Principles of Infection Prevention and Control
Chain of Infection
Routes of Infectious Disease Transmission
Infection Prevention and Control Measures
The Infection Prevention and Control team
Isolation Practices: Standard Precautions and Additional (Transmission-Based) ­Precautions
Hand Hygiene
Personal Protective Equipment
Surveillance
Screening
Patient Screening
Visitor Screening
Occupational Health
Selected Topics in Policy, Procedure, and Program Development to Prevent Health Care–Associated Infection
Intervention Bundles
Antibiotic Stewardship
Antibiotic Prophylaxis
Antibiotic Cycling
Antibiotic Gastric Decontamination
Specific Infection Syndromes in the Pediatric Intensive Care Unit
Bloodstream Infections
Epidemiology
Prevention
Management
Respiratory Infections and ­­Ventilator-Associated Pneumonia
Respiratory Infections
Epidemiology
Prevention
Ventilator-Associated Pneumonia.
Management
Ventilator-Associated Pneumonia.
Sinusitis
Epidemiology
Prevention
Management
Urinary Tract Infections
Epidemiology
Prevention
Management
Skin and Surgical Site Infections
Epidemiology
Prevention
Surgical Site Infection Bundle
Management
Ventriculostomy-Related Infections
Hospital-Associated Diarrhea
Chapter 98 - Autoimmune Diseases: Diagnosis, Treatment, and Life-Threatening Complications
Rheumatologic Diseases: Clinical Presentation, Diagnosis, and Treatment
Juvenile Idiopathic Arthritis
Clinical Presentation
Laboratory Studies
Complications
Management
Systemic Lupus Erythematosus
Clinical Presentation
Central Nervous System Disease.
Pulmonary Involvement.
Gastrointestinal Involvement.
Cardiovascular Disease.
Renal Involvement.
Hematologic Involvement.
Musculoskeletal Manifestations.
Endocrine Issues.
Immune Dysfunction.
Laboratory Studies.
Management
Neonatal Lupus Syndromes
Juvenile Dermatomyositis
Laboratory Studies.
Management.
Mixed Connective Tissue Disease (Overlap Syndrome)
Antiphospholipid Antibody Syndrome
Laboratory Studies
Management
Vasculitic Syndromes
Small Vessel Vasculitis Syndromes
Laboratory Studies.
Management
Wegener Granulomatosis
Laboratory Studies
Management.
Microscopic Polyangiitis
Laboratory Studies.
Management.
Medium Vessel Vasculitis
Diagnosis.
Management.
Large Vessel Vasculitis
Diagnosis.
Management.
Primary Vasculitis of the Central Nervous System
Diagnosis.
Management.
Kawasaki Disease
Clinical Presentation
Laboratory Studies
Management
Scleroderma (Systemic Sclerosis)
Clinical Presentation
Critical Rheumatic Disease– Related Events in the Intensive Care Unit
Infections
Severe Infections
Endocrine Involvement
Adrenal Insufficiency
Airway Compromise
Pulmonary Involvement
Pneumonitis
Pleuritis and Pleural Effusions
Pulmonary Hemorrhage
Pulmonary Embolism
Cardiovascular Events
Pericarditis and Pericardial Tamponade
Myocarditis
Valvular Disease
Arrhythmias
Acute Coronary Syndromes
Gastrointestinal Involvement
Gastrointestinal Hemorrhage
Acute Surgical Abdomen: Peritonitis and Intestinal Perforation
Pancreatitis
Renal Involvement
Renal Failure and Malignant Hypertension
Central Nervous System Involvement
Hematologic and Immunologic Involvement
Thrombotic Thrombocytopenic Purpura
Macrophage Activation Syndrome
Complications of the Treatment of Rheumatologic Diseases
Summary
Chapter 99 - Genomic and Proteomic Medicine in Critical Care
Genomics
From the Discovery of the Double Helix to the Human Genome Project
Gene Expression and Microarrays
Gene Expression Microarrays
Quantifying Gene Expression
Genes and Human Variation
Single-Nucleotide Polymorphisms
Copy-Number Variations
Genotyping and Microarrays
Proteomics
Metabolomics
Systems Biology
Clinical Applications
Cancer
Pharmacology
Drug Discovery
Biomarkers
Critical Care
Gene Expression Microarrays
