Intensive Care of Emergency Conditions - V. M. Zaporozhan 2006

Specifics of Intensive Care in Children

Studying the specifics of pediatric intensive care is essential for medical students not only because some of them will choose child healthcare as their primary career, but also because surgeons, general practitioners, and other physicians may encounter emergency situations requiring them to provide immediate care to children without waiting for pediatricians or pediatric surgeons.

Administering intensive care (IC) requires a thorough understanding of the anatomical and PHYSIOLOGICAL CHARACTERISTICS OF the pediatric body.

It is crucial to remember the immaturity and rapid exhaustion of regulatory mechanisms governing Respiration, thermoregulation, and The Cardiovascular system. Drug dosages must be calculated individually, taking into account clinical and physiological data. This is particularly critical for newborns and premature infants, as they represent very high-risk patients. Due to the uneven developmental rates of various body systems During the first months of life, infants exhibit high oxygen consumption, excessive heat loss, and insufficient heat production.

Minimal energy reserves, Central Nervous system immaturity, and low body weight make children highly vulnerable to shifting rapidly from one critical condition to another under METABOLISM/18.html">The Influence of various factors, including intensive care Procedures. For instance, during infusion therapy, dehydration can quickly turn into hyperhydration, while inadequate oxygenation in hypoxemia can lead to hyperoxia.

Among all Organs and systems, The Nervous System is the least developed in young children. An infant's Brain mass accounts for approximately 1/8 (12%) of their total body weight (compared to

1/40 in adults). This is associated with increased tissue hydrophilicity. Newborns lack well-defined Cerebral Cortex sulci and gyri; their differentiation occurs mainly by the age of 3 and is only completed by age 8. The subcortical structures and the Blood-brain barrier are immature, making the latter more permeable to fluids, medications, and toxins. All of this creates favorable conditions for The Development of cerebral edema even with moderate hyperhydration. Due to insufficient differentiation of brain Cells, most neonatal Reflexes are mediated subcortically. Consequently, in response to stimuli (such as pain, hypothermia, dehydration, hyperhydration, or certain medications), a convulsive syndrome may develop.

Underdevelopment of the Autonomic nervous system frequently leads to the destabilization of respiration, Circulation, thermoregulation, and other vital body Functions.

A newborn's hemodynamic status is transitional, bridging fetal and postnatal circulation. Shunts persist between the right and left atria, as well as between the pulmonary artery and the aorta. Consequently, oxygenated blood flows via the umbilical vein into the INFERIOR VENA CAVA, where it mixes with blood returning from the lower extremities and abdominal organs. Subsequently, this partially mixed blood enters the right atrium and flows through the left ventricle into the aorta.

Thus, the majority of pulmonary arterial blood bypasses the Lungs because pulmonary vascular resistance is significantly higher than systemic resistance. At birth, once the umbilical cord is clamped, Pulmonary Circulation increases, and the pressure in the left atrium exceeds that in the right. Under favorable conditions, these shunts close within 2 to 3 weeks; however, under unfavorable conditions, severe circulatory disturbances may occur. Acidosis, hypoxemia, hypercapnia, and catecholaminemia trigger vasoconstriction. Pulmonary vascular resistance rises, and the patent foramen ovale and ductus arteriosus resume functioning, routing up to 80% of the Cardiac Output through these shunts. Oxygen inhalation and the administration of alpha-blockers help reduce pulmonary Hypertension and close the shunts.

The Heart mass relative to body weight is 1.5 times greater in infants than in adults. It doubles by 6-7 months and triples by 1.5-2 years (reflecting rapid growth), after which growth slows down until Puberty, when it increases again. At birth, the right and left sides of the heart are equal in size. Cardiac volume increases 12-fold from birth to maturity. By age 5-7, the apex beat is located in the fourth intercostal space, later shifting to the fifth intercostal space medial to the nipple line; the area of Percussion dullness is wider up to age 12. The first heart sound is muffled up to age 2, after which it becomes clearer and stronger than in adults. Arteries and Veins in children have nearly identical calibers (whereas in adults, venous lumens are twice as wide as arterial ones). The myocardium in children is exceptionally well-vascularized due to wide capillaries.

