PAEDIATRIC CRITICAL CARE
Special considerations in
paediatric intensive care
Sarah Edmunds
Arun Ghose
Matthew Harvey
Abstract
Paediatric critical care units (PCCU) provide care to the most critically
ill or injured children. Children are admitted to PCCU with a wide vari-
ety of illnesses, injuries and following a range of surgical procedures.
High staff-to-patient ratios are required both because of the potentially
rapid evolution of critical illness in children, as well as the complexity
of the supportive therapies offered. Definitive evidence for specific
paediatric therapies is often limited with extrapolation taken from
adult experience, but there are increasing international collaborative
efforts that have produced consensus treatment guidelines that
serve to promote the use of best practice therapies. This article re-
views therapies and techniques that define care in the PCCU and in
particular outline principles of management of acute respiratory
distress syndrome (ARDS), septic shock and traumatic brain injury
(TBI). Neonatal and cardiac intensive care medicine topics are outside
the scope of this article.
Keywords Airway; brain; intensive care; paediatric; sepsis; support;
ventilation
Royal College of Anaesthetists CPD Skills Framework: Paediatrics, inten-
sive care management and emergency management
Around 20,000 children are admitted to paediatric critical care
units (PCCU) in the UK each year, with an average admission
rate of 143 per 100,000 childhood population per year.1 The
majority of children admitted to PCCU are under 1 year of age
(Figure 1). Around 40% of PCCU admissions are planned, with
the remainder being emergency presentations. Respiratory and
cardiovascular causes each account for nearly 30% of patients
presenting to PCCU (Figure 2). Children differ from adults in
many ways, including anatomy, physiology and response to
drugs; for this reason they need to be managed differently and
this article seeks to illustrate some of these differences in
management.
Sarah Edmunds FRACP is a Senior Trainee in Paediatric Critical Care
at the Royal Children’s Hospital, Melbourne, Australia. Conflicts of
interest: none declared.
Arun Ghose MBCHB FRCPCH PGDip is a Consultant in Paediatric Critical
Care at Birmingham Children’s Hospital & Consultant in Paediatric
Critical Care Retrieval with the KIDS (Kids Intensive Care & Decision
Support) service, UK. Conflicts of interest: none declared.
Matthew Harvey MBCHB MRCPCH PGCert is a Consultant in Paediatric
Critical Care at Birmingham Children’s Hospital & Consultant in
Paediatric Critical Care Retrieval with the KIDS (Kids Intensive Care &
Decision Support) service, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx
Please cite this article as: Edmunds S et al., Special considerations in paediatric intensive care, Anaesthesia and intensive care medicine, https://
doi.org/10.1016/j.mpaic.2023.08.010
Learning objectives
After reading this article, you should be able to:
C list the critical therapies that define care in the paediatric
intensive care unit
C describe some of the techniques of management of airway,
ventilation and circulation in paediatric critical care
C recognize the differences in management of sepsis, acute
respiratory distress syndrome and traumatic brain injury in children
Airway management
Paediatric airway management is a cause of much anxiety, but a
structured, team approach can reduce the incidence of adverse
events.
The paediatric airway differs anatomically from the adult in a
number of ways, including having a large occiput, large tongue, a
high and anterior larynx and a highly compliant trachea. The
small diameter of paediatric airways results in higher resistance
to air flow and increased chance of airway obstruction. Knowl-
edge of these differences is important in airway management in
PCCU, as is considering how these change over the age range of
children seen in PCCU.
Airway opening manoeuvres supported by appropriate patient
positioning (e.g. a shoulder roll in an infant, due to a relatively
large occiput) are the essential foundation of initial airway
management. In trauma patients, manual inline C-spine immo-
bilization should be used.
Pre-oxygenation should be performed, gentle invasive posi-
tive pressure ventilation is often used and consideration given to
apnoeic oxygenation, as low or impaired functional residual ca-
pacity reduces time to desaturation. Decompressing the stomach
using a nasogastric tube can be helpful if bag-mask ventilation
causes abdominal insufflation.
The correct sized endotracheal tube (ETT) and depth is
calculated using the formulae:

Internal diameter endotracheal size ¼ (age/4) þ 4 mm
(where age >1 year) for uncuffed tubes. The appropriate
cuffed ETT size being 0.5 mm smaller.

Approximate depth in cm ¼ age/2 þ 12 (to the lips for oral
intubation) OR age/2 þ 15 (at the nares for nasal
intubation).
Smaller tracheal tubes have proportionally higher resistances to
flow and small reductions in ETT diameter, for example from
secretions, will have a more pronounced effect with smaller sized
tubes. The wider bore, uncuffed tube may prove better than the
smaller bore cuffed tube in some circumstances Additionally, even
small changes in position of the tube can compromise ventilation
in infants. Cuffed ETTs may ensure a reliable airway seal, reduce
aspiration incidence and allow greater sophistication of ventilation
technique. There have been concerns around the use of cuffed
tubes in infants because of the risk of subglottic stenosis but no
difference in the rate of complications has been demonstrated,
particularly with the use of microcuff (high volume, low pressure)
devices.2 Cuff pressure should be routinely monitored with the use
of a manometer and should be kept below 20 cmH2O. The use of
cuff manometers can help prevent tracheal injury.
1 Ó 2023 Published by Elsevier Ltd.
 PAEDIATRIC CRITICAL CARE

Admissions by age and sex to UK paediatric intensive care units,

2016–2018
20,000

15,000
Admissions

10,000

5000

0
0 2 4 6 8 10 12 14 Unknown
1 3 5 7 9 11 13 15
Age (years)

Male Female

From Paediatric Intensive Care Audit Network Annual Report 2019

(published December 2019): Universities of Leeds and Leicester.

