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FUHRMAN & ZIMMERMAN’S
PEDIATRIC
CRITICAL CARE
SIXTH EDITION
FUHRMAN & ZIMMERMAN’S
PEDIATRIC
CRITICAL CARE
JERRY J. ZIMMERMAN, MD, PhD, FCCM ALEXANDRE T. ROTTA, MD, FCCM
Faculty, Pediatric Critical Care Medicine, Seattle Children’s Division Chief, Pediatric Critical Care Medicine Duke
Hospital, Harborview Medical Center, University of Children’s Hospital; Professor of Pediatrics; Duke University
Washington School of Medicine, Seattle, Washington School of Medicine, Durham, North Carolina
Robert S.B. Clark, MD Sapna Ravi Kudchadkar, MD, PhD, FCCM

Professor and Vice Chair, Critical Care Medicine, University Associate Professor, Anesthesiology and Critical Care
of Pittsburgh School of Medicine; Associate Director, Safar Medicine, Pediatrics, and Physical Medicine and
Center for Resuscitation Research, University of Pittsburgh, Rehabilitation, Charlotte R. Bloomberg Children’s Center,
Pittsburgh, Pennsylvania Johns Hopkins University School of Medicine, Baltimore,
Maryland
Bradley P. Fuhrman, MD, FAAP, MCCM

Professor of Pediatrics in Medical Education, Monica Relvas, MD, FAAP, FCCM, MSHA
Clinical Educator and Gold College Mentor, Paul L. Foster Medical Director, Pediatric Critical Care Medicine,
School of Medicine, Texas Tech University HSC El Paso, Covenant Children’s Hospital, Associate Clinical Professor,
El Paso, Texas Texas Tech University, Lubbock, Texas
Joseph D. Tobias, MD
Chair, Department of Anesthesiology and Pain Medicine,
Nationwide Children’s Hospital; Professor of Anesthesiology
and Pediatrics, The Ohio State University, Columbus, Ohio
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FUHRMAN AND ZIMMERMAN’S PEDIATRIC CRITICAL CARE,

SIXTH EDITION ISBN: 978-0-323-67269-6
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Contributors
Isaac Josh Abecassis, MD Ben D. Albert, MD

Resident Physician Program Director, Critical Care Medicine Fellowship
Department of Neurological Surgery Department of Anesthesiology, Critical Care, and Pain Medicine
University of Washington Boston Children’s Hospital
Seattle, Washington Boston, Massachusetts
Jayani Abeysekera, MD, FRCP Alicia Alcamo, MD, MPH

Assistant Professor Assistant Professor of Critical Care and Pediatrics
Department of Pediatrics Department of Anesthesiology and Critical Care Medicine
Division of Cardiology University of Pennsylvania Perelman School of Medicine
Dalhousie University/IWK Health Centre Children’s Hospital of Philadelphia
Halifax, Nova Scotia, Canada Philadelphia, Pennsylvania
P. David Adelson, MD, FAAP, FACS, FAANS Matthew N. Alder, MD, PhD
Diane and Bruce Halle Chair of Children’s Neurosciences Assistant Professor
Director, Barrow Neurological Institute at Phoenix Children’s Critical Care Medicine
Hospital Cincinnati Children’s Hospital Medical Center
Professor, Department of Child Health Cincinnati, Ohio
University of Arizona College of Medicine;
Professor, Department of Neurosurgery Omar Alibrahim, MD, FAAP
Mayo Clinic Chief, Pediatric Critical Care Division
Phoenix, Arizona John R. Oishei Children’s Hospital
Associate Professor of Pediatrics
Rachel S. Agbeko, FRCPCH, PhD Jacob’s School of Medicine
Consultant University of Buffalo
Paediatric Intensive Care Unit Buffalo, New York
Great North Children’s Hospital
Newcastle upon Tyne Hospitals NHS Trust Veerajalandhar Allareddy, MBBS, MBA
Newcastle upon Tyne, United Kingdom Section Chief, Pediatric Cardiac Intensive Care
Duke University Medical Center
Michael S.D. Agus, MD Professor of Pediatrics
Chief of Medical Critical Care Duke University School of Medicine
Department of Pediatrics Durham, North Carolina
Division of Medical Critical Care
Boston Children’s Hospital Melvin C. Almodovar, MD
Boston, Massachusetts The George E. Batchelor Chair in Pediatric Cardiology
Chief, Pediatric Cardiology
Mubbasheer Ahmed, MD University of Miami Miller School of Medicine;
Cardiac Intensive Care Unit Director, Children’s Heart Center
Texas Medical Center Director, Cardiac Intensive Care
Texas Children’s Hospital Hotz Children’s Hospital, Jackson Health System
Houston, Texas Miami, Florida
Alireza Akhondi-Asl, PhD Alexandra Aminoff, MD