Circulatory energy is twice that of adults, placing a child's circulation in a more favorable condition. The cardiovascular system is more mature at birth than other body systems. A relatively large heart and wide vascular lumens facilitate blood flow; because the heart Muscle has not been exposed to harmful factors such as infection, alcohol, or nicotine, it possesses significant reserve capacity.

In infants, the pulse rate corresponds to approximately 3–3.5 heartbeats per breath, changing as the child grows. Specifically, the heart rate is 120–140 bpm in newborns, 110–130 bpm In the second half of the first year, 110–120 bpm at 1–2 years, 100–110 bpm at 3–4 years, 100 bpm at 5 years, 78–85 bpm at 10 years, 72–80 bpm at 13 years, and 70–76 bpm at 15 years.

Blood pressure in children is lower than in adults. At 1 year of age, systolic blood pressure is approximately 80 mmHg, and thereafter is calculated as 80 + (age in years × 2). Diastolic blood pressure equals half of the systolic pressure + 10. Blood Circulation speed and heart rate are significantly higher, driven by a higher metabolic rate and increased oxygen consumption. Infants also have a relatively larger circulating blood volume (CBV); during the first months of life, it accounts for up to 10% of body weight, decreasing to 7–8% by age 6–7. At birth, the total CBV averages 350–400 ml, making a blood loss of just 40–60 ml clinically significant for a child.

Underdevelopment of muscular elements in the arterioles and precapillary sphincters, when combined with stress, can lead to microcirculatory disturbances and centralizing circulation. Because a substantial volume of blood resides in the lungs and heart, Shock states develop much more frequently in children than in adults.

Hematopoiesis begins during the Embryonic period. In newborns, it occurs in the Bone Marrow of all bones. Gradually, Cytology/practical/86.html">Red bone marrow is replaced by yellow marrow, and by age 12–13, active blood formation is restricted to flat bones and the epiphyses of long bones. Newborns exhibit neutrophilia of up to 65%, which shifts to up to 55% lymphocytes by age 3. At 4–5 years, neutrophil and lymphocyte counts equalize, and neutrophilia reappears by school age.

While immature hematopoiesis frequently predisposes children to anemia, they concurrently demonstrate a relatively high regenerative capacity.

Lymph Nodes in children are underdeveloped; their growth and maturation are completed by age 12–13.

Children have a higher blood Hemoglobin concentration: 110–240 g/L in newborns and 110–130 g/L in infants, which facilitates more efficient Oxygen transport to Tissues. Concurrently, a high hematocrit and the presence of fetal hemoglobin impair blood rheological properties. Low hemoglobin levels and hypothermia during septic states increase blood viscosity, potentially triggering disseminated intravascular coagulation (DIC). Consequently, under adverse conditions, acute cardiovascular failure develops much more frequently in children than in adults.

The pediatric airway possesses unique Anatomical Features. Narrowing of the upper sections, the absence of Teeth, delayed gastric emptying (up to 8 hours), a relatively large Tongue, a soft and high epiglottis, and tracheal narrowing at the level of the cricoid Cartilage frequently lead to airway obstruction. Due to this specific anatomical interplay among the tongue, epiglottis, and Larynx, direct endotracheal intubation is frequently challenging in children.

Small anatomical dead space volumes and minute ventilation values heighten the risk of a sharp increase in dead space during resuscitation procedures. For instance, dead space volume increases significantly through the improper use of a face mask during oxygen inhalation. The potential for Hypoxic Hypoxia in children is further compounded by a thickened alveolar-capillary membrane and an immature respiratory center, which impair gas diffusion as well as respiratory rhythm and rate.