Figure 1

Induction agents should be carefully considered depending on Non-invasive respiratory support

the clinical situation, particularly in cases where a child is hae-
modynamically unstable. Common induction agents include:
ketamine (1e2 mg/kg), fentanyl (2e5 micrograms/kg) and
rocuronium (0.6e1.2 mg/kg).
Respiratory support
The respiratory system in infants and children differs from
adults. Infants in particular have limited respiratory reserve.
Ventilation is primarily diaphragmatic, so enlarged abdominal
organs or a gas-filled stomach can splint the diaphragm and
reduce an infant’s ability to be ventilated easily. The chest wall is
more compliant and minute ventilation is rate dependent as in-
fants have few ways to increase tidal volumes. Infants and
children have a relatively large physiological dead space and this
can be exacerbated by ventilation equipment and therefore
impair CO2 clearance so should be attempted to be kept to a
minimum.
Knowledge of cardiopulmonary interactions is important
when managing any child on mechanical ventilation.3 Positive
pressure ventilation (PPV) results in an increased mean airway
pressure, which in turn impedes right ventricular preload,
whereas positive intrathoracic pressure decreases left ventric-
ular afterload by reducing the left ventricular outflow trans-
mural pressure gradient. This results in improved systemic
blood flow and for this reason PPV may be considered as a
means of supporting cardiac output in left ventricular
dysfunction.
There is increasing use of non-invasive respiratory support in
PCCU, in particular high-flow nasal prongs. These deliver hu-
midified gas with a controlled oxygen content. This is adminis-
tered using nasal cannula at a relatively high flow rate (e.g. 2e3
litres/kg/minute), at or above the normal minute volume for the
child. Proposed mechanisms of action include ‘washout’, whereby
the anatomical dead-space of the upper airway is reduced or
eliminated by flushing with fresh gas; delivery of positive airway
pressure; and reduction of the nasal anatomic contribution
to upper airway resistance. Positive airway pressure devices
(continuous positive airway pressure (CPAP) and bi-level positive
airway pressure (BiPAP)) are also commonly used for a variety of
obstructive and restrictive lung diseases. Non-invasive PPV mo-
dalities can also have favourable haemodynamic effects by
decreasing left ventricular afterload and are often used after
extubation to wean from respiratory support.
Mechanical ventilation
Conventional mechanical ventilation in PCCU can be divided into
control mode and support mode ventilation.3 In control modes of
ventilation, the work of breathing is borne entirely by the
ventilator, whereas in support mode ventilation the patient’s
native respiratory efforts are augmented. Early in the course of
therapy control modes predominate, whereas during weaning
stages support modes are increasingly used. Combinations of
these two modes are also commonly used.
Volume control (VC) and pressure control (PC) are the basic
forms of control mode ventilation. In both VC and PC ventilation,

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Please cite this article as: Edmunds S et al., Special considerations in paediatric intensive care, Anaesthesia and intensive care medicine, https://
doi.org/10.1016/j.mpaic.2023.08.010
 PAEDIATRIC CRITICAL CARE

Primary diagnostic group of admissions to UK paediatric intensive

care units, for patients aged less than 16 years, 2016–2018

30

Admissions (%) 25

20

15

10

Trauma
Blood/lymphatic
Body wall
and cavities
Cardiovascular
Endocrine/
metabolic
Gastrointestinal

Infection

Multisystem

Musculoskeletal

Neurological

Oncology

Respiratory

Other

Unknown
From Paediatric Intensive Care Audit Network Annual Report 2019
(published December 2019): Universities of Leeds and Leicester.

Figure 2

the frequency and duration of respiratory cycle are set. In VC Synchronized intermittent mandatory ventilation (SIMV) refers
ventilation, the tidal volume is set. This tidal volume is delivered to a control mode ventilation, during which the patient can take
by means of a constant gas flow over the duration of the inspi- additional spontaneous breaths between mechanical breaths.
ration. In this form of ventilation, airway pressure increases over These additional breaths are pressure supported as in PS
the course of each inspiration and peak airway pressure varies ventilation.
with changes in lung mechanics. In contrast, with PC ventilation, Permissive hypercapnia be allowed in ventilated patients in
a prescribed maximum airway pressure is maintained over the PCCU, which allows patients to be ventilated with lower plateau
course of each breath, resulting in a diminishing flow pattern and pressures and tidal volumes that reduce ventilator-induced lung
variable tidal volumes depending on the lung pathology. Pres- injury.
sure control ventilation reduces the risk of barotrauma by con- Two modes of ventilation e airway pressure release ventila-
trolling the pressure delivered, but unregulated volumes can tion (APRV) and high-frequency oscillatory ventilation (HFOV) e
result in volutrauma with the opposite being true for volume are used most frequently for refractory, or challenging ventila-
control. Dual control modes are increasingly used in the PCCU in tion. APRV is a relatively newer mode of ventilation that allows
an attempt to get the benefits of each mode. In a dual control spontaneous breathing throughout the ventilation cycle and is
mode the tidal volumes are set as with a VC mode, but gas flow time cycled, alternating between two levels of positive airway
patterns are manipulated by the ventilator to approximate the pressure, with the main time on the high level and a brief expi-
constant inspiratory airway pressure of a PC mode. This means ratory release to facilitate ventilation. This mode should facilitate
pressure is constant across the inspiratory phase, in contrast to recruitment, increase mean airway pressure while limiting peak
volume control mode where flow is constant across the inspira- pressures and avoid atelectotrauma. It has been reported to be of
tory phase and airway pressure is variable. The ventilator adjusts benefit in adults with acute respiratory distress syndrome
its pressure control as needed to maintain the target tidal volume (ARDS); however, in paediatrics there is limited evidence with
so it is independently able to account for breath-to-breath vari- some concerns of harm and APRV should only be used as a
ability in patient compliance. In pressure support ventilation, the rescue therapy when conventional ventilation has failed.4 High-
timing and duration of each breath is determined by the patient, frequency ventilation modes are used commonly as rescue
with each breath being supported, or augmented, by the appli- modes in the PCCU. HFOV is a non-conventional ventilation
cation of a prescribed amount of additional airway pressure. mode in which a constant mean airway pressure is applied