Departments of Anesthesiology, Critical Care, and Pain Acting Assistant Professor
Medicine Department of Pediatric Rheumatology
Division of Critical Care Seattle Children’s Hospital
Boston Children’s Hospital Seattle, Washington
Boston, Massachusetts
v
vi Contributors
Catherine Amlie-Lefond, MD Adnan M. Bakar, MD

Professor Assistant Professor of Pediatrics
Department of Neurology Section Head, Pediatric Cardiac Critical Care
University of Washington Cohen Children’s Medical Center of Hofstra/Northwell
Seattle, Washington New Hyde Park, New York
Rajesh Aneja, MD Katherine Banker, MD

Clinical Chief, Division of Pediatric Critical Care Medicine Clinical Assistant Professor
Medical Director, Pediatric Intensive Care Unit Department of Pediatrics, Critical Care
Children’s Hospital of Pittsburgh of UPMC; Seattle Children’s Hospital
Professor Seattle, Washington
Department of Critical Care Medicine and Pediatrics
University of Pittsburgh School of Medicine Piers C.A. Barker, MD
Pittsburgh, Pennsylvania Professor of Pediatrics and Obstetrics/Gynecology
Department of Pediatrics
Abigail Apple, ARNP Duke University School of Medicine
Pediatric Critical Care Durham, North Carolina
Seattle Children’s Hospital
Seattle, Washington Lee M. Bass, MD
Andrew C. Argent, MD Departments of Gastroenterology, Hepatology & Nutrition
Professor Ann & Robert H. Lurie Children’s Hospital of Chicago
School of Child and Adolescent Health Northwestern University Feinberg School of Medicine
University of Cape Town; Chicago, Illinois
Medical Director
Paediatric Intensive Care Rajit K. Basu, MD, MS, FCCM
Red Cross War Memorial Children’s Hospital Associate Professor of Pediatrics
Cape Town, South Africa Emory School of Medicine;
Research Director
Joan C. Arvedson, PhD Division of Pediatric Critical Care Medicine
Program Coordinator, Feeding & Swallowing Services Children’s Healthcare of Atlanta
Speech Pathology and Audiology Atlanta, Georgia
Children’s Hospital of Wisconsin;
Clinical Professor Hülya Bayir, MD
Department of Pediatrics Safar Center for Resuscitation Research
Medical College of Wisconsin Department of Critical Care Medicine
Milwaukee, Wisconsin University of Pittsburgh School of Medicine
Children’s Hospital of Pittsburgh of UPMC
François Aspesberro, MD Pittsburgh, Pennsylvania
Pediatric Cardiothoracic ICU
Miller Children’s & Women’s Hospital Long Beach Lance B. Becker, MD
Long Beach, California Chair, Emergency Medicine
Donald and Barbara Zucker School of Medicine at
Nir Atlas, MD Hofstra/Northwell
Clinical Fellow Hempstead, New York
Division of Pediatric Critical Care
Children’s Healthcare of Atlanta–Egleston Jamie L. Bell, MD
Emory University School of Medicine Assistant Professor of Pediatrics
Atlanta, Georgia Department of Pediatrics
Children’s Hospital of Michigan
John E. Baatz, PhD Wayne State University School of Medicine
Professor Detroit, Michigan
Medical University of South Carolina Michael J. Bell, MD
Charleston, South Carolina Chief, Pediatric Critical Care Medicine
Harris P. Baden, MD Children’s National Medical Center
Professor and Chief Washington, DC
Pediatric Cardiac Critical Care
University of Washington
Seattle, Washington
Contributors vii
Melania M. Bembea, MD, MPH, PhD Naomi B. Bishop, MD