Genetic Variation
Ethical Issues
Chapter 100 - Molecular Foundations of Cellular Injury: Necrosis, Apoptosis, and Autophagy
Cell Death
Pathways of Apoptosis and Autophagy
Human Studies
Sepsis
Noninfectious Inflammation
Animal Studies
Sepsis
Noninfectious Inflammation
Chapter 101 - Endotheliopathy
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
Conclusions
Chapter 102 - Neuroendocrine–Immune Mediator Coordination and Disarray in Critical Illness
Organization of the Stress Response
Central Stress Response
Immune Response to Microscopic Threats
Acute Versus Chronic Stress
Neuroendocrine–Immune Dysfunction Causing Critical Illness
Hypothalamic-Pituitary-Adrenal Axis
Vasopressin
Intensive Care Unit Therapies That Interfere with the Neuroendocrine–Immune System
Catecholamines and Autonomic ­Control of Inflammation
Growth and Lactogenic Hormone Family
Prolactin
Growth Hormone and Insulin-like Growth Factor
Morphine and Other Opioids
Somatostatin
Other Neuroendocrine–Immune Mediators
Macrophage Migration Inhibitory ­Factor
Substance P, Neuropeptide Y, and Calcitonin Gene-Related Peptide
Clinical Relevance
Chapter 103 - Sepsis
Epidemiology
Definitions
Clinical Presentation
Pathogenesis
Pathogen Recognition and Signal Transduction
Cytokines as Principal Mediators of the Sepsis Response
Tumor Necrosis Factor-α
Interleukin-1β
Interleukin-6
Interleukin-8
Macrophage Migration Inhibitory Factor
Interleukin-18
Interleukin-10
High-Mobility Group Box 1
Adhesion Molecules
Nitric Oxide
The Coagulation Cascade
The Peroxisome Proliferator-Activated Receptor-γ Pathway
The 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
Immune Modulation
The Case for More Effective Stratification in Pediatric Septic Shock
Concluding Perspectives
Chapter 104 - Inflammation and Immunity: Systemic Inflammatory Response Syndrome, Sepsis, Acute Lung Injury, and Multiple Organ Failure
The Inflammation/Coagulation/Immune Dysfunction/Dysregulated Metabolism Hypothesis
Definitions and Scoring
Outcomes
Multiple Organ Failure/Dysfunction Phenotypes, Respective Biomarkers, and Therapies
Thrombocytopenia-Associated Multiple Organ Failure
Immune Paralysis and Lymphoid Depletion Syndrome
Viral/Lymphoproliferative ­Disease–Associated Sequential or ­Liver-Associated ­Multiple Organ Failure Syndrome
Secondary Hemochromatosis-Associated Cardiac Hepatopancreatic Multiple Organ Failure
Hyperleukocytosis-Associated Multiple Organ Failure
Therapeutic Approaches to Systemic Inflammatory Response Syndrome, Sepsis, Acute Lung Injury, and Multiple Organ Failue
Time Course of Systemic Inflammatory Response Syndrome, Sepsis, and Multiple Organ Dysfunction
Summary
Section VII: Environmental Hazards, Trauma, Pharmacology, and Anesthesia
Chapter 105 - Principles of Toxin Assessment and Screening
Common Agents Involved
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
Additional Readings
Chapter 106 - Toxidromes and Their Treatment
Opiates
Sympathomimetic Agents
Anticholinergic Agents
Cholinergic Agents
Methemoglobinemia
Hyperthermia
Malignant Hyperthermia
Serotonin Syndrome
Neuroleptic Malignant Syndrome
Metabolic Acidosis with Increased Anion Gap
Methanol and Ethylene Glycol
Carbon Monoxide
Cyanide
Iron
Isoniazid
Salicylates
Bradycardia, Hypotension, and Cardiac Conduction Abnormality
Calcium Channel Antagonists
β-Adrenergic Antagonists
Digoxin
Acetaminophen (Paracetamol)
Tricyclic Antidepressants
Chapter 107 - Bites and Stings
Snakebites
Epidemiology
Pathophysiology
Clinical Presentation
Diagnostic Studies
Pitfalls
Prehospital Care
Emergency and Critical Care
Therapeutic Complications
Resources
Disposition
Prognosis
Future Directions
Widow Spider Bites
Epidemiology
Pathophysiology
Clinical Presentation
