Pediatric Critical Care Medicine: Volume 1: Care of the Critically Ill or Injured Child

Foreword to the First Edition
Preface to the Second Edition
Preface to the First Edition
	Promises to Keep
Acknowledgements
Contents
Contributors
Part I: The Practice of Pediatric Critical Care Medicine
	1: Pediatric Critical Care: A Global View
		Introduction
		What Is Required to Provide Critical Care?
		What Is Required to Provide Intensive Care?
		Critical Care in Mass Disaster Situations
		Ethical Considerations
		Conclusions
		References
	2: Pediatric Critical Care and the Law: Medical Malpractice
		Introduction
		Medico-legal Civil Liability for Pediatric Critical Physicians
		Steps to Minimize Medico-legal Liability for the Pediatric Critical Care Physician
		Legal Standards for Admissibility of Medical Evidence and Expert Testimony
		Unique Issues in the Pediatric Intensive Care Unit Setting
		Emerging Medico-legal Issues Resulting from the Availability of Electronic Data from EHR
		References
	3: Architectural Design of Critical Care Units: A Comparison of Best Practice Units and Design
		Introduction
		A Little History and Statistics
		Advances in Health Design and Sources for Inspiration
		Case Studies, Comparisons and Practice
			Construction Types
			Functional Types
			Layout Types
			Unit Circulation
			Departmental Areas
			Patient Room Design and Bed Number
			Space Allocation by Category
		Discussion and Exemplary Designs
			Patient Care
				Patient Toilet Facilities and Waste Disposal
				Patient Bed Location and Medical Utilities
				Patient Room and Technology
			Staff and Material Support
				Degree of Nursing Centralization
			Staff Facilities
				Staff Access to Nature
			Diagnostic and Therapeutic
				Proximity to Diagnostic and Treatment Support
			Administration and Education
				Proximity to Administration and Education Spaces
			Public and Family
				Family Space
			Outdoor Space
				Green Space
		Conclusion and Future Trends
		References
	4: PICU Administration
		Introduction
		Pediatric Intensive Care Unit Structure
			Historical Perspective
			Levels of Care
			Patient Population
			Subspecialty Care
		Team Structure
			Medical Director
			Physician Team
			Nursing Team
			Respiratory Therapy
			Ancillary Staff
			Multidisciplinary Approach
		Roles of the Leadership Team
			Quality and Safety Assurance
			Team Development
			Family Centered Care
			Hospital Relations
			Education and Training
		Conclusion
		References
	5: Nursing Care in the Pediatric Intensive Care Unit
		Role of the Pediatric Critical Care Nurse
		Education
			Orientation of New Staff
			Clinical Preceptorship
			Senior Staff Development
		Administration
			Structure
			Staffing
		Innovation and Research
		Conclusion
		References
	6: Scoring Systems in Critical Care
		Introduction
		History
		Use of Scoring Systems
		Elements of a Scoring System
		Reliability
		Validity
		Types of Scoring Systems
			Intervention Specific Scoring Systems
			Physiology Specific Scoring Systems
				Adult Mortality Scores
				Pediatric Mortality Scores
				Pediatric Morbidity Scores
			Disease or Condition Specific Scoring Systems
				Trauma
				Congenital Heart Disease
				Other
			Functional Outcome Scores
		The Future of Scoring Systems
		Conclusion
		References
	7: Pharmacology in the PICU
		Principles of Pharmacokinetics and Pharmacodynamics
		Pharmacokinetics
			Absorption
			Drug Distribution
			Drug Metabolism
			Drug Elimination
		Developmental Effects on Pharmacokinetics and Pharmacodynamics
		Pharmacogenomics
		Bedside Application of Pharmacokinetic Principles
			Bioavailability
			Volume of Distribution
			Clearance
			Elimination Half-Life
		Target-Effect Versus Target-Concentration Strategies
		Drug Interactions
			Drug-Drug Interactions
			Pharmacokinetic Interactions
				Absorption
				Distribution
				Metabolism
				Elimination
			Pharmacodynamic Interactions
			Herbal-Drug Interactions
			Pharmaceutical Interactions
			Drug-Food and Drug-Enteral Formula Interactions
			Drug-Disease Interactions
		Drug Safety
		References
	8: Telemedicine in the Pediatric Intensive Care Unit
		Introduction
		The Use of Telemedicine in Emergency Departments
		The Use of Telemedicine During Transport of Critically Ill Children
		The Use of Telemedicine for Children Hospitalized in Intensive Care Units
			Consultative Model
			Continuous Oversight Model
			Telemedicine Technologies
		The Future of Telemedicine in the PICU
		References
	9: Quality Improvement Science in the PICU
		What Is Health-Care Quality?