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 PAEDIATRIC CRITICAL CARE
without interruption. Removal of carbon dioxide is achieved with
very small tidal volumes, delivered at a high frequency (4e16
cycles per second). Because there is no release of airway pressure
during HFOV, lung recruitment, and thus oxygenation, is opti-
mized for any given airway pressure. Inspiration and expiration
are active processes driven by piston motion. The theoretical
benefit of HFOV is its ability to recruit and maintain gas exchange
units by using a higher mean airway pressure compared to
conventional ventilation as well as reducing risk of lung injury
and pneumothorax associated with volutrauma and atelecto-
trauma. HFOV has not shown benefit in adult patients with
ARDS, but neonatal and paediatric studies are suggestive of po-
tential benefit and HFOV may still be used as a rescue method for
children with severe ARDS and those with refractory hypoxia
and/or hypercapnia. High-frequency jet ventilation (HFJV) de-
livers small breaths as brief pulses of pressure surrounding a
prescribed mean airway pressure. Expiration is passive in this
mode. The favourable inspiratory:expiratory ratio permits its use
in a variety of conditions, including air leak syndromes and
obstructive conditions.
Inotropic and vasoactive medications
Continuous infusions of inotropic and vasoactive medications
are used to provide haemodynamic support for patients in PCCU.
Inotropic and vasoactive medications commonly used in the
PCCU are summarized in Table 1. The catecholamines exert their
effect via stimulation of a and b adrenergic receptors located in
myocardial and peripheral vascular tissue.5 The a1 receptors are
present on vascular smooth muscles; activation leads to
increased systemic vascular resistance. The a2 receptors are
present in the central nervous system as well as blood vessels,
the gastrointestinal tract and other areas. They are not clinically
important in terms of inotropes but they have clinical use as anti-
hypertensives and sedatives. b1 receptors are present in the heart
and kidney; stimulation results in increased heart rate and
contractility of the myocardium as well as increased renin release
from the kidneys. b2 receptors are present in smooth muscles of
airway, blood vessels among others and are also present in the
myocardium but much less predominant than b1 receptors.
Stimulation leads to bronchodilation and vasodilation as well as
some chronotropic and inotropic effect. The number and affinity
Commonly used inotropic and vasoactive medications in the paediatric intensive care unit
Drug Mechanism Contractility HR
Adrenaline a, b stimulation [[ [[
Noradrenaline a > b stimulation [ 4
Dopamine a, b stimulation [ [
Dobutamine b > a stimulation [ [
Milrinone Phosphodiesterase III inhibition [ 4
Phenylephrine a stimulation 4 4
Vasopressin V1 receptor agonist 4 4
HR, heart rate; mcg, micrograms; min, minute; PVR, pulmonary vascular resistance; SVR, systemic vascular resistance. a effects increase relative to b effects (increased
SVR, PVR) at higher dose range.
Adapted from: Peters C, Pitfield A, Froese N. Special considerations in paediatric intensive care. Anaesth. Intensive Care Med. 2017; 18(11):572e580.
Table 1
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of receptors appears to change both acutely and chronically,
depending on clinical status; for example, critically unwell in-
fants show significant b2 down-regulation.6 Corticosteroids may
help restore b receptor density and decrease the catecholamines
required in catecholamine-resistant hypotension.
Type III phosphodiesterase inhibitors inhibit the metabolism
of cyclic adenosine monophosphate (cAMP), which causes pe-
ripheral vascular relaxation as well as increased myocardial
contractility. Phosphodiesterase inhibitors such as milrinone also
enhance the re-uptake of intracellular calcium, causing improved
diastolic relaxation. Milrinone has also been shown to work in
synergy with adrenaline and reduce the dose of adrenaline
required. In patients with poor ventricular function where
afterload reduction may be beneficial, the combination of milri-
none and adrenaline is often used.
An increase in extracellular calcium ions leads to an increase
in myocardial contractility in neonates and infants. Hypo-
calcaemia is common in infants and in these circumstances cal-
cium salts may act to aid myocardial contractility, but at normal
concentrations the major effect is an increase in vascular resis-
tance rather than inotropy so caution is advocated when used as
an inotrope in these settings.
The choice of inotrope used in children is subject to contro-
versy and there have been very few randomized controlled trials.
There is no ideal inotropic drug and there are advantages and
disadvantages of each agent related to the patient and conse-
quent pathology, drug pharmacology, method of administration
and cost.7
Renal replacement therapy
Renal replacement therapies are used in PCCU for a number of
reasons, to:8