Lung tissue exhibits reduced elasticity, pronounced vascular engorgement, and lower air content. The thoracic cavity is relatively small, and Respiratory Muscles are weakly developed, limiting respiratory excursions. Poor development of elastic tissue and restricted chest excursion frequently lead to Atelectasis, particularly in poorly ventilated lower lung regions. With age, Connective Tissue elements are gradually replaced by elastic fibers, and the number of alveoli and vital capacity (VC) increase. Lungs expand primarily toward the pliable Diaphragm; consequently, prior to walking, infant respiration is predominantly diaphragmatic, later transitioning to thoracic and thoracoabdominal patterns.

Class="center">Table 14 Respiratory rates in children

Pulmonary ventilation in children is comparable to that of adults; however, respiratory muscle strength is limited. The respiratory surface area of the lungs is small, meaning oxygen debt is compensated for by an increased respiratory rate. Because a child cannot breathe slowly and deeply, gas exchange is maintained through hyperventilation. Following birth, regular breathing patterns take several days to establish. Newborns average 40–60 breaths per minute. As the child grows, breathing slows down to match adult rhythms. Age-specific respiratory rates for children are listed in Table 14.

Up to the age of 8, boys exhibit a higher respiratory rate than girls. Children's respiratory centers are highly excitable; therefore, even minor physical exertion, emotional agitation, or elevated ambient and body temperatures can significantly accelerate breathing.

The tidal volume in newborns averages 20 cm³, in a one-month-old infant — 80 cm³, at 5 years — 150 cm³, at 12 years — 250 cm³, and at 14-16 years — 300-400 cm³. These values can vary sharply depending on the situation. For instance, when a child cries, their respiratory volume increases 25-fold.

The minute respiratory volume in newborns is 800-900 cm³, at one month of age — 1400 cm³, and at 1 year — 2600 cm³.

The vital capacity of the lungs, depending on the child's age, is shown in Table 15.

Genitourinary system. The Kidneys in children are located low, and their lobulation disappears by the age of 8. The Ureters are wide, with a weak muscular layer and high elasticity.

During the first 6 months, There are 20-25 urinations per day. Diuresis at 1 month is 300 ml, at 1 year — 600 ml, at 4-5 years — 1000 ml, and at 10 years — 1.5 l.

Endocrine System. Newborns have low hormone levels. The Thymus develops in the first months, The Thyroid Gland in 3-4 months, and slightly later — the anterior lobe of the Pituitary Gland. The Gonads mature by 11-15 years of age.

Gastrointestinal tract. The Oral Cavity in infants is relatively small. The tongue is large, and the mucous membrane is delicate, highly vascularized, dry, and prone to injury. The Esophagus is relatively large; the distance from the alveolar process to the cardiac part of The Stomach is 17 cm, at 1 year — 20 cm, at 2 years — 25 cm, and at 4 years — 30 cm. The esophageal mucosa is delicate and vascular, with a weak muscular layer.

The muscular layer of the stomach is also weak. The empty stomach is contracted, and the entrance is wide, which makes children prone to vomiting. The stomach capacity at 1 year is 250 ml. The intestine is long (6 times body length, compared to 4 times in adults). Muscles are weak. The permeability of the intestinal wall is increased, which reduces the barrier function against toxins. The Innervation of the intestine is immature. Food passage through the gastrointestinal tract takes 12-36 hours. The Liver is large.

Considering that medications, especially with prolonged use, adversely affect the growing Organism, they must be administered taking into account dosage, age-related features, as well as functional and pathological disorders.

Table 15 Vital capacity of the lungs in children, cm³

To determine a child's weight for any month of the first year of life, a simple, yet highly approximate calculation can be used:

Weight (g) = birth weight (3500) +

+ (600 or 500 ∙ number of months of life).

A child's weight after one year can be roughly calculated using the formula:

Child's weight (kg) = 9.5 + (2 ∙ age in years).

A child's body weight changes daily due to the dynamic instability of Water-electrolyte metabolism. Relative to body mass, the volume of extracellular fluid is twice as large as in adults. With age, its proportion decreases, reaching relative adult values by 2-3 years of life.

