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(BQ) Part 2 book Paediatric intensive care presents the following contents: Specific specialties (Cardiac disorders and postoperative care, respiratory disease, neurocritical care, trauma and burns,...), compassionate and family-orientated care.
Part 00 Section Specifi Part title c specialties 20 21 22 23 241 251 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Cardiac disorders and postoperative care Respiratory disease Neurocritical care Trauma and burns kdl;fjh;lgfk;ghjkl'hkg;l Infection control policies and PICU kdl;fjh;lgfk;ghjkl'hkg;l Immunity and infection Sepsis and multiple organ failure Laboratory investigations for infectious disease Antimicrobial use on the PICU Neonatology Gastroenterology and hepatology Nephrology Diabetes and endocrinology Metabolic disorders Haematology Brain death, organ donation, and transplantation Poisoning Technology-dependent children Genetic syndromes Paediatric intensive care medicine in the developing world 347 407 451 493 24 531 24 535 569 585 589 603 625 645 669 693 709 723 741 755 761 779 This page intentionally left blank Chapter 20 Cardiac disorders and postoperative care Applied cardiovascular anatomy 348 Applied cardiovascular physiology 350 Bedside monitoring of the cardiovascular system/circulation 350 Cardiac arrhythmias 350 Congestive heart failure 356 Pathophysiology of congenital heart disease 357 Pulmonary hypertension syndromes 361 Systemic hypertension 363 Dilated cardiomyopathy and myocarditis 364 Infective endocarditis 366 Pericarditis and cardiac tamponade 367 Postoperative care 369 Immediate postoperative care 369 Early postoperative problems 373 Late postoperative problems 382 Staged palliation of a univentricular heart 384 Common surgical procedures (A to Z) 385 347 348 CHAPTER 20 Cardiac disorders Applied cardiovascular anatomy This section describes salient features in a normal heart Cardiac anatomy (see Fig 20.1) Right heart • Deoxygenated blood from the systemic circulation returns to the right atrium (RA) through the superior and inferior caval veins (SVC and IVC) • Cardiac venous blood enters the heart through the coronary sinus and directly through the thebesian veins • During diastole, blood flows from the RA to the right ventricle (RV) through the tricuspid valve; this valve has leaflets (anterosuperior, septal, and inferior leaflets) • The RV is triangular shaped, and much thinner than the left ventricle (LV) It is heavily trabeculated, and it has a muscular sleeve (infundibulum) separating the tricuspid valve from the pulmonary valve • The main pulmonary trunk arises to the left and anterior relative to the aorta • It courses posteriorly before branching into the left and right pulmonary arteries Left heart • Oxygenated blood from the lungs returns to the left atrium (LA) through the right- and left-sided pulmonary veins • During diastole, blood enters the LV through the mitral valve, which is a bicuspid valve (posterior/mural leaflet and anterior leaflet) • Each leaflet is secured at the base to the mitral annulus, and the free end is linked to the papillary muscles via thin tendinous structures (chordae tendineae) • During systole, the papillary muscles contract to increase tension on the chordal apparatus and thus maintain valvar competency • The aortic valve is in fibrous continuity with the mitral valve, and is a trileaflet structure • of its cusps (left and right) support the origin of the appropriate coronary arteries, the 3rd leaflet being termed non-coronary • The left ventricular wall is times thicker than the RV • Its fibres are oriented in layers; the inner (subendocardial) layer is the most important in children, and young adults • The outermost oblique layer, along with the subendocardial layer, have their fibres running longitudinally from the apex to the base, while the middle layer is made up of a radial arrangement of fibres • Systole involves ventricular contraction which shortens, thickens, and twists towards the apex • The aorta ascends as a central structure from the heart, and usually arches to the left curving over the heart to descend posteriorly to the left of the spine APPLIED CARDIOVASCULAR ANATOMY 75% 100/60 95% 30/10 75% 95% 75% 100/6 30/3 95% 75% (a) (b) Fig 20.1 a) Normal heart structures; b) normal O2 sat and pressure measurements Sequential segmental analysis To evaluate patients with suspected congenital heart disease, it is imperative to analyse the heart in a segmental pattern based on: • Position of the heart, and other organs (thoracic and abdominal): • Visceral sidedness (situs solitus or inversus) • Cardiac position (location and orientation) • Connections between the different regions (veins, atria, ventricles, and arteries) • Description of a cardiac region based on its morphological characteristics rather than its position, or relation to other structures It is also important to understand that: • Connection is an anatomic term showing a direct link between structures; drainage a haemodynamic one, referring to flow of blood • Single refers to an absence of a corresponding contralateral structure (single valve in tricuspid atresia); common refers to bilateral components with an absent division (e.g common AV valve) The endocardium is the inner layer of the heart, which is metabolically active in contributing to cardiovascular function The pericardium, a fibroserous sac consisting of visceral and parietal layers, is a dynamic and adaptive structure which: • Protects the heart by acting as a barrier • Reduces friction due to cardiac motion Conduction system Contraction is triggered by electrical impulses which are generated and conducted through a system of specialized cells—the conduction system The sinoatrial node (SA node) generates the electrical impulse which spreads through the atrial chambers • SA node is situated at the SVC/right atrium junction There is a single point of electrical connectivity between the atria and the ventricles; the atrioventricular node (AV node) • AV node is situated in the triangle of Koch (near the coronary sinus) The conduction system then proceeds as the bundle of His before dividing into the left and right bundles and then into various fascicles 349 350 CHAPTER 20 Cardiac disorders Circulation (see also b Chapter 11) • There are vascular beds in the circulation—the pulmonary and systemic through which the blood is driven by the appropriate ventricles (see Fig 20.1): • The pressure in the pulmonary circulation is significantly lower than that in the systemic circulation • The vessels become smaller and thinner as they get farther from the great arteries, becoming arterioles, and finally capillaries which are the units where gas and metabolic exchange takes place: • Arterioles are small arteries with relatively thick muscle and constitute the majority of the resistance to the relevant vascular bed; they regulate blood flow Applied cardiovascular physiology (See b Chapter 7) Bedside monitoring of the cardiovascular system/circulation (See b Chapter 7) Cardiac arrhythmias Cardiac arrhythmias can be due to (Box 20.1): • Disturbances of rhythm (tachyarrhythmia): • Supraventricular tachycardia (SVT) • Ventricular tachycardia (VT) • Disturbances of conduction (bradyarrhythmia): • Sinus node dysfunction • AV dissociations (1st, 2nd, or 3rd degree) Box 20.1 Cardiac arrhythmias in children can be due to: • Structural heart disease: • Native • Postoperative • Abnormal pathway • Cardiomyopathy/myocarditis • Heart failure • Miscellaneous: • Electrolyte imbalance • Drugs • Systemic disturbance CARDIAC ARRHYTHMIAS Substrates for the genesis of the arrhythmias are: • Re-entrant mechanisms: these require the presence of electrical pathways separated by an electrically inert tissue, having different properties, setting up an electrical circuit • Automatic mechanisms: this is due to an abnormally active electrical focus either inherent (atrial ectopic tachycardia) or due to a secondary cause (imbalance, strain) • Triggered mechanisms Presentation Palpitations Funny turns Dizziness Syncope Cardiac compromise • deffort tolerance • Failure to thrive • Breathless, difficulty in feeding • Ventricular dysfunction (if prolonged) • Incidental finding • • • • • Supraventricular arrhythmias These are conditions that involve structures above the bifurcation of the bundle of His Re-entrant tachycardias are the commonest mechanism for arrhythmias seen in children with normal hearts • Usually paroxysmal • Narrow QRS complex • Regular (constant R–R interval) • Initiated or terminated by a premature event Classically, these rhythms can be terminated with cardioversion Examples are: • AV re-entry tachycardia (AVRT) • AV nodal re-entry tachycardia (AVNRT) • Wolff–Parkinson–White (WPW) syndrome • Atrial flutter Automatic mechanisms are much less frequently seen • Usually incessant • Can present with cardiomyopathy or cardiac compromise • Usually have a narrow QRS complex but have varying R–R interval (irregular) • Do not respond to cardioversion Examples are: • Atrial ectopic tachycardia (AET) • Junctional ectopic tachycardia (JET) • Atrial fibrillation 351 352 CHAPTER 20 Cardiac disorders Diagnosis • Detailed history • 12-lead ECG, preferably during an episode (Fig 20.2) • Intracardiac electrophysiological studies (‘EP study’): an identification of the pathway (or focus) can be made invasively; usually combined with definitive management (ablation) in the same procedure P Atrial ECG from pacing wires P waves are conducted in a retrograde fashion represented as a spike following the QRS P waves on corresponding surface ECG not identified Fig 20.2 Atrial (V1) and surface (V2) ECGs in nodal rhythm Reproduced from Mackay J and Arrow Smith, J (eds) (2004) Core topics in cardiac anaesthesia, with permission from Cambridge University Press Treatment Based on presentation and identification of the mechanism Acute management will usually involve IV adenosine or synchronized cardioversion Specific treatment depends on the mechanism: • Vagal manoeuvres: Valsalva, diving reflex • Drug therapy: • Re-entry tachycardias will respond to adenosine (200mcg kg -1) given as a fast IV bolus • B-blockers (sotalol, propranolol) or digoxin (contraindicated in WPW syndrome) • Flecanide • Amiodarone reserved for resistant tachycardias • Definitive therapy: • Radio-frequency ablation of the pathway (or focus) by intracardiac mapping has become the mainline of treatment even in children Ventricular arrhythmias VT is defined as at least consecutive beats of ventricular origin with a rate >120beats/min • Extremely rare in paediatric practice CARDIAC ARRHYTHMIAS • A group of heterogeneous conditions with variable substrates and mechanisms • As in SVTs the mechanisms involved are re-entrant or triggered automaticity (more common in VT) • Ventricular fibrillation (VF) is a series of uncoordinated ventricular depolarizations associated with an absence of cardiac output Important clues on ECG to help identification (Fig 20.3): • QRS axis • QRS morphology • Propensity to remain same (monomorphic) or vary (polymorphic) Box 20.2 Causes • Primary (idiopathic): • RV outflow tract tachycardia • Arrhythmogenic RV dysplasia • Catecholamine sensitive polymorphic VT • Familial (Brugada syndrome, congenital long QT syndrome) • Myocardial: • Cardiomyopathy — hypertrophic cardiomyopathy — dilated cardiomyopathy • Myocarditis • Myocardial ischaemia • Conduction abnormality (heart block) • Miscellaneous: • Structural heart disease (native or palliated) • Metabolic derangements • Drugs • Trauma with myocardial injury Fig 20.3 Ventricular tachycardia Diagnosis • A detailed history, with emphasis on family history along with a 12-lead ECG, and identification for a cause should be the primary aim • ECG monitoring (Holter, loop recorders) • Specific investigations: genetic testing (long QT syndrome, cardiomyopathy) or cardiac MRI (arrhythmogenic RV dysplasia) • Invasive EP study will help to map the focus, and ablate it 353 354 CHAPTER 20 Cardiac disorders Treatment Acute management of VT depends upon hemodynamic status: • If the patient is stable, amiodarone can be considered • If the subject has any evidence of cardiac compromise cardioversion should be used: • Synchronized cardioversion for VT • Non-synchronized cardioversion for VF Specific management of ventricular arrhythmias includes: • Individuals at risk (previous history, family history): • Surveillance • Prophylactic measures (ò-blockers, implantable debrillators (ICDs) Pharmacotherapy: Class IA (procainamide), IB (mexiletine) IC (flecanide), B-blockers, Amiodarone • Definitive management: • Ablation of focus (pathway) • Implantation of ICD pacemaker Bradyarrhythmias These are due to abnormalities in the generation of an electrical impulse or conduction defects They can be seen in children with structurally normal hearts (complete congenital heart block) or with structural heart disease (ventricular inversion, post surgical) They can be classified as: • AV block: • 1st degree: prolonged PR interval • 2nd degree: — Type I (Wenckebach) — Type II • 3rd degree: complete AV block • Sinus node dysfunction: bradycardia Chronotropic incompetence 2nd-degree AV blocks with Wenkebach phenomenon (Type I) is a progressive prolongation of PR interval leading to a blocked impulse Type II is an abrupt block of an impulse without prolongation of PR interval Presentation and coexisting conditions In children, overt symptoms due to bradycardia are relatively uncommon Neonates and infants • Heart failure (fetal hydrops) • Apnoea • Hypoxia • Gastro-oesophageal reflux with laryngospasm • Breath holding Older children and adolescents • Heart failure • Syncope • deffort tolerance • Easy fatigability • Sudden death 903 INDEX infusion compatibilities 302 intravenous doses 193 in neonates 610 patient-controlled analgesia (PCA) 189 mortality meetings 832 mortality prediction 17 mortality rate 14 motion sickness during transfers 321 motor delay, metabolic causes 480 mucolytics, inhaled 163 Mucor spp., sensitivities 598 multidisciplinary approach 8, 10 in long-term ventilation 759 ‘Munchausen by proxy’ 856 muscle biopsy, in metabolic disorders 707 muscle relaxants, in RSI 133 muscular dystrophies Becker 765 Duchenne 768 muscular VSD 405–6 mushroom poisoning 752 myasthenia gravis diagnosis 489 juvenile 489 myasthenic crisis versus cholinergic crisis 490 persistent neonatal (congenital) 489 transient neonatal 489 treatment 489 mycophenolic acid 734 myelitis, transverse 472 myocardial contractility and arterial waveforms 69 impaired 374 myocardial dysfunction 107 in sepsis 577 myocarditis 364 treatment 365 viral 564 myoclonic jerks, postresuscitation 482 myoclonic status epilepticus 468 myopathy critical illnessassociated 485 metabolic causes 481 myotonic dystrophy 772 N-acetyl cysteine in fulminant hepatic failure 633 in paracetamol poisoning 748 in smoke inhalational injury 523 naloxone 748, 876 nasal intubation 131 nasal swabs 588 nasogastric tubes, verification of position 332 natural killer (NK) cells 539 natural killer cell defect 542 near-drowning 526 near-hanging 528 near infrared spectroscopy, cerebral monitoring 101 during cardiopulmonary bypass 227 nebulized drug administration 163 necrotizing enterocolitis (NEC) 381, 616 first-line antibiotics 594 necrotizing fasciitis causes 563 clinical features 562 diagnosis 563 management 563 needle cricothyroidotomy 138 needle sizes 873 negative extrathoracic pressure ventilation (NEPV) 160 settings 161 negative pressure noninvasive ventilation 160 Neisseria meningitidis, antibiotic sensitivities 591 neomycin, use in fulminant hepatic failure 633 neonatal ECMO 