The use of a radioisotope scan has been limited since the development of the CT scan. The child is held in place with the back close to the edge of the examination table.
Brain Tissue Oxygen Monitoring
Verify low SjVO2 levels: check the light intensity indicator on the monitor, send a blood sample for laboratory measurement, reposition the patient's head and neck, and flush the catheter with 2 to 3 mL of normal saline. If a percutaneous blood sample is obtained from a site close to the jugular bulb (within 2 cm), withdraw the blood sample at a minimum rate of 2 ml/min to avoid extracerebral contamination.
Near-Infrared Spectroscopy
The height of the drip chamber relative to the reference point controls the rate of CSF drainage. CSF flow is controlled by physician order (ie, drip chamber level), initial problem, and hydration status.
Internal Ventricular Shunt
CSF drains automatically when the ICP is greater than the pressure created by the level of the drip chamber (1 mmHg equals 1.36 cm H2O). Assess for fluctuation of the CSF fluid in the tube with each heartbeat and breath (if the system does not have a one-way valve).
Antimicrobial Therapy
Louis virus, herpes simplex type 2, varicella zoster, HIV, mumps virus, measles virus, lymphocytic choriomeningitis virus. Louis virus, Eastern equine virus, Powassan virus, herpes simplex type 1, influenza virus, HIV, rabies virus.
Hyperosmolar Therapy Used to Control Cerebral Swelling
Treatment with acyclovir should be initiated in all suspected cases of encephalitis until the results of diagnostic studies are available. Other antiviral drugs commonly used to treat some forms of encephalitis include ganciclovir and foscarnet (elderly patients and adults).
Anticonvulsant Medications Used to Control Seizures
Evidence-based guidelines: Treatment of status epilepticus in children and adults: Report of the guideline committee of the American Epilepsy Society. Vasogenic edema occurs after vascular injury (eg, abscess, hemorrhage, infarction, and contusion), tumors, or disruption of the BBB and accumulation of extracellular fluid.
Pathophysiology
Progression of the herniation may occur with unilateral displacement of the uncus on the medial temporal lobe through the tentorial notch. Downward displacement of one or both cerebellar tonsils (downward tonsillar herniation) occurs through the foramen magnum.
Clinical Presentation
A central herniation is a symmetrical displacement of the cerebral hemispheres, basal ganglia, diencephalon, and midbrain downward through the tentorial notch. On the other hand, increased ICP may be irreversible due to cytotoxic edema and neuronal death.
Patient Care Management
Steroids are used in children with certain neurological conditions (for example, brain tumors); however, its use is not recommended in patients with TBI (Kochanek et al., 2012). Unlike SIADH, where there is free water retention (euvolemia or hypervolemia) and hyponatremia due to elevated ADH, CSW syndrome is associated with hyponatremia with hypovolemia (Maesaka et al., 2014).
Outcomes
Barbiturate coma is generally used when all other conventional therapies have been exhausted in hemodynamically stable patients with a salvageable head injury (Kochanek et al., 2012). Corrects sodium disturbances due to diabetes insipidus (DI), syndrome of inappropriate antidiuretic hormone (SIADH), or cerebral salt wasting syndrome (CSW).
Definition and Etiology
Classification of seizures varies among experts, but the International League Against Epilepsy (ILAE) Commission on Classification and Terminology divides seizures into two broad classifications: focal and generalized (Berg et al., 2010). The underlying types (etiology) of seizures are genetic, structural/metabolic and unknown (Berg et al., 2010).
Clinical Presentation 1. History
Structural abnormalities that may be the cause of the seizure should be investigated and neuroimaging recommended (eg, an MRI or CT scan). In most patients, the incidence of epileptiform discharges is highest in the first 24 hours; however, in some children, the EEG immediately after a seizure may be normal or with nonspecific findings.
Patient Care Management 1. Preventive Care
Most AIS in children occur in the distribution of the middle cerebral artery (Rosa et al., 2015). Focal signs may be present that correlate with the location of the hemorrhage (Lanni et al., 2011).
