5  Paediatric Critical Care

5.1 Background

In resource-limited resource settings, such as those lacking access to healthcare staff, equipment, and resources, pediatric emergency and critical care (PECC) play an essential role. These settings bear the highest burden of severe acute illness and life-threatening injuries. Still, due to underappreciation of its importance, critical care has not been incorporated as an essential part of the health system.(Sakaan et al. 2022)

An infant, child, or adolescent with an illness, injury, or post-operative state that increases the risk for or results in acute physiological instability (abnormal vital signs, laboratory values, or clinical findings) falls under acute paediatric critical illness.(Appiah et al. 2018)

Many paediatric lives can be saved with low-cost resuscitation techniques and procedures, supportive care and referral pathways available at all levels of care. Over sixty per cent of children die because of poor emergency and critical care. SDG may not be achieved unless PECC service is available to every acutely ill child.

By providing prompt and adequate medical care to critically ill children, paediatric emergency and critical care services can contribute to a decrease in childhood death rates.

5.2 Reasons for PECC

Children who require specialised care due to severe diseases or injuries should ideally be referred or managed at the paediatric emergency or critical care (PICU). Any space available should and can be used to offer such services. In that sense, any clinician can advocate for or institute measures to provide PECC.

The following are typical reasons for PICU admissions:

• Acute respiratory distress and failure e.g., (acute respiratory distress syndrome (ARDS), pneumonia, severe exacerbations of asthma, or any cause are all considered respiratory distress.
• Shock: hypovolemic shock, septic shock, (e.g., from severe dehydration or haemorrhage). cardiogenic shock (e.g., from myocarditis or heart failure),
• Trauma: accidental and non-accidental polytrauma injuries, burns, or other causes.
• Neurological emergencies: Seizures, severe brain damage, cerebral bleeding, meningitis, or encephalitis are examples.
• Cardiovascular: Heart failure, myocarditis, arrhythmias, and exacerbations of congenital heart disease are examples.
• Sepsis: Systemic infections caused by bacteria, viruses, or fungi that result in septic shock or sepsis.
• Metabolic disorders include metabolic acidosis, severe electrolyte imbalances, diabetic ketoacidosis (DKA), and inborn metabolic abnormalities.
• Conditions that result in the failure or dysfunction of numerous organ systems, including multiple organ failure, are called multi-organ dysfunction.
• Post-operative support: Children undergoing difficult procedures, especially those requiring close cardiovascular monitoring of organ function.
• Haematological and oncological disorders: coagulation issues, thrombocytopenia, or severe anaemia, side effects of cancer treatment, such as tumour lysis syndrome or neutropenia caused by chemotherapy.
• Exposure to poisonous substances, overdosing, or poisoning are examples of toxicological emergencies.
• Endocrine: include thyroid storm, adrenal crises, and diabetic emergencies.
  Gastrointestinal: intussusception, typhoid ileal perforation, necrotizing enterocolitis, or extreme dehydration are examples of.
• Renal disorders: include electrolyte abnormalities, acute kidney damage, and renal failure.

5.3 Evaluation of critically ill

A methodical and comprehensive approach is necessary when evaluating a severely unwell child to promptly recognize and treat life-threatening diseases. The clinical plan that is frequently applied in emergency and critical care settings for children:

Initial assessment and stabilisation

ABCDE technique: This methodical technique entails evaluating the airway, breathing, circulation, disability, and exposure.

A – check for airway patency. Determine at risk or not at risk of obstruction.

B – the breathing sufficient

C – assess circulation for perfusion

D – evaluate the neurological status using GCS or AVPU

E – expose the infant while keeping them warm.

Vital Signs: Take your blood pressure, temperature, heart rate, breathing rate, oxygen saturation and pain score assessment.

During this assessment, any irregularities ought to be taken care of right away before the next category is done.

5.3.1 History

A focused history that covers the child’s presenting complaints, medical history, current medications, recent illnesses, immunization status, and events leading up to the current presentation should be obtained from caregivers.
Inquire about symptoms like fever, coughing, breathing problems diarrhoeaa, vomiting, lethargy, seizures, trauma, or toxin intake.

5.3.2 Physical examination

Examine the child thoroughly, beginning with a general assessment of their look and state of consciousness.
Perform a comprehensive examination from head to toe, encompassing evaluation of the respiratory, neurological, gastrointestinal, abdominal, cardiovascular, renal, and musculoskeletal systems.
Keep an eye out for symptoms of trauma, dehydration, altered mental status, cyanosis, irregular breath sounds, abnormal heart sounds, and respiratory distress.