216 neonatal period, definition 604 neonatal sepsis 617 causative organisms 617 early-onset 617 investigations 618 late-onset 617 symptoms and signs 618 treatment 619 neonates 604 acute liver failure, metabolic causes 704 ammonia levels 698 analgesia 610 brainstem death tests 726 cardiovascular function 110 chronic lung disease 614 congenital bowel anomalies 620 drug handling 611 fluid balance 610 glucose control 609 handling 606 hearing screening 878 hypoglycaemia causes 681 treatment 610 hypothermia avoidance 607 hypoxic ischaemic encephalopathy 615 immunity 618 intraventricular haemorrhage 616 intubation 611 jaundice 607 investigations 607–8 patterns 609 treatment 608 kidney function 648 necrotizing enterocolitis 616 nutrition 276 postoperative care 621 renal failure 660 renal function 610 respiratory distress infant respiratory distress syndrome (IRDS) 612 meconium aspiration 614 persistent pulmonary hypertension of the newborn (PPHN) 613 transient tachypnoea of the newborn (TTN) 612 retinopathy of prematurity 615 routine examination 878 screening 877 sedation 610 seizures 619 temperature control 606 neostigmine, in neurotoxic snake bites 811 nephrogenic diabetes insipidus 684 nephron, anatomy 646–7 nephrotic syndrome, immunosuppression 543 nephrotoxins 659 neurofibromatosis type (Von Reckinghausen’s disease) 773 neurogenic pulmonary oedema 241, 501 neurogenic shock 500 neuroleptic malignant syndrome 292 904 INDEX neurological assessment, in head injury and spinal cord injury 501 neurological examination 452 brain stem reflexes 454 breathing disorders 453 circulation 454 eyes 454 Glasgow coma scale (GCS) score 457–8 temperature 454 neurological history 452 neurological investigations 459 cranial imaging 460 electroencephalography 460 evoked potential studies 461 lumbar puncture 459 neurology infection and inflammatory conditions 471 infective paralysis and weakness syndromes 471 neurometabolic disorders acute encephalopathy 480 as cause of myopathy 481 as cause of stroke 481 chronic encephalopathy with acute deterioration 480 investigations 481 post-mortem protocol 481 neuromuscular blockade in asthma 433 drug interactions 486 postoperative 373 prolonged 485 recommendations 198 neuromuscular blocking agents (NMBAs) 196 dosing schedules 198 neuromuscular disorders 484 neuromuscular examination 456 neuropathic pain 189 neuroprotection, in head injury 496, 504 neurotoxic snake bites 809, 812 neurotoxic spider bites 812 neurotoxins, scorpion venom 813 neutropenia 537, 713 causes 713 congenital 541 management 542, 713 neutrophil defects, management 542 neutrophils, immune function 539 new admissions 40 care plans 43 history and examination 40 immediate evaluation 40–1 initial management 42 investigations 42 regular assessment 43 nifedipine 206 in scorpion stings 815 nitric oxide (NO) 165 in ARDS 436 dose 164 in pulmonary hypertension 379 role in inflammation 578 nitroglycerine (GTN) 206 nitroprusside 206 infusion compatibilities 302 in scorpion stings 815 nitrous oxide (N2O) 182 dose 164 NJ tube, see pyloric tube ‘No Chance Situations’ 825 noise, during transfers 321 non-accidental injury (NAI) actions to take 852 bruising 851 burns 857 documentation 344, 852 examination, concerning features 851 fabricated or induced illness 856 head injury 854 documentation 344 history, concerning features 850 intra-abdominal 855 presentations 850 salt poisoning 857 non-convulsive status epilepticus (NCSE) 468 non-heart beating organ donation 727 withdrawing life support 731 non-invasive ventilation (NIV) 160 in asthma 432 nonmaleficence 825 non-shockable rhythms 24 non-steroidal antiinflammatory drugs (NSAIDs) 188 renal effects 663 Noonan syndrome 773 ‘No Purpose Situations’ 825 norepinephrine (noradrenaline) 207 in anaphylaxis 34 infusion compatibilities 302 inotropic effects 209 postoperative use 375 in septic shock 465 Norwood procedure 394 nosocomial infection common causes 548–9 definition 548 diagnosis 548 preventive measures 549 risk factors 547 nursing staff nutrients, digestion and absorption 626 nutrition 276 burns patients 520–1 effects of critical illness 278 energy requirements prediction 278, 280 enteral 281 in head injury 507 in neurological conditions 463 parenteral 285 postoperative 372 underfeeding 281 nutritional assessment 277 nutritional recommendations 280 obstructive hydrocephalus, in meningitis 555 obstructive sleep apnoea (OSA) 441 causes 442 diagnosis 442 management 442 manifestations in intensive care 442 octreotide 627 in chylous pleural effusion 422 oculocephalic reflex (doll’s eye manoeuvre) 454 oculovestibular response 454 brainstem function testing 726 oedema mechanisms 241 physiology 112 oesophageal atresia 621 oesophageal perforation 511 oesophagus, caustic injury 643 oliguria 649, 658 905 INDEX management 380, 661 in organ donors 731 postoperative 372 Omsk haemorrhagic fever 790 transmission 787 see also viral haemorrhagic fevers O negative blood transfusion, emergencies 719 open lung strategy, HFOV 159 open pneumothorax 511 open units 10 ophthalmologic injury examination 515 history 515 investigations 515 management 515 opioids 187 epidural infusion 183 fentanyl 188 morphine 187 poisoning 747 in rapid sequence induction 133 remifentanil 188 oral intubation 131 Oramorph® 187 orf, sensitivity to antiviral agents 600 organ donation 724, 727, 830 donor workup 728 problems following brainstem death 729 organ donors management 730 matching to recipient 732 withdrawing life support 731 organophosphate poisoning 751 ornithine carbamoyltransferase (OCT) deficiency 694, 697 oseltamivir 601 virus sensitivities 600 osmolality 232 of IV solutions 301 normal levels 865 of urine 651 osteogenesis imperfecta 773 outcome measurement 16 outlet VSD 405–6 outreach 35 overfeeding 280 oxalate, urinary 866 oxidation of drugs 298 oxidative phosphorylation 91 oxygenation index 409, 863 oxygenators, cardiopulmonary bypass 223 oxygen consumption (VO2) 862 brain, measurement of 92 calculation 87 DO2/VO2 imbalance 117 global measurements 87 indirect global estimates 88 oxygen delivery (DO2) alveolar–arterial difference (A–a DO2), 118–19 assessment 125 calculation 87 DO2/VO2 imbalance 117 global measurements 87 indirect global estimates 88 oxygen extraction ratio (OER) 88 oxygen flux 86 determinants 87 oxygen requirements, transfers 324 oxygen tension, effect of altitude 326 oxygen therapy 143 burns patients 519 cautions 144 hyperbaric 166 indications 144 inspired oxygen concentration 144 methods 145 monitoring 145 principles 143 in respiratory failure 413 in resuscitation 28 Venturi masks 54 weaning 145 pacemakers 355 postoperative 376 rapid atrial pacing 378 pacing modes 377 packed cell transfusion, indications 711 PaCO2 high, management 152 normal levels 865 Paediatric Index of Mortality (PIM) 17–18 paediatric intensive care (PIC) definition developments across the world developments in the UK evolution standards of lead centres in the UK paediatric intensive care services centralization organization in the UK Paediatric Intensive Care Society (PICS) paediatric intensive care units (PICUs) calculation of required numbers of beds 12 definition staffing paediatric intensivists Paediatric Risk of Mortality Score (PRISM) 17–18 pain assessment 186–7 pain relief see analgesia palivizumab 565 RSV prophylaxis 428 pancreas, functions 627 pancreas donation, evaluation of organ suitability 728 pancreatic fluid, composition 237 pancreatic injury, assessment 513 pancreatitis, acute 641 pancuronium 197–8 and rapid sequence induction 133 Panton–Valentine leucocidin (PVL) infections, treatment 596–7 PaO2 determining factors 144 low, management 152 normal levels 143, 865 PaO2/FiO2 ratio 409, 862 papillary muscle infarction 360 papillitis 455 papilloedema 455 paracetamol 188 doses 193 paracetamol nomogram 749 paracetamol poisoning 748 need for liver