Patient Care Management 1. Preventative Care
Forelimb syndrome from damage to the forelimb results in loss of motor function below the level of the injury. Neurological deficits in the spinal cord often increase in the immediate hours after the injury.
OUTCOMES
Traditionally, growing rods are implanted above and below the curve and then surgically lengthened every 6 to 12 months. The device is then used to widen the ribs every 2 to 3 months as the baby continues to mature skeletally (Watts, 2016).
Description and Etiology
B. The patient requires immediate evacuation of the epidural hematoma and control of bleeding
Due to the flexibility of the pediatric cervical spine, significant spinal cord injury is possible, significant spinal cord injury is possible without obvious vertebral injury. If elevated ICP is suspected, lumbar puncture should be delayed until normal ICP is confirmed.
B. The meningitis is viral and antibiotics are not indicated
Guidelines for determining brain death in infants and children: an update of the 1987 task force recommendations - Executive summary. Management of stroke in infants and children : a scientific statement from a special writing group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young.
Anatomic Location
Anatomic Structure
RENAL SYSTEM
Basic Transport Mechanisms
For example, if water is reabsorbed from the tubule and urea concentration in the tubule increases, urea diffuses out of the tubule. For example, as sodium is reabsorbed from the tubule and its concentration outside the tubule increases, water flows out of the tubule to balance the concentration gradient.
Urine Formation
Renal tubule segments use special transport modes to reabsorb certain substances. The primary "driver" for most proximal tubular transport is active sodium transport.
Water and Sodium Balance
The concentration of sodium is greater in the lumen of the tubule than in the cells surrounding the tubule, so sodium moves into the tubule cells. As water is reabsorbed from the filtrate into the peritubular capillaries, the substances remaining in the tubule become more concentrated.
Electrolyte Balance 1. Potassium Ion (K + )
Aldosterone increases sodium reabsorption by increasing the number of sodium channels in the apical plasma membrane of the principal cell. Hyponatremic metabolic acidosis can be treated with administration of sodium, partly in the form of sodium bicarbonate.
Regulation of Acid–Base Balance
Renal phosphate excretion is the body's primary mechanism for phosphate regulation; therefore, patients with renal failure are at high risk of hyperphosphatemia. Hypocalcemia stimulates the release of PTH, which decreases renal calcium excretion and increases urinary phosphorus excretion.
Regulation of Arterial Blood Pressure
The carbonic acid quickly dissociates and diffuses into the tubular cell, where carbonic anhydrase catalyzes the reaction between CO2 and H2O to form HCO3– and H+. If an increase in filtrate bicarbonate is secondary to increased serum concentration, bicarbonate excretion is increased.
Regulation of RBF
As angiotensin I circulates in the lungs, it is converted to angiotensin II (and also produces aldosterone).
Elimination of Toxins and Metabolic Wastes 1. Urea is produced in the liver as a by-product of
- Stimulation of Bone Marrow Erythrocyte Production
Imaging
Low RBF or abnormal blood flow associated with renal artery stenosis may also be detected. Dimercaptosuccinic acid scan (DMSA) is the critical test for renal scarring associated with reflux as well as detection of urinary obstruction and urinary leakage.
Laboratory Evaluation
Causes
The side effects of the accumulation of uremic toxins are obvious (fullness, insomnia, itching, slurred speech, anorexia, nausea, vomiting, confusion, asterixia, seizures, coma). AKI secondary to postrenal failure is a relatively small percentage of AKI cases, but it is an important cause of renal failure in newborn males with posterior urethral valve.
Laboratory Findings in AKI
Uremic pericarditis occurs only in the presence of long-standing severe renal failure and is due to chemical irritation of the pericardium secondary to the metabolic abnormalities. IV administration of bicarbonate in the form of sodium bicarbonate or THAM may be necessary for significant correction (Table 5.7).
Management of AKI
Thiazide diuretics inhibit sodium reabsorption in the distal tubules, leading to excretion of sodium, chloride, potassium, bicarbonate, magnesium, phosphate, calcium, and water. Non-thiazide sulfonamide diuretics inhibit sodium reabsorption in the cortical dilution site and proximal tubules, resulting in increased excretion of sodium and water, as well as potassium and hydrogen ions.