		Engaging Healthcare Providers in Quality Improvement
		The Case for Health-Care Quality as a Priority for Pediatric Critical Care
		Models for Understanding Quality
		The Science of Quality Improvement
		Understanding Variation Through Statistical Process Control
		A Few Key Tools and Change Concepts for Quality Improvement
		Summary
		References
	10: Patient Safety in the PICU
		Introduction
		The Challenge of Measurement of the Patient Safety Events
		What Harm and Risk Exists in PICUs
		Systems, Systems Thinking and Patient Safety in PICUs
		Improving Safety in the PICU: A Systems Approach
			Special Safety Topics
		Patient Safety in the PICU
		References
	11: Outcomes Research in the PICU
		Introduction
		Rationale for Pediatric Critical Care Outcomes Research
		Definition of Outcome Measures
			Survival Status
			Functional Health Status
			Health-Related Quality Of Life
		Severity of Illness as an Important Mediator of Outcomes
		Methods of Outcome Assessment: Pathways to Studying Outcomes
			Structure-Process-Outcomes Model
			HRQOL Model
		Types of Outcome Research
		Health Resource Utilization and Costs
		The Future of Outcomes Research in Pediatric Intensive Care
		References
	12: Resident and Nurse Education in Pediatric Intensive Care Unit
		Introduction
		Uniqueness of Pediatric Intensive Care Units
		Resident Education Techniques
		Resident Education in Pediatric Critical Care
		Evaluation of Residents
		Educating New Graduate Nurses
		Use of Simulators in Medical Education
		Conclusion
		References
	13: Epidemiology of Critical Illness
		Challenges of Defining a Population in Critical Care
		Epidemiology of Children Receiving Critical Care Services
		Epidemiology of Mechanical Ventilation and ARDS/ALI
		Epidemiology of Sepsis
		Epidemiology of Status Asthmaticus
		Conclusion
		References
	14: Ethics in the Pediatric Intensive Care Unit: Controversies and Considerations
		Introduction
		Informed Consent/Parental Permission
			Informed Consent
			Parental Permission
			Assent
			Emancipated Minor and Mature Minor Exceptions
		Communication in the Pediatric Intensive Care Unit
		Provision of End of Life Care in the Pediatric Intensive Care Unit
			Use of Medication at the End of Life
			Withholding Artificially Provided Fluids and Nutrition
			Unilateral Decision Making and Futility
			Conflict Resolution
		Declaring Death and Organ Donation
			Declaration of Death
			Organ Donation
			Ethical Issues Related to Donation After Cardiac Death
		Research in the Pediatric Intensive Care Unit
		Caring for the Caregiver
		References
	15: Palliative Care in the PICU
		Introduction
		The Definition of Palliative Care
		Epidemiology of Palliative Care Patients in the PICU
		Integration of Palliative Care in the Critical Care Setting
		The Interdisciplinary Palliative Care Team
		Family-Centered Communication
		Goals of Care and Decision Making
		Symptom Management
		Spiritual Distress
		Attention to Siblings
		Practical Considerations During the Peri- death Period in the PICU
		Bereavement
		Caring for Healthcare Professionals
		Conclusion
		References
	16: Evidence-based Pediatric Critical Care Medicine
		A Clinical Scenario Raises Important Clinical Questions
		The Need for EBM
		The EBM Process and Approaching the EBM Core Topics
		Evidence-Based Clinical Practice in Pediatric Critical Care: Challenges and Next Steps
		References
	17: Simulation Training in Pediatric Critical Care Medicine
		Adverse Events and Medical Error in the Intensive Care Unit: Rationale for a Robust Training Model
		Heritage of Medical Simulation as a Tool to Mitigate Human Error
		Simulation-Based Teamwork Training in Pediatric Critical Care
			Curriculum
			Delivery Modes
			Outcomes of CRM Training
		Simulation as a Teaching Tool: Principles of Practice
			Simulation-Based Curricula Founded on Principles of Adult Learning Theory
			Simulation Scenario Design
			Debriefing
		Applications of Simulation-Based Skills Training in Critical Care Training
			Resuscitation Training
			Procedural Training
			Airway Management
		Other Applications of Simulation to the Pediatric Critical Care Environment
		Conclusion
		References
	18: Career Development in Pediatric Critical Care Medicine
		Introduction
			Developing “Mastery” in Clinical Pediatric Critical Care Medicine
		Workforce and Career Development