Associate Professor Assistant Professor
Department of Anesthesiology and Critical Care Medicine Department of Pediatric Critical Care Medicine
Johns Hopkins University School of Medicine Weill Cornell Medical College
Baltimore, Maryland New York, New York
M.A. Bender, MD, PhD Julie Blatt, MD

Director, Sickle Cell and Hemoglobinopathy Program Professor
Odessa Brown Children’s Clinic; Pediatric Hematology Oncology
Associate Professor University of North Carolina
Department of Pediatrics Chapel Hill, North Carolina
Seattle, Washington Lauren Bodilly, MD
Critical Care Fellow
Alexis L. Benscoter, DO Department of Pediatric Critical Care
Assistant Professor of Clinical Pediatrics Cincinnati Children’s Hospital
University of Cincinnati College of Medicine; Cincinnati, Ohio
Department of Cardiac Critical Care Medicine
Division of Cardiology Robert H. Bonow, MD
Cincinnati Children’s Hospital Medical Center Resident Physician
Cincinnati, Ohio Department of Neurological Surgery
Wade W. Benton, PharmD Seattle, Washington
Chief Development Officer
Eicos Sciences, Inc. E. Alexis Bragg, MD
San Mateo, California Assistant Professor of Anesthesiology and Pediatrics
Department of Anesthesia and Critical Care Medicine
Robert A. Berg, MD Children’s Hospital Los Angeles
Professor Keck School of Medicine–University of Southern California
Departments of Anesthesiology, Critical Care Medicine, Los Angeles, California
and Pediatrics
University of Pennsylvania Perelman School of Medicine; Barbara W. Brandom, MD
Division Chief, Critical Care Medicine Retired Professor
Departments of Anesthesiology and Critical Care Medicine Department of Anesthesiology
Children’s Hospital of Philadelphia University of Pittsburgh;
Philadelphia, Pennsylvania Retired Director
North American MH Registry of MHAUS
Emily Berkman, MD Pittsburgh, Pennsylvania
Assistant Professor
Departments of Pediatrics and Bioethics and Humanities Richard J. Brilli, MD
University of Washington School of Medicine; Chief Medical Officer
Division of Pediatric Critical Care Hospital Administration
Department of Pediatric Bioethics Nationwide Children’s Hospital;
Treuman Katz Center for Pediatric Bioethics Professor
Seattle Children’s Hospital Department of Pediatrics
Seattle, Washington Division of Critical Care Medicine
The Ohio State University College of Medicine
Carol Berkowitz, MD Columbus, Ohio
Chief, Division of General Pediatrics
Department of Pediatrics Thomas V. Brogan, MD
Harbor-UCLA Medical Center Professor
Torrance, California; Department of Pediatrics
Distinguished Professor of Pediatrics University of Washington School of Medicine
David Geffen School of Medicine at UCLA Seattle, Washington
Los Angeles, California
Ronald A. Bronicki, MD, FCCM, FACC
Katherine V. Biagas, MD Professor
Associate Professor Departments of Critical Care Medicine and Cardiology
Department of Pediatrics Texas Children’s Hospital and Baylor College of Medicine
Vice Chairman for Faculty Development Houston, Texas
Stony Brook Children’s and the Renaissance School of Medicine
Stony Brook, New York
viii Contributors
Samuel R. Browd, MD, PhD, FAANS, FAAP Michael P. Carboni, MD