Types of HUS
It is the most common cause of acute renal failure in young children (Kliegman, Stanton, St. Geme, & Schor, 2016).
Outcomes
Patients who are resistant to steroids or have frequent relapses can be treated with cyclophosphamide. In addition, antibody titers to other antigens such as antistreptolysin O or antihyaluronidase, DNAase-B, and streptokinase demonstrate recent streptococcal infection and may be elevated.
Hepatorenal Syndrome
Acute glomerulonephritis refers to a specific group of renal diseases (such as lupus nephritis and poststreptococcal nephritis) resulting from immunological mechanisms that cause inflammation and proliferation of glomerular tissue. Clinical signs and symptoms include salt and water retention due to decreased GFR, RBC, or granular casts in the urine, decreased renal function, hypertension, hematuria, oliguria, and other nonspecific symptoms such as fever, malaise, abdominal discomfort , nausea, or vomiting.
Tumor Lysis Syndrome
Cardiac Failure and Cardiopulmonary Bypass Changes in renal function may be attributed to hypo-
Rhabdomyolysis
Renal failure can result from myoglobinuria resulting from ferrihemate toxicity, tubular obstruction, altered GFR, hypotension, and crystal formations. Prevention of renal failure depends on prompt and aggressive treatment that includes volume depletion and maintaining high urine output.
Methods of Solute Clearance and Water Removal: Convection, Diffusion, Ultrafiltration
Aspartate aminotransferase and alanine aminotransferase may also be elevated when released from the necrotic muscle.
Peritoneal Dialysis
Smaller solutes, such as creatinine, urea, and potassium, are distributed down a concentration gradient in peritoneal dialysis, and removal is maximal at the beginning of the stay. After the dwell time is over, the catheter is unclamped and the leak is drained into a urine collection bag for measurement.
Hemodialysis
Failure of ultrafiltration may occur as a result of failure to remove PD fluid that meets the patient's volume balance needs. If the extracorporeal circulation volume is greater than 10% of the child's circulating blood volume or if the child weighs less than 10 kg, the circulation may be filled with colloidal material.
Continuous Renal Replacement Therapy 1. Indications for CRRT include ARF with hemo-
Depending on the extracorporeal volume of the circuit compared to the size of the child, a significant amount of heat can be lost through the circuit. The goal of therapy is to maintain ionized calcium levels below 0.5 mmol/L.
Etiology and Risk Factors
Urological issues must be addressed before transplantation, and the patient must be free of any major multi-system complications (malignancy, advanced cardiopulmonary disease) and active infection. Nutritional status should be optimized, and psychiatric and socioeconomic parameters should be considered as appropriate (Chaudhuri, Gallo, & Grimm, 2015).
Clinical Manifestations
Classification
Desired Patient Outcomes 1. Absence of hematuria
Treatment
Background
Summary of Guidelines
Effectiveness
Her mother says she and the girl's father had mild nausea and vomiting after eating at a fast food restaurant last week.
CRRT B. Hemodialysis
- C. Peritoneal dialysis is the preferred mode of dialy- sis for this diagnosis at this time
- D. Per Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelines, this
The presence of ectopy is alarming, likely a symptom of hypo-ectopy is alarming, likely a symptom of hypokalemia. Many of the most powerful therapies used in the pediatric intensive care unit (PICU) are media.
Endocrine Glands
Integrated functions include input from the central nervous system (CNS) to the endocrine system via the hypothalamus-pituitary complex. Most diseases of the endocrine system occur due to hypersecretion, hyposecretion, altered response at the tissue level, or tumors in an endo.
Hormones
Functions of the endocrine system include control and regulation of metabolism, maintenance of energy stores, growth and development, reproduction and sex differentiation, growth and coordination of the body's response to stress (e.g., trauma, critical illness, infection, major surgery) through the secretion of counter.
