- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Multiorgan Failure |
90 |
|
|
Sajith Kesavan and Bala Ramachandran |
|
A 1-year-old infant was admitted to pediatric intensive care unit (PICU) with fever, shock, and lethargy. After administering ßuid boluses and starting on inotropes, he was intubated and shifted to PICU. Investigations showed leukocytosis and thrombocytopenia with severe metabolic acidosis. Within 6 h of admission, urine output decreased, and he started bleeding from the nasogastric tube. He had persistent tachycardia with cold extremities. Investigations showed persistent metabolic acidosis, elevated liver enzymes, and severe coagulopathy (both prothrombin and partial thromboplastin time were prolonged) with rising serum creatinine.
Multiple organ failure (MOF) deÞned as dysfunction of more than two organs, is quite frequently seen in the PICU associated with high mortality. Mortality increases as the number of organ involved increases. Early and appropriate management involving multiorgan support improves outcome in these patients.
Step 1: Initial resuscitation
The patient should be resuscitated, taking care of airway, breathing, and circulation.
Step 2: Assess renal function
¥Renal dysfunction is deÞned as serum creatinine more than two times the upper limit of normal for age or twofold increase in baseline creatinine.
S. Kesavan, M.D. (*)
Department of Pediatrics Intensive Care Unit, Kanchi Kamakoti Childs Trust Hospital, Chennai, India
e-mail: ksajith120@yahoo.com
B. Ramachandran, M.D., D.A.B.P.
Department of Intensive Care & Emergency Medicine, Kanchi Kamakoti Childs Trust Hospital, Chennai, India
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
713 |
DOI 10.1007/978-81-322-0535-7_90, © Springer India 2012 |
|
714 |
|
S. Kesavan and B. Ramachandran |
|
|
|
Table 90.1 ModiÞed pediatric RIFLE criteria |
|
|
|
Serum creatinine criteria |
Urine output criteria |
Risk |
eCCL decreased by 25% |
Urine output <0.5 mL/ |
|
|
Kg/h × 8 h |
Injury |
eCCL decreased by 50% |
Urine output <0.5 mL/ |
|
|
Kg/h × 16 h |
Failure |
eCCL decreased by 75% or |
Urine output <0.3 mL/ |
|
eCCL < 35 mL/min/1.73 m2 |
Kg/h × 24 h or anuria × 12 h |
Loss |
Persistent failure (>4 weeks) |
|
End-stage kidney disease |
End-stage kidney disease (>3 months) |
|
eCCL estimated creatinine clearance |
|
|
Table 90.2 ClassiÞcation using renal failure indices |
|
|
|
Prerenal |
Renal |
Urine sediment |
Bland |
Broad, brownish granular casts |
Urine sodium (mEq/L) |
<20 |
>30 |
Urine osmolality (mosm/L) |
>400 |
<350 |
Fractional excretion of Na |
<1 |
>1 |
¥Intensivists prefer the modiÞed pediatric RIFLE criteria to deÞne and classify acute kidney injury.
¥The acronym RIFLE stands for the increasing severity classesÑrisk, injury, and failureÑand the two outcome classesÑloss and end-stage kidney disease (Table 90.1).
Renal failure can also be classiÞed into prerenal and renal causes by using renal
failure indices (Table 90.2).
Fractional excretion of Na = urine sodium ´ plasma creatinine ´100 plasma sodium ´ urine creatinine
Step 3: Send investigations
¥Urine routine examination
¥Renal function test with electrolytes
¥Urine sodium
¥Urine osmolality
¥Urine-speciÞc gravity
¥Arterial blood gas analysis
¥ECG
90 Multiorgan Failure |
715 |
|
|
Oliguria
No evidence of volume overload or cardiac failure |
Evidence of volume overload or cardiac failure |
Determine volume status |
Restrict fluid (400 mL/m2/24 hours+urine output) |
IV normal saline 20 mL/kg over 30 minutes |
|
Repeat if in shock
Hypovolemic patient usually voids in 2 hours
If no urine output (intrinsic or postrenal ARF)
Consider diuretics if hemodynamically stable (frusemide 2–4mg/kg single dose)
No urine
Consider continuous infusion of diuretics (frusemide 0.5–1 mg/kg/h)
No urine
Stop diuretics and start fluid restriction (400mL/m2/24 hours+urine output), consider renal replacement therapy early
Fig. 90.1 Algorithm for oliguria
Step 4: Manage renal failure
¥Follow oliguria algorithm (Fig. 90.1).
¥Avoid nephrotoxic drugs.
¥Maintain kidney perfusion with ßuids and inotropesÑjudicious use of ßuids to prevent ßuid overload and further ischemic damage to the kidney.
¥Adjust drug dosages according to eCCL.