transplantation 734 paradoxical aciduria 255 parainfluenza 564 sensitivity to antiviral agents 600 paraldehyde in seizures 876 in status epilepticus 469 paralysis, infective causes 471 paralytic ileus 635 X-ray appearance 334 906 INDEX paraquat poisoning 752 parathyroid hormone, action on kidney 648 parental responsibility 835 parental rights 835 parenteral formulations 302 parenteral nutrition 285 parents brainstem death tests, explanation 540 conflicts over management 822, 827, 839 of dying children 828 follow-up after a death 831 guidance after death of a child 831 presence during resuscitation attempts 31 and retrievals 320 Parkland Formula, modified 520 partial pressures, Dalton’s law 48 Patau syndrome 774 patient characteristics 14 patient-controlled analgesia (PCA) 189 Payment by Results PCR (polymerase chain reaction) 587 peak flow meters 59 PEEP see positive-end expiratory pressure pelvic fractures 509 penicillins 595 in leptospirosis 804 pentamidine, dose 164 pentaspan 236 pentobarbital, in refractory status epilepticus 470 performance measurement 16 pericardial drainage 369 pericardiocentesis 512 pericarditis causes 367 diagnosis 368 presentation 368 treatment 368 pericardium 349 perimembranous VSD 405–6 peripheral venous access 62 venous sites 63 peristaltic sounds 630 peritoneal dialysis (PD) 259 advantages 259 catheter insertion 260 complications 261 contraindications 259 cross-flow 262 cycles and fluid volumes 262 delivery systems 262 dialysis fluid 261 disadvantages 259 drug clearance 306 fluid additives 262–3 leakage 263 peritonitis 263 troubleshooting 265 peritoneal access 260 postoperative 374 peritoneal lavage, diagnostic 513 peritonitis first-line antibiotics 594 PD-associated 263 permethrin poisoning 807 permissive hypercapnoea, ventilation 154 persistence of arterial duct (PDA) 357 persistent neonatal (congenital) myasthenia gravis 489 persistent pulmonary hypertension of the newborn (PPHN) 613 ventilation 153 persistent vegetative state (PVS) 491 withdrawal of treatment 825 petechial rash 556 pH effect on drug absorption 298 normal levels 865 pH-stat management 225 relationship to hydrogen ion concentration 248, 867 phaeochromocytoma 689 phagocyte deficiencies 541 pharmacodynamics 296 pharmacogenomics 298 pharmacokinetic variability, predisposing conditions 304 pharmacokinetics 296 pharyngeal swabs 588 phase I pathways (activation) 298 phase II pathways (detoxification) 298 phenobarbitone emergency treatment of seizures 876 in status epilepticus 469–70 phenoxybenzamine, in phaeochromocytoma 690 phenylephrine 207 phenytoin clearance 299 emergency treatment of seizures 876 poisoning 749 in status epilepticus 469 phosphate conversion factor to SI units 652 daily requirements 231 phosphate levels 246 normal range 865 phosphine gas (PH3) poisoning 806 phosphodiesterase inhibitors (PDEIs) 204 amrinone 205 enoximone 205 milrinone 204 phototherapy, neonatal jaundice 608 phrenic nerve injury, evaluation of diaphragm 338 physical restraints 193 PICANet (Paediatric Intensive Care Audit Network) 14 Pierre Robin sequence 774 pin-point pupils 455 PIP see positive inspiratory pressure piperacillin-tazobactam 595 bacterial sensitivities 591 PIRO framework 573 plantar (Babinski) reflex 457 plasma free Hb, normal levels 864 plasma osmolality, in diabetes insipidus 683 plasmafiltration 274 in fulminant hepatic failure 633 Plasmodium spp 793 see also malaria platelet count in infection 537 in septic shock 572 platelet disorders thrombocytopenia 714 thrombocytosis 715 platelet transfusions 720 play 822 pleconaril 602 virus sensitivities 600 pleural effusion 419 907 INDEX chest X-ray appearance 333 chylous 422 CT appearance 335 in dengue fever 783 investigations 420 para-pneumonic, management flowchart 421 in renal failure, cardiac failure, or malignancy 422 pleural fluid, composition 866 PLOD1 gene mutations 769 pneumatic pulsatile VADs 218, 220 pneumococcal disease clinical features 561 diagnosis 561 epidemiology 561 management 562 pneumococcal HUS 664 pneumococcal meningitis 538, 553 see also meningitis pneumococcus, antibiotic sensitivities 591 Pneumocystis jiroveci pneumonia (PCP) 544–5, 799 pneumonia aspiration 418 causative organisms 415 decompensation after intubation 416 diagnosis 415 first-line antibiotics 592 in HIV infection 799 indications for transfer to PICU 415 management 415 medical treatment 416 pneumococcal 561 presentation 414 ventilator-associated definition 417 management 417 risk-reduction 417 viral 564 pneumonitis, chest X-ray appearance 333 pneumotachograph 60 pneumothorax 511 chest X-ray appearance 333 CT appearance 335 PO2 monitoring 82 transcutaneous 83 poisoning alcohol 744 aluminium phosphide 806 amphetamines 744 aspirin and salicylates 745 benzodiazepines 745 beta-blockers 746 carbon monoxide 750 cocaine 746 corrosives 751 digitalis compounds 753 hemlock 753 history taking 743 hydrocarbons 751 iron 747 kerosene 808 lead 751 management 742 activated charcoal 743 gastric emptying 743 haemodialysis 743 resuscitation 742 methanol 747 mushrooms 752 opiates 747 organophosphates 751 paracetamol 748–9 paraquat 752 phenytoin 749 pyrethroids 807 salt 857 tricyclic antidepressants 750 poliomyelitis 472 polymeric feeds 282 polymyxin 596 bacterial sensitivities 591 polyneuropathy, critical illness-associated 485 polyomaviruses, sensitivity to antiviral agents 600 Pompe disease 774 porphobilinogen, urinary 866 portal circulation 628 posaconazole 599 organism sensitivities 598 positive-end expiratory pressure (PEEP) 147 in asthma 433 PEEPi 434 in head injury 507 in respiratory failure 413 in septic shock 582 positive inspiratory pressure (PIP) in asthma 433 in septic shock 582 positive pressure ventilation cardiovascular effects 113 non-invasive ventilation 160 positron emission tomography (PET), monitoring of the brain 101 post-coarctectomy syndrome 385 posterior (inlet) VSD 405–6 post-hyperventilation apnoea 453 post-mortem examination 830 Human Tissue Act 2004, 840 in suspected metabolic disorders 707 postoperative care 369 analgesia 372 epidural infusion 183 arterial to pulmonary artery shunts 387 atrial septal defects 388 atrioventricular septal defects 389 bidirectional cavopulmonary shunts 390 brain tumours 477 cardiovascular 369 coarctation of the aorta 385 diaphragmatic hernia 622 early problems bleeding and cardiac tamponade 381 low cardiac output state 373 necrotizing enterocolitis (NEC) 381 pulmonary hypertension 378 renal failure 380 exomphalos 623 Fontan operation 392 gastroschisis 623 infection 371 inotropic support 374–5 postoperative care, late problems, brain injury 383 late problems chylothorax 382 paralysis of hemidiaphragm 382 neonates 621 neuromuscular blockade 373 Norwood procedure 394 nutrition 372 oesophageal atresia 621 pulmonary artery banding 395 pulmonary atresia 396 renal 371 respiratory 370 sedation 373 tetralogy of Fallot 399 908 INDEX postoperative care (Cont.) total anomalous pulmonary venous connection 401 transposition of the great arteries 402 truncus arteriosus 404 ventricular septal defect 405 postoperative fever 537 postoperative ileus 635 post pyloric drug administration 301 post-renal ARF, causes 658 post-resuscitation care 30 posture, effect on V/Q 117 potassium addition to peritoneal dialysis fluid 262–3 daily requirements 231 in diabetic ketoacidosis 671, 675 maximum solution concentrations 231 normal levels 865 removal by peritoneal dialysis 265 renal handling 653 see also hyperkalaemia; hypokalaemia potassium deficiency, malnutrition 816 potassium replacement therapy 243 potassium sparing diuretics 655 Potts shunt 387 power 5-point scale 456 definition 46 poxviruses, sensitivity to antiviral agents 600 pralidoxime, in organophosphate poisoning 752 prazosin, in scorpion stings 815 pre-albumin, in nutritional assessment 277 predictions models 17 pre-digested feeds 282 