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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.