Professor Medical Director, Pediatric Heart Failure & Transplant
Department of Neurological Surgery Department of Pediatrics
Seattle Children’s Hospital Duke Children’s Hospital
University of Washington Durham, North Carolina
Seattle, Washington
Joseph A. Carcillo, MD
Timothy E. Bunchman, MD Professor of Critical Care Medicine and Pediatrics
Professor and Director, Pediatric Nephrology Children’s Hospital of Pittsburgh
Children’s Hospital of Richmond University of Pittsburgh School of Medicine
Virginia Commonwealth University School of Medicine Pittsburgh, Pennsylvania
Richmond, Virginia
Antonio Cassara, MBChB
Jeffrey P. Burns, MD, MPH Associate Professor
Chief and Endowed Shapiro Chair of Critical Care Medicine Department of Anesthesia
Chair, Governance Committee of the Intensive Care Units Ruby Memorial Hospital
Boston Children’s Hospital Morgantown, West Virginia
Professor of Anesthesia
Harvard Medical School Nina Censoplano, MD
Boston, Massachusetts Attending physician
Pediatric Critical Care Medicine
David F. Butler, MD INOVA Fairfax Medical Center
Fellow Falls Church, Virginia
Division of Critical Care Victoria Chadwick, PharmD, BCCCP
Seattle Children’s Hospital Critical Care Pharmacist
Seattle, Washington Seattle Children’s Hospital
Seattle, Washington
Derya Caglar, MD
Fellowship Director, Pediatric Emergency Medicine Reid C. Chamberlain, MD
Associate Professor, Pediatrics Pediatric Cardiology Fellow
University of Washington School of Medicine Department of Pediatrics
Attending Physician Duke University Hospital
Division of Pediatric Emergency Medicine Durham, North Carolina
Seattle, Washington Anny Chan, PharmD
Hematopoietic Stem Cell Transplant Clinical Pharmacist
Michael W. Camitta, MD Seattle Children’s Hospital
Associate Professor of Pediatrics Seattle, Washington
Duke University School of Medicine John R. Charpie, MD, PhD
Durham, North Carolina Amnon Rosenthal Professor & Director of Pediatric Cardiology
University of Michigan Medical School
M. Jay Campbell, MD, MHA Co-Director, University of Michigan Congenital Heart Center
Associate Professor of Pediatrics C.S. Mott Children’s Hospital
Department of Pediatrics Michigan Medicine
Duke University School of Medicine Ann Arbor, Michigan
Durham, North Carolina
Ira M. Cheifetz, MD
Sally Campbell, MBBS(Hons), FRACP, FRCPA Professor
Paediatric Haematologist Departments of Pediatrics and Anesthesiology
Royal Children’s Hospital Duke University Medical Center
Melbourne, Australia Durham, North Carolina
Karel D. Capek, MD Saurabh Chiwane, MD

Fellow Assistant Professor
Acute Burn, Critical Care, and Reconstruction Department of Pediatrics
Shriners Hospitals for Children Saint Louis University
Galveston and the University of Texas Medical Branch St. Louis, Missouri
Galveston, Texas
Contributors ix
Robert H. Chun, MD Craig M. Coopersmith, MD

Associate Professor Professor
Department of Pediatric Otolaryngology Department of Surgery
Medical College of Wisconsin Emory University
Milwaukee, Wisconsin Atlanta, Georgia
Jeff Clark, MD Seth J. Corey, MD, MPH

Staff Intensivist Professor
Pediatric Critical Care Medicine Departments of Pediatrics and Molecular Medicine
Vice Chair of Pediatrics Cleveland Clinic
Ascension St. John Children’s Hospital Cleveland, Ohio
Detroit, Michigan
Mary K. Dahmer, PhD
Jonna D. Clark, MD Associate Professor
Associate Professor Department of Pediatrics
Departments of Pediatrics and Critical Care Medicine Division of Critical Care
University of Washington; University of Michigan Medical School
Faculty Ann Arbor, Michigan
Treuman Katz Center for Pediatric Bioethics
Seattle Children’s Hospital Heidi J. Dalton, MD, MCCM, FELSO
Seattle, Washington Director of ECMO Program Development and Research
INOVA Fairfax Medical Center
Robert S.B. Clark, MD Falls Church, Virginia;
Professor and Vice Chair Professor of Pediatrics
Critical Care Medicine Virginia Commonwealth University
University of Pittsburgh School of Medicine; Richmond, Virginia;
Associate Director, Safar Center for Resuscitation Research Professor of Clinical Surgery
University of Pittsburgh George Washington University
Pittsburgh, Pennsylvania Washington, DC
April Clawson, MD Rahul C. Damania, MD, FAAP

