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  1. Noninvasive positive pressure ventilation and high-flow nasal cannula are two important management strategies for respiratory failure of diverse etiologies in children.

  2. Non-conventional modes of mechanical ventilation and respiratory adjuncts are commonly employed, and frequently serve as rescue therapies in children with severe respiratory failure.

  3. Acute respiratory distress syndrome is a heterogeneous disease with high-mortality risk when associated with multi-organ failure.

  4. Insufficient oxygen delivery to meet the tissue metabolic demands defines shock.

  5. Nutrition support and attention to electrolyte and glucose derangements are important in the care of the critically ill child.

  6. Acute kidney injury is common in critically ill children and often requires treatment by renal replacement therapy.

  7. Sepsis, commonly encountered in critically ill children, requires early recognition and early source control for successful treatment.

  8. Patients with traumatic brain injury often suffer from secondary brain injury, which significantly increases morbidity and mortality. Treatment should focus on reducing secondary injury by maintaining an appropriate cerebral perfusion pressure.

  9. Critical illness comes with the cost of highly complex care, and as such, hospital-acquired conditions are frequent and lead to an increased morbidity and mortality. Every physician caring for a critically ill child is responsible for helping to prevent these conditions.

The field of pediatric critical care medicine is relatively young, having been established in the 1980s.1 Prior to its formalization, many different types of physicians cared for critically ill children, including pediatric anesthesiologists. The focus on physiology, pharmacology, resuscitation, bedside care, life-sustaining technology, and procedural interventions is a shared focus between the two fields. This chapter will introduce the pediatric anesthesiologist to common disease states and management strategies undertaken in the pediatric intensive care unit (PICU), to allow for a common language and understanding between the pediatric anesthesiologist and intensivist.


Modes of Ventilation

Noninvasive Ventilation

Noninvasive positive pressure ventilation (NPPV) is a management strategy for children with respiratory failure that provides respiratory support via a noninvasive facemask. It avoids complications associated with intubation, namely the need for sedation and airway clearance mechanisms. NPPV maintains small airway patency, increases end-expiratory lung volumes, and improves compliance. Continuous positive airway pressure (CPAP) provides a constant end-expiratory pressure to achieve the aforementioned goals, whereas bilevel positive airway pressure also provides an inspiratory pressure that further helps to support fatigued respiratory muscles. The NPPV can be used to support pediatric patients with respiratory failure due to upper airway pathology by maintaining upper airway patency and preventing apnea and hypopnea.

High-flow nasal cannula (HFNC) provides heated and humidified gas at levels that may meet or exceed a patient’s spontaneous inspiratory flow rate. HFNC improves oxygenation and reduces dead space through washout of upper airway CO2, effectively increasing ventilation. HFNC also likely generates some positive pressure, the degree of which is unknown. HFNC is used in a variety of situations ...

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