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Kevin M. Creamer M.D. Pediatric Critical Care Walter Reed AMC. PICU Primer II. Physiology Hypoxia / Hypoxemia ABG’s and Acidosis Sodium and H 2 O metabolism Hemodynamics and Cardiopulmonary interactions. ICU Care Postoperative issues Mechanical Ventilation Common Problems

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Kevin m creamer m d pediatric critical care walter reed amc

Kevin M. Creamer M.D.

Pediatric Critical Care

Walter Reed AMC

PICU Primer II

The primer outline


Hypoxia / Hypoxemia

ABG’s and Acidosis

Sodium and H2O metabolism

Hemodynamics and Cardiopulmonary interactions

ICU Care

Postoperative issues

Mechanical Ventilation

Common Problems

Head trauma


The Primer Outline

Postoperative issues
Postoperative Issues

  • Borrowed in part from Akron syllabus

  • Know the surgery

    • what can you expect from a posterior spinal fusion is different than a tracheal reconstruction

  • Know the patient

    • Age, PMHx, Syndromes

  • Be there when they get out of the OR

Postoperative evaluation
Postoperative Evaluation

  • ABC’s

  • Look at the breathing pattern

  • Listen to the chest--breath sounds, stridor?

  • Listen to the heart--gallop, murmur?

  • Feel the pulses--strong, weak, thready?

    • Cap refill?, Extremity warmth?

The anesthesia report
The Anesthesia Report

  • “History of present illness” for surgical patients

    • Difficulties with induction or intubation?

    • Drugs used during case

    • Regional techniques employed?

    • Extubation-problems?

  • Vital signs- BP, HR, RR, SaO2, temp

    • Patients are frequently cold!

The anesthesia report1
The Anesthesia Report

  • Ventilation parameters/difficulties

  • Fluids--ins and outs

  • Any “events”?

  • Lines and tubes

Intraoperative fluids
Intraoperative Fluids

  • Pediatrician: “Why do they always get so much fluid?”

  • Anesthesiologist: “Because they need it”

    • maintenance + replacement of “third space” losses

      • “third space” losses can be 15 cc/kg/hr

        + replacement of 3 X blood loss

Anesthesia and fluid balance
Anesthesia and Fluid Balance

  • General anesthesia produces vasodilation and some decrease in myocardial contractility.

  • Increased intrathoracic pressure, and stress response to surgical stimulus, may lead to increased ADH production and decreased urine output

Blood loss and replacement
BLOOD loss and replacement

  • Blood loss isestimated

  • Transfusion Criteria - it depends

    • Check Hct, HR, UOP, pH, ongoing loss, Hemodynamics …

  • When do you need Component Tx?

    • after a “massive” transfusion or ( 0.75-3.0 blood volumes)

Blood products how much
Blood Products - How much?

  • PRBCs - 4cc/kg of will Hb 1gm/dl

  • Platelets - 1unit/5kg will  count by 50000

  • FFP - 10 ml/kg round up/down to closest unit

  • Cryoprecipitate - 1bag/every 5-10kg

Surgeons get extremely persnickety if you transfuse THEIR patient without letting them know ahead of time!

The surgical report
The Surgical Report

  • Since we are not surgeons we need to know what they anticipate and worry about

    • Amount of pain

    • Third spacing

    • Possible complications

  • Their wish list:

    • Extubate tomorrow, MRI at midnight

    • Special meds: antibiotic and stress ulcer prophylaxis

The surgical report1
The Surgical Report

  • What to touch and not to touch?

    • NG, foley, chest tube, rectum, etc.

  • Check all their orders for appropriate dosing and fluids

    • mg/kg/dose is not in surgical vocabulary

  • Who is in Charge? (Us vs. Them)

  • Surgical POC?

    • Interface with surgeons before they return to the OR in AM regarding the plan

Assessment of fluid balance
Assessment of Fluid Balance:

  • Vital signs (HR/BP)

  • Urine output

  • Extremity warmth, CRT

  • Acid-base status

  • Occasionally invasive monitoring

    • Remember the Liver!

