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Cattigan- Doing it for the Kids

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Claire Cattigan is an Intensivist and Deputy Director of ICU at The University Hospital Geelong. She is interested in the management of paediatric patients in mixed ICUs and gives a fascinating talk on the challenges and rewards of introducing paediatric patient care into a general, adult intensive care unit.

Published in: Health & Medicine
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Cattigan- Doing it for the Kids

  1. 1. Doing it for the kids Caring for paediatric patients in an adult ICU Dr Claire Cattigan, University Hospital Geelong
  2. 2. Geelong • Largest Regional Centre in Victoria • >16,000 paediatric presentations to ED per year • >2500 admission to paediatric ward per year
  3. 3. ICU - Barriers • Unfamiliarity • Underskilled • Equipment/resources • Centralisation of services • Fear
  4. 4. Adult ICU team Leadership and Teamwork Resuscitation skills Patient/Famil y centred Care Crisis Resource Management Medication Knowledge External Collaboration Effective Communication Airway Skills
  5. 5. Paediatrics • Hospital Mortality 3.4% • Top 5 admit dx 1. Bronchiolitis ? 2. Seizures ✔ 3. Pneumonia/pneumonitis ✔ 4. Asthma ✔ 5. Adenoidectomy/tonsillecto my ✔ Adult • Hospital Mortality 8.6% • Top 5 admit 1. CABG surgery 2. Orthopaedic surgery 3. GI surgery for neoplasm 4. Valvular heart surgery 5. Drug overdose http://www.anzics.com.au/Downloads/CORE%20Annual%20Report%202013-14.pdf
  6. 6. Differences • Diagnostic – Congenital cardiac conditions – Trauma and management – Inborn errors of metabolism – Cancers • Physiological – Vital sign ranges – Fixed stroke volume, reduced respiratory reserve – Transitional circulation – Thermoregulation – glucose/metabolism • Risk – PRISM/PIM vs APACHE • Psychology – Age appropriate interaction (4mo v 4y v 14y) – Parents/Carers
  7. 7. AIRWAY
  8. 8. Cannula (birds) to 75.0 ETT (giraffe) http://www2.pedsanesthesia.org/newsletters/2015fall/sessVI.html
  9. 9. Developed by Anaesthetics, Emergency Medicine, ICU and Paediatrics SIG - Barwon Health Pre- oxygenate (bag/mask/T- piece) Positioning – age appropriate IV Access, secured, with flush Consider intraosseus if unable to gain IV Airway Assessment MONITORING ECG BP SpO2 CAPNOGRAPHY Cuff Manometer EQUIPMENT Mask/Bag/T-piece Guedel ETT x 3 Laryngoscopes (2) Bougie/Introducer Suction DRUGS Induction Paralysis Maintenance Atropine/ Adrenaline Vasopressor Is appropriate TEAM present? 2x Consultant (Anaes/ICU/Paed/ ED) TEAM ROLES Team Leader First Intubator Drugs/Second Intubator Intubator Assistant Cricoid Scribe (C-spine) PLAN DISCUSSED? PLAN FOR DIFFICULTIES VENTILATION Guedel/NPA Bag/Mask or T- Piece/Mask Nasogastric decompression INTUBATION Change position Different Laryngoscope blade (+/-CMAC) BURP Frova LMA Fibreoptic Bronchoscope Surgical Airway Pa#ent' Equipment' Team' Difficult' Intuba#on' Plan' AGE PREM NEO- NATE INFANT SMALL CHILD CHILD WEIGHT' <1.5kg 1.563.5kg 3.566kg 7612kg 12616kg 16620kg 20624kg 24630kg FACE%MASK 0"(white) 1"(pink) 2"(yellow) 3"(green) GUEDEL 000"pink 00"orange 0"blue 1"purple 2"white NP#AIRWAY 2.5 3.0 3.5 3.5 4.0 4.5 5.5 6.0 MILLER/MAC) BLADE 0 1 2 ETT##(UNCUFFED) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 ETT#(CUFFED) 3.0 3.5 4.0 4.5 5.0 5.5 LMA 1"(<5kg) 1.5!(5!10kg) 2"(10!20kg) 2.5$(20!30kg) STYLET 6Fr$(ETT$2.064.5) Adult&14&Fr&(ETT&>&4.5) BOUGIE 5Fr$(pink)'ETT#2.063.5 10Fr% ETT#4.066.0 Adult&(blue)'ETT#>#4.5 FROVA xxx Paediatric!(yellow) Adult&(blue) SUCTION(CATHETER ETT#363.5,%suction%catheter%6Fr ETT#464.5,%suction%catheter%8%Fr ETT#>5,#suction#catheter#10Fr
  10. 10. Breathing/Ventilation Ventilation Secured ETT (nasal >oral) Sedation (beware propofol) Monitoring (incl capnography), pulse oximetry, ecg telemetry. VT 6-8, RR 15-25, PEEP 5, PIP 20-25
  11. 11. Circulation
  12. 12. Medications
  13. 13. Resources • Paediatric equipment (appropriate sized airway equipment, monitoring, suction, cots, breastmilk fridge) • Paediatric resuscitation trolley • Cognitive aides • Paediatric medication chart • Paediatric Check list (ward round, intubation) • Age specific ICU chart with vital signs
  14. 14. Education • Nursing – In house 3 stage program • RCH • APLS, PLS • APICS • Beyond Paediatric Basic
  15. 15. Geelong ICU Geelong Paediatricians Geelong Paed and SCN RCH PICU Geelong Anaesthetics Geelong ED Geelong/RCH Radiology Geelong Pharmacy Mx Cmt
  16. 16. Can this patient be managed at Geelong?
  17. 17. Pre 2011 2011 2012- 2015 Future 0 20 40 60 80 100 120 140 160 180 200 2010 2011 2012 2013 2014 2015 2016 ICU MET TF ICU Ventilated

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