بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. NAAMA experience By Yasser Elborai, MD Assisstent Lecturer of Pediatric Oncology NCI – Cairo University

3. NAAMA “National Arab American Medical Association” is a Non Governmental Organization (NGO) composed of an Arabian doctors living in America • They are trying to help doctors in Egypt and other Arabian countries by different ways like offering training courses and research work

4. Due to collaboration between National Cancer Institute (NCI) – Egypt and National Arab American Medical Association (NAAMA) – USA, there was a 3 months training course for Pediatric Intensive Care Unit (PICU) • This training course was in DeVos children’s hospital – Michigan – USA

5. Pediatric Intensive Care Unit(PICU) • What is the aim of building PICU ? • How do you construct PICU ? • How do you manage PICU ?

6. What is the aim of building PICU ? • To give our critically ill patients a proper treatment • To create a new subspecialty in our pediatric department • To decrease the load of work on main ICU in our institute

7. How do you construct PICU ? • Number of rooms • Number of beds • Isolation rooms • Equipments • Supplies • Aeration of the room • Design of the room • Character of walls and floor

8. Comparison between PICU in DeVos children’s hospital-Michigan and newly developing PICU in NCI-Cairo • # rooms 16 rooms 1 room • # beds 16 beds 4 beds • Isolation 2 rooms No rooms DeVos children’s hospital-Michigan newly developed PICU in NCI-Cairo

9. Each room has all equipments to be an operative room for any minor or major procedures Each bed has monitor, infusion pump, syringe pump, common ECG apparatus and blood warmer apparatus for all beds DeVos children’s hospital-Michigan newly developed PICU in NCI-Cairo • Equipments • Supplies All types of syringes, lines, tubes, masks,… Air conditioned Air conditioned • Aeration

10. The bed is in the center of the room to be accessible from all sides that facilitate the work The bed is only accessible from 3 sides as usual DeVos children’s hospital-Michigan newly developed PICU in NCI-Cairo • Design of • room The walls and floors are washable and can be easily cleaned by anti septic measures • Character of • walls and floor

11. How do you manage PICU ? • Criteria of admission • Nursing notes • Doctor’s notes • Multidisciplinary team to deal with the patient • Computer based system • Ratio between nurses and patients • Criteria of discharge

12. Criteria of admission: There are many indications for PICU admission but the most common cause here in our institute will be shock specially septic shock ► if the patient is hemodynamically unstable: - Heart rate greater than: • 90 beats per minute at the age of puberty or more. • 110 beats per minute at the age of 10 years. • 120 beats per minute at the age of 4 years or less.

13. - Systolic arterial pressure lower than: • 90 mm Hg at the age of puberty or more. • 70 mm Hg at the age of 10 years. • 50 mm Hg at the age of 4 years or less. for at least 30 minutes despite adequate fluid replacement and more than 5 µg/kg of body weight of dopamine or current treatment with epinephrine or norepinephrine. • Urinary output of less than 0.5 mL/kg of body weight for at least 1 hour • Arterial lactate levels higher than 2 mmol/L

14. Stages of shock 1- Early shock: tachycardia, poor capillary perfusion cold extremities, but in septic shock may be worm extremities because ischemia of precapillary sphincter 2- Established shock: clinical triad tachycardia, hypotension, peripheral hypoperfusion will be evident. The patient looks pale and anxious

15. 3- Advanced shock: the blood flow will increase to more vital organs (brain, heart) at the expenses of the less vital organs (kidneys, lungs, GIT) kidneys: acute renal failure (oliguria, metabolic acidosis) Lungs : Adult Respiratory Distress Syndrome (ARDS) GIT : Ischemia, stress ulcer, hemorrhage, ileus Blood : Disseminated Intravascular Coagulation (DIC) Metabolic: metabolic acidosis, electrolytes disturbance Brain : Hypoxic ischemic encephalopathy Heart : Myocardial ischemia, arrhythmia

16. 4- Irreversible shock: irreversible cellular damage (mitochondria, cell membrane) clinically, serious arrhythmia, deep coma, pH below 7.0 in spite of vigorous correction with sodium bicarbonate So, our role is how to detect this hemodynamically unstable patient in his early stage of shock to give him the best supportive treatment and careful observation to get a better out come

17. Septic Shock SIRS/Sepsis/Septic shock Mediator release: exogenous & endogenous Maldistribution of blood flow Cardiac dysfunction Imbalance of oxygen supply and demand Alterations in metabolism Outcomes of mediator release in systemic inflammatory response syndrome (SIRS), sepsis, and septic shock

18. Septic Shock Is Unique • Cardiac output may be normal, increased, or decreased. • Hypotension and poor end-organ perfusion may be present despite “good” skin perfusion. Hypotension is still a sign of decompensation. • Early signs of sepsis/septic shock include • Fever or hypothermia • Tachycardia and tachypnea • Leukocytosis, leukopenia, or increased bands

19. Septic Shock: “Warm Shock” • Early, compensated, hyperdynamic state • Clinical signs • Warm extremities with bounding pulses, tachycardia, tachypnea, confusion. • Physiologic parameters • widened pulse pressure, increased cardiac output and mixed venous saturation, decreased systemic vascular resistance. • Biochemical evidence: • Hypocarbia, elevated lactate, hyperglycemia

20. Septic Shock: “Cold Shock” • Late, uncompensated stage with drop in cardiac output. • Clinical signs • Cyanosis, cold and clammy skin, rapid, thready pulses, shallow respirations. • Physiologic parameters • Decreased mixed venous sats, cardiac output and CVP, increased SVR, thrombocytopenia, oliguria, myocardial dysfunction, capillary leak • Biochemical abnormalities • Metabolic acidosis, hypoxia, coagulopathy, hypoglycemia.

21. Septic Shock (con’t) • Cold Shock rapidly progresses to MOSF or death, if untreated • Multi-Organ System Failure: Coma, ARDS, CHF, Renal Failure, Ileus, hemorrhage, DIC • More organ systems involved, worse the prognosis • Therapy: ABCs, fluid • Appropriate antibiotics, treatment of underlying cause

22. Nursing notes: the nurse should take a brief history about the patient’s illness and his previous vital signs Doctor’s notes: The doctor should take a full detailed history about the present and past illness and medications Multidisciplinary team to deal with the patient: Interactions between other department e.g. surgery, radiotherapy, radio diagnosis, and clinical pathology is extremely essential for the sake of the patient

23. Computer based system: If the system is computer based that will facilitate detection of any deterioration of the patients’ clinical condition through the curves drawn temperature, blood pressures, urine output,…….. Ratio between nurses and patients: nurse to patient ration should be 1:1 or at least 1:2 Criteria of discharge: If the patient is hemodinamically stable for at least 24 h, he can transferred to normal floor to continue his treatment

24. Conclusions

25. We are trying to create a new pediatric care unit similar to that we observed in DeVos children’s hospital-Michigan-USA But as an initial step it will be a pediatric intermediate care unit and in the near future it will be a pediatric intensive care unit

26. Thank You