		Maintenance of Workforce
		Leadership and Team Science in Pediatric Critical Care
		Job Activity and Career Development in Pediatric Critical Care
		Intensivist as Educator
		RESEARCH…research…Translational Research and Implementation Science…and Mentoring
		Career Development…beyond Pediatric Critical Care Medicine
		References
Part II: The Science of Pediatric Critical Care Medicine
	19: Genetic Polymorphisms in Critical Illness and Injury
		Introduction
		Genetic Polymorphisms
			Techniques Involved in Genotyping of Polymorphic Sites
		Influence of Genetic Polymorphisms in Sepsis
			Genetic Variation in Genes Involved in the Recognition of Pathogens
			Genetic Variation in Genes Involved in the Response to Pathogens and Other Stimuli
		Influence of Genetic Polymorphisms in Respiratory Failure and Lung Injury
		Influence of Genetic Polymorphisms in Cardiopulmonary Bypass
		Influence of Genetic Polymorphisms and Risk of Thrombosis
		Pharmacogenomics: The Study of the Genomics of Drug Response and Adverse Effects
		Limitations and Study Design Issues in Genetic Association Studies
		Conclusion
		References
	20: Genomics in Critical Illness
		Introduction
		Gene Association Studies
		Genome-Wide Expression Profiling
		Proteomics
		Comparative Genomics
		Epigenetics
		Pharmacogenomics
		Other Branches of “Omics”
		Conclusion
		References
	21: Signal Transduction Pathways in Critical Illness and Injury
		Introduction
		Historical Perspective of Signal Transduction
		Basic Overview of Signal Transduction
		Stimuli Triggering Signal Transduction
		General Strategies for Signal Propagation
		Specific Pathways
			Nuclear Factor-k B Pathway
		Mitogen-Activated Protein Kinase Pathways
			p38 Mitogen-Activated Protein Kinase Pathway
			JNK Mitogen-Activated Protein Kinase Pathway
			ERK Mitogen-Activated Protein Kinase Pathway
		Regulation of Signal Transduction Pathway
		Phosphatases as Regulators
		Intracellular Protein Modulators
		Epigenetic Mechanisms as Regulators
			Histone Modifications
			microRNA
		Conclusion
		References
	22: Pro-inflammatory and Anti- inflammatory Mediators in Critical Illness and Injury
		Introduction
		Cellular Elements
			Innate Immunity
			Adaptive Immunity
		Cytokines and Chemokines
		The Inflammatory Response in Critical Illness
			Circulating Cytokine Levels
			Gene Expression Profiling
		Immunoparalysis
			Innate Immunity
			Adaptive Immunity
			Reversal of Immunoparalysis
		Tipping the Scales
		Conclusion
		References
	23: Oxidative and Nitrosative Stress in Critical Illness and Injury
		Introduction
			Reactive Oxygen Species and Reactive Nitrogen Species
			Antioxidants
		Redox Homeostasis and Physiologic Function
			Endothelial Relaxation and Adherence Properties
			Immune Responses
			Regulation of Mitochondrial Respiration
		The Role of Reactive Oxygen Species and Reactive Nitrogen Species in Critical Illness
			Sepsis
				Vascular Dysregulation in Sepsis
				Cytopathic Hypoxia and Mitochondrial Dysfunction in Sepsis
				ROS and Nuclear Factor kappa-B in Sepsis
				Antioxidants in Sepsis
				Therapies Targeting Oxidative and Nitrosative Stress in the Treatment of Sepsis
			Traumatic Brain Injury and Epilepsy
				Therapies for Traumatic Brain Injury and Epilepsy
		References
	24: Ischemia-Reperfusion Injury
		Introduction
		Metabolic Derangements of Ischemia
			Alteration of Oxygen Supply
			Energy Failure and Calcium Overload During Ischemia
		The Reperfusion Injury
			Oxidative and Nitrosative Stress
				Direct Oxidative and Nitrosative Injury: Damage of Macromolecules, DNA and Activation of Poly (ADP-ribose) Polymerase-1 (PARP-1)
				Indirect Oxidative and Nitrosative Injury: The Interactive Role of Oxidants with Protein Kinases, Phosphatases and Transcription Factors
			Sources of Reactive Oxygen and Nitrogen Species
				Mitochondrial Production
				Xanthine Oxidase
				Oxidative Burst from the Infiltrated Neutrophils: The NAD(P)H Oxidase
				Nitric Oxide and Nitrosative Stress
				Other Sources
				Alteration of Anti-oxidant Mechanisms
			The Endothelial Dysfunction and Neutrophil Infiltration
				Expression of Adhesion Molecules on Endothelial Surface: Loss of Endothelial Barrier Function
				Loss of Endothelial Barrier: The Injury Vicious Cycle
			Complement Activation
			Toll-Like Receptors and Damage Associated Molecular Patterns