Extubation time
Extubation Time?

  • Adequate airway (edema? ,Leak?)

  • Maintain oxygenation and ventilation

  • Neurologically able to protect the airway and maintain adequate drive.

  • Small/young infants are at increased risk of apnea

    • Especially if post-conceptual age < 50weeks

Sedation and analgesia
Sedation and Analgesia

  • Analgesia for painful diseases and procedures

  • Compliance with controlled ventilation and routine intensive care

  • Sedation for amnesia for the periods of noxious stimuli

  • Reduce the physiologic responses to stress

Sedation and analgesia1
Sedation and Analgesia

  • The idea of titrating drugs to effect--there is no “dose”.

    • Keep in mind what the “target” response is.

  • Consider Round-the-clock Tylenol for 24-48 hours as adjunct

    • First PR dose may be 30-40 mg/kg

  • Anesthesia service manages Epidurals

  • Consider a continuous drip

Muscle relaxants
Muscle Relaxants

  • They provide ZERO sedation/analgesia.

  • Indications (always relative)

    • Mechanical ventilation where risk of extubation is great, or risk of baro/volutrauma is high

    • Procedures such as central line placement or biopsy in the intubated patient

    • Intractable intracranial hypertension (IF ICP being monitored)

Problems with blockade
Problems with Blockade

  • Fluid retention

  • Long term weakness

    • continuous infusions

    • most commonly the steroid based NMBs

    • myopathy associated with Atracurium

    • consider using cis-Atracurium

  • Consider Train of Four testing





    • Mechanical ventilation

This is not the NICU!

Lesson learned vali predisposing factors
Lesson Learned:VALI –Predisposing Factors

  • High lung Volumes

    • With high peak pressure and alveolar overdistension

  • Repeated alveolar collapse and reopening

  • High inspired oxygen Concentrations

  • Preexisting lung injury

Slutsky Am J Resp CCM, 1999, Dreyfuss Am J Resp CCM 1998

Mechanical ventilation
Mechanical Ventilation

  • Do’s and Don’ts

    • Avoid Overdistension and High Pressure by limiting Tv

    • Avoid Hyperoxic Lung damage by turning FIO2 down (Sat 90% okay)

    • Avoid cyclic collapse by using PEEP to recruit FRC and keep it above Closing volume

  • Infant high risk 2° high elastic recoil and complaint chest wall

Getting started settings
Getting Started (Settings)

  • FIO2 - 50%, if sick 100%

  • It - minimum .5 sec, older kids 1 sec

  • Rate - age appropriate 15 -30 to start

  • Tv - 10ml/kg to start

  • Look / Listen / Ask

  • PEEP - 4cm, higher if FRC compromised

I t and time constants
IT and Time Constants



  • The time to fill each alveolus is determined by its time constant

  • TC= Resistance X Compliance

  • A Short IT decreases TV, or increases PIP

Mechanical ventilation1
Mechanical Ventilation

  • First hour

    • CXR and “Blood Gas”

    • Watch peak pressures as compliance estimate

      • PP << 20 ideal

      • PP 20-30 moderately  compliance

      • PP >> 30 severely  compliance

      • PP >> 35 high risk for VALI, DO SOMETHING

Mechanical ventilation2
Mechanical Ventilation

  • Change Tv only for inappropriate chest rise or for elevated inspiratory pressures (Don’t WEAN Tv)

  • Sedation to allow patient - ventilator synchrony (Paralytics aren’t required)

Monitoring adjuncts
Monitoring adjuncts

  • Pulse oximeter

  • End tidal CO2 - can use for Dead space estimate

  • ABG’s and CBG’s

  • Calculate Compliance, A-a gradient, Oxygenation Index (OI), check for Autopeep

  • Graphics - PV and flow-volume loops


  • Dead Space = 1 - (EtCO2/PaCO2)

  • Static Comp. = Tv/ (Pplat- PEEP)

