Care of the critically ill child –
the intensivist’s perspective
Andrew C Argent
Red Cross War Memorial Children’s Hospital and
University of Cape Town
what do we want to achieve?
• the best possible results for our patients
– survival
– minimal morbidity
– least complications
• at the lowest possible cost
– to the child and family
– to the health service
– to the staff
introduction
• critical care vs. intensive care
– emergency care
• from community through to tertiary hospitals
– care of patients requiring major surgery
• care from first presentation to end of
rehabilitation (or through death)
• seamless care
focus of energy, resources and passion in the right place
what is paediatric critical care?
• care of any child (or neonate) with a lifethreatening injury or illness
• care that is “critical” – constantly evaluating what
it does, what could be improved
• care that is focused on priorities
• care that is focused on optimal utilization of
resources
in the ideal world
• paediatric critical care services are:
– appropriately situated relative to:
• the population of children
• the disease prevalence of children
– fully integrated into and co-ordinated within:
• the health services, and particularly the health services for children
• the emergency services for children
• the highly specialized medical services for children
– sustainable
• consumable utilization
• training of adequate numbers of staff
• monitoring and data systems
in the ideal world
• paediatric critical care services consist of:
– on presentation
appropriate emergency care
transport services to appropriate centres
– during ICU stay
comprehensive care by range of children’s health professionals
in PICU where required
full range of infrastructure and support services
– after discharge
transport back to home
ongoing integrated health care
care for chronic health problems
care around death
with comprehensive communication between all levels
Land Mass
Children
worldmapper.com
HIV
Mortality
1-4 years
worldmapper.com
Population
Public Health
Expenditure
worldmapper.com
what is the developing world?
gapminder.com
healthcare resources
Country
Income per capita
Government health
Doctors per
Nurses per 1 000
(GDP per capita in
expenditure per
1 000
population
US$)
person per annum
population
(current US$)
USA
$39 710
$2 548
2.56
9.37
South Africa
$10 960
$114
0.77
4.08
Chile
$10 500
$137
1.09
0,63
Brazil
$8 020
$96
1.15
3.84
India
$3 100
$7
0.6
0.8
$930
$6
0.28
1.7
Nigeria
Sepulveda et al, Lancet, 2006
resources for paediatric care?
• financial
• personnel
– health care
– administrative and management
• infrastructure
– basic
– critical care related
• allocation of those resources
Political will
critical care responses
• early antibiotic therapy for neonatal infections
Bhutta et al, Pediatr Infect Dis J 2009
• innovative training programs in pre-hospital
trauma care
Arreola-Risa C et al, J Trauma 2000
Mock C et al, Inj Control Saf Promot 2003
Mock C, J Trauma 2003;
Son NT and Mock C, Int J Inj Contr Saf Promot 2006
Tiska MA et al, Emerg Med J 2004;21:237-239
Mock CN et al, J Trauma 2002
critical care responses
• increased availability of oxygen monitoring and therapy for children
with pneumonia
Duke T et al, Arch Dis Child 2002
Wandi F et al, Ann Trop Paediatr 2006
Matai S et al, Ann Trop Paediatr 2008
Duke T et al, Lancet 2008;372
• improved care for sick children at district hospitals
Duke T et al, J Trop Pediatr 2006
Duke T et al, Lancet 2006
Duke T et al, Arch Dis Child 2003
English M et al, Lancet 2004
English M et al, Lancet
• improved structure and organization of acute care services for
children
Molyneux E,Trans R Soc Trop Med Hyg 2009
Molyneux E et al, Bull World Health Organ 2006
critical care responses
• development of triage and management systems
Robertson MA et al, Arch Dis Child 2001
Robertson MA, Molyneux EM, Arch Dis Child 2001
Gove S et al, Arch Dis Child 1999
• development rapid response teams and “early warning
systems”
• impact of early and effective therapy
• intensive care organisational structure
what does paediatric intensive care do?
• enable paediatric subspeciality care
– cardiac
– surgical
the impact comes from
getting the basics right
ALL the time
• care for acute paediatric illness
• care for paediatric trauma
not just emergency care
• training in critical care
not just intensive care
what is paediatric intensive care?
• intensive care
• expensive care
comprehensive care for the
child and his / her family
• care in an intensive care unit
• technological care
• care by adrenaline junkies
• meticulous care
different things in different places
what is paediatric intensive care?
•
“…PICU must provide multidisciplinary definitive care for a wide range of complex,
progressive, and rapidly changing medical, surgical and traumatic disorders
occurring in pediatric patients of all ages, excluding premature newborns.”
•
“Each … PICU should be able to address the physical, psychosocial, emotional, and
spiritual needs of patients with life-threatening conditions and their families”
•
“Level II PICUs may be necessary to provide stabilization of critically ill children
before transfer to another center or to avoid long-distance transfers for disorders
of less complexity or lower acuity. It is imperative that the same standards of
quality care be applied to patients managed ….”
