Page 709 - ACCCN's Critical Care Nursing

686 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

Fentanyl boluses are not recommended in neonates as Australia, where the legal age for consent is 14 and 16
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they may cause glottic and chest wall rigidity. Sedation years, respectively. However, a young person with the
management in children is similar to that in adults, emotional maturity and intellectual capacity to agree to
except for the use of propofol, which should be used with medical procedures, in circumstances where he or she is
caution in children. Although there is no strong evidence, not legally authorised or lacks sufficient understanding
propofol infusion in children has been associated with for giving consent competently can provide informed
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sudden myocardial failure and death. More recent data assent. 77,78 To be considered competent, young people
shows that propofol has an acceptable safety profile and must be able to understand the nature of the decision as
could be used in children for short term deep sedation well as the consequences of making or not making the
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under close monitoring of the airways. Use of dexme- decision. Whenever possible, it is recommended to
detomidine in paediatrics is promising, but additional obtain the child’s assent for treatment or procedures.
safety and efficacy studies need to be carried out before Children, even when deemed not competent, have the
routine use as a sedative agent can be recommended in right to be informed and, when appropriate, to be asked
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children. Indications for the use of neuromuscular for their permission. However refusal of treatment by a
blocking agents in children, monitoring of the effects and child has no legal bearing when a parent has consented.
management are similar to adult practice. 69 Importantly, parents may also refuse consent, and in that
case national laws and legal mechanisms for resolving
FAMILY ISSUES AND CONSENT disputes may be used. 77,79
When children are admitted to an ICU, the whole family THE CHILD EXPERIENCING UPPER
is affected by the hospitalisation. ‘Family-centred care’
(FCC) provides a framework for the care of children and AIRWAY OBSTRUCTION
their family in hospital. FCC means that during a hospital Upper airway obstruction is common in infants and
stay, nursing care is ‘planned around the whole family, young children for two major reasons: the anatomical
not just the individual child, and in which all the family size of the airway and the frequency of respiratory infec-
members are recognised as care recipients’. 70, p. 1318 Parents tions experienced in early childhood. Congenital struc-
should receive unbiased information at regular times, be tural abnormalities, infections, as well as foreign body
involved in the decision-making process and the care of aspiration are the three categories of causes of upper
their child; this parent–professional collaboration should airway obstruction in children.
be facilitated at all levels of healthcare. 70,71 As the devel-
opmental issues highlight, parents are essential to a
child’s coping with critical illness. Critically ill children GENERAL DESCRIPTION AND CLINICAL
are particularly vulnerable to short- and long-term emo- MANIFESTATIONS
tional and psychological sequelae, but parental presence General indicators of respiratory distress will be present
and participation in care can make a difference. 72 in a child suffering from upper airway obstruction. Spe-
cific clinical signs of upper airway obstruction in children
Parents need to feel involved in their child’s care,
which includes the need for information, communica- include:
tion, understanding the child’s illness and being part l a longer inspiratory phase with unchanged expiratory
of the decision-making process. 31,34,73,74 A partnership phase
between staff and parents is the ideal situation, but l stridor on inspiration
parents often need to be reminded on how to maintain l recessions of the chest wall
the parental role and how they can effectively care for l lower respiratory rate
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both their child’s and their own psychological health. l in infants, head bobbing and nasal flaring
Parents should be allowed to be present during poten- l hoarseness
tially stre ssful situations such as endotracheal suction, l drooling of saliva. 19
cannulation and resuscitation if they choose to, pro-
viding adequate support from a nurse or another des- Observing and listening to the child’s symptoms without
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ignated health care worker is given. Being present at disturbing them will provide important clues about the
the end of their child’s life may help them accept the level and degree of obstruction the child is experiencing.
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death. Not allowing parents to be present during The aim is to assess the child without causing further
procedures is a form of paternalism that goes against distress, as a crying, agitated child can further increase the
the right of the patient. Parents should however be degree of obstruction and work of breathing, leading to
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informed that it is their right to leave if they wish. respiratory collapse. The Paediatric Assessment Triangle
(PAT) is a useful tool to facilitate rapid assessment of the
child’s appearance, work of breathing, and skin circula-
CONSENT AND ASSENT tion. Stridor indicates obstruction in the upper airway,
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Except for emergency treatment, parents or legal guard- while wheeze is suggestive of lower airway disease. When
ians need to consent to all aspect of medical care, includ- stridor is also associated with a barking cough, it is likely
ing preventive, diagnostic or therapeutic measures for to be croup. A softer stridor in a child who looks systemi-
children. The legal age of consent differs between legis- cally unwell may indicate epiglottitis. When a previously
lations but is 18 years in major European countries and well child presents with a sudden onset of stridor, it is
all Australian states, except New South Wales and South likely to indicate foreign body aspiration, and eliciting