The water requirement of the child's body differs from that of adults (Table 16).

Table 16 Children's water requirements by age (according to W. Seifart, 1976)

This is due to a higher rate of water turnover and a higher water content in children compared to the adult body (Table 17).

The absolute volume of blood, plasma, and erythrocytes increases simultaneously with the child's body mass. Total blood volume also increases with age (Table 18).

Table 17 Body water content by age (according to W. Seifart, 1976)

The ionic requirements of a child's body differ significantly from those of adults (Table 19).

The requirement for CL^- varies in parallel with the requirements for Na⁺ and K⁺.

Acid-base balance in children also has its specific features. For instance, they show a predisposition to acidosis. Respiratory Regulation of the acid-base balance occurs very rapidly, whereas renal regulation, by contrast, is very slow. Therefore, when performing mechanical ventilation in children, the ventilation mode must be selected with utmost care. During infusion therapy, rapid fluid administration is not recommended, as it may lead to acidosis. Diuretics should be prescribed to children with caution, since rapid fluid loss can trigger alkalosis.

A child's body requirements for energy and protein are significantly higher than those of adults, which is associated with the GROWTH AND DEVELOPMENT of the pediatric organism (Table 20).

Table 18 Body weight, height, and blood volume depending on age (according to W. Seifart, 1976)

Table 19 Ion requirements depending on age

Table 20 Energy and protein requirements depending on age (according to W. Seifart, 1976)

When calculating Energy Requirements, it should be kept in mind that the body utilizes only a certain portion of it — namely, the energy generated from the metabolism of various chemical compounds (Table 21).

Infants and young children are less sensitive to a drop in blood glucose levels; hypoglycemia in newborns occurs when glucose concentration drops to 2.2 mmol/L.

Young children are also highly sensitive to decreases in body Temperature. Hypothermia impairs oxygen delivery to tissues and worsens microcirculation, which can lead to the development of metabolic acidosis. Against the Background of such disorders, acute cardiovascular failure occurs. Hypothermia reduces the Enzymatic Function of the liver, thereby slowing down the Hydrolysis of medications.

In children, thermoregulation is inadequate, and body temperature heavily depends on the ambient temperature. Therefore, intensive monitoring requires thorough thermometry. Thermal stability is ensured by keeping the crib constantly warmed to 28-30 °C.

Hyperthermic reactions also exert an adverse effect on children. They lead to a drop in blood pressure, tachycardia, and cardiac rhythm disturbances. Convulsive syndrome may develop against this background. In cases of hyperthermia, physical and pharmacological Methods of temperature reduction are used (undressing, ice packs, wrapping in wet sheets, and fan cooling combined with intramuscular or intravenous administration of antipyretics and neuroleptics).

If mechanical ventilation is necessary, tracheal intubation in children must be performed with extreme care, as the mucous membrane of the Upper Respiratory Tract is easily injured. Proper Selection of the endotracheal tube is of great importance. Its diameter is chosen According to the formula proposed by D. Aladzhova:

Table 21 Energy yield of nutrients in the body (according to W. Seifart, 1976)

It is preferable that the tube be thermoplastic, and inflatable cuffs should be used strictly according to indications. The length of the tube is selected using the formula by P. K. Dyachenko and V. M. Vinogradov:

During mechanical ventilation under anesthesia and surgery, it is necessary to:

1. Maintain a moderate hyperventilation regimen (preferably manually).

2. Perform rapid inspiration (2–3 times faster compared to expiration).

3. Keep dead space to a minimum. To prevent atelectasis, tidal volume should be tripled every 10 minutes.

The Specific features of infusion therapy in children also include the correction of acid-base balance. Metabolic acidosis is corrected under the control of acid-base parameters by intravenous administration of a 4% sodium bicarbonate solution. If such monitoring is not feasible, the appearance of signs of metabolic acidosis warrants administering this solution at a dose of 4 mL/kg. Concurrently, adequate oxygenation must be provided.