¥Use Schwartz formula for calculating glomerular Þltration rate (GFR):
( |
2 |
) |
= k ´ |
height in centimeters |
GFR mL / min/1.73m |
|
|
serum creatinine |
|
|
|
|
|
where k is 0.33 in preterm infants, 0.45 in infants, and 0.55 in older children.
716 |
|
|
S. Kesavan and B. Ramachandran |
||
|
|
|
|
|
|
Table 90.3 Types of dialysis |
|
|
|
|
|
|
|
Use in |
|
Volume |
|
Type |
Complexity |
hypotension |
EfÞciency |
control |
Anticoagulation |
Peritoneal dialysis |
Low |
Yes |
Moderate |
Moderate |
No |
Intermittent |
Moderate |
No |
High |
Moderate |
Yes |
hemodialysis |
|
|
|
|
|
CVVH |
Moderate |
Yes |
Moderate |
Good |
Yes |
CVVHDF |
High |
Yes |
High |
Good |
Yes |
¥Schwartz formula is not accurate in a sick child with rapidly changing physiological status. Measuring creatinine clearance directly by using the following formula is better estimate of GFR:
urine creatinine ´ volume of urine in mL/min |
´ |
1.73 |
|
body surface area in m2 |
|
plasma creatinine |
¥In a sick child with oliguria and kidney injury, it is better to assume GFR less than 10 while dosing.
¥Early nutritional supportÑhigh-calorie enteral diet with adequate protein is started early.
¥Try to convert hemodynamically stable oliguric into nonoliguric renal failure if possible by using diuretics.
¥Start renal replacement therapy early.
Step 5: Monitor
¥Hourly intakeÐoutput chart, daily weight if possible
¥Hemodynamic monitoring
¥6th-hourly serum electrolytes, daily renal function test
Step 6: Renal replacement therapy
Indications of renal replacement therapy are as follows:
¥Oliguria/anuria with ßuid overload, refractory to diuretic therapy
¥Persistent hyperkalemia not responding to other measures
¥Severe metabolic acidosis unresponsive to medical management
¥Severe electrolyte abnormality
Types of dialysis (Table 90.3)
¥Intermittent hemodialysis
¥Peritoneal dialysis
¥Continuous renal replacement therapy (CRRT)Ñcontinuous venovenous hemoÞltration (CVVH) or continuous venovenous hemodiaÞltration (CVVHDF)
90 Multiorgan Failure |
717 |
|
|
The choice of renal replacement therapy depends on the clinical circumstances, availability of expertise, good vascular access, size of the child and hemodynamic stability.
A. Peritoneal dialysis is the easiest and most widely used modality.
¥Solute clearance is achieved by diffusion and solvent drag. Fluid removal happens by osmosis.
¥It can be done through a catheter placed at the bedside or the surgically placed Tenckhoff catheter. Dialysate volume of 10Ð20 mL/Kg with dwell time of 30 min to 1 h is a good starting prescription.
¥Increasing the dextrose concentration of the dialysate, increasing dwell volume, shortening the dwell time and doing more cycles help in more ultraÞltrate.
¥Hypertonic dialysate ßuid may cause hyperglycemia and rapid ultraÞltration. Heparin (500 units/mL) may be added to the dialysate ßuid to prevent catheter blockage.
¥Potassium can be added to the PD ßuid to a maximum of 4 mEq/L of PD ßuid if there is hypokalemia.
¥Dialysate can be changed to bicarbonate-based instead of lactate-based if there is severe lactic acidosis.
B.Intermittent hemodialysis is done in hemodynamically stable children.
¥Children with multiorgan dysfunction and shock may not be good candidates for it. The advantage of hemodialysis is the rapid removal of toxins and ultraÞltration of ßuid.
C.CVVH is preferred in hemodynamically unstable children.
¥Care should be taken to minimize the amount of blood in the extracorporeal circuit and blood priming of the hemoÞltration circuit may be necessary at the outset.
¥Fluid removal is adjusted according to the patientÕs clinical state during the treatment.
¥The extracorporeal circuit requires good central venous access, usually via a dual-lumen catheter, to allow the high blood ßows necessary to prevent clotting in the hemoÞlter.
¥Blood volume in the extracorporeal circuit should be less than 10% of the patientÕs circulatory volume. Blood ßow of 6Ð9 mL/Kg/min or 8% of circulating blood volume prevents excessive hemoconcentration in the Þlter.
¥Automated machines with appropriate accuracy are recommended for children for delivering the CRRT prescription safely and have replaced pumpassisted hemoÞltration using volumetric pumps.
¥If only ßuid removal is required, then relatively low rates of Þltration are needed, often referred to as slow continuous ultraÞltration. There will be negligible solute removal under these circumstances.
When more solute clearance is needed in addition to ßuid removal, dialysis component is added to the CVVH to make it CVVHDF.