PEDIATRIC SURGICAL CRITICAL CARE SYLLABUS & STUDY GUIDE First Edition 2018 On behalf of the American Pediatric Surgical Association Critical Care Committee Editors-in-Chief: Mary K. Arbuthnot, DO Samir Gadepalli, MD Pramod S. Puligandla, MD ©2018 American Pediatric Surgical Association 1 Corresponding Author: Mary K. Arbuthnot, DO LCDR, MC, USN Department of General Surgery Pediatric Surgical Critical Care Naval Medical Center Portsmouth [email protected] [email protected] Cardiovascular Critical Care Respiratory Critical Care Neurological Critical Care Infectious Disease Renal Disease Gastrointestinal Disease Critical Care Nutrition Hematology Endocrinology Analgesia and Sedation Toxicology Thermal Injuries Obstetrical Critical Care Pediatric Emergencies The Elderly Emergency/Trauma Surgery Transplant Statistics Ethics Principles of Administration Contributors: Shahab Abdessalam, MD Director, Trauma, Burns and Critical Care Associate Professor of Surgery Children’s Hospital and Medical Center - Omaha Omaha, Nebraska Infectious Disease Renal Disease Jennifer H. Aldrink, MD Associate Professor of Clinical Surgery and Pediatrics Department of Surgery, Division of Pediatric Surgery The Ohio State University College of Medicine ©2018 American Pediatric Surgical Association 2 Nationwide Children’s Hospital Columbus, OH Emergency/Trauma Surgery Ethics Kelly Austin, MD, MS, FACS, FAAP Associate Professor of Surgery University of Pittsburgh School of Medicine Children’s Hospital of Pittsburg of UPMC Pittsburgh, PA Gastrointestinal Disease Obstetrical Critical Care David W. Bliss, MD, FACS, FAAP Professor of Clinical Surgery Keck USC School of Medicine Cardiovascular Critical Care Neurological Critical Care Critical Care Nutrition Alexander Feliz, MD Assistant Professor of Surgery and Pediatrics University of Tennessee Health Science Center Le Bonheur Children's Hospital Hematology Endocrinology Samir Gadepalli, MD Assistant Professor of Surgery Division of Pediatric Surgery, Department of Surgery University of Michigan Ann Arbor, MI Cardiovascular Critical Care Statistics Principles of Administration David Juang, MD Director, Trauma and Surgical Critical Care Director, Pediatric Surgical Critical Care Fellowship Children’s Mercy Hospital Associate Professor of Surgery University of Missouri - Kansas City Kansas City, MO Thermal Injuries Transplant ©2018 American Pediatric Surgical Association 3 Chris Newton, MD Director, Trauma and Surgical Critical Care Director, Pediatric Neuroscience Center Department of Surgery UCSF-Benioff Children's Hospital Oakland Pediatric Emergencies Pramod S. Puligandla, MD Professor of Pediatric Surgery, Pediatrics and Surgery Program Director, Pediatric Surgery McGill University, Faculty of Medicine Attending Staff, Pediatric General and Thoracic Surgery Attending Staff, Pediatric Critical Care Medicine Montreal Children's Hospital, McGill University Health Centre Montreal, QC, Canada Respiratory Critical Care Robert Ricca, MD CAPT, MC, USN Associate Professor of Surgery, USUHS Director, Surgical Services Naval Medical Center Portsmouth, VA Toxicology The Elderly Ana Ruzic, MD Assistant Professor of Surgery Division of Pediatric Surgery Kentucky Children’s Hospital Analgesia and Sedation PEDIATRIC SURGERY NaT www.pedsurglibrary.com/apsa Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government Copyright Statement: I am (a military service member) (an employee of the U.S. Government). This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties. ©2018 American Pediatric Surgical Association 4 Table of Contents: Chapter 1: Cardiovascular Critical Care page 6 Chapter 2: Respiratory Critical Care page 18 Chapter 3: Neurological Critical Care page 31 Chapter 4: Infectious Disease page 36 Chapter 5: Renal Disease page 43 Chapter 6: Gastrointestinal Disease page 46 Chapter 7: Critical Care Nutrition page 48 Chapter 8: Hematology page 49 Chapter 9: Endocrinology page 54 Chapter 10: Analgesia and Sedation page 58 Chapter 11: Toxicology page 64 Chapter 12: Thermal Injuries page 66 Chapter 13: Obstetrical Critical Care page 70 Chapter 14: Pediatric Emergencies page 71 Chapter 15: The Elderly page 79 Chapter 16: Emergency/Trauma Surgery page 81 Chapter 17: Transplant page 86 Chapter 18: Statistics page 89 Chapter 19: Ethics page 91 Chapter 20: Principles of Administration page 92 References page 95 ©2018 American Pediatric Surgical Association 5 1. Cardiovascular Critical Care i. Physiology i. Understand the definitions of