Care of the critically ill child –the intensivist’s perspective

Andrew C Argent

Red Cross War Memorial Children’s Hospital andUniversity of Cape Town

what do we want to achieve?

• the best possible results for our patients– survival– minimal morbidity– least complications

• at the lowest possible cost– to the child and family– to the health service– to the staff

introduction

• critical care vs. intensive care– emergency care

• from community through to tertiary hospitals

– care of patients requiring major surgery

• care from first presentation to end of rehabilitation (or through death)

• seamless carefocus of energy, resources and passion in the right place

what is paediatric critical care?

• care of any child (or neonate) with a life-threatening injury or illness

• care that is “critical” – constantly evaluating what it does, what could be improved

• care that is focused on priorities

• care that is focused on optimal utilization of resources

in the ideal world• paediatric critical care services are:

– appropriately situated relative to:• the population of children• the disease prevalence of children

– fully integrated into and co-ordinated within:• the health services, and particularly the health services for children• the emergency services for children• the highly specialized medical services for children

– sustainable• consumable utilization• training of adequate numbers of staff• monitoring and data systems

in the ideal world• paediatric critical care services consist of:

– on presentationappropriate emergency care transport services to appropriate centres

– during ICU staycomprehensive care by range of children’s health professionalsin PICU where requiredfull range of infrastructure and support services

– after dischargetransport back to homeongoing integrated health carecare for chronic health problems

with comprehensive communication between all levels

care around death

Children

Land Mass

worldmapper.com

HIV

Mortality 1-4 years

worldmapper.com

Public Health Expenditure

Population

worldmapper.com

what is the developing world?

gapminder.com

healthcare resourcesCountry Income per capita

(GDP per capita in US$)

Government health expenditure per

person per annum (current US$)

Doctors per 1 000

population

Nurses per 1 000 population

USA $39 710 $2 548 2.56 9.37

South Africa $10 960 $114 0.77 4.08

Chile $10 500 $137 1.09 0,63

Brazil $8 020 $96 1.15 3.84

India $3 100 $7 0.6 0.8

Nigeria $930 $6 0.28 1.7

Sepulveda et al, Lancet, 2006

resources for paediatric care?• financial

• personnel– health care– administrative and management

• infrastructure– basic– critical care related

• allocation of those resourcesPolitical will

critical care responses

• early antibiotic therapy for neonatal infectionsBhutta et al, Pediatr Infect Dis J 2009

• innovative training programs in pre-hospital trauma care

Arreola-Risa C et al, J Trauma 2000Mock C et al, Inj Control Saf Promot 2003

Mock C, J Trauma 2003; Son NT and Mock C, Int J Inj Contr Saf Promot 2006

Tiska MA et al, Emerg Med J 2004;21:237-239 Mock CN et al, J Trauma 2002

critical care responses• increased availability of oxygen monitoring and therapy for children with

pneumoniaDuke T et al, Arch Dis Child 2002

Wandi F et al, Ann Trop Paediatr 2006 Matai S et al, Ann Trop Paediatr 2008

Duke T et al, Lancet 2008;372

• improved care for sick children at district hospitalsDuke T et al, J Trop Pediatr 2006

Duke T et al, Lancet 2006 Duke T et al, Arch Dis Child 2003

English M et al, Lancet 2004English M et al, Lancet

• improved structure and organization of acute care services for childrenMolyneux E,Trans R Soc Trop Med Hyg 2009

Molyneux E et al, Bull World Health Organ 2006

critical care responses• development of triage and management systems

Robertson MA et al, Arch Dis Child 2001Robertson MA, Molyneux EM, Arch Dis Child 2001

Gove S et al, Arch Dis Child 1999

• development rapid response teams and “early warning systems”

• impact of early and effective therapy

• intensive care organisational structure

what does paediatric intensive care do?

• enable paediatric subspeciality care– cardiac – surgical

• care for acute paediatric illness

• care for paediatric trauma

• training in critical carenot just emergency care

not just intensive care

the impact comes from getting the basics right

ALL the time

what is paediatric intensive care?

• intensive care• expensive care• care in an intensive care unit• technological care

• care by adrenaline junkies• meticulous care

different things in different places

comprehensive care for the child and his / her family

what is paediatric intensive care?• “…PICU must provide multidisciplinary definitive care for a wide range of complex,

progressive, and rapidly changing medical, surgical and traumatic disorders occurring in pediatric patients of all ages, excluding premature newborns.”

• “Each … PICU should be able to address the physical, psychosocial, emotional, and spiritual needs of patients with life-threatening conditions and their families”

• “Level II PICUs may be necessary to provide stabilization of critically ill children before transfer to another center or to avoid long-distance transfers for disorders of less complexity or lower acuity. It is imperative that the same standards of quality care be applied to patients managed ….”