restore fluid balance

normalize serum solutes and electrolytes

normalize acid/base balance

eliminate drugs and toxins.
Continuous methods of renal replacement therapy are fav-
oured in the unstable, critically ill patient. The two most
commonly used modalities are peritoneal dialysis and contin-
uous veno-venous haemofiltration. Intermittent haemodialysis is
less commonly used due to the rapid fluid removal which can be
Diastolic function SVR PVR Dose
4 [ [ 0.02e0.5 mcg/kg/min
4 [[ [ 0.02e0.5 mcg/kg/min
4 [ [ 2e15 mcg/kg/min
4 Y Y 2e15 mcg/kg/min
[ Y Y 0.25e0.75 mcg/kg/min
4 [[ 4 0.1e2 mcg/kg/min
4 [[ 4 0.0003e0.008 units/kg/min
 PAEDIATRIC CRITICAL CARE
a drawback in critically ill, haemodynamically unstable patients
where they may be intravascularly dry.
Peritoneal dialysis relies on the exchange of fluids and elec-
trolytes between the blood and dialysis fluid by using the peri-
toneal membrane as a dialysing membrane. It is generally well
tolerated and relatively simple to implement. Cycles of dialysate
are infused into the peritoneal cavity via a peritoneal catheter,
allowed to dwell, drained and then replaced by fresh dialysate.
Dialysate fluids typically contain physiological concentrations of
sodium, chloride, magnesium, calcium and a base such as
lactate, acetate or bicarbonate. Dialysis fluid is available with
varying glucose concentrations between 1.5% and 4.25% with a
higher glucose concentration promoting increased fluid removal
due to an increased osmolality, but it can cause hyperglycaemia.
Typically, dialysis volumes are between 10 and 40 ml/kg/cycle.
Larger volumes promote increased fluid and solute exchange but
can cause increased intra-abdominal pressure swings that
contribute cyclical decreases in blood pressure and impairment
of ventilation.
Continuous renal replacement therapies used in the PCCU
include slow continuous ultrafiltration (SCUF), continuous veno-
venous hemofiltration (CVVH), continuous veno-venous hae-
modialysis (CVVHD), and continuous venovenous hemodiafil-
tration (CVVHDF). With SCUF, blood is passed through a
semipermeable membrane with water and small solutes removed
continuously via convection. With CVVH, a larger ultrafiltrate
volume is removed and partially replaced by a balanced salt
solution. CVVHD is similar to intermittent haemodialysis, in that
solutes and water move between blood and dialysis fluid across
an extracorporeal semipermeable membrane. CVVHDF combines
the benefits of CVVHF and CVVHD, utilizing convection as well
as diffusion.
A major limitation of all continuous renal replacement ther-
apies in children, particularly infants, is the requirement for
large-bore central vascular access. A double-lumen central
venous catheter is commonly placed to facilitate this, commonly
in the internal jugular vein in smaller children with the femoral
vein also being an option in the older child. In the neonate, a 6.5
French catheter is required. For all methods of continuous renal
replacement therapy, anticoagulation is required to prevent
thrombus in the circuit as the artificial tubing and filters used are
prone to clot. Regional anticoagulation using citrate or systemic
anticoagulation using heparin are commonly used. Regional
anticoagulation is achieved by pre-filter administration of citrate
to bind calcium, and post-filter or patient administration of cal-
cium to maintain normal patient calcium concentration. Citrate
lock can occur, particularly in the setting of liver failure causing
citrate to accumulate and a very high total calcium but a normal
ionized calcium.
Equipment
Central venous catheterization
Central venous catheters are used commonly in PCCU, with in-
dications including provision of secure vascular access, delivery
of vasoactive and inotropic drugs, administration of concentrated
parenteral nutrition solutions and for central venous pressure
monitoring.9 Common sites for catheter placement include the
internal jugular vein, subclavian vein and the femoral vein.
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Multi-lumen catheters are frequently used and are available in a
variety of sizes; for example a 4 French 5 cm catheter can be used
in the right internal jugular position in a typical full-term
neonate. The choice of vascular access device depends upon
the likely nature, duration and frequency of treatment as well as
likely future needs for vascular access.
Catheter placement is performed by the Seldinger technique
and ultrasound guidance has now replaced surface landmark
techniques and is associated with a decrease in both number of
insertion attempts and inadvertent arterial puncture. Catheter tip
position can be confirmed on X-ray. Catheter-related blood-
stream infection is a common complication that can be mini-
mized by strict adherence to prevention guidelines, often pro-
moted as bundled care. These include maximal barrier pre-
cautions, chlorhexidine skin preparation at the time of inser-
tion, aseptic handling of accessing the line and prompt removal
of unnecessary lines.
Venous thrombosis at the site of cannulation is increasingly
recognized. Diagnosis requires a high index of suspicion and
confirmation with ultrasound Doppler imaging. Treatment in-
volves prompt removal of the catheter and consideration of
anticoagulation with low-molecular-weight heparin or warfarin.
Critical care ultrasonography
There is increasing use of bedside ultrasonography in the pae-
diatric critical care setting. Procedural use of ultrasound is well-
established and is now standard of care for central vascular ac-
cess. Benefits include decreased complications, decreased num-
ber of attempts, increased success rates and shorter procedure
times.10 Ultrasonography can also be used for guiding thor-
acentesis, localization of structures for peripheral and central
neuraxial blocks and guidance for soft tissue (abscess drainage)
and abdominal (paracentesis) procedures.
Goal-directed echocardiography (GDE) in the intensive care
unit can permit rapid assessment of cardiac preload, function and
for detection of pericardial effusions. GDE is accomplished by
acquiring four basic views: parasternal longitudinal axis, para-
sternal short axis, apical four chamber and subxiphoid. This
combination of views provides information about preload and
contractility of the right and left ventricles, the left ventricular
outflow tract, the pericardium and depending on expertise gross
valvular lesions such as vegetations or chamber wall defects.
Use of point of care ultrasonography (POCUS) is also increasing
with regards to lung, abdominal and cranial applications and
guidelines regarding their application are being developed.
Extracorporeal life support
Extracorporeal life support (ECLS) is a technique of mechanical
replacement of heart and/or lung function that can be used to
support children with severe cardiac, respiratory or cardiorespi-
ratory failure.11 The mode of ECLS chosen depends on the
physiological state of the patient. Systemic anticoagulation is
required to prevent clotting in the ECLS circuit in either mode.
Cardiac failure requires venoarterial (VA) ECLS where a
venous cannula is placed in a large systemic vein or right atrium
with the arterial cannula placed in a large systemic artery. In this
case oxygenated blood is returned to the arterial system,
bypassing the heart and lungs and providing near total me-
chanical haemodynamic support.
5 Ó 2023 Published by Elsevier Ltd.
 PAEDIATRIC CRITICAL CARE