In children, acidosis can quickly transition into alkalosis, primarily caused by potassium ion loss. To correct this, potassium chloride is administered intravenously at a dose of 2 mmol/kg per day. It is given as a drip at a concentration not exceeding 0.75% in a 3% or 10% glucose solution with Insulin. The maximum infusion rate should not exceed 1/5 of the daily loss per hour, which in infants during the postoperative period is approximately 3 mmol/L.

Correction of hyponatremia is calculated using the formula:

Newborns are particularly prone to sodium loss.

Protein deficits in children are replenished using blood protein preparations, protein hydrolysates, and amino acid mixtures. The most suitable options among these include Aminosol, Aminol, Alvesin, and Vamin. In cases of severe Protein metabolism disorders, children are administered 3–4 g/kg of protein per day via blood products (albumin, plasma, protein fractions).

Critically ill children require full parenteral Nutrition. On average, the daily caloric requirement is 110–130 kcal/kg for infants in their first months of life, 80–90 kcal/kg for children aged 1–3 years, 70–80 kcal/kg for ages 4–5, 50–60 kcal/kg for ages 10–12, and 35–45 kcal/kg for older age groups. For every 100 kcal, the following are added: 3–5 mg of ascorbic acid, 20–30 mg of cocarboxylase, 0.1 mg of thiamine, 0.1 mg of riboflavin, 0.3 mg of pantothenic acid, 5–10 mg of Choline, 0.7 mg of nicotinic acid, 0.1 mg of pyridoxine, 2 mg of Folic acid, and 0.04 mg of cobalamin.

Parenteral nutrition must be well-balanced. The optimal ratio of proteins, fats, and carbohydrates is 1:1.8:6.6. The ratio between the volume of fluid administered and the caloric intake is 1 mL of water per 1 kcal. As soon as possible, a gradual transition to enteral (natural) feeding should be made.

In pediatric practice, cardiopulmonary resuscitation differs significantly from that in adults. This applies first and foremost to newborns.

Fetal depression or Neonatal Asphyxia may come as a surprise; however, the birth of a newborn requiring resuscitation can often be anticipated prior to delivery based on antenatal factors (maternal illness, complicated Pregnancy) or intranatal factors (labor complications, depressant effects of medications).

While awaiting the birth of the infant, the delivery room must be equipped with suction devices (rubber bulb syringe, mechanical or electrical suction apparatus, appropriate-sized catheters and gastric tubes), ventilation equipment (a bag capable of delivering 100% oxygen, face mask, oral Airways, oxygen supply), intubation tools (laryngoscope with blades #0 and #1, endotracheal tubes sizes 2.5, 3.0, 3.5, 4.0, and a stylet), as well as medications (such as adrenaline, naloxone, etc.).

The sequence of resuscitation steps, taking into account the time allowed for each, is as follows. Within the first 20 seconds after birth, it is necessary to:

— prevent heat loss (radiant warmer, drying the Skin thoroughly);

— ensure a patent airway by properly positioning the infant (on the back or side with the neck slightly extended) and suctioning the Mouth AND Nose;

— stimulate breathing if needed (gentle tactile stimulation like flicking the SOLE OF THE FOOT or rubbing the back);

— assess the infant's condition (respiration, heart rate, skin color).

If breathing is adequate, evaluate the heart rate; otherwise, initiate artificial lung ventilation.

If the heart rate is > 100 bpm, assess skin color; if it is lower, begin lung ventilation.

The presence of localized cyanosis confined to the hands and feet (acrocyanosis) is considered normal. Central cyanosis of the entire body indicates hypoxemia; in this case, oxygen must be administered even to a spontaneously breathing infant. If Oxygen therapy is required for longer than a few minutes, it must be warmed and humidified.

The presence of meconium in amniotic fluids carries a risk of aspiration. Thoroughly suction the mouth, Pharynx, and nose; under laryngoscopic visualization, suction the hypopharynx, and perform endotracheal intubation to clear the lower airways.

