Page 721 - ACCCN's Critical Care Nursing

698 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

Infants and children with meningitis require intensive is relatively rare in critically ill children, the incidence of
care management when there is a reduced level of con- renal impairment secondary to the underlying illness is
sciousness, respiratory and/or circulatory compromise. recognised increasingly in children, although a paucity
The broad aims of management are to support ventila- of prospective studies remains problematic. The total
tion and circulation, while preventing secondary brain incidence of ARF in PICU is currently between 4.5% and
injury. Regular assessment and monitoring of associated 10%. 210,211 Diagnoses associated with primary ARF in
risks such as seizures, syndrome of inappropriate antidi- children are haemolytic uraemic syndrome, oncological
uretic hormone secretion (SIADH) or cerebral salt wasting diagnoses and following congenital cardiac surgery. 210,212
and sepsis is essential. The RIFLE criteria used to describe kidney injury in
211
adults (see Chapter 18) also applies to children. Both
ENCEPHALITIS primary and acquired kidney injury in children are asso-
The most common type of encephalitis in children is ciated with increased length of stay and increased mor-
acute viral encephalitis, and the causative agent is usually tality. Consequently, continuous renal replacement
202
herpes symplex virus (HSV). Left untreated, HSV is therapy (CRRT) should be considered earlier in manage-
almost uniformly fatal, with over half of survivors expe- ment than has previously been the case. Critically ill
riencing significant long-term morbidity. 174,203-205 Other children experiencing, or at risk of developing, acute
causes of encephalitis in children include: renal failure will benefit from prompt transfer to spe-
cialty PICU.
l enteroviruses (e.g. enterovirus 71, coxsackievirus,
polio and echovirus) The child’s GIT will need protection from developing GIT
l varicella zoster virus ulceration and bleeding in critical illness. A potentially
l Epstein-Barr virus fatal complication, stress ulceration and bleeding, has a
l cytomegalovirus current incidence of around 10% in critically ill chil-
213
l adenovirus dren. Clinically significant bleeding that causes haemo-
l rubella dynamic instability or the need for transfusion is reported
213
l measles in about 1.6% of children in PICU. The same treat-
l Murray Valley encephalitis (MVE) virus ments can be used in both children and adults, with no
l Kunjin virus. one agent, dose or regimen standing out as better for
minimising bleeding and ulceration or leading to fewer
The incidence of acute encephalitis is over 10 cases per complications such as pneumonia. 213
206
100,000 children. Children under one year of age are
at higher risk of developing encephalitis. Other risk NUTRITIONAL CONSIDERATIONS
factors include immune dysfunction and exposure to risk
animals, or specific geographic location. For example, The aims of nutrition in critically ill children are two-fold.
Murray Valley encephalitis and Kunjin viruses are endemic First, children are at particular risk of malnutrition because
in the Kimberley region of the Northern Territory, and they are growing, have greater energy requ irements for
Japanese B virus has been reported on Cape York Penin- their weight and less storage capacity than adults. Second,
sula; it is endemic in southeast Asia. 207 children are at particular risk of developing protein–
calorie malnutrition, which can lead to immunodysfunc-
Encephalitis symptoms are similar to meningitis, but tion, increased risk of infections, morbidity and death in
often with a much slower onset. Progressively worsening those children with organ dysfunction. 214
headache, fever and decreased level of consciousness or
behavioural changes characterise encephalitis. Focal neu- In addition, nutrition is important to maintain gut
rological signs and seizures may indicate involvement of mucosa integrity, prevent the development of hypo- and
the meninges or spinal cord. 208 hyperglycaemia, assist with maintenance of immune
function and in modulating the immune response as well
214
Management as providing energy. One barrier to achieving adequate
nutrition for critically ill children is the fluid restrictions
Prompt administration of aciclovir, if HSV is the sus- that are routine practice in the ICU, so liberalising fluids
pected cause, is warranted due to high mortality and where possible for enteral nutrition to be maximised
morbidity rates. Other viruses are also treated with aci- should be considered.
clovir. Ganciclovir is useful for resistant organisms, but
is more toxic. 208,209 Intensive care management involves When caring for critically ill infants and children, nutri-
supporting ventilation and managing neurological com- tion to support growth needs to be considered. Ideally,
plications such as seizures and cerebral oedema. If the enteral feeding of critically ill children should commence
child is unconscious on presentation, the disease course within 12–24 hours of admission to ICU, but may not
will be more severe. 203 be achievable until the child is transferred to a specialist
centre. It may not be appropriate to commence feeds if
GASTROINTESTINAL AND RENAL the child will require transfer, surgery or intubation. A
CONSIDERATIONS IN CHILDREN dietician should be consulted to advise on appropriate
enteral feeding formulas for children, in addition to orga-
Many critically ill infants and children are also at risk of nising caloric supplementation of feeds. The dietician can
developing complications involving the gastrointestinal advise on handling of human milk while in hospital for
tract (GIT). Although primary acute renal failure (ARF) breastfeeding mothers, who will need to express milk