Diagnostic Studies
Pitfalls
Emergency and Critical Care
Therapeutic Complications
Resources
Disposition
Prognosis
Prevention
Future Directions
Hymenoptera Stings (Bees, Wasps, and Ants)
Chapter 108 - Heat Injury
Definitions
Epidemiology
Pathophysiology and Pathogenesis of Heat-Related Illnesses
Acclimatization
Acute Phase Response
Systemic Clinical Features
Central Nervous System
Pulmonary
Cardiovascular
Renal
Gastroenterologic
Metabolic
Hematologic
Infectious
Treatment
Chapter 109 - Accidental Hypothermia
Pathophysiology
Central Nervous System
Cardiovascular System
Respiratory System
Renal System
Coagulation
Treatment
Outcome
Chapter 110 - Drowning
Definitions
Epidemiology
Pathophysiologic Considerations
Type of Aspirated Fluid
Pulmonary Effects
Cardiovascular Effects
Central Nervous System Effects
Effects on Other Organ Systems
Submersion Hypothermia
Mammalian Diving Reflex
Preexisting Associated Conditions
Management
Management at the Scene
Emergency Department Evaluation and Stabilization
Management in the Intensive Care Unit
Prognosis
Chapter 111 - Burn and Inhalation Injuries
Types of Burn Injuries
Scald Burns
Thermal Burns
Electrical Burns
Chemical Burns
Depth and Extent of the Burn Injury
Normal Anatomy
Superficial Burns
Superficial Partial-Thickness Burns
Deep Partial-Thickness Burns
Full-Thickness Burns
Zones of Injury
Estimating the Extent of the Burn
Early Management of Burn Injuries
Transfer to Burn Centers
Burn Resuscitation
Colloid Resuscitation
Complications of Resuscitation
Inhalational Injury
Pathophysiology of Inhalation Injury
Diagnosis of Inhalation Injury
Management of Inhalation Injury
Nutritional Support in Burn Patients
Calculating Nutritional Requirements
Monitoring Nutritional Status
Enteral Support
Parenteral Support
Vitamin and Anabolic Steroid Supplementation
Wound Care
Chapter 112 - Evaluation, Stabilization, and Initial Management After Multiple Trauma
Prehospital Care and Trauma Team Activation
Trauma Resuscitation
The Primary Survey
Overview
Establish an Airway with Cervical Spine Stabilization (A)
Breathing (B)
Circulation (C)
Disability (D)
Exposure (E)
The Secondary Survey
Diagnostic Assessment
Laboratory Studies
Radiographic Imaging
Emergency Department Thoracotomy
Stabilization and Definitive Care
Conclusions
Chapter 113 - Child Abuse and Neglect
Recognition of Child Abuse
History of Injury
Patterns of Injury
Bruising
Burns
Fractures
Skeletal Survey
Abusive Head Trauma
Characteristics of the Infant Brain and Cervical Spine
Mechanisms of Head Injury
Neuroimaging of Abusive Head Trauma
Retinal Hemorrhages
Shaken Baby Syndrome
Inflicted Abdominal and Thoracic Trauma
Abdominal Trauma
Thoracic Trauma
Sexual Abuse
Protocol for the Medical Investigation of Child Abuse
Fatal Child Abuse
Osseous Injury in Fatal Child Abuse
Scene Investigation in Fatal Child Abuse
Autopsy
Organ Procurement Organization and Fatal Child Abuse
Documentation and Testifying in Court
Chapter 114 - Thoracic Injuries in Children
Epidemiology
Anatomic and Physiologic Considerations with Chest Injuries
Diagnosis and Immediate Management of Chest Injuries
Rib Fractures
Clavicle, Sternal, and Scapular Fractures
Pulmonary Contusion
Traumatic Asphyxia
Pneumothorax/Hemothorax
Tracheobronchial Injuries
Cardiac Injuries
Commotio Cordis
Aortic and Great Vessel Injuries
Other Miscellaneous Injuries
Penetrating Trauma
Functional Outcome
Summary
Chapter 115 - Abdominal Trauma in Pediatric Critical Care
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
Chapter 116 - Principles of Drug Disposition in the Critically Ill Child
Drug Disposition in Infants and Children
Determinants of Effective Therapy
Pharmacokinetics
Pharmacokinetics
Drug Absorption
Intramuscular Administration.