prednisolone, in croup 444 preload 106 low 374 prematurity definition 604 intraventricular haemorrhage 616 retinopathy of 615 preoperative assessment 177 preoperative fasting 177 preoxygenation 178 pre-renal ARF, causes 658 pressure Boyle’s law 47 Dalton’s law of partial pressures 48 definition 46 intra-abdominal 638 measurement 55 relationship to flow 51 see also blood pressure; intracranial pressure pressure areas 507 infection risk 543 pressure control (PC) ventilation 148 pressure-regulated volume control ventilation 148 pressure support ventilation 150 pressure–volume (compliance) curve 121 deflation limb 122 in management of ARDS 122 pressure–volume measurement, ventilated patients 120 pressure–volume relationship, ventricular 108–9 pre-term babies, terminology 604 PRIMACORP (Prophylactic use of Milrinone After Cardiac Operations in Paediatrics) study 205 composition 268 priming, cardiopulmonary bypass 224 primitive neuroectodermal tumours (PNETs) 478 primum ASD 387–8 Prismasol 4, procalcitonin, as marker of infection 537 procedures preparation for 822 sedation 194 Procurator Fiscal, reporting deaths 878 professional development 844 proliferative glomerulonephritis 662 promethazine 192 dose 193 prone positioning, ARDS 436 propionic acidaemia 694, 697 propofol 180 in rapid sequence induction 133 sedation 190–1 in septic shock 580 propofol infusion syndrome 180, 191 proportional assist ventilation 150 propranolol in phaeochromocytoma 690 in thyroid storm 691 propylene glycol, presence in liquid medicines 302 propylthiouracil, in thyroid storm 691 prostacyclins anticoagulation in CVVH and CVVHDF 269 in ARDS 437 prostaglandin E, infusion compatibilities 302 prostaglandins, action in kidney 647 protein normal levels 865 urinary 866 protein-binding of drugs 299 neonates 611 protein losing enteropathy, immunosuppression 543 protein metabolism, liver 628 protein provision, TPN 286–7 prothrombin, as marker of hepatic drug metabolism capacity 307 prothrombin time 864 proton pump inhibitors 627 stress ulcer prophylaxis 640 protoporphyrin, normal levels 865 protozoa, identification 587 pseudohyponatraemia, in diabetic ketoacidosis 671 PTPN11 gene mutations 773 pulmonary artery banding 394–5 pulmonary artery catheters (PACs) 78, 87 pressure waveforms during insertion 79 pulmonary artery pressure lines 80 precautions 81 pulmonary atresia (PA) 358, 395 management 396–7 postoperative care 396 presentation 395 909 INDEX pulmonary blood flow, decreased 112 pulmonary collapse, chest X-ray appearance 334 pulmonary congestion, physiology 112 pulmonary emboli CT appearance 335 diagnosis 343 pulmonary function assessment 114 pulmonary gas exchange 114, 409 pulmonary hypertension aetiology 361 diagnosis 362 outcome 362 persistent pulmonary hypertension of the newborn (PPHN) 613 postoperative 378 clinical features 379 diagnosis 378 treatment 379–80 presentation 361 treatment 362 pulmonary infiltrates, neutropenia 714 pulmonary mechanics 410 pulmonary oedema in brainstem death 729 causes 107 chest X-ray appearance 333 in congestive heart failure 356 CT appearance 335 in diabetic ketoacidosis 677 in malaria 797 mechanisms 241 neurogenic 501 non-cardiogenic 438 physiology 112 in septic shock 582 pulmonary root autograft (Ross procedure) 398 pulmonary sequestration 449 investigations and management 450 problems and complications 450 pulmonary to systemic flow ratio (Qp/Qs) 862 pulmonary valve regurgitation 360 pulmonary vascular resistance, changes after birth 357 pulmonary vascular resistance index (PVRi) 106, 862 pulmonary venous obstruction 360 pulmonary venous return anomalies 359 pulsatile perfusion, CPB 226 pulse, normal ranges 861 pulseless electrical activity (PEA) 24 pulseless ventricular tachycardia 26 pulse oximetry 81 limitations 82 pulse pressure 67 pulsus paradoxus 69 pumps, cardiopulmonary bypass circuit 223 pupillary reflex, brainstem function testing 726 pupils constriction, drugs as cause 743 dilation drugs as cause 742 unilateral 455 size and responses 455 pyelonephritis, first-line antibiotics 594 pyrethroid poisoning 807 management 808 pyrexia 536 during blood product transfusions 722 after head injury 508 postoperative 371, 537 in thyroid storm 691 pyruvate carboxylase deficiency 701, 695, 697 pyruvate dehydrogenase deficiency 701, 695, 697 pyruvate, normal levels 865 Q fever 804 quality cardiopulmonary resuscitation (Q-CPR) 22 quality of care 16, 844 quinine, in treatment of malaria 794–5 radiography abdominal X-ray 334 chest X-rays (CXR) 332 computed tomography 334 fluoroscopy 337 radiotherapy, immunosuppression 543 raised intracranial pressure 465 clinical features 466 CT 336 hypertension management 206 in head injury 503, 506 treatment 496 in meningitis 466, 552, 555 in meningococcal disease 560 signs 453 rapid atrial pacing 378 rapid infusions, choice of cannulae 62 rapid sequence induction (RSI) 132 rasburicase, prevention of tumour lysis syndrome 663 rash, meningococcal infection 556 Rasmussen’s encephalitis, status epilepticus 470 Rastelli repair 397 rationing of healthcare 827 reactive airway disease (RAD), association with bronchiolitis 429 receptors downregulation 201 physiology 300 recruitment manoeuvre, HFOV 159 rectal formulations 303 red blood cell galactose1-phosphate uridyl transferase 705 red cell transfusions 719 ‘red man syndrome’, glycopeptides 597 reducing substances, urinary 705 re-entrant tachycardias 351–2 referrals inappropriate 329 management advice 316 retrieval team activation 317 triage 316 unsalvageable child 329 reflexes brain stem 454 deep tendons 457 refractory status epilepticus (RSE) consequences 469 definition 469 management 470 surgery 470 refusal of consent 836 regional anaesthesia 176 regional anticoagulation, CVVH and CVVHDF 269 910 INDEX regional low-flow cerebral perfusion, CPB 226 regular attendees 822 rejection of transplanted organs 732 relationships with families 822 relative humidity 54 remifentanil 188 doses 193 renal ARF, causes 658 renal blood flow 648 ‘renal dopamine’ 202 renal excretion of metabolites 298 renal failure, acute aetiology 658, 660 acute tubular necrosis 659 definition 658 in fulminant hepatic failure 633 in lepstospirosis 803–4 in malaria 798 management 661 of oliguria 661 neonates 661 pleural effusion 422 postoperative 380 in septic shock 582 renal Fanconi syndrome 663 renal function, neonates 610, 648 renal function evaluation glomerular flow rate (GFR) 651–2 history 649 investigations 649 oliguria, practical points 649 renal imaging 651 renal impairment, prescribing 306–7 renal injury 516 management 514 renal replacement therapies 258 CVVH and CVVHDF 266 drug clearance 306 drug considerations 308 haemoperfusion 272 intermittent haemodialysis 272 plasmafiltration 274 postoperative 347, 380 see also peritoneal dialysis (PD) renal tract infections, firstline antibiotics 594 renal transplantation 735 renal tubular acidosis 656 renal ultrasound 339 renin 647 renin activity, normal levels 865 renin–angiotensin system 648 reperfusion injury 91 research 842 in sepsis 575 residual volume (RV) 118 respiratory acid 247 respiratory acidosis 249 management 253 respiratory alkalosis 249 management 254 respiratory centre 410 respiratory distress after bone marrow transplantation 738 in malaria 797 neonates 612 respiratory drive 410 respiratory dysfunction, septic shock 572 respiratory ECMO 215 neonatal 216 paediatric 217 respiratory failure 411 in acute brain injury 461 causes 412 investigations 413 management 413 presentation 411 treatment 414 respiratory formulae 862 respiratory syncytial virus (RSV) antiviral therapy 565 prevention of infection 428 sensitivity to antiviral agents 600 respiratory tract, microbiological specimen collection 588 restraining therapies 193 resuscitation in acute abdomen 637 advanced life support 23 defibrillation 26 drugs used 27 rhythm recognition 