			Matrix Metalloproteinases
		Cellular and Molecular Defenses Against Cell Injury
			The Hypoxia-Inducible Factor-1 (HIF-1)
			The Heat Shock Response
			The Reperfusion Injury Salvage Kinase (RISK) Pathway
			Autophagy
			Endogenous Hydrogen Sulfide Production
			The Ischemic Preconditioning Response
		Conclusion
		References
Part III: Resuscitation, Stabilization, and Transport of the Critically Ill or Injured Child
	25: Post-resuscitation Care
		Introduction
		Post-cardiac Arrest Syndrome
			Pathophysiology of the Post-arrest Reperfusion State
			Post-resuscitation Care of the Respiratory System
			Post-resuscitation Care of the Cardiovascular System
			Post-resuscitation Neurologic Management
				Pathophysiology
				Clinical Manifestations
				Management
				Prognosis
			Blood Glucose Management
			Acid-Base and Electrolyte Management
			Immunologic Disturbances and Infection
			Coagulation Abnormalities
			Gastrointestinal Management
			Acute Kidney Injury
			Endocrinologic Abnormalities
		Conclusion
		References
	26: Predicting Outcomes Following Resuscitation
		Introduction
			Out-of-Hospital Cardiac Arrest
			In-Hospital Cardiac Arrest
		Classifying Outcomes Following Resuscitation
		Predicting Outcomes Following Resuscitation
			List of Predictors (Pre-arrest, Arrest, Post-arrest)
			Neurological Diagnostic Studies for Prognostification
				Neurologic Exam
				Neurophysiologic Studies
				Biomarkers
				Neuroimaging
			Other Important Considerations
		Conclusion
		References
	27: Basic Management of the Pediatric Airway
		Introduction
		Developmental Anatomy and Physiology of the Pediatric Airway
		Basic Airway Management
			Positioning
			Airway Adjuncts
		Tracheal Intubation
			Indications
			Assessment and Preparation
			Equipment
			Airway Pharmacology
				Pre-induction Agents
				Induction Agents
				Neuromuscular Blocking Agents (NMBs)
			Oral Tracheal Intubation
			Nasal Tracheal Intubation
			Rapid Sequence Intubation (RSI)
			Complications of Tracheal Intubation
			Tracheal Extubation
		References
	28: Pediatric Difficult Airway Management: Principles and Approach in the Critical Care Environment
		Introduction
		What Is a Difficult Airway?
		Principles of Difficult Airway Management: The ASA Difficult Airway Algorithm
			Basic Management Problems
				Difficult Ventilation
				Difficult Intubation
				Difficult Supraglottic Airway Insertion/Placement
				Difficulty with Patient Cooperation
				Difficult Tracheostomy
			Basic Management Choices
				Awake Intubation vs. Anesthetized Intubation
				Non-invasive vs. Invasive Technique for Initial Approach to Intubation
				Preservation vs. Ablation of Spontaneous Ventilation
		Preparation
		Venue
		Pharmacologic Management
			Sedation for Intubation with Spontaneous Ventilation Maintained
				Benzodiazepine and Opiates
				Dexmedetomidine
				Ketamine
			Neuromuscular Blockade
				Succinylcholine
		Airway Management Equipment
			Ventilation Adjuncts
				Oral Airways
				Nasopharyngeal Airways
				Modified Nasopharyngeal Airway
				Two-Person, Two-Handed Ventilation
				Laryngeal Mask and Supraglottic Airways
			Tracheal Intubation Tools
				Direct Laryngoscopy
				Flexible Bronchoscope
				Video/Indirect Laryngoscopes
				Bullard Laryngoscope
				Glidescope Cobalt
				Storz Video Laryngoscope
				Airtraq
				Optical Stylets
				Laryngeal Masks as Intubation Conduits
		The Unanticipated Difficult Airway
		Systems Management
		Tracheal Extubation in the Child with a Difficult Airway
		Conclusion
		References
	29: Central Venous Vascular Access
		Introduction
		Choice of Sites and Type of Catheter
		Femoral Venous Catheterization
			Demographic and Historical Data
			Indications and Contraindications for Placement
			Anatomy
			Insertion Technique
			Confirmation of Placement
			Complications and Risks
		Subclavian Vein Catheterization
			Demographic and Historical Data
			Indications
			Anatomy
			Insertion Technique
			Confirmation of Placement
			Complications
		Internal Jugular Vein Catheterization
			Demographic: Historical Data: Indications for Placement
			Anatomy
			Insertion Technique
			Confirmation of Placement
			Complications
		Axillary Vein Catheterization
			Demographic and Historical Data: Indications for Use
			Anatomy
			Technique
			Complications
		Ultrasound-Guided Central Vein Catheterization: The New Standard?