5.3.3 Focused assessment and investigations

• Prioritize testing including blood tests (e.g., complete blood count, electrolytes, blood gas analysis), imaging studies (e.g., chest X-ray, ultrasound, CT scan), and

• other tests (e.g., ECG, echocardiogram, lumbar puncture) based on the first assessment and history.
  If available and appropriate, take into consideration bedside testing such as point-of-care ultrasound or quick diagnostics for infectious disorders.

5.3.4 Management and treatment

Based on the results of the diagnostic tests and clinical findings, begin the necessary treatment. This can involve the use of supportive care measures, oxygen therapy, fluid resuscitation, and drug delivery (such as antibiotics, inotropes, analgesia and sedatives).

Prioritize treating life-threatening disorders including shock, respiratory failure, and obstruction of the airway.

5.3.5 Monitoring and reassessment

Monitoring is a cardinally important part of critical care. It allows for evaluation of the patient’s response to interventions. Patients with critical illness or injury require more frequent monitoring in the first 24-48 to identify deterioration patients or those not responding to treatment. Keep a close eye on the child’s vital signs, reaction to therapies, and general state of health.

Regularly reevaluate the child and modify the management plan in response to treatment response and changes in the child’s clinical status. If resources permit all patients should be on patient monitor for continuous vital signs evaluation. Additional staffing may be required or assigned to monitor and alert other clinicians of abnormal values. This will ensure a timely response.

5.3.6 Multi-disciplinary and referral

Critical illness may involve or result or lead to multiple pathologies as a result multidisciplinary team approach to care cannot be over-emphasised. If additional evaluation and management are needed, consult with the appropriate specialists (paediatric surgeons, paediatric intensivists, neurologists, infectious disease specialists, etc.).

MDT in critical care involves discussing patients in detail with the appropriate specialist(s) to determine the best care for the desired outcome. If the child’s condition calls for specialized interventions or resources not provided by the current facility, consider transferring to a higher level of care.

5.3.7 Family centred care

The family’s role in providing care for a sick child must always be considered during management. Recall that the patient is best known by their parents, guardians, or relatives. Their engagement from the patient’s history to recognizing and comprehending their condition will be optimal.

Involve caregivers in decision-making wherever possible, respecting their choices and cultural views. Communicate effectively with the child’s caregivers, giving them updates on the child’s status, outlining the planned interventions, and answering any worries or questions they may have.

5.4 Interventions

Children who are critically ill require emergent and timely life-sustaining interventions. Resuscitation and supportive care are two interventions that are usually utilized to revive patients and assist vital organs to recover until they can function within the survivable level.

5.4.1 Resuscitation

The process of treating a critically ill patient’s physiological abnormalities is known as resuscitation, and it occurs in every hospital department. It involves various methods that call for a broad range of capabilities that have been systematically developed and applied over time.(Arias et al. 2024)

It refers to the act of reviving someone from apparent death or unconsciousness because of cardiorespiratory arrest, often involving procedures such as chest compression, ventilation, cardiac massage, and the use of a defibrillator.(Lewis and McConnell 2018)

Clinical presentation of cardiac arrest in children presents differently from adults. Cardiac (shock), respiratory (respiratory tract infection) and gastrointestinal (diarrhoea and vomiting) conditions are the common predisposing risks that get children into cardiorespiratory arrest.(Meghani 2021) Children frequently move to cardiac arrest through respiratory or circulatory failure, the pre-arrest period in children is typically characterized by respiratory distress or failure, shock, or a combination of these factors.

5.4.2 Critical organ dysfunction or failure

Manifestation of children’s pre-cardiac arrest stage includes:

1. Respiratory distress
   1. Increased work of breathing: Using auxiliary muscles, nasal flaring, grunting, and retractions (intercostal, subcostal, and suprasternal).
   2. Abnormal breath sounds including crackles, stridor, wheezing, or reduced breath sounds.
   3. Alterations in breathing pattern: Bradypnea (slow breathing) or tachypnoea (fast breathing).
2. Respiratory failure
   1. Cyanosis: Bluish discolouration of the skin, especially around the lips and fingertips, indicating hypoxemia.
   2. Altered Mental Status: Lethargy, irritability, or unresponsiveness due to inadequate oxygenation.
   3. Apnoea: Periods of stopped breathing or significant pauses in breathing.
3. Circulatory impairment/failure (shock)
   1. Tachycardia or abnormally rapid heart rate is frequently the result of an early compensatory mechanism.
   2. Hypotension: Low blood pressure in children is a late and concerning sign.
   3. Poor perfusion: Cold, clammy skin; longer than two seconds for capillary refill; sluggish or non-existent peripheral pulses.
   4. Altered mental status: Incomprehension, agitation, or a reduction in reactivity.
4. Neurological dysfunction
   1. Altered Mental State: Diminished level of alertness, agitation, or lethargy.
   2. Seizures: In children with known seizure disorders, a new or alterations in seizure patterns.
5. Vital Sign Changes
   1. Abnormal Heart Rate: Tachycardia is common, whilst bradycardia is usually a late sign suggesting severe deterioration.
   2. Abnormal Respiratory Rate: Both tachypnoea and bradypnea are worrying.
   3. Hypotension: in children, it is frequently a late sign of shock.
6. Laboratory and Monitoring Data:

