Critical care clinics
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Prolonged complete support of the circulation and of gas exchange can be achieved by extracorporeal membrane oxygenation (ECMO) in infants and children with potentially reversible, albeit life-threatening, disease. This allows lung rest or cardiac rest at times when dependence in those organs would be physiologically expensive. Although ECMO has no intrinsic healing powers, pediatric hearts and lungs exhibit tremendous recuperative power once the cycle of injury, inefficient performance, abuse, and secondary injury can be broken. ⋯ Most recent progress in ECMO derives from refinement of clinical practices and the application of this technology to new patient populations. ECMO is not itself an experiment. It is the application of ECMO that is experimental.
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The pathophysiology and clinical management of acute brain injury in infancy and childhood are presented using acute traumatic brain injury as a model. The principles of stabilization, transport, and intensive care management are critically reviewed.
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Pain in critically ill and injured pediatric patients may go unrecognized and undertreated since children often suffer silently and caretakers are often fearful to intervene aggressively to alleviate pain. Methods are now readily available to relieve pain in the vast majority of ICU patients. ⋯ This can be achieved by the use of continuous intravenous infusions of opioids, PCA, or epidural administration of local anesthetics or opioids. Flexibility is essential so that the appropriate technique or agent can be selected for a particular pediatric ICU patient.
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It is evident that the field of pediatric critical care is evolving rapidly, but the prime issue remains the proper delivery of scarce and expensive resources to the most patients. In order to do so it is necessary to determine where current resources exist. This has been difficult to accomplish accurately on a national basis, although it may be possible on a regional level. ⋯ Models of regionalization will provide the basic structure for the development of these systems. The Model for a Pediatric Critical Care System proposed by the California Critical Care Coalition and District IX of the American Academy of Pediatrics should be readily applicable to any region. It is hoped that the information and examples provided in this article will provide some guidelines for those interested in promoting regionalization of pediatric critical care across the nation.
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Current methods of ventilation do not allow adequate ventilation of the affected lungs in the presence of unilateral disease, e.g., unilateral atelectasis, diaphragmatic hernia, or lobar emphysema. Using a bilumen endotracheal tube and two independent ventilators, synchronized simultaneous independent lung ventilation (SILV) can be achieved. This technique provides a method of treating unilobar, unilateral, or multifocal lung disease effectively. This article describes the author's methodology and clinical experience with SILV.