24 after care 30 basic life support 21–2 decision to stop 30–1 Do Not Attempt Resuscitation (DNAR) orders 31 extracorporeal 32 in near-drowning 526 neurological complications 482 parents’ presence 31 in poisoning 742 scope 20 successful, prognostic assessment 483 treatment algorithms 20 resuscitation equipment 28 resuscitation skills 20 resuscitation teams 28 reticulocyte count 711 retinal haemorrhages 455 retinopathy of prematurity 615 retrieval process advice to referring team 316 arrival at PICU 319 care during transfer 319 dealing with parents 320 death in transit 329 departure checklist 318 stabilization of the patient 317–18 transport physiology 320 triage 316 unsalvageable child 329 retrieval services 310 air transport 326 ambulances 322 equipment requirements 313, 323 organization 311 oxygen requirements estimation 324 safety considerations 312 team members 313, 314 retrieval team activation 317 retrieval team composition 311 retropharyngeal abscess 447 rewarming, cold injury 527 rhabdomyolysis 662 treatment 663 rhythm recognition 24 ribavirin 565, 602 inhaled, dose 164 in viral haemorrhagic fevers 788 virus sensitivities 600 rib cage, anatomy 408 rib fractures, pathophysiology 510 rickettsial infections 804 clinical features 805 diagnosis 805 treatment and outcome 805 rifampicin, in ventriculitis 475 911 INDEX Rift Valley fever 790 transmission 787 see also viral haemorrhagic fevers right heart failure, CVP 73 ‘RIGHT’ management, snake bites 810 rights of child 835 parental 835 right-to-left intracardiac shunts anaesthesia 179 apparent dead space 85 right ventricle, effects of mechanical ventilation 113 risk adjustment 16 risk management 847 long-term ventilation 759 ritonavir, in HIV post-exposure prophylaxis 801 Rocky Mountain spotted fever (RMSF) 804 rocuronium 197 dosing schedule 198 infusion compatibilities 302 mechanism of action 300 in rapid sequence induction 133–4 room air, use during resuscitation 28 Ross procedure 398 rotameters 59–60 rule of nines, burns assessment 517 safety anaesthesia 178 defibrillation 26 helicopters 328 during transfers 312 salbutamol dose 164 in asthma 432 in hyperkalemia 244 salicylates clearance 299 poisoning 745 saline, hypertonic in cerebral oedema 676 hyperosmolar therapy 506 inhaled, dose 164 preparation of 3% solution 506 saline solutions, composition 231 saline washout, extravasation injury 64 salt poisoning 857 SaO2 monitoring 82 SARS 564 saturated vapour pressure (SVP) 47 sawtooth CFM waveforms 94 scalds 517 Scedosporium, sensitivities 598 scoring systems 17 scorpion stings 813 clinical features 814 pathophysiology 813 prognosis 816 treatment 815 screening, neonatal 877 scrub typhus 804 sea snake venom 809 secundum ASD 387–8 sedation in asthma 433 CFM waveform 94 neonates 610, 621 for practical procedures 194 postoperative 373 recommendations 190 scorpion stings 815 withdrawal syndrome 195 sedative agents benzodiazepines 191 midazolam 191 clonidine 191 doses 193 enteral 192 ketamine 192 propofol 191 seizures in alcohol poisoning 744 in cerebral malaria 797 CFM waveforms 94 emergency treatment 876 in meningitis 555 neonatal 619 post-hypoxic 30 post-resuscitation 482 risk after head injury 508 in tricyclic antidepressant poisoning 750 see also status epilepticus Seldinger technique chest drain insertion 423 femoral venous access 77–8 PD catheter insertion 260 selective serotonin reuptake inhibitors, (SSRIs), serotonin syndrome 750 sepsis 570 adrenal insufficiency 689 definition 571 DIC 716 epidemiology 573 fatality by age and co-morbidity 574 incidence by age and sex 574 lactate production 91 neonatal 617 causative organisms 617 early-onset 617 investigations 618 late-onset 617 symptoms and signs 618 treatment 619 outcome 573 pathophysiology endothelial dysfunction 576 inflammatory response 576 myocardial dysfunction 577 thrombosis and bleeding 577 PIRO framework 573 research 575 systemic inflammatory response syndrome (SIRS) 570 septic shock ACCM algorithm for stepwise management 581 anaesthesia 179, 580 dealing with the cause of sepsis 581 definition 571 in malnutrition 817 in neutropenia 714 organ dysfunction criteria 572 resuscitation 579 fluid therapy 579 goal-directed therapy 580 inotropic/pressor support 465 supportive care 581 septicaemia first-line antibiotics 592 see also meningococcal disease: septicaemia serology 586–7 serotonin syndrome 292, 750 serum, composition 231 severe combined immune deficiency 540 presentation 539 severe sepsis, definition 571 sevoflurane 181 dose 164 sharp head injury 497 912 INDEX shock anaesthesia 179 in adrenal insufficiency 687, 689 in diabetic ketoacidosis 673 in meningococcal disease 558 in trauma 494 see also septic shock shockable rhythms 26 short bowel syndrome 634 short Synacthen test 688 Shprintzen syndrome 777 shunt equation 117, 863 shunts 115–16,74 V/Q mismatch 117 siblings 822 sick euthyroid syndrome 692 sickle cell crises 712 sickle cell disease 712 acute splenic sequestration 713 single ventricle 359 sinoatrial node (SA node) 349 sinus node dysfunction 354 sinus venosus ASD 387–8 sirolimus 734 skin meningococcal disease 560 microbiological specimen collection 588 topical anaesthesia 189 skin biopsy, in metabolic disorders 707 skin grafting, burns 520 sleep, CFM waveform 94 sleep patterns 186 smoke inhalation history and examination 522 investigations 522 management 523 pulmonary 521 pathophysiology 522 snake bites 809 antisnake venom administration 810 clinical features 809 coagulopathy 810 management 810 neurotoxic, neostigmine 811 supportive care 812 toxins and pathogenesis 809 SNM1 gene mutations 775 sodium daily requirements 231 fractional excretion (FENa+) 232–3 in diabetic ketoacidosis 671, 675–6 normal levels 865 reabsorption in gut 627 removal by peritoneal dialysis 265 renal handling 653 urinary 650, 654 see also hypernatraemia; hyponatraemia sodium benzoate, in hyperammonaemia 700 sodium bicarbonate in acidosis 254 in anaphylaxis 34 in hyperkalemia 244 sodium citrate, anticoagulation in CVVH and CVVHDF 269 sodium imbalance, diagnostic algorithm 233 sodium nitroprusside, in hypertensive crisis 667, 690 sodium phenylbutyrate, in hyperammonaemia 700 somatosensory evoked potentials (SSEPs) 93, 461 somatostatin 627 sorbitol, presence in liquid medicines 302 speaking valves, tracheostomy tubes 142 spider bites 812 spinal abscess 476 spinal anaesthesia 176 spinal cord, MRI 344 spinal cord injury without radiographic abnormality (SCIWORA) 499 spinal cord lesions 484 spinal injury 499 assessment of patient 337, 500 cervical cord 410 hypotension, causes 500 indications for intubation 500 lumbar spine 514 magnetic resonance imaging 503 management 509 neurological assessment 501 skeletal 509 spinal muscular atrophies 484, 775 spinal shock 499 spirometry 58–9 spironolactone 655 splenic sequestration, acute 713 splenic trauma 514 spotted fever diseases 804 sputum, microbiological examination 588 sputum retention, postextubation 156 stability, medical definition 756 stabilization, prior to transfers 317, 318 staff appraisals 844 follow-up after a death 832 retrieval services 311, 313 stand-alone retrieval teams 311 standard base excess 250 standardized mortality rate (SMR) 16 standards of care 844 staphylococci, antibiotic sensitivities 591 Staphylococcus aureus antibiotic sensitivities 591 toxic shock syndrome 562–3 Starling curves 107 Starling forces 112 Starling, Ernest 241 static compliance 120 status epilepticus (SE) 467 anaesthesia 179 anticonvulsant treatment 468–9 causes 468 consequences of prolonged seizure activity 469 convulsive 467 investigations 468 non-convulsive 468 refractory definition 469 management 470 surgery 470 steady state 303 steroids in ARDS 437 during cardiopulmonary bypass 225 in croup 444 in hypotension 208–9 in inflammatory bowel disease 643 in meningitis 554 in meningococcal septicaemia 561 in