ENDOCRINE SYSTEM
Feedback Mechanism
Feedback loops are used to regulate hormone secretion in the hypothalamic pituitary loop (Figure 6.1). Negative feedback (Figure 6.2) is the main mechanism in the control of hormonal regulation and prevents the overproduction of hormones in their pitch.
Hypothalamic–Pituitary Complex (Neuroendocrine System)
Somatostatin is secreted by cells in the periventricular area (located above the optic chiasm) in the hypothalamus and. A decrease in circulating blood volume sensed by the baroreceptors in the carotid sinus of the aortic arch also stimulates ADH release.
Thyroid Gland
Sick euthyroid syndrome is discussed in the section Thyroid-stimulating hormone, Role in critical illness. Calcitonin or thyrocalcitonin is a polypeptide produced by the parafollicular or C cells of the thyroid gland.
Parathyroid Glands
The PTH response to hypocalcemia develops slowly in infants during the first weeks of life (Brashers et al., 2014; Dattani & Gevers, 2016). It is stored in secretory granules in the cytoplasm of principal cells (Brashers et al., 2014).
Pancreas 1. Embryology
Hyperglycemia, high levels of circulating fatty acids and somatostatin suppress the release of glucagon (Brashers et al., 2014). Somatostatin is a polypeptide synthesized from the islet cells and secreted by the delta cells of the pancreas (Brashers et al., 2014).
Adrenal Glands 1. Embryology
- Hyperfunction of adrenal medulla is rare, and is most often caused by a catecholaminesecreting
Epinephrine secretion is 80% of the total catecholamine secreted by the adrenal medulla and at rest it is released at 0.2 mcg/kg/min (Hall, 2016). Other effects of stimulation of the beta2adrenergic receptors are bowel, bladder and uterine relaxation, and bronchial dilation.
History
This tumor arises when the adrenal gland's chromaffin cells fail to involute and the excess production can cause life-threatening hypertension, tachycardia, diapho. Pheochromocytoma is a catecholamine-secreting tumor that can cause life-threatening hypertension, hyperthermia, and cardiovascular collapse.
Physical Assessment
- Respiratory assessment includes the rate and depth of respiration, any alterations of breath odor,
- Abdominal assessment notes the presence of bowel sounds, tenderness or pain, with notice of
- Genitourinary assessment includes palpation of the kidneys; examination of external genitalia and
- Musculoskeletal assessment includes evaluation for disproportionate growth or body habitus with
- Check general appearance for cleanliness, alert
Musculoskeletal assessment includes assessment for disproportionate growth or body habitus with disproportionate growth or body habitus with reported limb length discrepancy. Define basic short-term and long-term memory by developmental level (Babler et al., 2013; Brashers et al., 2014).
Diagnostic Studies
Ultrasound of the neck and abdomen is used to determine kidney and pancreas function, to evaluate thyroid, adrenal, and pancreatic tumors, and to determine function. Pediatric research is aimed at quick and accurate diagnosis and the best treatment algorithm.
Pathophysiology
CIRCI is a relatively new diagnosis in adult intensive care and its presence is rapidly gaining ground in the pediatric intensive care literature.
Etiology and Risk Factors
Lab Data
Interpretation of Diagnostic Studies
Diagnoses
- Complications
This catabolism leads to immunodeficiency, which can lead to poor wound healing and can increase the risks of hospital-acquired infections (von Saint Andrevon Arnim et al., 2013). It usually develops in people of Asian or African descent and can be a result of other diseases such as pancreatitis (Brashers et al., 2014).
Diabetic Ketoacidosis
- Complications a. Acute
Glycogenolysis (breakdown of glycogen), gluconeogenesis (synthesis of glucose from non-carbohydrate sources), proteolysis, and lipolysis contribute to the metabolic changes of DKA (Brashers et al., 2014; Sperling et al., 2014). The white blood cell (WBC) count is elevated with a shift to the left (Sperling et al., 2014).
Precipitating Factors
This condition leads to the release of harmful cytokines and impairment of coagulation pathways (V. Srinivasan & Agus, 2014). This delay can lead to profound shock, renal dysfunction, altered mental status or coma, rhabdomyolysis, hyperthermia, and ventricular arrhythmias (Price, Losek, & Jackson, 2016; Zeitler et al., 2011).
