Page 703 - ACCCN's Critical Care Nursing

680 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

four weeks of age. Boys make up 58% of children admit-
4
ted to ICUs. The overall ICU mortality rate is 11% for TABLE 25.1 Guide to maintenance water in
4
Australia and 13% for New Zealand, however the paedi- healthy children
5
atric mortality rate is 3%. Over the past 30 years, although
length of stay and severity of illness to the PICUs have For each of the first 10 kg body weight: 100 mL/kg/day or
not essentially changed, mor tality has halved while dis- 4 mL/kg/h
ability has increased. 6 + For each of the second 10 kg of body weight: 50 mL/kg/day or
2 mL/kg/h
ANATOMICAL AND PHYSIOLOGICAL + For every subsequent kg of body weight: 25 mL/kg/day or
CONSIDERATIONS IN CHILDREN 1 mL/kg/h
2
Children require age- and developmentally-appropriate Weight (kg) mL/h mL/kg/day mL/m /day
care. An appropriate range of paediatric equipment is 4 16 100 1600
required to assess, monitor and treat all ages and sizes
of infants and children. The most obvious difference 6 24 100 1800
is the range of weights and sizes across the paediatric 8 32 100 1920
population. General considerations based on differences 10 40 100 2040
between children and adults are described and then a
systems approach is used to identify specific differences. 12 44 88 1960
Children tend to be clustered into one of five stages: 14 48 82 1890
infant, toddler, preschool child, school child and adole- 16 52 78 1860
scent. Developmental considerations for these five stages
are considered later in the chapter. The terms ‘infants’ and 18 56 75 1840
‘children’ are used throughout the remainder of this 20 60 72 1820
chapter. ‘Infants’ includes all children up to the age of 1
year and all other age groups are ‘children’. 30 70 56 1580
40 80 48 1500
A number of general considerations, based on anatomical
and physiological differences from adults, need to be 50 90 43 1460
considered for the critically ill child. 60 100 40 1450
l Children have increased surface area to volume ratio 70 110 38 1470
compared with adults, which leads to increased heat Adapted from (9).
loss and insensible fluid losses, placing infants and
children at increased risk of developing hypothermia
10
and dehydration. Providing an environment that resuscitation. Table 25.1 provides a guide for fluid
maintains the infant and small child’s body tempera- maintenance requirements of children based on body
ture is essential. Avoid exposing infants and children weight.
more than necessary; use warming blankets, open l Excluding the newborn period, normal values for all
care systems for all newborns and infants under 4 kg blood gas and serum electrolyte levels are the same
and overhead heaters when exposure is unavoidable. as adult levels. Creatinine and urea levels will vary
Temperature monitoring is required when using any with age.
heating devices to avoid iatrogenic thermal injury. l Methods of oxygen delivery (humidified if possible)
l Lower glycogen stores and increased metabolic rate for infants include via nasal prongs (maximum rate
predispose infants to hypoglycaemia. There are few 2 L/min) or a head box. A head box can reliably
standard doses in paediatric ICU; rather, medication deliver a required percentage of oxygen, but visualisa-
doses and fluid requirements are calculated on age tion of the infant is often compromised and there
and kilograms of body weight. Weight of infants and is a sense of separation between the parents and
children should therefore be estimated as accurately the infant. Comforting, touching and regular nursing
as possible. The Broselow tape measure is a colour- assessment are more easily achieved when nasal
coded method to estimate weight and is particularly prongs are used. Hudson masks and partial non-
7,8
accurate in children ≤ 25 kg. Some differences may rebreather masks are available in paediatric sizes.
occur in estimated weight of children of different
origin. 7
l Fluid requirements are based on body weight, and Practice tip
aim to ensure adequate hydration while preventing
fluid overload. Maintenance intravenous (IV) fluids Using the Broselow tape measure: (a) place the tape so the red
for infants and young children typically require the arrow is positioned at the top of the child’s head, (b) align the
addition of glucose. Common IV maintenance fluids tape parallel to the side of the child who must be lying in a
used are 0.45% sodium chloride with either 2.5% supine position, (c) Extend the legs straight, and (d) bend the
glucose or 5% glucose and 0.9% sodium chloride with ankle so the toes are pointing straight up. Look at the weight
9
5% glucose. Isotonic sodium chloride is recom- in the coloured areas directly under the bottom of the foot.
mended as the first choice fluid bolus in paediatric