		Complications Associated With Central Venous Catheter Placement
			Pneumothorax
			Arterial Puncture
			Catheter Malposition: Femoral Catheters
			Catheter Malposition and Post Procedure Chest Radiographs: Cervicothoracic Catheters
		References
	30: Shock
		Historical Perspective
		A Brief Overview of Cellular Respiration and the Cellular Basis of Shock
		Differences Between Pediatric Shock and Adult Shock
		Pathophysiology of Shock
			Hemodynamic Relationships in Shock
			Compensatory Mechanisms in Shock
		Functional Classification of Shock
			Hypovolemic Shock
			Obstructive Shock
				Tension Pneumothorax
				Pulmonary Embolism
				Cardiac Tamponade
				Left Ventricular Outflow Tract Obstruction
				Right-sided Obstructive Lesions
			Cardiogenic Shock
			Distributive Shock
		Diagnosis of Shock
		Therapeutic Endpoints of Resuscitation in Pediatrics
			Traditional Endpoints
			Cardiac Filling Pressures
			Venous Oximetry and Near-Infrared Spectroscopy
			AVDO 2
			Lactate
		Management of Shock
			Fluid Therapy
			Blood Products
			Vasoactive Medications
				Inotropes
				Dopamine
				Dobutamine
				Epinephrine
				Norepinephrine
				Phosphodiesterase Inhibitors
				Other Agents
			Vasodilators
			Vasopressors
				Phenylephrine
				Vasopressin
			Hydrocortisone
			Extra-Corporeal Life Support (ECLS)
		Conclusion
		References
	31: Acute Respiratory Failure
		Introduction
		Definition
		Etiologies of Respiratory Failure
			Upper Airway Obstruction
			Lower Airway Obstruction
			Hypoventilation
			Respiratory Muscle Insufficiency
			Ventilation/Perfusion (V/Q) Inequality
			Shunting
			Diffusion Impairment
		Evaluation of Respiratory Failure
			Oxygenation
			Carbon Dioxide Retention
		Treatment of Respiratory Failure
		References
	32: The Multiply Injured Child
		Introduction
		Trauma Related Mortality and Morbidity
		Age Distribution
		Injury Patterns and Mechanisms of Injury
		Incidence of Multiple Trauma and Trauma Scoring
		Pathophysiology of Major Trauma and Mechanisms of Secondary Damage
			Hypoperfusion, Hypoxemia and Tissue Hypoxia
			Reperfusion Injury
		Pathophysiologic Responses to Major Trauma
			Neuroendocrine and Metabolic Stress Response
			The Systemic Inflammatory Response to Trauma
			Multi-Organ Dysfunction Syndrome (MODS) and Multiple Organ Failure (MOF) Following Trauma in Children
		Clinical Implications of Multiple Trauma
		Pre-hospital Care of the Multiply Injured Child
			Pre-hospital Airway Management
		Emergency Department Management of the Multiply Injured Child
			Role of the PICU Physician
			Primary Survey, Resuscitation and Initial Stabilization
				Airway
				Breathing and Mechanical Ventilation
				Circulation
			Vascular Access
			Fluid Resuscitation
			Blood and Coagulation Factors Transfusion
		Imaging of the Multiply Injured Child
		Management of the Multiply Injured Child in the Intensive Care Unit
			Triad of Death
			Damage Control in the Unstable Injured Child
		Blunt Abdominal Trauma in the Multiply Injured Child
		Thoracic Injury in the Multiply Injured Child
		References
	33: Coma and Altered Mental Status
		Introduction
		Epidemiology
		Consciousness and Coma and Altered Mental Status Definitions
		Anatomy of the Brain in Relation to Coma
		Causes of Coma
		Evaluation of the Comatose Child
			History
			Physical Examination
			Neurologic Examination
				Glasgow Coma Score (GCS)
				Response to Stimuli
				Cranial Nerve Examination
					Fundoscopic Examination
					Pupillary Exam
					Eye Position and Motility
					Oculocephalic and Oculovestibular Reflexes
					Gag Reflex
					Other Brainstem Reflexes
		Diagnostic Testing
		Associated Problems
			Intracranial Hypertension
			Seizures
		Outcome Prediction
			General Considerations
			Scoring Tools
			Adjunct Tools
				Neurologic Exam
				Neurophysiology
				Neuroimaging
		Conclusion
		References
	34: Interfacility Transport
		Introduction
		Historical Perspective
		The Transport Team
			Medical Director
			Transport Coordinator
			Transport Team Personnel
		Training and Education
		Equipment
		Communications Center
		Mode of Transport
		Aeromedical Transport Considerations
			Altitude Physiology
		Safety in Transport
		Medicolegal Issues
		Clinical Care Stabilization of the Critically Ill or Injured Child for Transport
			Airway and Respiratory Care
			Sepsis
			Vascular Access
		Family Centered Care and Interfacility Transport
		Unique Transport Situations
			Scene Flights
			Organ Procurement
			Extracorporeal Membrane Oxygenation (ECMO)
			Burns
		Quality Improvement in Transport
		Future of Pediatric Transport
		References
	35: Multiple Organ Dysfunction Syndrome