respiratory failure 414 913 INDEX and scorpion stings 815 see also dexamethasone; hydrocortisone; prednisolone Stewart’s approach, acid– base balance (strong ion difference) 251 stings 812 scorpions 813 stomach, acid production 627 stool examination 630 strangulation, intestinal 635 streptococci, antibiotic sensitivities 591 stress response ADH secretion 235 effect on nutrition 626 immunosuppression 543 neonates 606 stress ulcers 640 aetiology 640 prophylaxis 640 stretch receptors, lungs 410 stridor in croup 444 following extubation 156 stroke associated metabolic disorders 481 causes 478 investigations 479–80 management 478 sickle cell disease 712 treatment 479 stroke volume 104, 861 stroke volume index 861 strong ion difference (SID) 251 subarachnoid haemorrhage 479 subclavian catheters, insertion length 873–4 subdural effusion, in meningitis 555 subdural empyema 476 subdural haematoma (SDH) 498 sub-glottic stenosis, as result of intubation 448 succinylacteone, urinary 705 sucralfate, stress ulcer prophylaxis 640 sucrose solutions, analgesic effect 189 suction, chest drains 425 suction catheter sizes 872 suctioning of airway 168 sudden death in infancy (SUDI) 441 sugammadex 134 sugar, presence in liquid medicines 302 sulphation 298 support staff suppositories 303 supraventricular arrhythmias 351 diagnosis 352 treatment 352 postoperative 376 surface area, normal values 860 surfactant 162 in ARDS 437 in IRDS 612 surfactant protein disorders 162 surgical cricothyroidotomy 139 surgical wound infections, first-line antibiotics 593 suxamethonium avoidance after burns 521 in rapid sequence induction 133 swinging trace, arterial waveforms 69–70 sympathomimetic agents 200 sympathomimetic poisoning, hyperthermia 292 Synacthen, short Synacthen test 688 synchronized intermittent mandatory ventilation (SIMV) 150 syndrome of inappropriate antidiuretic hormone (SIADH) 555, 685 diagnosis 685 differentiation from cerebral salt wasting 686 systemic inflammatory response syndrome (SIRS) 570, 577 causes 572 definition 571 role of gut 629 in scorpion stings 813 systemic vascular resistance (SVR) 104 systemic vascular resistance index (SVRi) 106, 862 tablets 17.S7.1 tachycardia 106 causes 66 postoperative 376 re-entrant 351 tacrolimus 734 tamponade see cardiac tamponade TBX5 mutations 770 T-cell immune deficiency, presentation 539 technological dependency 756 see also long-term ventilation teicoplanin 597 addition to peritoneal dialysis fluid 263 temperature control in head injury 508 neonates 606 tendon reflexes 457 tenofovir, in HIV post-exposure prophylaxis 801 tension pneumothorax 25, 511 terbulatine, dose 164 tetanus 474 tetracycline, in leptospirosis 804 tetralogy of Fallot (TOF) 398 anatomy 400 hypercyanotic spells 358 management 399 postoperative care 399 presentation 399 surgery 399–400 tham (tromethamine) 254 theophylline clearance 299 diuretic action 655 therapeutic drug monitoring 303, 305 thermic effect of feeding 279 thiazide diuretics 655 thiopentone 180 clearance 299 distribution 297 in refractory status epilepticus 470 in rapid sequence induction 133 in septic shock 580 thoracic injuries airway injuries 511 cardiac contusion 512 cardiac tamponade 512 diaphragm, rupture of 511 great vessel injury 512 haemothorax 511 history and examination 510 investigations 510 management 510 oesophageal perforation 511 pathophysiology 510 pneumothorax 511 914 INDEX thoracic SCIWORA 499 thoracocentesis equipment 427 indications 426 landmarks 427 pitfalls 427 set-up and technique 427 throat swabs 588 thrombin clotting time 864 thrombocytopenia 714 in dengue fever 783 parenteral nutrition, precautions 286 thrombocytosis 715 thromboembolic disease, cardiac arrest 25 thrombolysis 717 thrombolytic agents 718 thrombosis 717 in sepsis 577 thrombotic stroke, sickle cell disease 712 thrombotic thrombocytopenia (TTP) 665 thyroid stimulating hormone (TSH), normal levels 865 thyroid storm 691 thyrotoxicosis 691 thyroxine, normal levels 865 tidal volume (TV) 118 tight glycaemic control 680 tobramycin addition to peritoneal dialysis fluid 263 inhaled, dose 164 in PD-associated peritonitis 263 tone assessment 456 tonic status epilepticus 468 tonicity 232 topical analgesia 189 torsade de pointes 245 total anomalous pulmonary venous connection (TAPVC) 400 classification 400 management 400 postoperative care 401 total anomalous pulmonary venous drainage (TAPVD) 359 total cavopulmonary connection, Fontan operation 392 total energy expenditure (TEE) 278 total lung capacity (TLC) 118 total parenteral nutrition (TPN) 285 monitoring 287 toxic megacolon 643 toxic shock syndrome (TSS) clinical features 562 diagnosis 563 epidemiology 562 management 563 trace element provision, TPN 287 trachea, anatomy 408–9 tracheal stenosis congenital 449 as result of intubation 448 tracheitis anaesthesia 179 bacterial 446 first-line antibiotics 592 tracheobronchography 337 tracheobronchomalacia 438 aetiology 439 diagnosis 439 investigations 440 management 440 presentation 439 tracheo-oesophageal fistula 621 tracheostomy 141 blocked 142 in brain injury 462 burns patients 521 displaced 142 indications 141 infection risk 543 long-term issues 143 ventilation 143 tracheostomy care 141 tracheostomy tubes changing 142 sizes 869 types 142 training carers, long-term ventilation 758 medical staff resuscitation teams 28 train-of-four (TOF) nerve stimulation, NMB monitoring 196–7 transcranial Doppler ultrasound 101 during cardiopulmonary bypass 227 transcutaneous carbon dioxide (TcPCO2) monitoring 83 transcutaneous oximetry (TcPO2) 83 transdermal patches 303 transdiaphragmatic pressure measurement 120 transducers, pressure measurement 55, 68 transfer types 310 transferrin, in nutritional assessment 277 transfers 310 air transport 326 ambulances 322 death in transit 329 equipment 313, 323 in head injury 504 organization of retrieval services 311 oxygen requirements estimation 324 retrieval process 316 retrieval team composition 311 retrieval team members 313, 314 safety considerations 312 transport physiology 320 after trauma 496 transfusion reactions, management 722 transfusions flow rates of peripheral cannulae 52 low theory 50 see also blood product transfusions transient neonatal myasthenia gravis 489 transient tachypnoea of the newborn (TTN) 612 transoesophageal echocardiography (TOE) 342 transplantation 724 of bone marrow 737 graft failure 739 of heart 736 heart/lung 736 immunosuppressant drugs 734 of liver contraindications 734 indications 734 modes 735 outcome 735 reasons for PICU management 735 of lungs 736 matching donor and recipient 732 organ dysfunction 739 rejection 732 renal 735 transport, physiological effects 320 transposition of the great arteries (TGA) 401 anatomy 402 915 INDEX congenitally corrected 402 D-TGA 401–2 transposition physiology 359 transpyloric tubes, placement 284 transtentorial herniation 466–7 pupil size 455 transverse myelitis 472, 484 trauma abdominal CT 336 epidemiology 494 examination 494 general management 495 head injury 497 computed tomography 336 history 494 investigations 495 pathophysiology 494 secondary survey 496 spinal cord injury 337, 499 transfer 496 traumatic axonal injury (TAI) 498 triage of referrals 316 triamterene 655 triazoles 598 Trichosporon beigelii, sensitivities 598 tricuspid atresia 359 tricuspid valve regurgitation 360 tricyclic antidepressants, poisoning 750 trigger scores 36 triggering ventilators 149 troubleshooting 153 triglycerides, normal levels 865 triiodothyronine (T3) normal levels 865 in septic shock 208 trimethoprim 596 bacterial sensitivities 591 troponin I, normal levels 865 truncus arteriosus 359, 403 anatomy 404 classification 403 postoperative care 404 surgery 404 TSC1/TSC2 gene mutations 775 tuberculosis clinical features 566 diagnosis 566 epidemiology 566 in HIV infection 800 management 567 spread of infection 566 tuberculous