Pure respiratory failure can be supported by using venove-
nous (VV) ECLS whereby both cannulae are placed in large
systemic veins. Oxygenated blood is returned to the venous
system, to be further pumped to the systemic circulation by the
child’s heart.
Extracorporeal cardiopulmonary resuscitation (eCPR) is
emerging as a common approach to cardiac arrest whereby ECLS
is used as a rescue support technique for children with refractory
cardiac arrest.
Contraindications to ECLS include technical reasons,
including small size as well as lethal underlying disease, un-
controlled haemorrhage or irreversible brain damage. Compli-
cations in children include haemorrhage from the surgical site,
intracranial haemorrhage or stroke as well as infection. Although
ECLS is a powerful support tool, its use is appropriate only in
cases in which there is reasonable expectation of recovery from
the underlying organ dysfunction or if it is used as a bridging
treatment prior to transplant.
Specific clinical scenarios
Paediatric acute respiratory distress syndrome
(PARDS)
PARDS is an acute lung injury characterized by pulmonary
inflammation, alveolar oedema and hypoxaemic respiratory
failure. This can be triggered by a variety of pulmonary or extra-
pulmonary causes. In one description of PARDS the primary
aetiologies were pneumonia (35%), aspiration (15%), sepsis
(13%), near-drowning (9%), concomitant cardiac disease (7%)
and other conditions (21%).12
The Pediatric Acute Lung Injury Consensus Conference
(PALICC) publishing a paediatric-specific definition for ARDS in
2015.13 An important difference compared with adult definitions
is the use of oxygen saturations and oxygenation index instead of
requiring invasive monitoring to obtain PaO2. The PARDS defi-
nition is described in Table 2. The mortality of PARDS is reported
to vary from between 10% and 33% and depends on both the
underlying cause and severity but is less than ARDS in adults.
Treatment of PARDS should include treating the underlying
cause, as well as respiratory support to ensure oxygenation and
ventilation despite lung dysfunction.14 Both mechanical ventila-
tion and high levels of inspired oxygen are themselves a cause of
lung injury. Ventilator-induced lung injury (VILI) can occur due
to barotrauma, atelectotrauma and volutrauma. Ventilatory
strategies in ARDS are aimed at limiting FiO2 and minimizing
VILI. To achieve this, small tidal volumes are recommended (3
e6 ml/kg if poor compliance and 5e8 ml/kg if preserved
compliance) and limiting peak plateau pressures to 30 cmH2O.
Optimal positive end-expiratory pressure should be determined
by improvement in FiO2 and lung compliance. Permissive
hypoxaemia (88e92% in severe PARDS) and permissive hyper-
capnia (pH 7.15e7.3 in moderate/severe PARDS).
Prone positioning is also used in PARDS and can improve
oxygenation. Lung consolidation in ARDS is non-homogenous
and is predominately located in dependent, dorsal lung units.
The prone position brings the more aerated lung units into a
dependent position where pulmonary blood flow is preferentially
distributed. Prone positioning has been shown to reduce mor-
tality in adults with severe ARDS but this conclusion is not
supported by paediatric data. Likewise, use of HFOV has shown

Paediatric acute respiratory distress syndrome (PARDS) definition

Age Exclude patients with perinatal-related lung disease
Timing Within 7 days of known clinical insult
Origin of oedema Respiratory failure not fully explained by cardiac failure or fluid overload
Chest imaging Chest imaging findings of new infiltrate(s) consistent with acute pulmonary parenchymal disease
Oxygenation Non-invasive mechanical ventilation Invasive mechanical ventilation
PARDS (No severity stratification) Mild Moderate Severe
Full face mask bi-level ventilation or CPAP  5 cmH2O2 4  OI < 8 8  OI < 16 OI  16
PF ratio  300 5  OSI < 7.51 7.5  OSI < 12.31 OSI  12.31
SF ratio  264 1

Special populations
Cyanotic heart disease
Chronic lung disease
Left-ventricular dysfunction
Standard criteria above for age, timing, origin of oedema and chest imaging with an acute deterioration in
oxygenation not explained by underlying cardiac disease.3
Standard criteria above for age, timing and origin of oedema with chest imaging consistent with new infiltrate and
acute deterioration in oxygenation from baseline that meet oxygenation criteria above.3
Standard criteria for age, timing and origin of oedema with chest imaging changes consistent with new infiltrate and
acute deterioration in oxygenation that meet criteria above not explained by left-ventricular dysfunction.

From: Paediatric acute respiratory distress syndrome consensus recommendations from the Paediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med
2015; 16 (5):428-39.
1
Use PaO2-based metric when available. If PaO2 is not available, wean FiO2 to maintain SpO2  97% to calculate oxygen saturation index (OSI; [FiO2  mean airway
pressure  100]/SpO2:FiO2 (SF) ratio.
2
For non-intubated patients treated with supplemental oxygen or nasal modes of non-invasive ventilation.
3
Acute respiratory distress syndrome severity groups stratified by oxygenation index (OI; [FiO2  mean airway pressure  100]/PaO2) or OSI should not be applied to
children with chronic lung disease who normally receive invasive mechanical ventilation or children with cyanotic congenital heart disease. CPAP, continuous positive
airway pressure; OI, oxygenation index; OSI, oxygen saturation index; PF, PaO2:FiO2.