		Introduction
		Definition of Pediatric Multiple Organ Dysfunction Syndrome (MODS)
		Pediatric MODS Scoring Systems
		Epidemiology
		Etiology
			Sepsis
			Congenital Heart Diseases
			Multiple Trauma
			Solid Organ or Bone Marrow Transplantations
		Pathogenesis
			Evolutionary Ties Between Sepsis and Tissue Injury
			Inflammation and Immune System
			Adaptive Immunity and Immune Suppression
			Coagulation and Fibrinolysis
			Capillary Leak Syndrome
			Neuroendocrine Response
			Hyper and Hypometabolism
			Cellular Dysoxia
		Organ Dysfunctions in Critically Ill Children
			Cardiovascular Dysfunction and Septic Shock
			Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS)
			Gut Mucosal Barrier Dysfunction
			Neuromuscular Syndromes
		Outcome of Pediatric MODS
		Treatment of Pediatric MODS
			General Supportive Care
			Organ Therapeutic Management
				Hemodynamic Management
				Lung Protective Ventilation
				Renal Failure Management
				Nutritional Support
				Withdrawal of Curative Care
		References
	36: Withdrawal of Life Support
		Introduction
		Ethical Framework
			Autonomy
			Beneficence and Nonmaleficence
			Justice
		Family Centered Care and Conflict
		Providing Care During Withdrawal of Life Support
		Providing Care Around the Time of Death
		References
	37: Brain Death
		History of the Brain Death Concept
		The Neurological Determination of Death: Concept, Terminology and Clinical Relevance
			Whole-Brain Versus Brainstem Death
			Brain Death Versus Brain Arrest
		End-of-Life Care and the Obligations of the PICU
		Demographics and Etiology
		Pathophysiology
		Minimum Clinical Criteria
			Brainstem Reflexes
				Etiology and Coma
				Absent Motor Response
				Absent Brainstem Reflexes
			Apnea Testing
			Confounding Factors
			Physician Expertise
			Subsequent Clinical Examinations and Time Intervals
			Age Related Adjustments
			Legal Time of Death
		Ancillary Testing
			Electroencephalography (EEG)
			Tests of Intracerebral Blood Flow
				4-Vessel Cerebral Angiography
				Nuclear Medicine Imaging Techniques
				Transcranial Doppler Ultrasonography
				Magnetic Resonance Angiography with Magnetic Resonance Imaging (MRA with MRI)
				Computed Tomographic Angiography (CTA)
			Other Tests of Interest
		Variability and Practice Controversies
		References
	38: The Physiology of Brain Death and Organ Donor Management
		Introduction
		The Physiology of Brain Death
			Neurogenic Myocardial Dysfunction
			Neurogenic Pulmonary Edema
			Inflammatory State
		Donor Management: General
			Cardiovascular Performance and Monitoring
			Hemodynamic Targets and Supports
				Preload
				Contractility
				Systemic Vascular Resistance
				Vasopressin and Catecholamine Sparing in Brain Death
			Oxygenation and Ventilation Strategies
			Metabolic and Endocrine
				Glycemia and Nutrition
				Diabetes Insipidus and Hypernatremia
				Thyroid Hormone
				Corticosteroids
				Combined Hormonal Therapy
			Transfusion Thresholds
			Invasive Bacterial Infections
		Donor Management: Organ Specific
			Heart
			Lungs
				Bronchoscopy and Bronchopulmonary Infections
			Liver
			Kidney
			Intestine
		Logistics of Organ Donation
			Donor Management Protocols and Education
			Optimal Time of Organ Procurement
			Decisions Regarding Transplantability
		References
Part IV: Monitoring the Critically Ill or Injured Child
	39: Respiratory Monitoring
		Introduction
		Monitoring Gas Exchange
			Monitoring Oxygenation
				Arterial Blood Gas Monitoring
				Pulse Oximetry
			Monitoring Ventilation
				Arterial Blood Gas Analysis
				End-Tidal CO 2 Monitoring
				Transcutaneous CO 2 (TcCO 2) Measurements
		Monitoring the Mechanics of the Respiratory System
			Scalars
				Flow-Time Scalars
				Pressure-Time Scalar
				Volume-Time Scalar
			Loops
				Pressure-Volume (PV) Loops
				Recruitment/Derecruitment
				Overdistention
			Flow-Volume (FV) Loops
		Conclusion
		References
	40: Hemodynamic Monitoring
		Introduction
		Vascular Pressure Measurement
		Cardiac Output
			Indicator Dilution Techniques
				Pulmonary Thermodilution (Swan-Ganz Catheters)
				Transpulmonary Thermodilution
				Transpulmonary Ultrasound Dilution
				Dye Dilution
				Lithium Dilution
			The Fick Principle
				Oxygen Consumption Measurement
				Arterial and Mixed Venous Oxygen Content
				Presence of Anatomical Shunt
				Indirect Fick Principle
			Doppler Ultrasound
			Impedance/Conductance Methods
				Thoracic Impedance
				Intracardiac Impedance
				Arterial Pulse Contour Analysis
			Other Methods
		Measuring the Adequacy of Flow
			Mixed Venous Oxygen Saturation
			Near Infrared Spectroscopy (NIRS)