Indications for mechanical ventilation (MV):

— absence of breathing or gasping respirations (gasping for air);

— heart rate < 100 bpm.

Ventilate the newborn's lungs at a rate of 40–60 breaths per minute using pressures that achieve barely noticeable chest rise and fall. Given that adequate ventilation can be achieved using a face mask in the majority of cases, endotracheal intubation should only be resorted to if mask ventilation is unsuccessful.

Since determining the heart rate in the absence of an assistant requires stopping ventilation, to minimize time loss, count the heart rate for 6 seconds and multiply the result by

10. If, after 15–30 seconds of positive pressure ventilation with 100% oxygen, the heart rate remains < 60 or between 60 and 80 without increasing, chest compressions must be initiated. Performing chest compressions requires an additional resuscitation team member.

Cardiopulmonary resuscitation in children is performed according to the ABC principle described in the relevant section. A specific feature of chest compressions in newborns is that compressions are delivered using the tips of the middle and second (index) or fourth (ring) fingers of one hand. The other hand Supports the newborn's back if the infant is not on a sufficiently firm surface. Alternatively, the two-thumb encircling technique can be used. In this approach, the hands encircle the infant's chest, the thumbs (placed side by side or one over the other) are positioned on the lower third of the Sternum, and the remaining fingers support the back.

The sternum is depressed to a depth of 1-2 cm. The compression rate is 90 compressions per minute with a compression-to-ventilation ratio of 3:1 (90 compressions and 30 breaths).

Heart rate is assessed every 30 s. If the heart rate reaches 80 and continues to rise, compressions are stopped, and Artificial ventilation is continued until spontaneous adequate breathing is established.

If the newborn does not respond to adequate ventilation with 100% oxygen and chest compressions, medications and volume expanders are administered at doses proportional to body weight, which is estimated visually before the infant is weighed or assessed prior to delivery.

Routes of medication administration:

— umbilical vein (umbilical catheter);

— peripheral veins (less accessible VEINS OF THE scalp and extremities);

— endotracheal instillation.

Administered agents:

— adrenaline 1:10 000, 0.1-0.3 mL/kg;

— volume expanders (for acute Hemorrhage with symptoms of hypovolemia) — blood, 5% albumin, normal saline, Ringer's lactate solution 10 mL/kg;

— sodium bicarbonate (for confirmed or suspected acidosis) 4.2% slowly, over at least 2 min, 2 mmol/kg or 4 mL/kg of this solution;

— naloxone 0.1 mg/kg (0.1 mL/kg of a solution containing 1.0 mg per milliliter).

The administration of atropine and calcium, previously recommended for neonatal asphyxia, has not proven effective during the acute resuscitation period. If resuscitation is prolonged and the infant exhibits a thready pulse and other signs of shock, dopamine is administered via continuous infusion using an infusion pump, with careful monitoring of the infusion rate, to enhance myocardial contractility and increase blood pressure after consultation with a neonatologist. The infusion is started at a dose of 5 mcg/min, increasing it up to 20 mcg/min if necessary. For this purpose, the formula for calculating The amount of dopamine in milligrams to be added to each 100 mL of solution can be used:

For example:

— newborn weight 1200 g (1.2 kg);

— target dose 5 mcg/(kg∙min);

— target infusion rate 3 mL/h.

Substituting these data into the formula above, we obtain:

If resuscitation measures are initiated within the first 4 min of asphyxia, the prognosis is favorable, and no central nervous system pathology is observed in these children in either the short- or long-term periods.

With asphyxia lasting up to 10 min, normalization of condition occurs by the 8th-10th day, whereas if asphyxia lasts longer than 10 min, focal central nervous system lesions develop, accompanied by seizures and psychiatric disorders.

It should be noted that in pediatric practice, intensive care for emergency conditions requires not only theoretical knowledge but also practical skills, the acquisition of which merely begins during Practical Classes and must continue throughout the entire career of any physician striving to be a highly qualified specialist.

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