Page 722 - ACCCN's Critical Care Nursing

Paediatric Considerations in Critical Care 699

when the infant is not yet feeding orally or to provide concentration is increased to at least 5% and up to 10%.
milk for tube feeding. In addition, dieticians can assess The addition of potassium chloride into maintenance
the child’s energy requirements and the amount of feed fluids is common, particularly in fasting children, and
required to meet needs. requires serial monitoring of serum potassium. For fluid
resuscitation in infants and children, the use of glucose
Other recent studies have found a reduction in nosoco-
mial infections in children when enteral feeds have been containing IV fluids is contraindicated, and 0.9% sodium
used; transpyloric tube feeding versus gastric feeding and chloride is the resuscitation fluid of choice across the life
nutritional support teams result in improved nutritional span, including in the delivery suite for newborn fluid
delivery and enhanced enteral feeding rates in critically resuscitation.
ill children. 215-218 Glucose Control in Children

Supplements and Feeding Hyperglycaemia is associated with a worse outcome in
221
Whilst promising work has been undertaken in adult infants and children requiring ICU admission, however,
critical care with the supplementation of feeds and total the predisposition to hypoglycaemia in children has
parenteral nutrition (TPN) with supplements including meant that aggressive treatment of hyperglycaemia is not
amino acids such as L-arginine, glutamine, taurine, nucle- yet commonplace in critically ill children as it has been
otides, omega-3 and omega-6 fatty acids, carnitine, anti- in adults in ICU. Hypoglycaemia is documented to occur
oxidants, prebiotics and probiotics, the same outcomes more frequently in two groups of nondiabetic children:
have not been reproduced in children to date. The evi- those requiring mechanical ventilation and those requir-
214
222
dence for additives in enteral feeding is not clearcut in ing inotropic support. In the study cited here, hypogly-
children and therefore routine supplementation for criti- caemia was an independent predictor of increased
cally ill infants and children is not common practice. mortality. While studies are yet to recommend tight
glucose control in the paediatric population, monitoring
Intravenous Therapy for Children for hypoglycaemia continues to be an important assess-
Until enteral feeding is established, critically ill infants ment parameter, particularly in sicker children who
require ventilatory support, inotropic support and where
and children will require maintenance IV fluids. Tradi- enteral feeding may be contraindicated. Hypoglycaemia
tionally, hypotonic fluids – fluids containing a concentra- may be an indicator of worsening organ function, there-
tion of sodium lower than normal serum sodium – have fore further research needs to focus on the safety of
been administered as maintenance fluids. These included insulin therapy in the nondiabetic critically ill child
the hypotonic formulation of 0.225% sodium chloride before aggressive management of hyperglycaemia can be
with 3.75% glucose. Over the past decade this formu- recommended. 222
lation has largely been replaced with 0.45% sodium
chloride and 2.5% glucose as iatragenic hyponatraemia LIVER DISEASE IN CHILDREN
has been observed in otherwise-well children having Liver failure is relatively rare in children. It often arises as
surgery. 219,220 It has been common paediatric practice to a primary problem in children from countries where viral
use only 500 mL IV bags in children for safety reasons. hepatitis is endemic, is associated with paracetamol over-
In the modern era across westernised countries, use of dose, and chronic liver disorders, toxins, autoimmune
volumetric IV pumps and burettes have also been stan- disease, malignancies, vascular and biliary tree malforma-
dard paediatric practice, although changes to larger tions as well as unidentified causes. 223 Chapter 19 con-
volumes of IV formulations for children will need to be tains more detail on liver function and dysfunction. There
closely monitored.
are varying severities and forms of liver failure. Infants
The use of hypotonic fluids is under review in many and children experiencing fulminant hepatic failure and
countries, and changes underway in Australia will see hepatic encephalopathy, regardless of underlying cause,
500 mL bags of IV fluids change to 1000 mL bags in all are critically ill, and require transfer to a specialist PICU
children’s hospitals, with increased level of monitoring for ongoing management and possible liver transplanta-
of weight and serum electrolytes recommended. Hypo- tion. Mortality rate is strongly linked with the develop-
tonic fluids are implicated in hospital-acquired hypona- ment of cerebral oedema and intracranial hypertension,
traemia 219,220 and for critically ill children, the capacity to and is reported to be as high as 50% where cerebral
excrete additional free water is often impaired. In addi- oedema occurs. 224 Many critically ill infants and children
tion, a number of common conditions seen in the ICU are at risk of developing some degree of liver dysfunction;
increase secretion of antidiuretic hormone (ADH), therefore, liver function of all critically ill children requires
including pain, nausea and infections of the CNS, the careful monitoring and management. Clinical manifesta-
GIT, the lung and post surgery, thus promoting the reten- tions and management of infants and children with liver
tion of water. The risk of developing cerebral oedema failure are similar to those of adults.
220
is increased in children, who also have an increased body
tissue water content and studies indicate that there is an In summary, the mainstay of management in children
increased risk of developing acute hyponatraemia leading with fulminant liver failure is liver transplantation. All
to seizures. children with fulminant disease should be transferred
to a paediatric centre as soon as the diagnosis of liver
Infants and children generally require added glucose in failure is made. Children are at particular risk of develop-
IV fluids. In infants under three months, glucose ing protein–calorie malnutrition, which can lead to