Rosenberg et al, 2004. Crit Care Med
costs of “intensive care”
• basic monitoring and simple equipment a few
dollars per bed per day
• mechanical ventilation and cardiac monitoring
$US76 per day (calculated in Zambia)
• sophisticated intensive care $US1 000 per day or
more
Baker T. Trop Med Int Health 2009
Baker T. Paediatr Anaesth 2009
what harm can intensive care do?
• inappropriate diversion of resources
– personnel
– consumables
– support structures
• bad intensive care is lethal
–
–
–
–
–
ventilation
fluids
inotropes
medication
development of resistant micor-organisms
• effect on staff
where PICU is appropriate
• organize appropriately and effectively
– regionalization
– specifically trained personnel
• need for
– transparency on results and processes
• focused research AND implementation of research
• develop sustainability
outcome is substantially better if children are in
paediatric units:
Trent versus Victoria:
• With adjustment for severity of illness ...
the odds ratio for the risk of death for Trent (i.e. children in
adult units)
versus Victoria (children in PICU) was
2.09
(95% CI 1.37-3.19, p < 0.0005).
¶ “Our findings suggest substantial reductions in mortality if every
UK child who needed endotracheal intubation for more than 12-24 hours
were admitted to one of 12 large specialist paediatric ICUs.”
Pearson G, Shann F, et al. Lancet 1997 Apr 26;349(9060):1213-7
effects of regionalization
• 1991 vs 1999
– Trent Bridge area
– period during which PICU was centralized
–
–
–
–
–
PICU admissions rose from 1.3 to 2.3 / 1000 children
% of ICU admissions to a PICU rose from 61 to 90%
PICU mortality dropped from 9.39 to 6.27
% of deaths in ICU rose from 11.76 to 20.5
Child mortality fell by 34 deaths / 100 000 children
Pearson et al, Intensive Care Med, 2001
outcome is substantially better if:
• patients cared for by pediatric intensivist
– mortality in USA corrected by PSI fell by 5.3%
Pollack MM et al 1988, Crit Care Med 16: 11-17
– in Malaysia impact of 24 hour paediatric intensivist
availability
• SMR improved from 1.57 (95%CI 1.25-1.95) to 0.88 (95%CI 0.631.19)
• mortality odds ratio decreased by 0.234, 0.246 and 0.266 in the
low, moderate and high-risk patients.
Goh & Lum, Lancet, 2001
volume-outcome relationships in PICU
• 16 PICUs in US – members of PCCSG
• data on 11 106 consecutive admissions during 1993
• ave (sd) admissions per annum 863 (341)
• 100-patient increase in PICU volume decreased risk
adjusted mortality (OR 0.95) and LOS (OR 0.98)
Tilford et al, Pediatrics, 2000
what is the optimal unit size?
• cost of medical staff
– if have 24 hours intensivist cover makes no sense to have only 8
patients
• volume
– must be >600 and probably >800 per annum
• does depend on the geographical situation of the region
• not too big
– becomes difficult to provide focused cover to > 18-20 high intensity
patients
where do you put the units?
• often not open for discussion
• “… units should be located according to documented
demand or need and in concert with accepted
principles of regionalization of medical care.”
Rosenberg et al, Crit Care Med 2004
• geography
– population distribution
– transport realities
admission and discharge criteria
• need discussion and interaction with all stakeholders
• must be based on local realities of outcome
– HIV example
Zar et al, Pediatr Crit Care Med, 2001
Cowburn et al, Arch Dis Child, 2005
Jeena et al, J Med Ethics, 2005
• must be fairly and consistently applied
• tension between emergency and elective
impact of critically ill children on local
health care delivery
• not discussed in literature
• however
– the impact of trying to care for critically ill child on regional
health services
• the staff requirements for transport service relatively
small
what about the research?
• adult critical care data has limited applicability
to children
• the vast majority of published paediatric
critical care research is based in the first world
• even within that database there is a striking
lack of information
training
• critical care fellowships
– intensivists (2-3 years)
– critical care nurses (1-2 years)
• short courses
–
–
–
–
PALS, APLS etc
essentials of paediatric critical care
BASICS
ETAT
• congresses and meetings
– workshops
have to train
teams
training
• self-learning
• appropriate material
– practically orientated
– patient orientated in presentation
• Perinatal Education programme
• huge need and potential
support structures
• to countries
– what do you want to do
– these are the resources that you will require if you
want to do that
– these are the steps that will need to be taken to make
it worth your while
• to units
• to individual staff
conclusions
• no – we can’t take intensive care to everyone (yet)
• YES – we can and must take critical care to everyone
(now)
• we have to understand local context
• we must not repeat the mistakes and lessons of the
past
• balance …… and integration
6th World Congress
on Pediatric Critical Care
13-17 March 2011
Check the website www.pcc2011.com regularly for Congress updates!
We look forward to welcoming
you to a memorable event in
Sydney in 2011!