What is pediatric critical care?

Science and Profession

When a serious illness or injury occurs to children, they cannot simply be treated as small adults. The serious illnesses from which they suffer are different from those of adults. Children’s bodies respond differently to illness and injuries and require different types of resuscitative fluids and medications. The critical care pediatrician is specially trained to provide this special care.

A critical care pediatrician has undergone, in addition to four years of medical school, three years of pediatric
residency and three years of fellowship training in the care of critically ill or injured children. Critical care pediatricians usually practice in large referral hospitals or children’s hospitals.

The care of a seriously ill or injured child requires many skills, including the resuscitation and stabilization of the patient’s condition, consultation with other specialists, and the establishment and execution of a plan of action. The plan is often complicated, especially if more than one organ system is involved. The critical care pediatrician coordinates the work of the patient’s health team.

Resuscitation usually begins in the emergency room and is directed by the emergency room physician. The critical care pediatrician may take over care in the emergency room or when the patient is moved from there or from the operating room to the intensive care unit (ICU).

On the patient’s arrival at the hospital, the team first ensures that the patient is able to breathe adequately, and, if not, begins to ventilate the patient’s lungs. The patient’s cardiac output is quickly evaluated, and chest compression is begun if it is inadequate. The degree of shock is evaluated next and is treated with intravenous fluid. As this resuscitation is being carried out, the critical care pediatrician obtains a history of the illness or injury and conducts a thorough examination of the patient. Based on this information, the physician orders appropriate laboratory and radiographic tests and calls on other specialists, as needed, for help and advice.

Once the patient arrives in the ICU, the critical care pediatrician must continue to treat the initial problem as well as any complications and difficulties added by surgery or other therapies. The physician must be able to relate these problems to his or her knowledge of anatomy and physiology. A quick and accurate assessment of a large number of factors is required, as is the ability to gain an overview of all the conditions faced in the care of the patient.

The critical care pediatrician’s day is largely spent in a hospital emergency room and its intensive care areas. This type of specialist does not usually practice in a clinic except for occasional follow-up examinations of patients who have been discharged from the hospital.

Diagnostic and Treatment Techniques

The critical care pediatrician utilizes a wide variety of diagnostic techniques. Complete blood counts, blood chemistry tests, and cultures of blood, urine, and cerebrospinal fluid are initially helpful, especially in looking for bacterial infections. These tests must be performed periodically to assess the patient’s progress. Depending on the patient’s problem, more specific tests may be necessary. Imaging studies, such as x-rays, ultrasonography, and computed tomography (CT) or magnetic resonance imaging (MRI) scans, are often critical to this evaluation.

Besides closely monitoring the patient’s condition, the critical care pediatrician must be able to perform a number of procedures. One is the management of ventilators, machines that can breathe for a child who is too ill or injured to breathe adequately on his or her own. The critical care physician is also expert at inserting a number of intravascular devices, such as central intravenous catheters, for intravenous (IV) fluids and for monitoring the function of the heart, and intra-arterial catheters, for monitoring blood pressure and conducting blood gas tests, which are used to evaluate the function of the lungs.

A complicated form of cardiopulmonary support for some critically ill children is called extracorporeal
membrane
oxygenation (ECMO). It is the circulation of the child’s blood through an artificial lung machine using large intravenous tubes, generally inserted in the neck. This machine adds oxygen to and removes carbon dioxide from the child’s circulation. ECMO requires a team of highly trained technicians. Its use is overseen by the critical care pediatrician when the patient is older than a newborn. ECMO is available only in the largest referral hospitals.

The care of critically ill children requires much emotional maturity on the part of the physician. The child’s family is frightened and anxious, and the child is under great emotional stress. The team of caregivers feels the stress of working with these children as well. The critical care pediatrician must be able to provide empathetic support to all people involved in the health crisis while remaining calm and collected. Despite its share of tragedies, critical care pediatrics is a richly rewarding field. The outcome for critically ill children is better than that for equally ill adults.

Perspective and Prospects

While there have always been pediatricians with an interest in critical pediatric care, fellowships in the specialty were first developed in the last quarter of the twentieth century. Critical care was recognized as a subspecialty of pediatrics in 1987. By 1994, there were only sixty-five pediatricians who had been accepted as fellows of the American College of Critical Care Medicine. By then, there was a rapidly increasing demand for these specialists, with four to six positions being advertised for pediatric critical care doctors for every one adult position.

Bibliography

"A Primer on Critical Care for Patients and Their Families." American Thoracic Society, December 11, 1999.

Fuhrman, Bradley P., and Jerry J. Zimmerman, eds. Pediatric Critical Care. 4th ed. Philadelphia: Mosby/Elsevier, 2011.

Kliegman, Robert M., et al., eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Saunders/Elsevier, 2011.

Merenstein, Gerald B., and Sandra L. Gardner, eds. Merenstein and Gardner’s Handbook of Neonatal Intensive Care. 7th ed. Maryland Heights, Mo.: Mosby/Elsevier, 2011.

Todres, I. David, and John H. Fugate, eds. Critical Care of Infants and Children. Boston: Little, Brown, 1996.

"What Is a Pediatric Critical Care Specialist?" American Academy of Pediatrics, May 11, 2013.

"When Your Baby's in the NICU." Nemours Foundation, 2012.