   1. Hypoxemia: arterial saturation as measured by pulse oximetry.

   2. Hypercapnia: Elevated carbon dioxide readings, indicating inadequate ventilation.

   3. Metabolic Acidosis: Blood gas analysis shows a drop in blood pH and bicarbonate levels, indicating poor tissue perfusion and oxygenation.

Management of pre-cardiac arrest and cardiac arrest involves prevention by identifying patients at risk, monitoring and managing complications, cardiopulmonary resuscitation, and in advanced cases supportive care,

5.4.3 Early Recognition and Monitoring:

• Frequent or continuous monitoring of vital signs, including HR, RR, CRT, and SpO2 with or without BP.
• Repeated assessments of mental status and perfusion indicators.
• Following assessment and monitoring, any abnormalities should be responded to with appropriate interventions such as low SpO2 should be given oxygen and respiratory support for respiratory failure.

5.4.4 Supportive therapy

Aside from resuscitation among patients with cardiac arrest, those in pre-arrest or return of spontaneous circulation post-resuscitation need supportive care.

Respiratory Support:

• Providing oxygen therapy, non-invasive ventilation (e.g., CPAP or BiPAP), or mechanical ventilation if needed.
• Clearing airway obstructions and ensuring proper airway management.

Circulatory Support:

• Administering fluids judiciously to treat hypovolemia.
• Using vasoactive medications like epinephrine or norepinephrine for shock.

Treating Underlying Causes:

5.4.5 Optimisation of oxygen delivery

Prevention of cardiac arrest or restoration after cardiac arrest of a patient to health requires optimisation of the oxygen-carrying capacity of blood and flow of blood to the tissues. These require

1. Provide oxygen to the lungs so that red blood cells can take it
2. Sufficient haemoglobin levels to bind oxygen
3. Improve cardiac contractility to guarantee enough blood pumping optimum vascular tone for all tissue beds to be perfused
4. Effective intravascular volume to provide sufficient blood flow to the heart’s right side.

Children with critical illness require early identification, institution of timely intervention, assessment and effective monitoring.  Understanding the complex interaction of clinical, infrastructural, workforce, family, and systemic factors affects the outcomes of pediatric critical illness in hospitals. Improving these parameters using focused interventions, distribution of resources, education, and modifications to policies can greatly enhance the standard of care and survival rates for children with critical illness.

Appiah, J A, S Salie, A Argent, and B Morrow. 2018. “Characteristics, Course and Outcomes of Children Admitted to a Paediatric Intensive Care Unit After Cardiac Arrest.” Southern African Journal of Critical Care 34 (2): 58. https://doi.org/10.7196/sajcc.2018.v34i2.355.

Arias, Anita V, Michael Lintner-Rivera, Nadeem I Shafi, Qalab Abbas, Abdelhafeez H Abdelhafeez, Muhammad Ali, Halaashuor Ammar, et al. 2024. “A Research Definition and Framework for Acute Paediatric Critical Illness Across Resource-Variable Settings: A Modified Delphi Consensus.” The Lancet Global Health 12 (2): e331–40. https://doi.org/10.1016/s2214-109x(23)00537-5.

Lewis, Grant, and Paul McConnell. 2018. “Ethical Issues in Resuscitation and Intensive Care.” Anaesthesia & Intensive Care Medicine 19 (12): 644–47. https://doi.org/10.1016/j.mpaic.2018.09.004.

Meghani, Shaista. 2021. “Witnessed Resuscitation: A Concept Analysis.” Intensive and Critical Care Nursing 64 (June): 103003. https://doi.org/10.1016/j.iccn.2020.103003.

Sakaan, Firas, Adrian Holloway, Qalab Abbas, John Appiah, Jonah Attebery, Paula Caporal, Ericka Fink, et al. 2022. “643: ESTIMATING THE GLOBAL PREVALENCE OF PEDIATRIC ACUTE CRITICAL ILLNESS IN RESOURCE-LIMITED SETTINGS.” Critical Care Medicine 51 (1): 311–11. https://doi.org/10.1097/01.ccm.0000908304.12117.81.