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Intensive Care 73

300,000 children continue to die of AIDS-related illnesses worldwide Table 12.4: Evidence-based research.
63
every year. Title Review of paediatric intensive care ventilation practice
Paediatric critical care in developing countries is necessarily highly Authors Turner DA, Arnold JH
centralised. Most developing countries have large centres that provide
varying degrees of tertiary medical care, including paediatric critical Institution Harvard Medical School and Department of Anesthesia,
Division of Critical Care Medicine, Children’s Hospital,
care. However, the resources available to these tertiary centres are Boston, Massachusetts, USA
extremely inconsistent and unpredictable; as a result, the medical Reference Curr Opin Crit Care 2007; 13(1):57–63
capabilities differ widely across centres and countries. 72
In an attempt to provide critical care for children, hospitals must use Problem Review current paediatric ventilation strategies and
evidence.
existing resources to the best of their ability, including, for example,
using existing theatre facilities as an environment to care for critically Outcome/ Mechanical ventilation with pressure limitation by using low
tidal volumes has become the main form of ventilation in
effect
ill children in the short term or combining adult, paediatric, and paediatric intensive care units.
neonatal critical care. Historical Various ventilator strategies such as high-frequency
In view of the limited availability of paediatric critical care in significance/ oscillatory ventilation, airway pressure release ventilation,
developing countries, it is important to define priorities and recognise comments and adjuncts such as surfactant, need further evaluation.
those children who might benefit from being transferred and admitted
to a dedicated unit. The additional costs incurred by safe and effective
transport of the most vulnerable paediatric patients are a major
consideration in the decision-making process and undoubtedly will Table 12.5: Evidence-based research.
influence the allocation of limited resources. Determining those Title Clinical practice parameters for hemodynamic support of
admission criteria will depend on local as well as wider factors within pediatric and neonatal septic shock: 2007 update from the
a defined geographical area. American College of Critical Care Medicine
Unfortunately, data available on the provision of paediatric critical Authors Brierley J, Carcillo JA, Choong K, Cornell T, DeCaen A,
care in the developing world are lacking. Only the most sophisticated Deymann A, et al.
and developed units with dedicated resources for expensive diagnostic Institution American College of Critical Care Medicine, Mount
Prospect, Illinois, USA
and therapeutic drugs and equipment tend to publish data, thereby
creating a publication bias. As a result, published data may not reflect Reference Crit Care Med 2009; 37(2):666–688
1
the true spectrum of the clinical workload. Problem Clinical guidelines required to promote best practices and
improve patient outcomes in paediatric and neonatal septic
Conclusion shock.
Many complex factors affect the ability to provide dedicated paediatric Intervention Extensive literature search with experts in field grading
critical care units. Much of the modern infrastructure may be out of evidence.
reach to units due to cost. Caring for paediatric patients during acute Comparison/
critical illness or injury as well as following major surgery can be both control Compares centres that implemented previous guidelines.
challenging and rewarding. Attention and priority should be at main- (quality of
evidence)
taining a secure airway, followed by providing adequate respiratory
and cardiovascular support. Detailed clinical history, examination, and, Outcome/ Early use of paediatric and neonatal sepsis guidelines was
where possible, further investigations will provide clearer diagnostic effect associated with improved outcome.
information in the aim of providing definitive care. Paediatric critical
Historical Continue to support the early use of age-specific therapies
care not only provides the management of children with severe medi- significance/ to attain time-sensitive goals. Compared to adults, children
cal or surgical illness, but frequently goes beyond cure to encompass comments require proportionally larger quantities of fluid in resuscitation
holistic care of the patient and family. for sepsis. Early use of inotropic support is recommended.
Evidence-Based Research
Tables 12.4 and 12.5 present evidence-based reviews of ventilation
strategies and sepsis management, respectively.

Key Summary Points

1. Respiratory failure is a major cause of paediatric morbidity framework, demonstrating that aggressive fluid management of
and mortality worldwide, and early intervention is essential to hypovolemic and septic shock has a positive impact on outcome.
prevent progression to cardiopulmonary arrest. 4. Whenever possible, efforts should be made to minimise
2. Oxygen should be administered to all critically ill or injured inflation pressures in positive pressure ventilation to protect the
children in the highest possible concentration until the patient from lung injury.
assessment of cardiorespiratory status is complete. 5. The degree of intensive care support is dictated by the specific
3. International consensus guidelines on the management of set of clinical circumstances as well as the local resources.
paediatric and neonatal septic shock provide a clear treatment