Table Of Content

Handbook of Pediatric Surgical Critical Care First Edition 2013 from the Surgical Critical Care Committee of the American Pediatric Surgical Association Editor-in-Chief: Marjorie J. Arca, MD ©2013, American Pediatric Surgical Association EDITOR-IN-CHIEF CONTACT PERSON MARJORIE J. ARCA, MD PROFESSOR DEPARTMENTS OF SURGERY AND PEDIATRICS MEDICAL COLLEGE OF WISCONSIN [email protected] +1-414-266-6550 CONTRIBUTORS Marjorie J. Arca, MD Professor of Surgery Division of Pediatric Surgery, Department of Surgery Medical College of Wisconsin Milwaukee, WI Oxygen Kinetics, Mechanical Ventilation, The Surgical Neonate, Fluid/Elextrolytes/Nutrition, Transfustion and Anticoagulation, Cardiology Basics Felix C Blanco, MD Transplant Surgery Fellow University of Minnesota Medical Center Minneapolis, MN Renal Physiology, Renal Failure and Renal Replacement Therapy David W. Bliss, MD Associate Professor of Surgery Department of Surgery Children’s Hospital of Los Angeles Los Angeles, CA Monitoring in the ICU Anthony C Chin, MD Assistant Professor of Surgery Ann & Robert H. Lurie Children’s Hospital of Chicago Northwestern University Chicago, IL Pediatric Thoracic Trauma Utpala Das, MD Associate Professor of Pediatrics Children’s Hospital of Wisconsin Medical College of Wisconsin Milwaukee. WI Ventilation in the NICU Medical Conditions in the NICU Samir Gadepalli, MD Assistant Professor of Surgery Division of Pediatric Surgery, Department of Surgery University of Michigan Ann Arbor, MI Extracorporeal Membrane Oxygenation/Extracorporeal Lung Support, Sepsis Alessandra Gasior, DO Pediatric Surgical Critical Care Fellow Children’s Mercy Hospital Kansas City, MO Pediatric Neurotrauma Raquel Gonzalez, MD Assistant Professor of Surgery Department of Surgery Wayne State University School of Medicine Children’s Hospital of Michigan Detroit, MI Burns Ronald B. Hirschl, MD Professor of Surgery, Surgeon in Chief Division of Pediatric Surgery, Department of Surgery University of Michigan Ann Arbor, MI Extracorporeal Membrane Oxygenation/Extracorporeal Lung Support, Sepsis Aaron Jensen, MD, MEd Fellow in Pediatric Surgery Children’s Hospital of Los Angeles Los Angeles, CA ICU Monitoring David Juang, MD Director, Trauma, Burns and Critical Care Director, Pediatric Surgical Critical Care Fellowship Children’s Mercy Hospital Assistant Professor of Surgery University of Missouri - Kansas City Kansas City, MO Pediatric Neurotrauma Brian Kenney, MD Associate Professor of Surgery Division of Pediatric Surgery, Department of Surgery Nationwide Children’s Hospital The Ohio State University Columbus, OH Fluids and Nutrition in the ICU II Jennifer Liedel, MD Assistant Professor of Pediatrics Children’s Hospital of Wisconsin Medical College of Wisconsin Milwaukee. WI Ventilation in the NICU Medical Conditions in the NICU Peter C. Minneci, MD Assistant Professor of Surgery Center for Surgical Outcomes Research Division of Pediatric Surgery, Department of Surgery Nationwide Children’s Hospital The Ohio State University Columbus, OH A Primer on Quality Improvement in the ICU Daniel J. Ostlie, MD Surgeon-in-Chief, American Family Children's Hospital Chair, Pediatric Surgery Department of Surgery University of Wisconsin Madison, WI Pediatric Abdominal Trauma Pramod Puligandla, MD Associate Professor of Pediatric Surgery, Surgery, and Pediatrics Program Director, Pediatric Surgery Attending Staff, Pediatric General and Thoracic Surgery Attending Staff, Pediatric Critical Care Medicine Montreal Children's Hospital, McGill University Health Centre Montreal, QC Canada Shock, Low Cardiac Output, and Inotropic Support Faisal G. Qureshi, MD Assistant Professor of Pediatrics, Surgery George Washington University Children’s National Medical Center Washington, DC Renal Physiology, Renal Failure and Renal Replacement Therapy Robert L. Ricca, MD Assistant Professor of Surgery, USUHS Naval Medical Center Portsmouth Portsmouth, VA Transfusion and Anticoagulation III Anna Ruzic, MD Pediatric Surgery Fellow University of Florida, Gainesville Gainesville, FL Extracorporeal Membrane Oxygenation/Extracorporeal Lung Support, Sepsis Christina M. Shanti, MD Medical Director, Burn Program Department of Surgery Wayne State University School of Medicine Children’s Hospital of Michigan Detroit, MI Burns Sifrance Tran MD Pediatric Surgical Critical Care Fellow Ann & Robert H. Lurie Children’s Hospital of Chicago Northwestern University Chicago, IL Pediatric Thoracic Trauma Martin Wakeham, MD Associate Professor of Pediatrics Medical College of Wisconsin Milwaukee. WI Mechanical Ventilation Jill Zalieckas, MD, MPH Assistant Professor of Surgery Boston, MA Sedation and Analgesia Christopher Weldon, MD, PhD Assistant Professor of Surgery Boston Children’s Hospital Boston, MA Sedation and Analgesia IV NOTICE The authors, editors, and APSA disclaim any liability, loss, injury, or damage incurred as a consequence, directly or indirectly, of the use or application of any of the contents of this volume. While authors and editors have made every effort to create guidelines that should be helpful, it is impossible to create a text that covers every clinical situation that may arise in regards to either diagnosis and/or treatment. Authors and editors cannot be held responsible for any typographic or other errors in the printing of this text. Any dosages or instructions in this text that are questioned should be cross-referenced with other sources. Attending physicians, residents, fellows, students, and