Table 2

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 PAEDIATRIC CRITICAL CARE
no difference in mortality, duration of mechanical ventilation or
length of stay.
Inhaled nitric oxide (iNO), a potent pulmonary vasodilator, is
also used in ARDS to improve oxygenation by matching venti-
lation and perfusion. It does this as it is preferentially delivered to
adequately ventilated areas of lung. However, this resulted in
improvement in oxygenation but not mortality. Likewise use of
surfactant and steroids are not currently recommended as routine
therapy in ARDS.
Paediatric intensive care management of sepsis
Sepsis is a major cause of morbidity and mortality in children
and accounts for approximately 8% of patients admitted to PCCU
in high-income countries. Mortality ranges from 4% to 50%
depending on illness severity, risk factors and geographic loca-
tion. Most children who die from sepsis suffer from refractory
shock and/or multi-organ dysfunction. Early identification and
appropriate resuscitation and management are critical to opti-
mizing outcomes for children with sepsis.
The Surviving Sepsis Campaign was formed by the Society of
Critical Care Medicine, European Society of Intensive Care
Medicine and the International Sepsis Forum in 2001 to develop
evidence-based guidelines for the management of patients with
sepsis. Subsequent to this a paediatric specific guideline was
published in 2020.15 Septic shock in children was defined as
severe infection leading to cardiovascular dysfunction (including
hypotension, need for treatment with a vasoactive medication, or
impaired perfusion) and ‘sepsis-associated organ dysfunction’ as
severe infection leading to cardiovascular and/or non-
cardiovascular organ dysfunction.
As in adults, administration of appropriate antibiotics within 1
hour of making the diagnosis of sepsis is of paramount impor-
tance with empiric broad-spectrum therapy recommended prior
to narrowing antimicrobial coverage once the pathogen is
identified.
Intravenous fluid resuscitation of up to 40e60 ml/kg (given in
10e20 ml/kg per bolus) over the first hour, titrated to clinical
markers of cardiac output is recommended in early shock.
However, in resource-limited settings without the availability of
intensive care the group recommended against large amounts of
bolus fluid administration. Crystalloid solutions were preferred
over colloid solutions.
Vasoactive infusions were recommended after 40e60 ml/kg
of fluid resuscitation if patients continue to have abnormal
perfusion, with adrenaline or noradrenaline preferred over
dopamine. Adrenaline is recommended if there is myocardial
dysfunction. Vasopressin was recommended in children who
have septic shock resistant to high-dose catecholamines. Hae-
modynamic therapy should be titrated to therapeutic endpoints,
including normalization of physiological markers such as heart
rate, perfusion and urine output and laboratory markers such as
trends in blood lactate.
There is currently no evidence specific to support the early
intubation of children with refractory shock without respiratory
failure. However, a high metabolic demand from refractory
shock can be at least in part mitigated by early invasive me-
chanical ventilation. It should be noted that intubating children
with septic shock is a high-risk procedure and caution should be
taken to avoid worsening hypotension during intubation.
ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx
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There is limited evidence to suggest that intravenous corti-
costeroids in children who have septic shock resistant to cate-
cholamine treatment. Likewise, literature does not support using
insulin to maintain tight glucose control. ECLS is recommended
to be used as a rescue therapy in children with septic shock, only
if refractory to all other treatments. The group’s findings of both
initial resuscitation in sepsis and fluid and inotrope management
are summarized in Figures 3 and 4.15
Management of traumatic brain injury in children
Primary brain injury occurs at the time of trauma and can only be
addressed by injury prevention measures; these include cam-
paigns around road safety, for example. An important cause of
traumatic brain injury (TBI) in children is non-accidental injury,
particularly in children under 2 years of age.
Secondary brain injury occurs in the hours to days after the
primary insult and results from reduced perfusion of surviving
neural tissue, oxygen and metabolite delivery and clearance of
metabolic waste and toxins. Brain swelling results from vaso-
genic and cytotoxic oedema and occurs within the closed
compartment of the skull, which can lead to intracranial hyper-
tension, cerebral herniation, focal ischaemic injury and brain-
stem compression. Sustained elevation of intracranial pressure
(ICP) therefore represents a key variable in the occurrence and
severity of secondary brain injury. Management of TBI in PCCU
focuses on minimizing secondary brain injury.
The third edition of the Guidelines for the Management of
Paediatric Severe Traumatic Brain Injury is an update of a
multidisciplinary international group and provides a compre-
hensive consensus view of current evidence in paediatrics.16
These findings are summarized in Figure 5.
There are a number of aspects of care that should be used for
all children with severe traumatic brain injuries. An appropriate
level of analgesia and sedation should be maintained, which is
generally a benzodiazepine and opioid combination. Routine use
of neuromuscular blockade is not recommended because seizure
activity can be masked but may be required to control shivering
with its increased metabolic demand.
Controlled mechanical ventilation should be used with an FiO2
to achieve a target PaO2 of 90e100 mmHg and minute ventilation
adjusted to maintain a low normal PaCO2 of 35e40 mmHg.
Normothermia (<38 C) should be maintained in children with TBI
with moderate hypothermia (<35 C) recommended to be reserved
as an option for treatment for refractory raised ICP.
Early and aggressive reversal of hypoxia and hypotension are
crucial in management of children with severe TBI. There should
be careful examination for extracranial injuries, aggressive
replacement of blood loss and treatment of hypotension. A target
of normovolaemia should be used while targeting a sodium
concentration of >140 mmol/litre. Coagulopathy should also be
treated to avoid further bleeding. Other simple measures include:
promoting venous drainage of the head by keeping the head in
the midline position and raising the head of the bed by 30 . There
are insufficient data that treatment of seizures improves out-
comes in paediatric TBI; however, either phenytoin or levetir-
acetam are commonly used prophylactically depending on local
protocols and more commonly if there is blood in the ventricles
on CT. Continuous EEG or monitoring is often used particularly
with neuromuscular blockade.
7 Ó 2023 Published by Elsevier Ltd.
 PAEDIATRIC CRITICAL CARE