Subcutaneous Absorption.
Percutaneous Absorption.
Rectal Absorption.
Drug Distribution
Developmental Aspects of Protein Binding.
Developmental Aspects of Fluid Compartment Sizes.
Developmental Aspects of Body Composition
Critical Illness and Drug Distribution.
Drug Clearance
Biotransformation: Phase I Reactions
CYP1A2
CYP2C9
CYP2D6
CYP3A4.
Biotransformation (Phase II Reactions).
Additional Factors Affecting Hepatic Biotransformation.
Drug Elimination
Renal Excretion
Drug Delivery Systems
Effect of Extracorporeal Therapies on Drug Disposition.
Pharmacodynamics
Effect of Disease on Drug Action
Pharmacokinetic Principles
Evaluation of the Plasma Concentration-Time Curve
Applied Pharmacokinetics
Bioavailability
Half-Life
Apparent Volume of Distribution
Total Body Clearance
Critical Care Therapeutics
Target Concentration Strategy
Target Effect Strategy
Chapter 117 - Molecular Mechanisms of Drug Actions: From Receptors to Effectors
Targets For Drug Action
Receptors
Ion Channels
Enzymes
Carrier Proteins
Receptor Type and Regulation
Classification of Receptors
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 and Drug Targets and Signaling Mechanisms
Drug Response and Development
Drug Response and Disease
Conclusion
Chapter 118 - Adverse Drug Reactions and Drug-drug Interactions
Defining Adverse Drug Reactions
Adverse Drug Reactions by Organ System
Renal
Hepatic
Cardiovascular
Central Nervous System
Hematologic
Respiratory
Endocrine and Metabolic
Dermatologic
Drug-drug Interactions
Pharmacokinetic Drug-drug Interactions
Interactions Affecting Drug Absorption (Enteral Absorption)
Interactions Affecting Drug Absorption (Alternative Sites of Absorption)
Interactions Affecting Drug Distribution (Protein or Tissue Binding)
Alterations in Total Body Water
Interactions Affecting Drug Metabolism
Interactions Affecting Drug Excretion
Interactions Affecting P-Glycoprotein Receptors
Pharmacodynamic Drug-drug Interactions
Drug-drug Interactions in Intravenous Admixtures
Drug-Drug Interactions by Therapeutic Class
Cardiovascular Agents
Anticonvulsant Medications
Antiinfective and Antimicrobial Agents
Anesthetic Agents and Sedatives
Analgesic Agents
Anticoagulants
Immunosuppressive Agents
Pulmonary and Respiratory Medications
Antineoplastic Agents
Chapter 119 - Airway Management
Anatomic Considerations
Basic Airway Management
Nasopharyngeal Airway
Oropharyngeal Airways
Oxygen Delivery Devices
Nasal Cannulas
Oxygen Hoods
Masks
Noninvasive Positive Pressure Ventilation
Establishing a Functional Airway
Endotracheal Intubation
Indications
Respiratory Failure
Hemodynamic Instability
Neuromuscular Dysfunction
Failure of Central Nervous System Regulation of Ventilatory Drive
Other Indications
Physiologic Effects of Intubation
Recognition of a Difficult Airway
Process of Intubation
Pharmacologic Agents Facilitating ­Intubation
Anticholinergic Agents
Sedative and Analgesic Agents
Neuromuscular Blocking Agents
Orotracheal Intubation
Nasotracheal Intubation
Videolaryngoscopy
Flexible Fiberoptic Bronchoscopy
Extubation
Complications of Endotracheal Intubation
Prolonged Intubation
Special Circumstances
Full Stomach
Increased Intracranial Pressure and Neurologic Dysfunction
Cervical Spine Instability
Upper Airway Obstruction
Facial and Laryngotracheal Injury
Open Globe Injury
Alternative Approaches to the Airway
Lighted Intubation Stylet (Light Wand)–Assisted Intubation
Laryngeal Mask Airway
Tracheostomy
Cricothyrotomy and Retrograde Intubation
Chapter 120 - Organ System Considerations that Affect Anesthetic Management
Cardiovascular Performance