  • A-a gradient =

    • (Pb-PH2O) x FIO2 - (PCO2/.8) - PaO2

  • OI = (Paw x FIO2 x 100)/ PaO2

When things go wrong
When things go wrong

  • Don’t be a DOPE

  • Hypoxemia - PEEP to  FRC, to allow FIO2 wean to < 50%

  • Elevated peak pressures - suction, adopt Permissive hypercapnia, consider changing to pressure mode

  • Check circuit size

    • an inappropriately large circuit can gobble up lots of tidal volume

  • Paw (Area Under Curve )increases with increasing:

    • PIP, PEEP, TI/TE Ratio, Rate, and Flow












Circuit compliance
Circuit compliance

  • When using volume ventilation the ventilator circuit or tubing will stretch

    • Neonatal 0.35 ml / cm H2O

    • Pediatric 1.4 ml / cm H2O

    • Adult 2.8 ml / cm H2O

  • This means the stiffer the lung the more volume is lost in the circuit

Mechanical ventilation3
Mechanical Ventilation

  • First day and beyond

    • Watch for fluid overload

      • all patients on positive pressure ventilation retain lung water

    • Assist patient efforts

      • Pressure support or volume support

      • Trigger sensitivity (age and disease appropriate)

    • Treat underlying condition

    • Feed patient


  • Get condition under control

  • Stop paralytics (PEEP < 8)

  • Encourage patient’s efforts

    •  Rate (slow then fast)

    • add Pressure support (2/3 P)

  • Wean PEEP and PS slowly in 1-2 cm H2O increments

  • Wean FIO2 to 30% if possible

Signs of weaning failure
Signs of weaning failure

  • Increased Work of breathing

    • fast spontaneous RR

    • small spontaneous Tv

  • Increased FIO2requirement

  • Hemodynamic compromise

Time for extubation
Time for Extubation?

  • Think SOAP

    • Secretions / Sedation / Spontaneous Tv (>5ml/kg)

    • Oxygenation <35%

    • Airway - Maintainable?, Leak? , Steroids?

    • Pressures - PP <25, PEEP < 5

Special situations i
Special situations I

  • Obstructive Diseases

    • Asthma and RSV Bronchiolitis

    • Watch for air trapping / breath stacking

      • Low rate, larger Tidal volume, long Expiratory time

      • check Autopeep

      • preserve I-time

      • Consider Heliox, Ketamine, Halothane

Special situations ii
Special situations II

  • ARDS

    • Limit Tv accept hypercapnia

    • Increase PEEP for FRC

    • Prone positioning

    •  CaO2 and tolerate lower Sat %

    • consider High Frequency Oscillatory Ventilation>>> Surfactant>>> Nitric Oxide


861 patients 6ml/kg vs 12ml/kg Tv

ARDS Study Group, NEJM, 2000


Organ Failure

  • RCT 44 adults with ARDS

    • TV 7.6 vs. 11.1

    • PP 24 vs. 31 cm H2O

  • At 36° patients in low TV group had significantly lower levels of TNF and IL-1ra in both plasma and BAL fluid

Ranieri, JAMA,1999; Ranieri JAMA, 2000

Special situations iii
Special situations III

  • Head Trauma

    • Avoid Hypercarbia (PCO2 < 35)

    • Avoid Hypoxemia

    • PEEP may adversely effect venous return and  ICP

    • Coughing/gagging extremely bad (Use paralytics)

Special situations iv
Special situations IV

  • HFOV Indications

    • ARHF with OI > 13 for 6 hours

    • Contraindicated in High airway resistance,  ICP, unstable hemodynamics

  • Part of an Open lung strategy with  Mean airway pressure and Tv < dead space

Hfov vs cmv

  • Crossover study acute hypoxemic respiratory failure in children

  • HFOV 17/29 responded, 0/17 died

  • CMV 10/29 responded, 4/10 died

  • X-over to HFOV 11/19 survived

  • X-over to CMV 2/11 survived

Arnold, CCM 1994

Ventilation simulator
Ventilation Simulator

  • Not for the weak of heart

The end
The End

Mind what you have learned. Save you it can.