Fluid and inotrope management algorithm for paediatric sepsis

Fluid and Vasoactive-Inotrope

Management Algorithm For Children
Healthcare Systems
WITH Intensive Care ! Healthcare Systems
WITHOUT Intensive Care
SEPTIC
SHOCK

Abnormal perfusion with Abnormal perfusion Abnormal perfusion

or without hypotension WITHOUT WITH hypotension*
hypotension
are absent, administer are absent, administer
bolus unless
there are signs of
• Repeat assessment of • Assess the hemodynamic
dehydration with
hemodynamic response
(e.g. diarrhea).
boluses, 10–20 mL/kg, until mL/kg, until hypotension
shock resolves or signs of • Start maintenance resolves or signs of

• Assess cardiac function. • Monitor • Assess cardiac

hemodynamics function (if available).
• Consider epinephrine
closely.
if there is myocardial • Consider epinephrine/
dysfunction or epinephrine/ • Consider vasoactive– norepinephrine if
norepinephrine if shock inotropic support hypotension persists
persists after 40–60 mL/kg (if available). after 40 mL/kg or
(or sooner if signs of
overload develop.

Fluid in mL/kg should be dosed as ideal body weight.

Shock resolved, perfusion improved

• Do not give more • Consider • Monitor for signs/symptoms
of recurrent shock.

*Hypotension SBP SBP SBP Presence of all 3 World

in healthcare < 50 mm Hg < 60 mm Hg < 70 mm Hg Health Organization criteria:
systems WITHOUT in children in children in children OR cold extremities, prolonged
intensive care is aged < 12 aged 1 to 5 aged > 5
months years years weak, fast pulse

www.sccm.org/SurvivingSepsisCampaign/Guidelines/Pediatric-Patients
© 2020 the Society of Critical CAre Medicine and the European Society of Intensive Care Medicine, All Rights Reserved.

Reproduced with permission Weiss SL, Peter MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the
Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.Ped Crit Care Med. 2020; 21(2):e52-e106.
Copyright © 2020 by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.

Figure 3

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Please cite this article as: Edmunds S et al., Special considerations in paediatric intensive care, Anaesthesia and intensive care medicine, https://
doi.org/10.1016/j.mpaic.2023.08.010
 PAEDIATRIC CRITICAL CARE

Management of paediatric sepsis algorithm

Initial Resuscitation
Algorithm for Children
Systematic Screening for
! Sepsis in Children !
SEPTIC SEPSIS
Within 1 SHOCK SUSPECTED Within 3
hour of initial hours of initial
recognition of Suspicion of
septic shock Expedited sepsis
diagnostic
Shock evaluation
develops

Diagnostic evaluation supports

sepsis-associated organ dysfunction

1 2 3 4 5 6
Obtain Collect Start empiric Measure Start vasoactive
IV/IO blood broad-spectrum lactate. bolus(es) if shock agents if shock
access. culture. antibiotics. is present.* persists.*

Respiratory support
Assess for Peditaric Acute Respiratory Distress Syndrome

Infectious source control Continuous Fluid and vasoactive titration*

reassessment

Advanced hemodynamic monitoring if shock persists

• ± hydrocortisone • Avoid hypoglycemia VA or VV ECLS for refractory shock or

for refractory shock** • Antimicrobial oxygenation/ventilation failure (after addressing
• Nutritional support stewardship other causes of shock and respiratory failure)

is present or b) it is a low-resource setting without hypotension. Fluid in mL/kg should be dosed as ideal
body weight.

www.sccm.org/SurvivingSepsisCampaign/Guidelines/Pediatric-Patients
© 2020 the Society of Critical CAre Medicine and the European Society of Intensive Care Medicine, All Rights Reserved.

Reproduced with permission Weiss SL, Peter MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the
Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children.Ped Crit Care Med. 2020; 21(2):e52-e106.
Copyright © 2020 by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine.

Figure 4

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Please cite this article as: Edmunds S et al., Special considerations in paediatric intensive care, Anaesthesia and intensive care medicine, https://
doi.org/10.1016/j.mpaic.2023.08.010
 PAEDIATRIC CRITICAL CARE

Management of paediatric severe traumatic brain injury: 2019 consensus and guidelines-based
algorithm for first and second tier therapies