			Blood Lactate
		Regional Perfusion
			Tissue PCO 2 Monitoring Using Tonometry
			Optical Monitoring Methods
			Capillary Refill
		Assessing the Components of Cardiac Output
			Heart Rate
			Preload Versus Volume Responsiveness
			Contractility
			Afterload
			Diastolic Function
		References
	41: Neurological Monitoring of the Critically-Ill Child
		Physical Examination
		Intracranial Pressure (ICP) Monitoring
		Electrophysiological Monitoring
			Bispectral (BIS) Index Monitoring
			Electroencephalography (EEG)
			Evoked Potentials
		Assessments of Blood Flow and/or Metabolism
			Xenon Cerebral Blood Flow Determination
			Transcranial Doppler Ultrasonography: (TCD)
			Jugular Venous Oxygen Saturation: (SjvO 2)
			Near-Infrared Spectroscopy: NIRS
			Brain Oxygen Monitoring and Cerebral Microdialysis
			MR Spectroscopy: MRS
			Serum Markers of Neurological Injuries: Neuromarkers
		Conclusion
		References
	42: Nutrition Monitoring in the PICU
		Introduction
		Assessing Nutritional Status
			Subjective Global Nutritional Assessment (SGNA)
			Anthropometrics
			Obesity
			Malnutrition
		Monitoring Biochemical Markers
			Plasma Proteins
			Nutritional Indices
			Nitrogen Balance
			Creatinine Height Index- Body Protein Turnover
		Monitoring Resting Energy Expenditure
			Indirect Calorimetry
			The Standard Metabolic Monitor
			Recent Advances in Monitoring REE in the Critically Ill
			The Short Douglas Bag Protocol
		Alternative Methods Used to Predict Energy Expenditure
			Bicarbonate Dilution Kinetics
			Indirect Estimations of REE
			Predictive Equations
			Lessons Learned From Adult Studies
			The Pediatric Experience
		Body-Composition Tests
			Dual-Energy X-Ray Absorptiometry
			Bioelectrical Impedance: Magnetic Resonance Spectroscopy
			Doubly Labeled Water Technique
			Whole-Body Counting/Neutron Activation
		Miscellaneous Tests Indicating Nutritional Status/Stress Response
			Comparison with Recommended Dietary Allowances
			Routine Laboratory Tests
			Glucose Control
			Cell-Mediated Immunity and Lymphopenia
			Functional Tests of Malnutrition
		Clinical Data Impacting Nutrition and Metabolic Response Monitoring
			Cytokines
			Counter-Regulatory Stress Hormones
			Drugs Influencing Monitoring
			Critical Illness
		Nutrition Monitoring
			Early Nutrition Monitoring
			The Immunonutrition Question
			Protocols in the Role of Monitoring
			Monitoring the Metabolic Response
		Conclusions
		References
	43: Monitoring Kidney Function in the Pediatric Intensive Care Unit
		Introduction
		Defining the Problem
		Classic Parameters of Acute Kidney Injury
			Glomerular Filtration Rate (GFR)
			Serum Creatinine
			Serum Urea
			Urine Output
			Fluid Overload
			Urinalysis and Microscopy
			Urine Chemistry and Similarly Derived Indices
		The Need for Better Markers of AKI
		Emerging Biomarkers
			NGAL
			Cystatin C
			IL-18
			KIM-1
			L-FABP
			AKI Biomarker Combinations
			Renal Angina: Risk Stratification to Optimize AKI Biomarker Utility
			Future Perspectives in AKI Biomarkers
		References
Part V: Special Situations in Pediatric Critical Care Medicine
	44: Principles of Mass Casualty and Disaster Medicine
		Introduction
		Disaster Types, Preparedness, and Management
			Hospital Emergency Preparedness
			Community and/or Local Government Emergency Preparedness
			State Government Emergency Preparedness
			Federal Government Emergency Preparedness
			Public Health Emergency Preparedness
		Mass Casulaty Incidents
			Incident Command System (ICS)
			Casualties’ Flow within the Hospital
			Patient Triage
			Principles of Initial Hospital Management
			Use of Radiology
			Operating Room
			Secondary Transport
			Re-Assessment Phase
			Communication and Manpower Control
			Information Center and Public Relations
		Personal Protective Equipment
		Hospital Based Decontamination and Pediatric Considerations
		Crisis (or Disaster) Standards of Care
		Alternate Care Sites
		Communication and Information Technology Issues
		Unique Aspects of Children Related to Terrorism and Disasters
			Biologic, Chemical, Radiologic and Trauma Vulnerabilities
			Mental Health Vulnerabilities
			Children with Special Health Care Needs
		Pediatric Disasters Preparedness
		Epidemics and Pandemics Preparedness
		Terrorism Preparedness
		Conclusion
		References
	45: Care in an Austere Environment
		Introduction
		Provider Opportunities and Readiness
		Cultural Sensitivity
		Patient Care
		Conclusion
		References
	46: Agents of Biological and Chemical Terrorism
		Introduction
		Historical Context of Biological and Chemical Agents
		Pediatric Unique Factors
