Page 719 - ACCCN's Critical Care Nursing

696 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

conti nuous monitoring of heart rate, SvO 2 saturation, vasopressors are recommended. 162 Inotropic drugs that
quality of peripheral pulses, capillary refill, level of con- are recommended in children include dopamine, adre-
sciousness, peripheral skin temperature, urine output as naline and noradrenaline. Vasodilators, including sodium
indirect measures of cardiac output (CO) as well as serial nitroprusside or nitroglycerin, are used to recruit micro-
blood gas and electrolyte analysis. 162 circulation; type III phosphodiesterase inhibitors are used
to improve cardiac contractility. If shock persists and
Diagnosis of septic shock can be difficult in children.
When present, non-blanching rash is a specific sign of there is a risk for adrenal insufficiency, hydrocortisone
162
meningococcal septicaemia. 166 therapy is recommended. ECMO may also be consid-
ered for a child who appears to be developing irreversible
shock. 162
Practice tip Monitoring of blood glucose is essential in all critically
ill infants and children. In septic shock hyperglycaemia
As rash may be less visible in dark-skinned children, check soles may be present, which has been linked to higher mortal-
162
of feet, palms of hands and conjunctivae in those children. ity rates in paediatric septic shock. Blood glucose
should be monitored and maintained within normal
ranges (80–150 mg/dL) with appropriate use of insulin
However, a certain proportion of children will present and glucose administration. 104,162
with non-specific symptoms or signs of infection, such as
fever, vomiting, lethargy, irritability, or headache and the THE CHILD EXPERIENCING ACUTE
conditions may be difficult to distinguish from other
infections. 14,15,166 Laboratory testing of samples of blood, NEUROLOGICAL DYSFUNCTION
urine, stool, sputum, cerebrospinal fluid and any obvious There are many reasons why an infant or child can present
wounds or lesions is standard practice in adults and with an acute episode of neurological dysfunction.
children. Common presentations to an ICU include meningi-
tis, 173,174 encephalitis, 174 seizures and encephalopathy 175-177
MANAGEMENT OF SHOCK (see also Chapter 17). Assessment and recognition of the
Early recognition of shock, institution of appropriate clinical features and management of the various causes
goal-directed therapy and targeting the causative agent of neurological dysfunction in children are the keys to
remain the mainstay of managing septic shock in chil- achieving good outcomes.
dren as in adults. Goal-directed therapies such as oxygen
therapy, fluid resuscitation, maintenance of acceptable NEUROLOGICAL ASSESSMENT
blood pressure, and institution of pharmacological treat- To assess a child’s level of consciousness, several different
ment and other supportive treatments to achieve thera- scales can be used. The Glasgow Coma Scale (GCS) is
peutic goals are practised in managing shock in children, commonly used, 178 but the Glasgow Coma Motor sub-
and are linked to better outcomes. 162,163
score is more appropriate for children. 179 Another reliable
Large amounts of fluid may be required by children scale is the Full Outline of Unresponsiveness (FOUR)
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despite peripheral oedema or absence of overt fluid loss. score; it includes four parameters (eye response, motor
Early aggressive fluid resuscitation will improve survival response, pupil reflexes, and breathing) rated on a 0 to 4
in children with hypovolaemic and septic shock, particu- scale, giving a possible score situated between 0 (com-
larly if received within the first hour, when hypotension pletely unresponsive) and 16. 180 The FOUR score and
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has not yet developed. Intravascular access in children the GCS are both able to predict in-hospital morbidity
can be difficult and umbilical venous access in newborns and poor outcome at the end of hospitalisation.
and intraosseous access in children can be used before Other neurological assessment parameters include:
®
the placement of central lines. 162,167 The use of the EZ-IO
(Vidacare Corporations, Texas) paediatric intraosseous l Pupils: assess size, reaction and symmetry.
needle set and driver system has become common in l Posture: abnormal flexion posturing, often referred to
practice. 168,169 Other kinds of manually inserted intraos- as decorticate posturing, is a flexion response of the
seous needles are available, and regardless of type, intraos- arms with either flexion or extension of the legs, while
seous needles all allow rapid access to the intramedullary abnormal extension posturing, often referred to as
capillary network, facilitating delivery of fluids, drugs and decerebrate posturing, is an extension response of all
blood products. The site of choice in infants and children limbs, where arms rotate externally. Both abnormal
is the proximal tibia, 2–3 cm below the tibial tuberos- flexion and extension posturing in a previously normal
170
ity. Once sited, a syringe must be attached to aspirate child may indicate raised intracranial pressure.
and ascertain correct placement. Fluid boluses can then l Meningism: this is indicated by neck stiffness in a
be given via syringe into the intramedullary space with child and full/bulging fontanelle in an infant.
the aim of restoring circulating volume which will in turn
facilitate venous access with improvement of peripheral SEIZURES
perfusion. 171
Seizures are covered in Chapter 17. The various aetiolo-
Similarly to adults, after appropriate volume resuscitation gies of seizures in children include febrile convulsions,
has been given and symptoms of shock are not resolving CNS infection such as meningitis or encephalitis, meta-
or hypotension is developing, then inotropes and bolic imbalances, drugs, trauma or epilepsy. Seizures in