CO, preload, afterload, compliance, SVR ii. Understand the relationship between CO, right atrial pressure and venous return (Frank-Starling Relationship) and how it changes with certain conditions i.e cardiac tamponade, congestive heart failure, Persistent Pulmonary Hypertension of the Newborn (PPHN) Image courtesy of Pediatric Surgery NaT “Cardiophysiology and Shock” ©2018 American Pediatric Surgical Association 6 iii. Understand the phases of the cardiac cycle iv. Understand the effects of preload and afterload on the pressure-volume loops and the changes with pulmonary hypertension, cardiac tamponade, CHF ii. Understand fetal circulation and the physiology associated with persistence of fetal circulation iii. Know the common congenital heart defects. Images can be found at: http://www.stanfordchildrens.org/en/topic/default?id=congenital- heart-disease-90-P02346) Classification of congenital heart lesions Noncyanotic heart disease Cyanotic heart disease left to right shunts decreased pulmonary blood flow atrial septal defects tetrology of Fallot ventricular septal defects pulmonary stenosis atrioventricular septal defects pulmonary atresia aortopulmonary window tricuspid atresia patent ductus arteriosus Ebstein’s anomaly left sided obstructive lesions increased pulmonary blood flow coarctation of the aorta transposition of the great vessels congenital aortic stenosis double outlet right ventricle interrupted aortic arch total anomalous pulmonary venous mitral stenosis return truncus arteriosus single ventricle physiology hypoplastic left heart double inlet left ventricle Image courtesy of Pediatric Surgery NaT “Congenital Heart Disease” Congenital heart disorders left to right shunt (with atrial septal defect congestive heart failure) patent ductus arteriosus ©2018 American Pediatric Surgical Association 7 ventricular septal defect atrioventricular canal right to left shunt tetralogy of Fallot tricuspid atresia transposition of the great vessels total anomalous pulmonary venous return truncus arteriosus obstructive lesions (with aortic stenosis ventricular hypertrophy and coarctation of the aorta failure) pulmonary stenosis interrupted aortic arch total mixing lesions double outlet right ventricle hypoplastic left heart syndrome Image courtesy of Pediatric Surgery NaT “Congenital Heart Disease” iv. Hemodynamic Monitoring i. Invasive and noninvasive arterial blood pressure monitoring 1. Sphygmomanometer measurements give slightly higher systolic and lower diastolic pressures compared to intra-arterial measurements 2. Ideal MAP 60-90 but varies depending on cause of HD instability, history of hypertension, presence of TBI 3. In neonates, MAP is (gestational age at birth)+(age in weeks), but perfusion more important than MAP ii. CVP monitoring 1. CVP alone does not reflect volume status 2. Dynamic decreases of CVP > 2 mmHg with spontaneous respiration can be indicative of patient who are volume responsive iii. Pulmonary artery pressure and pulmonary artery occlusion pressure and assessment of LV 1. Understand correct placement 2. Pulmonary artery occlusion pressure (Ppao) can be used to assess PVR, pulmonary edema, intravascular volume, LV preload and performance ©2018 American Pediatric Surgical Association 8 a. Calculate PVR i. PVR = (mean pulmonary artery pressure –Ppao)/CO b. Preload=LVEDV c. Afterload = LV wall stress = LVEDV x diastolic arterial pressure iv. Recognition of normal right atrial tracings and pathological tracings and how they correspond to the QRS complex A - Atrial contraction X - Atrial relaxation C - Ventricular contraction V - venous return/filling Y - opening of tricuspid valve v. Cardiac output 1. Non-invasive a. Echo i. Can be used to assess stroke volume, ejection fraction, fluid resuscitation ii. Can assess RV pathology: pulmonary embolism (RV overload), cardiac tamponade (pericardial fluid, right ventricular diastolic collapse) iii. Can assess diastolic dysfunction: acute heart failure, volume overload b. Transcutaneous/esophageal Doppler ultrasound, bioimpedence, bioreactance, passive leg raise, pulse variation 2. Invasive a. Thermodilution (pulmonary arterial catheter), pulse waveform analysis vi. Tissue Oxygenation/Perfusion 1. Pulse oximetry a. Tissue light absorption 660 nm (red) and 940 nm (infrared) b. SpO2 <90% = hypoxia c. Understand the oxygen-hemoglobin disassociation curve and the Bohr effect i. Understand the p50 of Hgb and how PaO2 correlates with SpO2 Oxyhemoglobin Dissociation ©2018 American Pediatric Surgical Association