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Paediatric critical care
Children require intensive care for a variety of reasons; for example, respiratory difficulty due to an airway infection, a mechanical obstruction in the airway, septicaemia (blood poisoning), seizures or a serious traumatic incident.
Most children present to their local hospital and receive immediate care delivered by the emergency department, paediatric and anaesthetic staff. If the child is assessed to be seriously ill he/she will require specialist intensive care advice and treatment in a tertiary children’s hospital. A transfer will usually be required. This could involve travelling long distances, especially if the child lives in a rural location.
In 1993 the British Paediatric Association recommended that intensive care for children should be centralized and this led to the requirement for tertiary centres to provide transport for children requiring intensive care.
Results from a number of studies demonstrated decreased morbidity and a lower critical incident rate (e.g. endotracheal tube dislodgement) during transfer by a specialist team.
Each geographical region of the United Kingdom has provision to mobilize a specialist paediatric intensive care transport team. This could be a standalone team or a team based in one of the 31 paediatric intensive care units. The Paediatric Intensive Care Society (PICS) has produced standards of practice for the transportation of the critically ill child. This outlined areas such as staffing teams, education, communication and a recommended equipment list. These services also provide advice and support for staff caring for the seriously ill child while the transport team is mobilizing and travelling to the hospital.
Recognition and management of the seriously ill child
The assessment of the vital signs (heart rate, blood pressure, respiratory rate, temperature, capillary refill time) by age is essential to recognize the seriously ill child. Most hospitals now use an early warning score. This is an excellent tool to identify the deteriorating child through changes in their observations. A senior team needs to be alerted to ensure that treatment is administered quickly.
If the child is breathing spontaneously a non-rebreather mask (Hudson type) is recommended. Oxygen administration is essential and should be available via a flow meter that can deliver 15 L per minute.
There are two commonly used airway adjuncts that can be utilized until a definitive airway is achieved. Oropharyngeal airways (Guedel) are available in a variety of sizes and are used to provide a clear passage along the tongue and posterior pharyngeal wall. A nasopharyngeal airway tube is inserted via the nasal passage and is often better tolerated as it is less likely to cause laryngospasm. Insertion of these airway adjuncts should only be undertaken by a trained member of staff.
If the child’s breathing requires support this can be achieved by using a self-inflating bag (Ambu bag) or an Ayres T-piece or Mapleson T-piece.
Definitive airway support is achieved when a tube is passed via the mouth or nose into the trachea (windpipe). This requires the expertise of a senior anaesthetist. In order to place the tube, anaesthetic induction agents will be required via intravenous drugs or the inhaled route. Endotracheal tubes range from 2 mm to 8 mm (internal diameter) and require tape to secure to the child’s cheeks.
To ensure that the tube is inserted to the correct length a chest X-ray should be requested when tracheal intubation has been established. Accidental extubation is always a potential risk. Exhaled gases from the lungs contain carbon dioxide. Sampling the exhaled gas can be carried out to alert the team if the tube is dislodged from the trachea. Ventilation can be maintained after intubation by a mechanical ventilator that is suitable for a child.
The child will require a gastric tube to ensure that the stomach can be emptied. Air can be forced into the stomach during bag valve mask ventilation. This air, if not removed, can splint the diaphragm and cause difficulties in establishing mechanical ventilation.
Intravenous access is essential to facilitate drug administration. Peripheral cannulation can be difficult to achieve in the seriously ill child. The insertion of an intra-osseous needle allows rapid delivery of drugs and fluids.
Intravenous drugs are required to ensure the child remains asleep and able to tolerate the endotracheal tube. An infusion of an opiate such as morphine, combined with a sedative (e.g. midazolam) is frequently used. A paralysing agent is also administered to control the child’s breathing rate.
Accurate measurement of the child’s urine output can be very useful to determine renal efficiency and intravascular fluid volume. A Foley catheter may be required to record urine output hourly.
Blood sampling and analysis is an important diagnostic tool. The results are relied upon to interpret the efficacy of the treatment provided. Blood glucose levels should be frequently checked as all children, especially infants, can become hypoglycaemic when seriously ill.
Neurological assessment using the AVPU scale (alert, voice, pain, unresponsive) is a system by which a health care professional can measure and record the child’s responsiveness. Pupil reaction to light should be recorded regularly as changes in the response of the pupil could indicate serious brain disorder or injury.
Communication with the child and parents or carers should never be ignored. Explanation and information will allay fears in most situations so it is important to explain things as clearly and simply as possible.
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