PEDIATRIC SURGICAL CRITICAL CARE SYLLABUS & STUDY .Thermal Injuries Obstetrical Critical Care Pediatric

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  • 2018 American Pediatric Surgical Association 1

    PEDIATRIC SURGICAL CRITICAL CARE SYLLABUS & STUDY GUIDE

    First Edition 2018

    On behalf of the American Pediatric Surgical Association Critical Care Committee

    Editors-in-Chief:

    Mary K. Arbuthnot, DO

    Samir Gadepalli, MD Pramod S. Puligandla, MD

  • 2018 American Pediatric Surgical Association 2

    Corresponding Author:

    Mary K. Arbuthnot, DO LCDR, MC, USN

    Department of General Surgery Pediatric Surgical Critical Care

    Naval Medical Center Portsmouth Mary.k.arbuthnot.mil@mail.mil

    Mary.kathleen.arbuthnot@gmail.com Cardiovascular Critical Care

    Respiratory Critical Care Neurological Critical Care

    Infectious Disease Renal Disease

    Gastrointestinal Disease Critical Care Nutrition

    Hematology Endocrinology

    Analgesia and Sedation Toxicology

    Thermal Injuries Obstetrical Critical Care Pediatric Emergencies

    The Elderly Emergency/Trauma Surgery

    Transplant Statistics

    Ethics Principles of Administration

    Contributors:

    Shahab Abdessalam, MD

    Director, Trauma, Burns and Critical Care Associate Professor of Surgery

    Childrens Hospital and Medical Center - Omaha Omaha, Nebraska Infectious Disease

    Renal Disease

    Jennifer H. Aldrink, MD Associate Professor of Clinical Surgery and Pediatrics Department of Surgery, Division of Pediatric Surgery

    The Ohio State University College of Medicine

    mailto:Mary.k.arbuthnot.mil@mail.mil
  • 2018 American Pediatric Surgical Association 3

    Nationwide Childrens Hospital Columbus, OH

    Emergency/Trauma Surgery Ethics

    Kelly Austin, MD, MS, FACS, FAAP

    Associate Professor of Surgery University of Pittsburgh School of Medicine

    Childrens Hospital of Pittsburg of UPMC Pittsburgh, PA

    Gastrointestinal Disease Obstetrical Critical Care

    David W. Bliss, MD, FACS, FAAP

    Professor of Clinical Surgery Keck USC School of Medicine Cardiovascular Critical Care

    Neurological Critical Care Critical Care Nutrition

    Alexander Feliz, MD

    Assistant Professor of Surgery and Pediatrics University of Tennessee Health Science Center

    Le Bonheur Children's Hospital Hematology

    Endocrinology

    Samir Gadepalli, MD Assistant Professor of Surgery

    Division of Pediatric Surgery, Department of Surgery University of Michigan

    Ann Arbor, MI Cardiovascular Critical Care

    Statistics Principles of Administration

    David Juang, MD

    Director, Trauma and Surgical Critical Care Director, Pediatric Surgical Critical Care Fellowship

    Childrens Mercy Hospital Associate Professor of Surgery

    University of Missouri - Kansas City Kansas City, MO Thermal Injuries

    Transplant

  • 2018 American Pediatric Surgical Association 4

    Chris Newton, MD

    Director, Trauma and Surgical Critical Care Director, Pediatric Neuroscience Center

    Department of Surgery UCSF-Benioff Children's Hospital Oakland

    Pediatric Emergencies

    Pramod S. Puligandla, MD Professor of Pediatric Surgery, Pediatrics and Surgery

    Program Director, Pediatric Surgery McGill University, Faculty of Medicine

    Attending Staff, Pediatric General and Thoracic Surgery Attending Staff, Pediatric Critical Care Medicine

    Montreal Children's Hospital, McGill University Health Centre Montreal, QC, Canada Respiratory Critical Care

    Robert Ricca, MD

    CAPT, MC, USN Associate Professor of Surgery, USUHS

    Director, Surgical Services Naval Medical Center Portsmouth, VA

    Toxicology The Elderly

    Ana Ruzic, MD

    Assistant Professor of Surgery Division of Pediatric Surgery Kentucky Childrens Hospital

    Analgesia and Sedation

    PEDIATRIC SURGERY NaT www.pedsurglibrary.com/apsa

    Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official

    policy or position of the Department of the Navy, Department of Defense, or the United States Government

    Copyright Statement: I am (a military service member) (an employee of the U.S. Government). This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that Copyright protection under this title is

    not available for any work of the United States Government. Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States

    Government as part of that persons official duties.