Rosenberg et al, 2004. Crit Care Med

costs of “intensive care”

• basic monitoring and simple equipment a few dollars per bed per day

• mechanical ventilation and cardiac monitoring $US76 per day (calculated in Zambia)

• sophisticated intensive care $US1 000 per day or more

Baker T. Trop Med Int Health 2009Baker T. Paediatr Anaesth 2009

what harm can intensive care do?• inappropriate diversion of resources

– personnel– consumables– support structures

• bad intensive care is lethal– ventilation– fluids– inotropes– medication– development of resistant micor-organisms

• effect on staff

where PICU is appropriate• organize appropriately and effectively

– regionalization– specifically trained personnel

• need for– transparency on results and processes

• focused research AND implementation of research

• develop sustainability

outcome is substantially better if children are in paediatric units: Trent versus Victoria:

• With adjustment for severity of illness ... the odds ratio for the risk of death for Trent (i.e. children in adult units)

versus Victoria (children in PICU) was 2.09

(95% CI 1.37-3.19, p < 0.0005).

¶ “Our findings suggest substantial reductions in mortality if every UK child who needed endotracheal intubation for more than 12-24 hours were admitted to one of 12 large specialist paediatric ICUs.”

Pearson G, Shann F, et al. Lancet 1997 Apr 26;349(9060):1213-7

effects of regionalization• 1991 vs 1999

– Trent Bridge area– period during which PICU was centralized

– PICU admissions rose from 1.3 to 2.3 / 1000 children– % of ICU admissions to a PICU rose from 61 to 90%– PICU mortality dropped from 9.39 to 6.27– % of deaths in ICU rose from 11.76 to 20.5– Child mortality fell by 34 deaths / 100 000 children

Pearson et al, Intensive Care Med, 2001

outcome is substantially better if:

• patients cared for by pediatric intensivist– mortality in USA corrected by PSI fell by 5.3%

Pollack MM et al 1988, Crit Care Med 16: 11-17

– in Malaysia impact of 24 hour paediatric intensivist availability

• SMR improved from 1.57 (95%CI 1.25-1.95) to 0.88 (95%CI 0.63-1.19)

• mortality odds ratio decreased by 0.234, 0.246 and 0.266 in the low, moderate and high-risk patients.

Goh & Lum, Lancet, 2001

volume-outcome relationships in PICU

• 16 PICUs in US – members of PCCSG

• data on 11 106 consecutive admissions during 1993

• ave (sd) admissions per annum 863 (341)

• 100-patient increase in PICU volume decreased risk adjusted mortality (OR 0.95) and LOS (OR 0.98)

Tilford et al, Pediatrics, 2000

what is the optimal unit size?• cost of medical staff

– if have 24 hours intensivist cover makes no sense to have only 8 patients

• volume– must be >600 and probably >800 per annum

• does depend on the geographical situation of the region

• not too big– becomes difficult to provide focused cover to > 18-20 high intensity

patients

where do you put the units?• often not open for discussion

• “… units should be located according to documented demand or need and in concert with accepted principles of regionalization of medical care.”

Rosenberg et al, Crit Care Med 2004

• geography– population distribution– transport realities

admission and discharge criteria• need discussion and interaction with all stakeholders

• must be based on local realities of outcome– HIV example

Zar et al, Pediatr Crit Care Med, 2001Cowburn et al, Arch Dis Child, 2005

Jeena et al, J Med Ethics, 2005

• must be fairly and consistently applied

• tension between emergency and elective

impact of critically ill children on local health care delivery• not discussed in literature

• however – the impact of trying to care for critically ill child on regional

health services

• the staff requirements for transport service relatively small

what about the research?

• adult critical care data has limited applicability to children

• the vast majority of published paediatric critical care research is based in the first world

• even within that database there is a striking lack of information

training• critical care fellowships

– intensivists (2-3 years)– critical care nurses (1-2 years)

• short courses– PALS, APLS etc– essentials of paediatric critical care– BASICS– ETAT

• congresses and meetings– workshops

have to trainteams

training

• self-learning

• appropriate material– practically orientated– patient orientated in presentation

• Perinatal Education programme

• huge need and potential

support structures

• to countries– what do you want to do– these are the resources that you will require if you want to

do that– these are the steps that will need to be taken to make it

worth your while

• to units

• to individual staff

conclusions• no – we can’t take intensive care to everyone (yet)

• YES – we can and must take critical care to everyone (now)

• we have to understand local context

• we must not repeat the mistakes and lessons of the past

• balance …… and integration

6th World Congress on Pediatric Critical Care

13-17 March 2011Check the website www.pcc2011.com regularly for Congress updates!

We look forward to welcoming you to a

memorable event in Sydney in 2011!