Pediatric ICU Considerations

Pediatric ICU Levels

As with trauma centers and neonatal ICUs, pediatric ICUs may be classi­fied by level based on their resources and capabilities. Classifications for pediatric ICUs have been developed by the AAP and the Society of Critical Care Medicine (SCCM).

It has been demonstrated that critically ill or injured children admit­ted to a pediatric ICU, with its concentration of specialized personnel and resources, have an improved outcome compared with pediatric patients admitted to an adult ICU. Despite this, approximately 7% of hospitals in the United States report that they routinely admit children requiring intensive care to an adult ICU rather than transferring them to a pediatric facility. The practice seems to be more common with trauma patients, in which up to 10% of hospitals have reported a practice of admitting critically injured children to an adult ICU.

Burn Centers

The management of pediatric burn patients may require specific resources, because serious burns are uncommon and highly complex. Although adult burn units commonly are found at major medical centers, specialized care for pediatric burn patients is concentrated among a small number of facili­ties, such as the nationwide Shriner's Hospital system. Transfer to a pediatric burn center is often a secondary or even tertiary transport following resus­citation and/or stabilization at a community hospital or pediatric institution without a burn unit.

For the most part, pediatric burn centers are accustomed to receiving patients in transfer from other institutions, although some may be prepared to accept patients directly from the field under certain circumstances. Critical care transport programs should work with the closest regional pediatric burn center to develop procedures for the triage of seriously burned children directly to the burn center or in secondary transfer following resuscitation and stabilization at another facility. The American Burn Association has developed guidelines for transfer of pediatric patients to a pediatric burn center, as shown in Table 20.2 (http://www.ameriburn.org).

Burn patients are often transported by helicopter, but in many cases, air transport may be unnecessary because of an observed practice of “over­triage.” Studies have demonstrated that referring physicians regularly over­estimate burn size, favoring the use of air transport and increasing the costs of acute burn care.

Table 20.2: American Burn Association Burn Unit Referral Criteria

1. Partial-thickness burns greater than 10% total body surface area (TBSA)

2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints

3. Third-degree burns in any age group

4. Electrical burns, including lightning injuries

5. Chemical burns

6. Inhalation injury

7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality

8.

9. Burned children in hospitals without qualified personnel or equipment for the care of children

10. Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention

Adapted from American College of Surgeons, Committee on Trauma. Guidelines for the operations of burn units. In: Resources for Optimal Care of the Injured Patient. Chicago, IL: American College of Surgeons; 2006:79-86.

Hyperbaric Oxygen Therapy

Treatment in a hyperbaric oxygen chamber is available at selected centers in the United States. The most common indications for emergency use of hyperbaric oxygen therapy are acute carbon monoxide (CO) poisoning and cerebral air embolism (“the bends”) from decompression accidents, as occur with scuba diving. For patients with CO poisoning, arterial oxygen content is reduced by the very high affinity of CO for hemoglobin. Administration of 100% oxygen at atmospheric pressure will reduce the level of carboxyhe­moglobin in the blood over several hours’ time. Hyperbaric oxygen therapy (HBOT) has the theoretical additional benefits of accelerating the reduction in carboxyhemoglobin and increasing the concentration of dissolved oxygen in the blood, thus improving oxygen delivery to the tissues, especially the brain. In decompression sickness, patients who breathe pressurized gas mix­tures and return to atmospheric pressure too quickly may be harmed by the formation of gas bubbles in the tissues as the solubility of the gas in the blood decreases. In these cases, treatment of the patient under hyperbaric condi­tions will permit the gas to redissolve in the blood, after which the rate of decompression can be carefully controlled.

As with all emergency care, standard resuscitation and stabilization mea­sures take priority over adjunctive therapies such as HBOT. For example, a patient with CO exposure from a house fire also might have thermal burns, inhalation injury, and/or cyanide toxicity and should be treated first for problems with the airway, breathing, and circulation. After the immediate life-threatening problems have been identified and treated, the risks and ben­efits of additional therapies such as HBOT should be considered on the basis of the patient's condition and the severity of the suspected CO intoxication.

In general, patients who are unconscious after exposure to CO or those with a carboxyhemoglobin concentration of more than 40%, are considered candidates for HBOT. However, a patient with acute lung injury may be served best by admission to an ICU for expert management of mechani­cal ventilation. Given that controversy exists about the efficacy of HBOT in preventing or ameliorating the neuropsychiatric sequelae of CO intoxication, especially in pediatric patients, the transport destination should not routinely be determined by the availability of a hyperbaric oxygen chamber. Guidelines should be developed, in concert with the HBOT medical director and per­sonnel, regarding when direct transport to HBOT should be considered, with an emphasis on ensuring optimal pediatric assessment and monitoring in the HBOT location. This should include expectations for which physicians, nurses, and technicians will attend to the patient during the treatments, at the bedside and outside the chamber.

Implantable Pacemakers and Automated Internal Cardiac Defibrillators

Although primary cardiac disease is encountered less frequently in children than in adults, there is a population of children with congenital or acquired heart disease for whom there may be special considerations during critical care transport. Children with conduction system abnormalities often require placement of an implantable pacemaker, even during the neonatal period.

Organ Procurement and Transplantation

Solid organ transplantation is a highly specialized area of medicine that requires the close cooperation of multiple agencies, programs, and person­nel. In most states, there is a mandatory requirement to notify the regional organ procurement organization (OPO) when a diagnosis of brain death is considered or when a patient dies. The success of an organ transplant proce­dure is determined by many factors, among which are time to procurement and time to transplant following harvest (ischemic time). Most patients who are evaluated and listed for organ transplantation are required to relocate to the vicinity of the transplant center so that they can respond rapidly for surgery in case an organ becomes available. More often than not, however, it is necessary for the transplant team to travel to procure the organ and transport it back to the transplant center. In certain cases, transport teams may be requested to facilitate the transport of medical personnel or of the organs themselves because of the time-sensitive nature of the process. The United Network for Organ Sharing (UNOS) has published guidelines for the transport of organs for transplantation within the United States. In general, it is the responsibility of the “host” OPO (ie, the organization that makes the organ available) to make arrangements to transport the organ to the receiv­ing facility. Interestingly, the costs of transporting a kidney are borne by the host OPO, whereas the costs associated with the transport of other organs are the responsibility of the recipient facility. Transport team members should not be expected to package, label, or handle the organ for transplanta­tion, which is the responsibility of the host OPO.