meningitis antimicrobial therapy 538, 553 diagnosis 552 management 567 tuberous sclerosis 775 tubulointerstitial nephritis 663 tumour lysis syndrome 662 treatment 663 tumour necrosis factor (TNF), harmful effects 576 turbulent flow 50–1 Turner syndrome 776 typhus 804 tyrosinaemia 694, 704 management 705 uerthral injury 516 ulcerative colitis 643 ultrasound abdominal 339, 631 after trauma 513 advantages 338 cerebral 460 of chest 338 echocardiography 341 limitations 338 in pleural effusion 420 renal 339, 651 in venous thromboembolic disease 339 see also Doppler ultrasound ultrasound-guided interventions 340 umbilical cord blood transplants 737 ‘Unbearable Situations’ 825 uncal herniation 466–7 uncuffed endotracheal tubes 130 underfeeding 281 unifocalization of major aortopulmonary collateral arteries 396–7 units 46 conversion factors 867 univentricular heart, staged palliation 384 upper airway acute obstruction 442 anatomy 408–9 uraemia 658 urea conversion factor to SI units 652 normal levels 865 removal by peritoneal dialysis 265 urea cycle disorders 694, 697 urea levels 649–51 ureteric injury 516 uric acid, normal levels 865 urinary anion gap 251 urinary tract infections, firstline antibiotics 594 urine, normal values 866 urine alkalinization, aspirin poisoning 745 urine biochemistry 654 urine osmolality, in diabetes insipidus 683 urine output measurement 649 urine production 646 urokinase 718 in empyema 421 uroporphyrin 866 urticaria, during blood product transfusions 722 USA, paediatric intensive care VACTERL association 776 valproate, hepatotoxicity 305 valvar regurgitation 360 vancomycin 597 addition to peritoneal dialysis fluid 263 bacterial sensitivities 591 infusion compatibilities 302 in PD-associated peritonitis 263 in ventriculitis 475 vanillymandelic acid (VMA) 690 vapours 47 drug administration 163 varicella zoster antiviral therapy 565 sensitivity to antiviral agents 600 vascular access, peripheral veins 62–3 vascular endothelium, immune function 539 vasoactive drug use approaches 209 management of low cardiac output state 209 vasoactive drugs categories 201 choice of agents 201 chronotropes 208 inodilators 203 916 INDEX vasoactive drugs (Cont.) inotropes 202 choice of agents 210 vasoconstrictors 201, 207 vasodilators 201, 206 vasogenic cerebral oedema 465 vasopressin see arginine vasopressin (AVP) vasopressin receptors 200 vecuronium 197–8 dosing schedule 198 and rapid sequence induction 133 velocity, definition 46 veno-arterial ECMO 211–12 venom scorpions 813 snakes 809 venous access femoral vein 76–8 internal jugular vein 76, 78 venous pressure, CVVH and CVVHDF 271 venous sites 63 venous thromboembolic disease 339 venous thrombosis 717 prevention 717 treatment 717 veno–venous ECMO 211, 215 ventilation 146 in acute lung injury/ ARDS 153, 436 airway suctioning 168 alterations in cardiovascular physiology 113 in anaphylaxis 34 in asthma 153, 433 in brain injury 462 in bronchiolitis 429 bronchopulmonary fistula 426 burns patients 521 in cavopulmonary shunt 154 complications 154 CVP variation 73 in diabetic ketoacidosis 673 in diaphragmatic hernia 153 extubation 155 in Guillain–Barré syndrome 487 in head injury 502, 504 high-frequency 157 humidification 54 in hypertensive crisis 668 indications 146 initial settings 151 in malaria 797 monitoring 151 neonates, chronic lung disease 614 non-invasive 160 of organ donors 730 in postoperative pulmonary hypertension 379 permissive hypercapnoea 154 in persistent pulmonary hypertension of the newborn 153, 613 postoperative 370–1 principles 150 respiratory mechanics 120 in septic shock 582 in smoke inhalational injury 523 during transfers 323 triggering 149 troubleshooting 152 via tracheostomy 143 weaning 154 see also long-term ventilation ventilation index 863 ventilation rate 24 ventilation–perfusion (V/Q) abnormalities 115–16 V/Q mismatch 117 ventilation–perfusion measurement 120 ventilator-associated pneumonia (VAP) definition 417 management 417 risk-reduction 417, 533–4 ventilator modes 147 control modes 148 intermittent positivepressure ventilation (IPPV) 147 positive-end expiratory pressure (PEEP) 147 support modes 149 ventilatory failure, predisposing factors 146 ventricular assist devices (VADs) 218, 220 ventricular fibrillation (VF) 26, 352 ventricular function 104 ventricular performance 108–9 ventricular septal defect (VSD) 357 classification 405–6 clinical features 405 management 405 postoperative care 405 ventricular tachycardia (VT) 26, 352–3 causes 353 diagnosis 353 postoperative 376 treatment 354 ventricular volume, cardiac cycle 105 ventriculitis 475 ventriculoperitoneal shunts, infected 475 Venturi injector 53 clinical applications 54 verotoxin producing Escherichia coli (VTEC) 664 very long chain acyl-CoA dehydrogense (VLCAD) deficiency 695 hypoglycaemia 702 vibration during transfers 321 viper venom 809 viral haemorrhagic fevers 786 diagnosis 787 differential diagnosis 788 management 788 precautions 788 prognostic features 788 sensitivity to antiviral agents 600 transmission 787 viral infections causes of lower respiratory tract infections 565 diagnosis 565 management 565 myocarditis 564 pneumonia/ pneumonitis 564 viral meningitis 550–1 treatment 538, 554 diagnosis 552, 553 virtual bronchoscopy 335 viruses, identification techniques 586 viscosity 49 visual evoked potentials 93 vital capacity (VC) 118 vitamin provision, TPN 287 vocal cord paralysis, as result of intubation 448 volume control (VC) ventilation 148 volume of distribution (Vd) 296 clinical applications 299 volume support ventilation 150 Von Reckinghausen’s disease (neurofibromatosis type 1) 773 917 INDEX von Willebrand factorcleaving protease (ADAMTS 13) 665 voriconazole 599 organism sensitivities 598 v wave, CVP 72 wasp stings 812 water fractional excretion (FEH2O) 232–3 regulation by gut 627 renal handling 653 water content of body 230 water imbalance, diagnostic algorithm 233 Waterstone shunt 387 weakness, infective causes 471 weaning from oxygen therapy 145 weaning from ventilation 154 in asthma 434 failure 155, 757 support modes 149 see also long-term ventilation weight, normal values 860 weight monitoring 277 Weil’s syndrome 803 Wenkebach phenomenon 354 Wernig–Hoffman syndrome 484 white cell count, markers of infection 537 whole brain death 726 Williams syndrome 777 Wilson’s disease 704 diagnosis 705 management 705 Wiskott–Aldrich syndrome 541 withdrawal syndrome 195 withdrawing life support, organ donors 731 withholding/withdrawing treatment 491, 824 decision-making 826 disputes 827, 839 dying children 829 legal issues 838 mechanisms 827 scenarios 825 timing 826 witnessed resuscitation 31 Wolff–Parkinson–White (WPW) syndrome 351 work, definition 46 World Congress of Pediatric Intensive Care World Federation of Pediatric Intensive Critical Care Societies wound infections, first-line antibiotics 593 X-linked hyper IgM syndrome 541 X-linked hypogammaglobulinaemia 541 X-linked lymphoproliferative syndrome 542 X-rays abdominal 334, 631 in assessment of trauma 513 chest 332 in maxillofacial injury 515 yellow fever 792 transmission 787 see also viral haemorrhagic fevers Yorkshire pudding 867 zero order kinetics 299–300 zidovudine, in HIV post-exposure prophylaxis 801 zinc, normal levels 865 ... tachycardia (JET) • Atrial fibrillation 351 3 52 CHAPTER 20 Cardiac disorders Diagnosis • Detailed history • 12- lead ECG, preferably during an episode (Fig 20 .2) • Intracardiac electrophysiological studies... pressures) 371 3 72 CHAPTER 20 Cardiac disorders Box 20 .11 Principles of postoperative fluid and electrolyte management • Restrict fluid therapy to 25 –50% maintenance in the initial 24 –48h • Minimal... Rule of thumb is to reduce BP by no more than 25 % in first 12 24 H A quicker reduction is safe if the BP rise is of very recent onset 363 364 CHAPTER 20 Cardiac disorders Drugs include: • Nifedepine