    www.pedsurglibrary.com/apsa
  • 2018 American Pediatric Surgical Association 5

    Table of Contents: Chapter 1: Cardiovascular Critical Care page 6 Chapter 2: Respiratory Critical Care page 18 Chapter 3: Neurological Critical Care page 31 Chapter 4: Infectious Disease page 36 Chapter 5: Renal Disease page 43 Chapter 6: Gastrointestinal Disease page 46 Chapter 7: Critical Care Nutrition page 48 Chapter 8: Hematology page 49 Chapter 9: Endocrinology page 54 Chapter 10: Analgesia and Sedation page 58 Chapter 11: Toxicology page 64 Chapter 12: Thermal Injuries page 66 Chapter 13: Obstetrical Critical Care page 70 Chapter 14: Pediatric Emergencies page 71 Chapter 15: The Elderly page 79 Chapter 16: Emergency/Trauma Surgery page 81 Chapter 17: Transplant page 86 Chapter 18: Statistics page 89 Chapter 19: Ethics page 91 Chapter 20: Principles of Administration page 92 References page 95

  • 2018 American Pediatric Surgical Association 6

    1. Cardiovascular Critical Care i. Physiology

    i. Understand the definitions of CO, preload, afterload, compliance, SVR

    ii. Understand the relationship between CO, right atrial pressure and venous return (Frank-Starling Relationship) and how it changes with certain conditions i.e cardiac tamponade, congestive heart failure, Persistent Pulmonary Hypertension of the Newborn (PPHN)

    Image courtesy of Pediatric Surgery NaT Cardiophysiology and Shock

  • 2018 American Pediatric Surgical Association 7

    iii. Understand the phases of the cardiac cycle

    iv. Understand the effects of preload and afterload on the pressure-volume loops and the changes with pulmonary hypertension, cardiac tamponade, CHF

    ii. Understand fetal circulation and the physiology associated with

    persistence of fetal circulation

    iii. Know the common congenital heart defects. Images can be found at: http://www.stanfordchildrens.org/en/topic/default?id=congenital-heart-disease-90-P02346) Classification of congenital heart lesions

    Noncyanotic heart disease Cyanotic heart disease

    left to right shunts decreased pulmonary blood flow

    atrial septal defects

    ventricular septal defects

    atrioventricular septal defects

    aortopulmonary window

    patent ductus arteriosus

    tetrology of Fallot

    pulmonary stenosis

    pulmonary atresia

    tricuspid atresia

    Ebsteins anomaly

    left sided obstructive lesions increased pulmonary blood flow

    coarctation of the aorta

    congenital aortic stenosis

    interrupted aortic arch

    mitral stenosis

    transposition of the great vessels

    double outlet right ventricle

    total anomalous pulmonary venous

    return

    truncus arteriosus

    single ventricle physiology

    hypoplastic left heart

    double inlet left ventricle

    Image courtesy of Pediatric Surgery NaT Congenital Heart Disease Congenital heart disorders

    left to right shunt (with

    congestive heart failure)

    atrial septal defect

    patent ductus arteriosus

    http://www.stanfordchildrens.org/en/topic/default?id=congenital-heart-disease-90-P02346http://www.stanfordchildrens.org/en/topic/default?id=congenital-heart-disease-90-P02346https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829072/all/Patent_Ductus_Arteriosushttps://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829071/all/Congenital_Heart_Disease#20.1https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829071/all/Congenital_Heart_Disease#20.3https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829071/all/Congenital_Heart_Disease#20.0https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829071/all/Congenital_Heart_Disease#20.0https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829071/all/Congenital_Heart_Disease#20.2
  • 2018 American Pediatric Surgical Association 8

    ventricular septal defect

    atrioventricular canal

    right to left shunt tetralogy of Fallot

    tricuspid atresia

    transposition of the

    great vessels

    total anomalous

    pulmonary venous

    return

    truncus arteriosus

    obstructive lesions (with

    ventricular hypertrophy and

    failure)

    aortic stenosis

    coarctation of the aorta

    pulmonary stenosis

    interrupted aortic arch

    total mixing lesions double outlet right

    ventricle

    hypoplastic

    left heart syndrome

    Image courtesy of Pediatric Surgery NaT Congenital Heart Disease

    iv. Hemodynamic Monitoring

    i. Invasive and noninvasive arterial blood pressure monitoring 1. Sphygmomanometer measurements give slightly higher

    systolic and lower diastolic pressures compared to intra-arterial measurements

    2. Ideal MAP 60-90 but varies depending on cause of HD instability, history of hypertension, presence of TBI

    3. In neonates, MAP is (gestational age at birth)+(age in weeks), but perfusion more important than MAP

    ii. CVP monitoring 1. CVP alone does not reflect volume status 2. Dynamic decreases of CVP > 2 mmHg w