δ
TBI (GCS ≤ 8)
Ψ
Surgery as tempo of disease progression; interventions may need to be bypassed, repeated or initiated concurrently.
Cranial CT
indicated * ICP 20-25 for > 5 min; more rapidly for ICP > 25 mmHg
**Mannitol could be substituted
Insert ICP Monitor
# Monitor EEG
Baseline Care Maintain appropriate analgesia/sedation Herniation Pathway
Continue mechanical ventilation; maintain adequate arterial oxygenation; PaCO2 ~35 mmHg
Maintain normothermia (<38ºC) If signs and symptoms of herniation
Ensure appropriate intravascular volume status (CVP)δ • Pupillary dilation
Maintain Hgb > 7 g/dL (mimimum); higher levels may be optimal based on advaned monitoring • Hypertension/bradycardia
Treat coagulopathy • Extensor posturing
Elevate HOB 30º
Phenytoin or Levetiracetam/Consider continuous EEG monitoring throughout the management course Emergent Treatment:
Begin nutrition as early as feasible and treat hypoglycemia Hyperventilation titrate to reverse pupillary dilation
FiO2 = 1.0
ICP Pathway Bolus mannitol or hypertonic saline
CPP Pathway Maintain CPP Open EVD to continuous drainage
Appropriate for age ↑ ICP Ψ* Emergency CT
PbrO2 Pathway Minimum 40 mmHg
Yes No
If PbrO2 monitoring CSF drainage if ventriculostomy present
is used maintain
minimum of ↓ CPP Carefully wean To Surgery if
↑ ICP Ψ*
> 10 mmHg or withdraw indicated
Yes No ICP, CPP and/or
intravascular volume Bolus and/or infusion of hypertonic saline** PbrO2 directed
status [CVP] δ therapy
↓ PbrO2 Vasosuppressor infusion ↑ ICP Ψ*
Bolus of hypertonic Yes No Neurological
saline examination
Raise FiO2 Additional analgesia/sedation
may help guide
weaning or
↑ ICP Ψ*
withdrawal of
↓ PbrO2 Yes No therapy and/or
Neuromuscular blockade # extent of
Vasopressor
monitoring
infusion
Adjust PaCO2 ↑ ICP Ψ*
Optimize Hgb ↓ CPP Yes No
Additional hypertonic saline/hyperosmolar therapy
φNote: When ICP-directed care is deemed to be
↓ PbrO2
↑ ICP Ψ*
factors such as the level of ICP, the tempo of disease
Yes No progression and others.

φSecond Tier Therapy

PEDIATRIC CRITICAL CARE MEDICINE
From: Kochanek PM, Tasker RC, Bell MJ et al. Management of paediatric severe traumatic brain injury: 2019 Consensus and
guidelines-based algorithm for first and second tier therapies. Pediatric Critical Care Medicine 20(3):269-279, March 2019

Figure 5

Placement of an ICP monitor can facilitate ICP and cerebral
perfusion pressure (CPP)-guided therapy. Sustained elevations of
ICP >20 mm Hg are associated with poorer outcome. CPP should
be appropriate for age with a minimum target of 40e50 mmHg.
Signs of raised ICP with associated signs of herniation will
require urgent neurosurgical review and imaging (CT scanning).
This includes pupillary dilation, hypertension/bradycardia,
extensor posturing. Whilst waiting for review urgent medical
management includes: administration of 3% hypertonic saline (1
e3 ml/kg), hyperventilation and drainage of cerebrospinal fluid
if an external ventricular drain is in place.
Second tier therapies for ICP refractory to medical manage-
ment might include a barbiturate infusion, moderate hypothermia
32e34  C, hyperventilation (PaCO2 28e34 mmHg), higher levels
of osmolar therapy as well as decompressive craniectomy. A Replacement therapy in the critically ill child. Pediatr Crit Care
REFERENCES
1 Paediatric Intensive Care Audit Network. Annual report. Univer-
sities of leeds and leicester. Available at: https://www.picanet.org.
uk/wp-content/uploads/sites/25/2019/12/PICANet-2019-Annual-
Report-Summary_v1.0.pdf (accessed 23 March 2020).
2 Greaney D, Russelkl J, Dawkins I, et al. A retrospective observa-
tional study of acquired subglottic stenosis using low- pressure,
high-volume cuffed endotracheal tubes. Pediatr Anesth 2018; 28:
1136e41.
3 Gupta R, Rosen D. Paediatrice mechanical ventilation in the
intensive care unit. BJA Edu 2016; 16: 422e6.
4 Lalgudi Ganesan S. Airway pressure release ventilation in children.
Curr Opin Crit Care 2019; 25: 63e70.
5 Saha A, Sarka B. Vasoactive and inotropic therapy in PICU.
J Pediatr Crit Care 2014; 1: 39e53.
6 Grebenik C, Sinclair M. Which inotrope? Curr Paediatr 2003; 13:
6e11.
7 Clifford M. Inotropes in children. Aus Anaesth 2005; 129e34.
8 Westrope C, Fleming S, Kapetanstrataki M, et al. Renal
Med 2018; 19: 210e7.
9 Scott-Warren VL, Morley RB. Paediatric vascular access. BJA Edu
2015; 15: 199e206.
10 Singh Y, Tissot C, Fraga MV, et al. International evidence-based
guidelines on Point of Care Ultrasound (POCUS) for critically ill
neonates and children issued by the POCUS Working Group of

ANAESTHESIA AND INTENSIVE CARE MEDICINE xxx:xxx 10 Ó 2023 Published by Elsevier Ltd.

Please cite this article as: Edmunds S et al., Special considerations in paediatric intensive care, Anaesthesia and intensive care medicine, https://
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 PAEDIATRIC CRITICAL CARE

the European Society of Paediatric and Neonatal Intensive Care
(ESPNIC). Crit Care 2020; 24: 65.
11 Meyer-Macaulay C, Rosen D. Paediatric extracorporeal mem-
brane oxygenation and extracorporeal cardiopulmonary resusci-
tation. BJA Edu 2018; 18: 153e7.
12 Flori HR, Glidden DV, Rutherford GW, et al. Pediatric acute lung
injury: prospective evaluation of risk factors associated with
mortality. Am J Respir Crit Care Med 2005; 171: 995e1001.
13 Pediatric Acute Lung Injury Consensus Conference Group.
Pediatric acute respiratory distress syndrome: consensus
recommendations from the pediatric acute lung injury
consensus conference. Pediatr Crit Care Med 2015; 16:
428e39.
14 Cheifetz I. Pediatric ARDS. Respir Care 2017; 62: 718e31.
15 Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis
campaign international guidelines for the management of septic-
shock and sepsis-associated organ dysfunction in children. Intens
Care Med 2020; 46: 10e67.
16 Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the
management of pediatric severe traumatic brain injury, third edi-
tion: update of the brain trauma foundation guidelines. Pediatr Crit
Care Med 2019; 20: 280e9.

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