		Specific Chemical and Biological Agents of Terrorism
		Chemical Agents
			Nerve Agents (Tabun (GA), Sarin (GB), Soman (GD), and VX
				Mechanism of Action
				Signs/Symptoms
				Diagnosis
				Decontamination/Isolation
				Treatment
			Cyanide
				Mechanism of Action
				Signs/Symptoms
				Diagnosis
				Treatment
		Biologic Agents
			Inhalational Anthrax (Bacillus Anthracis)
				Signs/Symptoms
				Diagnosis
				Infection Control
				Treatment
			Pneumonic Plague ( Yersinia pestis)
				Signs/Symptoms
				Diagnosis
				Decontamination/Infection Control
				Treatment
			Tularemia ( Francisella tularensis)
				Signs/Symptoms
				Diagnosis
				Infection Control
				Treatment
			Smallpox (Variola)
				Symptoms/Signs
				Diagnosis
				Decontamination and Infection Control
				Treatment
			Botulinum Toxin
				Symptoms/Signs
				Diagnosis
				Decontamination/Infection Control
				Treatment
		Conclusion
		References
	47: Pandemic Influenza
		Introduction
		Molecular Description of the Influenza Virus
		Government Planning for Pandemic Influenza
		Critical-Care Planning for Pandemic Influenza
		Pediatric-Specific Issues
		2009 H1N1 Experience
		Ethics
		Conclusion
		References
	48: Pediatric Drowning
		Introduction
		Epidemiology
		Associated Conditions
			Associated Medical Conditions
			Associated Injuries
		Pathophysiology
			Immersion
			Submersion
			Hypothermia
		Effects on End-Organs
			Respiratory System
			Cardiovascular System
			Central Nervous System
		Clinical Evaluation and Decision Making
		Treatment
			Scene
			Emergency Department
			Intensive Care Unit
		Predicting Long-Term Outcome
			Clinical Neurologic Examination
			Neuroradiology
			Neurophysiology
		References
	49: Heat Illness and Hypothermia
		Thermoregulation
		Heat Illnesses
			Classification
			Pathophysiology
				Biochemical and Cellular Alterations
				Systemic Alterations
			Epidemiology
			Clinical Manifestations
				CNS Manifestations
				Cardiovascular Manifestations
				Respiratory Manifestations
				Skin Manifestations
				Gastrointestinal Manifestations
				Renal Manifestations
			Diagnosis and Clinical Evaluation
			Treatment
				Cooling
				End-Organ Support
			Prognosis
		Cold Injury
			Classification
			Pathophysiology
				Molecular and Cellular Alterations
				Systemic Alterations
			Epidemiology
			Clinical Manifestations
				CNS Manifestations
				Cardiovascular Manifestations
				Respiratory Manifestations
				Renal Manifestations
				Hematologic Manifestations
			Diagnosis and Clinical Evaluation
			Treatment
			Prognosis
		References
	50: Toxic Ingestions
		Introduction
		Evaluation
		Antidotes
		Decontamination
			Surface Decontamination
			Gastric Decontamination
				Activated Charcoal (AC)
				Whole Bowel Irrigation (WBI)
				Cathartics
			Enhanced Elimination
				Forced Diuresis
				Urine Alkalinization
				Hemodialysis
				Hemoperfusion
				Intravenous Lipid Emulsion (ILE)
		Specific Toxic Ingestions
			Recreational Drugs
				Cocaine
				Gamma-hydroxybutyrate (GHB)
				3,4-Methylenedioxymethamphetamine (MDMA)
				“Bath Salts”
				Ketamine
				Dextromethorphan
				2-C Phenethylamines
			Alcohols
				Ethylene Glycol
				Methanol
				Isopropyl Alcohol (Isopropanol)
				Ethanol
			Psychoactive Drugs
				Antipsychotics
				Selective Serotonin Reuptake Inhibitors (SSRIs)
				Tricyclic Antidepressants (TCAs)
			Antihypertensives
				Calcium Channel Blockers (CCBs)
				Beta-blockers (β-blockers)
				Clonidine
			Analgesics, Analgesics, Sedatives, and Antipyretics
				Opioids
				Benzodiazepines
				Acetaminophen
				Salicylates
				Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
			Organophosphates and Carbamates
				Iron
			Hydrocarbons and Inhalation Abuse
			Caustic Agents
			Smoke Exposure, Cyanide (CN) and Carbon Monoxide (CO)
				Cyanide
				Carbon Monoxide
			Antihistamines
			Anticonvulsants
				Barbiturates
				Phenytoin
				Valproic Acid (VPA)
				Carbamazepine
				Oxcarbazepine
				Levetiracetam
			Methemoglobinemia
		References
	51: Envenomations
		Introduction
		Venomous Snakes
			Snake Venoms and Toxins
			Clinical Manifestations of Envenomation
			Identification of the Snake
			Initial Management: Resuscitation and Stabilization (Fig.  51.8)
			Management: Antivenom (Antivenin) Therapy
			Monitoring
			Secondary Management and Follow-Up Care
			Sea-Snake Bite
			Uncommon and Exotic Snake Bites
		Spiders
			Funnel-Web Spiders
			Red-Back Spider
			Black Widow Spiders
			Brown Recluse Spiders
		Scorpions
		Bees, Wasps, and Ants
		Venomous Marine Animals
			Jellyfish
			Blue-Ringed Octopus
			Stinging Fish
			Venomous Cone Shells
		Shark Attacks
		References
Index