Signs and Symptoms (Table 6.5)
Serum sodium levels may be high, low, or normal with whole body sodium depletion secondary to urinary loss or dilutional hyponatremia secondary to hyperglycemia. Neurological impairment is significantly higher in children with HHS than in children with DKA because of hyperosmolality and its consequences.
Interpretation of Diagnostic Studies (Table 6.5) 1. Hyperglycemia is due to relative deficiency
Diagnoses
Treatment Goals
Complications
Etiology
Risk Factors
- Congenital hyperinsulinism
Signs and Symptoms
- Hepatomegaly and lactic acidosis suggests gly
- Low GH and cortisol levels indicate hypopituitarism
- Abdominal CT scan is rarely used to determine the presence of a pancreatic tumor or other anomalies
- Abdominal ultrasound can identify location and presence of an insulinoma. Insulinoma can be con
When low glucose is obtained, in new onset hypoglycemia, send critical labs before correction is made to help differentiate the causes of hypoglycemia. Additional urine tests should be sent with the first void after the hypoglycemic event and may be a bag together.
Treatment Goals
Abdominal CT is rarely used to determine the presence of a pancreatic tumor or other anomalies.
Management
When the body detects hypernatremia or rising osmolality, ADH is released to cause water retention or volume expansion (von Saint Andrevon Arnim et al., 2013). Transient cases are common after pituitary surgery and may last as long as 5 to 7 days after the inciting event (Table 6.6; Brashers et al., 2014).
Signs and Symptoms
Chronically ill or malnourished children may develop chronically increased secretion of ADH due to a decreased osmotic receptor reset; hyponatremia is chronic and ADH secretion occurs with a low serum osmolality g.
Laboratory Data
If hypervolemia remains, a loop diuretic can be judiciously used (von Saint Andrevon Arnim et al., 2013). Symptoms include tremors, nebulization, amnesia, coma and seizures (von Saint Andrevon Arnim et al., 2013).
Etiologies and Risk Factors
Signs and Symptoms (see Table 6.7)
Interpretation of Diagnostic Studies
Possibility of acute or chronic neurological insult related to underlying disease or too rapid rise in serum osmolality.
Management
Natriuretic peptides act on the renal tubules and cause inhibition of water and sodium reabsorption (Yee et al., 2010). Studies linking cerebral vasospasm and elevated BNP levels suggest a causal relationship between brain injury and the development of this hypovolemic, hyponatremic state (Yee et al., 2010).
Etiology and Risk Factors 1. Conditions Associated With CSW
The validity of CSW as a disease process has been debated in the literature since its description in 1950. The second theory involves natriuretic peptides (ANP, DNP, BNP and Ctype natriuretic peptide), which occur in the body to protect during periods of hypervolemia and sodium retention by promoting vascular relaxation.
Signs and Symptoms (Table 6.8)
- C. CSW is a hypovolemic, hyponatremic disor
- B. Cerebral edema is a rare but lifethreatening com
- C. Treatment of cerebral edema should begin at recognition: administering hypertonic saline or
Fluid should be given in the PSC to supplement the hypovolemic state caused by natriuresis and diuresis. Urine sodium levels are useful in guiding care and should be monitored with serum Na levels.
Embryologic Development of the Digestive Tract (Figure 7.1)
Gastric Activity
Immature Neonatal Liver
Structure and Function (Figure 7.2)
GASTROINTESTINAL SYSTEM
General Principles of Abdominal Assessment Examination of the abdomen can be difficult in a child
Abdominal Examination Assessment Techniques
Percussion is used to assess organ size and aid in the diagnosis of ascites, obstruction, and peritonitis. The absence of dullness over the liver can be determined by free air in the abdomen due to perforation.
Developmental Considerations
Bilirubin Bilirubin is a by-product of the heme part of the breakdown of the hemoglobin molecule. Ammonia Ammonia is formed from the deamination of amino acids during protein metabolism and is a by-product of the breakdown of colon bacteria proteins.
