Pediatric
Critical Care
Mary King, MD, MPH
Assistant Professor
Pediatric Critical Care Medicine
Harborview Medical Center and Seattle Children’s
≠ Pediatric Critical Care
Pediatric Critical Care =
Outline
• FEN
• RESP
– Upper airway
– Bronchioles
– Lungs
• CV
• ID
• NEURO
FEN
• Smaller
– Need less fluid
• Increased surface area
– Increased fluid losses relative to body size
– Fast changes in thermoregulation
• Glucose issues
– Less mature liver with decreased gluconeogenesis
– Difficult to maintain glucose while NPO
– Brain more susceptible to hypoglycemia with seizure
Resp: upper airway
• Intubation differences:
Smaller 
ETT size: (age/4) + 4
Shorter 
ETT depth: (age/2) + 12
Positioning 
shoulder roll
Floppy epiglottis straight blade
Resp: upper airway
• Higher risk for upper airway obstruction
• Why?
– Kids have smaller airways (resistance)
– Kids cry (turbulence)
– Kids have floppier airways (malacia)
Resp: upper airway
Remember resistance?  V = I X R
• Pearl: Resistance (laminar) = 8ηL/ π (radius)4
• Pearl: Resistance (turbulent) = 8ηL/ π (radius)5
Pediatric upper airways much smaller than adult:
• Baby: 3-4 mm
• Small child: 5-6 mm
• Adult: 7-9 mm
Resp: upper airway
Case:
• 6 mo old baby
• 4mm diameter glottis
• Baby gets sick with a cold and has a barky cough with
inspiratory stridor
• 1 mm of circumferential edema
• What is stridor?
• What is the effect of the airway size on airway resistance
at baseline and what is it with croup? (assume laminar)
Resp: upper airway
• 6 mo old baby with a 4mm diameter glottis gets croup
with 1 mm of circumferential edema.
Airway resistance at baseline:
• Resistance ~ 1/ (radius)4
• R ~ 1/ (2mm)4 ~ 1/ 16
Airway resistance with croup:
• Resistance ~ 1/ (radius)4
• R ~ 1/ (1mm)4 ~ 1/ 1
16/1 = 16 X increase in resistance
Resp: upper airway
• Compare to airway resistance in an adolescent with a
8mm diameter glottis who gets croup with 1 mm of
circumferential edema.
•
•
•
•
•
•
Airway resistance at baseline:
Resistance ~ 1/ (radius)4
R ~ 1/ (4mm)4 ~ 1/ 256
Airway resistance with croup:
Resistance ~ 1/ (radius)4
R ~ 1/ (3mm)4 ~ 1/ 81
256/81= 3X increase in resistance
Resp: upper airway
• 6 mo old baby with a 4mm diameter glottis gets croup
with 1 mm of circumferential edema.
• What should you do?
Resp: upper airway
Take upper aiway obstruction as an emergency!
• Peds pearls:
– Calm child (improves laminar airflow)
– Lower fever (decr minute ventilation  decr RR)
– Any desaturation is an emergent sign
• Consider:
– Steroids
– Racemic epinephrine
– Heliox
– Positive pressure
Resp: bronchioles
• Smaller bronchioles
– more bronchiolar obstruction
• Increased incidence of allergic disease
– more bronchiolar thickening and reactivity
• More frequent viral disease
– more frequent insult
Resp: bronchioles
• Treatment of wheezing in child:
• Same as adult:
– B-agonists (albuterol)
– Steroids (inhaled, enteral, or parenteral)
– Removing exposure
• What should also be on your differential
diagnosis for wheezing in a baby or child?
Resp: bronchioles
Differential diagnosis for wheezing in a baby/child:
• Foreign body aspiration
• Anaphylaxis
• Inhalation exposure
• Congenital malformation around airways:
– Cardiac ring/sling
– Tracheo-esophageal fistula
Resp: lungs
Some differences between kids and adults:
1)
2)
3)
4)
RDS vs. ARDS
Growing more alveoli with increase in height
Bronchoscopy difficult diagnosis limited
Ventilator differences and ECMO
What do you
see?
Resp: lungs
•
•
•
•
Child/Adult
ARDS
Loss of surfactant
Any age
• Treatment:
– Time
– Prevention of
Ventilator-Associated
Lung Injury (VALI)
•
•
•
•
Neonate
RDS
Insufficient surfactant
<35 wks gestation
• How to treat?
Intubated to
provide
surfactant
Resp: lungs
Neonatal RDS Therapies:
1) Treatment: Inhaled Surfactant in the delivery
room or upon diagnosis
2) Prevention: IV steroids to mom prior to
delivery after checking amniotic fluid for lung
maturity
Resp: lungs
Different Lung support for kids:
•
•
•
•
CPAP/BIPAP
Conventional ventilator (different modes)
High-frequency Oscillatory Ventilation
ECMO
off CPAP
4 days
later
High
Frequency
Oscillatory
Ventilation
(HFOV)
Resp: lungs
Extra-corporeal membrane oxygenation
(ECMO)
CV
•
•
•
•
Physiology
Anatomy
Rhythms
Therapies
CV: physiology
Differences between kids and adults:
•
•
•
•
•
CO = SV X HR  kids more dependant on HR
Much less cardiac ischemia, tolerate tachycardia better
Sepsis  cardiac depression common in kids
Limited use of/need for PA catheters in kids
Pulmonary HTN in neonates and some children with
chronic lung disease, congenital heart disease, T21
• Babies have less developed sympathetic tone, they
vagal and become bradycardic and arrest quite easily
CV: physiology
Given:
1) Cardiac depression is common in children with sepsis
2) Children are less susceptible to cardiac ischemia
•
Bonus question:
What agent is a good vasopressor for children with
hypotensive septic shock?
CV: physiology
• If pediatric hypotensive shock you probably need:
• B1 agonist, B2 agonist, and alpha agonist:
– Low-dose epinephrine
– or Dopamine
Pearls:
1) Not good agents for: stressed out heart or CHD.
2) Use pure alpha agonist if hypotensive and cardiac
function looks adequate.
CV: physiology
Persistent fetal circulation:
•
•
•
•
Patent ductus arteriosus (PDA)
Patent foramen ovale (PFO)
Pulmonary hypertension with hypoxemia (PHTN)
Severe cases progress to needing HFOV, Nitric
Oxide and ECMO
CV: therapies
Medical Therapy:
RV/LV failure- same management as adults
Cardiac surgery:
Repair of many congenital lesions
Outcome depends on lesion
ECMO/VAD/Berlin Heart:
CV failure not responding to medical or surgical tx
Heart Transplantation:
Increasing use in neonatal population
ID
Infections vary by age and immunocompetance:
• Immunodeficiency must be ruled out for young children
presenting with severe or recurrent disease
• RSV most prevalent infection in winter months causing
severe disease, especially in kids<1 yr and premie
• Meningococcemia one of the most devastating (rare)
pediatric diseases in schoolage child
• Staph PNA with empyema becoming more prevalent and
dangerous in the healthy pre-adolescent
Neuro
• Treatment often same as adults
• Etiology of disease often different
• Improvement usually superior in kids b/c of redundancy
of neurons
• Must consider Non-accidental Trauma in kids < 2 yrs old
with intracerebral hemorrhage especially when:
–
–
–
–
SDH
Retinal hemorrhages
History inconsistent or changing
Other signs of trauma and/or neglect
The End
Keep these slides for review prior to your
pediatrics, Neonatal ICU and PICU rotatations.
I have included many practical and frequently
tested pearls.