Changes with Development
Effects of Disease
Effects of Anesthetic Agents
Anemia and Transfusion
Respiratory Failure
Neurologic Injury
Intracranial Pressure
Regulation of Cerebral Blood Flow
Effects of Anesthetics on Cerebral Blood Flow
Hepatic Dysfunction
Effects of Anesthetics on Hepatic Blood Flow
Effects of Liver Disease on ­Pharmacokinetics
The Role of the Liver in Coagulation
Renal Failure
Fluid and Electrolyte Disturbances
Renal Drug Metabolism
Intravenous Alimentation
Chapter 121 - Anesthesia Principles and Operating Room Anesthesia Regimens
Preoperative Evaluation
NPO Guidelines
Preoperative Medication
Monitoring
The Pharmacology of Anesthetic Agents
Local Anesthetic Agents
Intravenous Anesthetic Agents
Opioids
Inhalational Anesthetic Agents
Neuromuscular Blocking Agents
Intraoperative Anesthetic Care
Maintenance Anesthesia
Intraoperative Fluid Management
Postoperative Care
Postoperative Analgesia
Conclusions
Chapter 122 - Neuromuscular Blocking Agents
The Neuromuscular Junction
Neuromuscular Blocking Agents: Depolarizing Agents
Neuromuscular Blocking Agents: Nondepolarizing Agents
Pancuronium
Vecuronium
Rocuronium
Pipecuronium
Rapacuronium
Mivacurium
Atracurium
Cis-atracurium
Doxacurium
Reversal of Neuromuscular Blockade
Monitoring Neuromuscular Blockade
Adverse Effects of Neuromuscular Blockade
Summary: Neuromuscular Blocking Agents in the PICU
Chapter 123 - Sedation and Analgesia
Opioids and Analgesia in the Pediatric Intensive Care Unit
Specific Opioid Agonists
Morphine
Meperidine
Fentanyl
Sufentanil
Alfentanil
Codeine
Remifentanil
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 and Dependence to the Benzodiazepines
Flumazenil
Chloral Hydrate
Other Agents for Sedation in the PICU Patient
Butyrophenones and Phenothiazines
Haloperidol
Droperidol
Chlorpromazine
The Lytic Cocktail
Neuroleptic Malignant Syndrome
Baclofen
Dexmedetomidine
Propofol
Special Issue Regarding Long-Term Infusion of Propofol
Propofol Infusion Syndrome
Sedation and Analgesia for Procedures
Types of Procedures and Preprocedure Evaluation
Monitoring During the Procedure
Postprocedure Care and Monitoring
Sedation for Magnetic Resonance Imaging
Specific Drugs for Sedation
Ketamine
Etomidate
Inhalational Anesthetic Agents
Apoptosis
Pharmacoeconomics
Chapter 124 - Malignant Hyperthermia
Pathophysiology
Genetics
Clinical Recognition of a Malignant Hyperthermia Episode in Humans
Potential Systemic Complications
Hyperthermia in the Pediatric Intensive Care Unit
Postoperative Fever
Abortive Malignant Hyperthermia Episodes and Isolated Masseter Spasm
Rhabdomyolysis
Treatment of an Episode of Malignant Hyperthermia
Remove Trigger Agents
Administer Dantrolene
Symptomatic Treatment
Urine and Blood Tests in Malignant Hyperthermia
The Course of a Clinical Episode of Malignant Hyperthermia
Recrudescence
Factors that “Trigger” Malignant Hyperthermia
Muscular Diseases Associated with Malignant Hyperthermia
Evaluation of Patients at Risk
Asymptomatic Elevation of Creatine Kinase Values
The “Safe” Anesthesia
Testing for Malignant Hyperthermia Susceptibility
In Vitro Caffeine-Halothane Contracture Testing
Less Invasive Tests of Malignant Hyperthermia Susceptibility
Neuroleptic Malignant Syndrome and Serotonin Syndrome
The Malignant Hyperthermia Assocation
Index
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B
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D
E
F
G
H
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J
K
L
M
N
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P
Q
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W
X
Z