Antiulcer/Gastroesophageal Reflux Disease Agents
Side effects include bradycardia, tachycardia, nausea, diarrhea, abdominal cramps, headache, dizziness, rash, elevated liver enzymes, hypomagnesemia, proteinuria, rash, and thrombocytopenia. Side effects include hypertension, hypotension, nausea, dyspepsia, abdominal pain, diarrhea, constipation, elevated liver enzymes, dizziness, and headache.
Prokinetics
Antidiarrheal Agents
Other Agents
Side effects include metabolic acidosis, potential for electrolyte disturbances, nausea, cramps, and abdominal distension. Side effects include metabolic acidosis, potential for electrolyte disturbances, nausea, cramps, and abdominal distension.
Immunosuppressive Therapy
Side effects include bone marrow suppression (anemia, leucopenia), hepatotoxicity, pancreatitis, nausea and vomiting, increased risk of malignancy and mucosal ulceration. Body mass index z-scores should be used to screen for extreme values (weight for height <2 years) or weight for age (if accurate height is not available; Mehta et al., 2017).
Macronutrient, Micronutrient, and Fluid Requirements
Thirty-one percent of pediatric intensive care unit (PICU) patients in an international prevalence survey of 31 PICUs were determined to be malnourished (Mehta et al., 2012). For obese patients, this guideline should be based on ideal body weight (Mehta et al., 2017).
Enteral Nutrition
Parenteral Nutrition
Protein provides 4 kcal/g and should constitute up to 14% to 20% of the total caloric composition of PN. It is not known when to start PN and it should be individualized and started within the first week of admission if they cannot receive enteral nutrition (EN) or for severely malnourished patients or those at risk of nutritional deterioration (Mehta et al ., 2017).
NG Tube
Protein can be administered as trophamine (recommended for infants under 1 year and for children with liver failure), or as clinisol or travasol (for children over 1 year). Fat emulsions (intralipid) can be administered as a separate solution to provide an important source of calories (20% solution provides 2 kcal/.ml) and should comprise 30% to 50% of total PN caloric intake.
Gastrostomy Tube
Nasojejunal Tube
Once placement in the stomach has been achieved, the tube should be passed through the pylorus, introducing air or water, and advanced until resistance is met. Nursing care includes securing the tube appropriately to prevent accidental dislodgement, and may be secured with a bridle, flushing the tube after administering medication or bottle feeding, and performing oral care every 4 hours.
Surgical Drains
If this is not tolerated, the child must be placed on his back with the head of the bed raised.
Wound Care
Ostomy Care
The evisceration of the abdominal contents, usually lateral and to the right of the navel, can be either the small or large intestine. Hernia of the intestine into the thorax with resulting lung hypoplasia (usually left; right may be affected if the mediastinum is displaced).
Patient Care Management 1. Direct Care
Total bilirubin is increased with most bilirubin in TABLE 7.13 Grading criteria for necrotizing enterocolitis. Kernicterus is the presence of yellow pigment in the basal ganglia of the brain and is a complication of severe unconjugated hyperbilirubinemia.
Patient Care Management 1. Acalculous
Weight measurements are more reliable if the child is weighed on the same scale at the same time every day. Initially, when stools are frequent and watery, the child is NPO and maintenance fluid requirements are provided intravenously.
Acute Liver Failure 1. Definition of ALF
The risk of developing FHF increases with continued use of the drug in the presence of developing hepatitis. The type of renal failure must be carefully distinguished before appropriate treatment can be instituted.
Chronic Liver Failure 1. Definition
A central shunt (portacaval shunt) is created by anastomosis of the portal vein to the inferior vena cava. Children with biliary atresia or those with small bile ducts require biliary reconstruction of part of the intestine.
Complications and Outcomes 1. Rejection
An upper GI series with small bowel follow-up may be performed to determine bowel length and evaluate bowel caliber if a bowel lengthening procedure is considered. Children with bowel failure should be referred to a bowel rehabilitation team, usually consisting of a gastroenterologist with specific expertise, advanced practice nurse, nutritionist, surgeon, social worker and speech therapist.
