Status epilepticus in the Paediatric Intensive Care Unit

This chapter covers pertinent issues around the management of children with status epilepticus within and outside of specialist centres. A detailed overview of the work-up of a child in status epilepticus is presented. Additionally, the potential management of patients with refractory status epilepticus and super-refractory status epilepticus is evaluated. Furthermore, the chapter focuses on strategies to aid decision-making related to the practical challenges paediatric intensivists face, such as the suitability of extubating patients at the referring hospital, the decision to transfer patients to specialist centres for ongoing management, the role of neuroimaging, and about use of quantitative electroencephalogram (EEG) as a continuous neuromonitoring modality.

Difficult airway in the Paediatric Intensive Care Unit

Children with difficult airways can come to significant harm if not appropriately assessed and managed. Chapter 10 discusses the signs of airway compromise in children and indications for intubation in the Intensive Care Unit (ICU). The role of the paediatric airway in respiratory physiology is examined. Recognizing a difficult paediatric airway is vital in the ICU—common causes of upper airway obstruction are listed and techniques for assessing paediatric airways addressed. The choice of drugs for rapid sequence induction in the Paediatric ICU is explained, and algorithms for the management of the unanticipated difficult tracheal intubation and ‘cannot intubate, cannot ventilate’ illustrated. Finally, the chapter includes the fundamental concepts of team brief, checklists, and crisis resource management in the safe management of difficult airways in children.

The collapsed neonate

Babies under one month of age in respiratory and/or cardiovascular failure can present a significant diagnostic and management challenge. This chapter describes the important initial management steps for a collapsed neonate, exploring, in particular, some uncertainties around the use of oxygen therapy when considering congenital cardiac disease in this patient group. The causes of neonatal collapse are discussed—cardiac, infective, bleeding/trauma, and metabolic/endocrine/seizures—focusing on the assessment, investigations, and specific management of each of the major diagnoses. This chapter includes a diagnostic algorithm for inherited metabolic disorders with neonatal presentation, as well as helpful hints to differentiate among the common underlying causes for neonatal collapse.

Acute severe asthma

Children with acute severe asthma requiring invasive ventilation are among the most difficult to manage in the Intensive Care Unit (ICU). This chapter begins by explaining the pathophysiology of asthma before examining the approaches to its management on the ICU—starting with the evidence for the use of non-invasive ventilation and bronchodilators. Indications for invasive ventilation in acute severe asthma are discussed and important considerations in the conduct of induction of anaesthesia and intubation in this patient group. Ventilation strategies are explored, with particular reference to the concepts of airway resistance, driving pressure, inspiratory flow limitation, and auto-positive end expiratory pressure (PEEP). The use of the mucolytic therapy intratracheal DNAse is discussed, and indications for the use of extracorporeal membrane oxygenation in refractory cases. Finally, the chapter reports on outcomes for children with acute severe asthma and factors associated with higher risk of mortality.

Acute liver failure

The work-up and management of patients with acute liver failure in paediatric critical care are often challenging. This chapter takes the readers through definitions, grading of severity, and diagnostic work-up of acute liver failure in children. General principles underlying the management of acute liver failure, including immediate resuscitation and retrieval; organ support, including renal replacement therapy; and the management of complications, including bleeding, are discussed. In particular, this chapter focuses on neuromonitoring and neuroprotection strategies in children with hepatic encephalopathy as a complication. The role of liver transplantation in fulminant liver failure and a brief overview of complications are also discussed.

Bronchiolitis

Bronchiolitis is one of the commonest reasons for paediatric critical care admission in infants. This chapter explores the epidemiology of bronchiolitis, risk factors for severe illness, and various management strategies. In particular, this chapter explores the assessment of a deteriorating child with bronchiolitis and escalation strategies, including high-flow nasal cannula oxygen and non-invasive respiratory support progressing to invasive mechanical ventilation. This chapter includes a review of the literature related to supportive therapies such as nebulized saline, bronchodilators, and saturation targets. Indications for intubation, various intensive care strategies, and their relative effectiveness are also discussed. The role of respiratory extracorporeal membrane oxygenation in bronchiolitis is also explored.

The stem cell transplant patient in the Paediatric Intensive Care Unit

Patients admitted to the Paediatric Intensive Care Unit after complications related to stem cell transplantation have high morbidity and mortality. Given the severity of immune dysfunction and dysregulation, this subset of patients are uniquely prone to a variety of infectious and non-infectious complications. Infections may be bacterial, viral, and fungal; non-infectious causes may include thrombotic microangiopathy, graft-versus-host disease, and idiopathic pulmonary syndrome. The importance of preventing/treating fluid overload and aggressive organ support strategies are discussed. In addition, this chapter also reminds clinicians that the patient and family are to be seen as partners in dialogue and decision-making. In the unfortunate situation where the prognosis appears bleak, the most appropriate course of action may involve frank discussions with the patient, family, and wider team members about the pros and cons of further escalation strategies.

Safeguarding children in the Paediatric Intensive Care Unit

Chapter 16 addresses the duties of medical professionals in safeguarding children. It covers the major types of child abuse and known risk factors. This chapter takes the readers through the assessment and management of a child suspected of having suffered non-accidental injury (NAI), including non-accidental brain injury. The features of specific subtypes of NAI are discussed, including ‘shaken baby syndrome’, spinal trauma, abdominal injuries, sexual abuse, and fabricated or induced illness. This chapter recommends a helpful list of investigations for suspected NAI. In addition, this chapter also addresses issues such as documentation, report-writing, and the role of the medic in court.

Low cardiac output state in a postoperative cardiac patient

Chapter 13 covers the low cardiac output state (LCOS) in children following cardiac surgery. It begins by explaining how LCOS is defined, risk factors for its development, and how to assess and investigate a child with LCOS. The role of echocardiography is discussed, and the limitations of other measurement techniques are examined. Modifiable causes of LCOS in postoperative cardiac surgical patients are examined, including residual cardiac lesions and arrhythmias—and their management discussed. Important physiological concepts in the understanding of LCOS are addressed, including preload, afterload, systolic and diastolic function, and fluid responsiveness. Finally, options for managing patients with LCOS are covered, including the role of drugs, surgery, and extracorporeal membrane oxygenation.

Traumatic brain injury

Chapter 7 covers the definition, epidemiology, pathophysiology, and management of traumatic brain injury (TBI). It explains the fundamental concepts of brain physiology: intracranial compliance; intracranial hypertension; cerebral perfusion pressure; cerebral blood flow; and autoregulation. Medical management of TBI is detailed, including hyperosmolar therapy and nutritional support. Neuromonitoring of patients with TBI in the intensive care unit is discussed, including the evidence base for seizure monitoring and antiepileptic drug prophylaxis. Patients with severe TBI and refractory intracranial hypertension may need escalation to second-tier therapies, which are evaluated, including the evidence for decompressive craniectomy. A concise summary of the different therapies is included.