providers using this handbook in the treatment of infants should recognize that this text is not meant to be a replacement for discourse or consultations with the attending and consulting staff. Management strategies and styles discussed within this text are neither binding nor definitive and should not be treated as a collection of protocols. I would like to extend my gratitude to contributors to this first edition of the Handbook of Pediatric Surgical Critical Care. Feedback regarding this edition as well as future editions is not only welcome, but also greatly appreciated. Marjorie Arca, MD April 2014 V INTRODUCTION To the Members of APSA: Two years ago, a group of pediatric surgeons with interest and training in surgical critical care met to cultivate and enhance our collective experience within pediatric surgery. We felt that as pediatric surgeons, our voices remain unique, relevant and valuable in caring for our patients, in the training of our fellows, and in informing our colleagues. One of the first projects that we embarked upon is a Handbook of Pediatric Surgical Critical Care. We felt that this would create a uniform basis for our critical care and pediatric surgical curriculum. We also thought that this handbook would provide another dimension to the training for neonatology, pediatric critical care, and adult critical care fellows. Finally, we felt that this project may be helpful to our colleagues, who already in practice, as a point of reference in the care of the most complex surgical patients. I personally would like to thank all the contributors to this seminal project. We also thank APSA Staff for helping us put this project together. We would also like to thank APSA for allowing the website to be the platform for dissemination of the handbook. The authors of this handbook welcome any and all comments from the membership. Marjorie J. Arca, MD Editor VI TABLE OF CONTENTS 1. Oxygen Kinetics ........................................................................................................ 8 2. The Pediatric Airway ............................................................................................... 16 3. Mechanical Ventilation…..……………………………………………...…………………20 4. Ventilation in the NICU ............................................................................................ 34 5. Extracorporeal Membrane Oxygenation/Extracorporeal Lung Support……..……… 53 6. Monitoring in the ICU .............................................................................................. 83 7. Shock, Low Cardiac Output and Inotropic Support ................................................ 106 8. Sepsis .................................................................................................................. 121 9. Fluid, Electrolytes and Nutrition ............................................................................ 152 10. Renal Physiology, Acute Renal Failure, and Renal Replacement Therapy in Children ................................................................................................................................... 176 11. Transfusion and Anticoagulation ........................................................................... 214 12. Sedation and Analgesia ....................................................................................... 232 13. Pediatric Neurotrauma ......................................................................................... 275 14. Pediatric ThoracicTrauma .................................................................................... 292 15. Pediatric Abdominal Trauma ................................................................................ 334 16. Pediatric Burns ..................................................................................................... 357 17. The Surgical Neonate .......................................................................................... 371 18. Medical Conditions in the Neonatal ICU ............................................................... 415 19. Cardiology Basics ................................................................................................ 462 20. A Primer in Clinic Research and Quality Improvement in Critical Care ................. 483 VII Chapter 1 OXYGEN KINETICS Marjorie J. Arca, MD I. Oxygen Consumption and Delivery In a state of equilibrium, oxygen demand equals oxygen consumption, which is the amount of oxygen used for aerobic metabolism. Under normal aerobic conditions, O2 delivery is 3 to 4 times what is consumed by the body and oxygen delivery does not dictate the amount of oxygen consumed. In a critically ill patient, delivery of oxygen must be closely considered. Oxygen delivery is the product of cardiac output (CO) and arterial oxygen content. During the process of metabolism, oxygen is consumed as is expressed as volume of oxygen per minute (V0 ) and is equal to 100-200 cc/m2/min. Oxygen 2 delivery (DO ) is equal to 500-600 cc/m2/min. 2 O Delivery = CO [ (1.34 x Hgb x O sat) + (0.003 x PaO )]. 2 2 2 An analogy for oxygen delivery is as follows: Think of oxygen as beer that needs to be delivered from Milwaukee to Green Bay. The hemoglobin molecules are the trucks that need to be filled (low O saturation) or if there are not enough 2 trucks (low Hgb), then the amount of beer that gets to Green Bay is less. The cardiac output is the foreman that decides who many trucks per hour comes out of the beer factor’s garage. 8