Fellow Clinical Fellow
Pediatric Emergency Medicine Division of Pediatric Critical Care
University of Arkansas Medical Center Children’s Healthcare of Atlanta–Egleston
Little Rock, Arkansas Emory University School of Medicine
Atlanta, Georgia
Jason A. Clayton, MD, PhD
Assistant Professor Mihaela A. Damian, MD, MPH
Department of Pediatrics Clinical Assistant Professor
Rainbow Babies & Children’s Hospital Department of Pediatrics
Cleveland, Ohio Stanford University
Palo Alto, California
Thomas Conlon, MD
Assistant Professor Lauren Dartois, PharmD
Department of Pediatric Critical Care Medicine Critical Care Clinical Pharmacist
The Children’s Hospital of Philadelphia Seattle Children’s Hospital
Philadelphia, Pennsylvania Seattle, Washington
Carol Conrad, MD Peter J. Davis, MD, FAAP

Associate Professor Professor
Department of Pediatrics Departments of Anesthesiology and Pediatrics
Stanford University University of Pittsburgh School of Medicine;
Palo Alto, California Anesthesiologist-in-Chief
Department of Anesthesiology
Edward E. Conway Jr, MD, MS Children’s Hospital of Pittsburgh of UPMC
Chairman and Pediatrician-in-Chief Pittsburgh, Pennsylvania
Milton and Bernice Stern Department of Pediatrics
Beth Israel Medical Center;
Professor of Pediatrics
Icahn School of Medicine at Mount Sinai
New York, New York
x Contributors
Leslie A. Dervan, MD Allan Doctor, MD

Assistant Professor Professor of Pediatrics (Critical Care)
Department of Pediatrics Director, Center for Blood Oxygen Transport and Hemostasis
Seattle Children’s Hospital University of Maryland School of Medicine
University of Washington School of Medicine Baltimore, Maryland
Seattle, Washington
John J. Downes, MD
Clifford S. Deutschman, MS, MD, MCCM Professor Emeritus of Anesthesiology and Critical Care, and
Vice Chair, Research Pediatrics
Department of Pediatrics University of Pennsylvania Perelman School of Medicine
Professor of Pediatrics and Molecular Medicine Chair Emeritus of Anesthesiology and Critical Care Medicine
Donald and Barbara Zucker School of Medicine at Children’s Hospital of Philadelphia
Hofstra/Northwell Philadelphia, Pennsylvania
Hempstead, New York;
Cohen Children’s Medical Center Christine Duncan, MD
New York, New York; Associate Clinical Director of Pediatric HSCT
Professor, Elmezzi Graduate School of Molecular Medicine Senior Physician
Professor, Feinstein Institutes for Medical Research Dana Farber/Boston Children’s Cancer and Blood Disorders
Manhasset, New York; Center;
Emeritus Professor of Anesthesiology & Critical Care and Assistant Professor of Pediatrics
Surgery Harvard Medical School
Perelman School of Medicine at the University of Pennsylvania Boston, Massachusetts
Philadelphia, Pennsylvania
Christopher M. Edwards, MD
Cameron Dezfulian, MD, FAHA Assistant Professor
Director, Adult Congenital Heart Disease ICU Department of Anesthesiology
Critical Care Medicine Section University of Florida College of Medicine
Texas Children’s Hospital; Gainesville, Florida
Senior Faculty
Baylor College of Medicine Lauren R. Edwards, MD
Houston, Texas Assistant Professor
Pediatric Critical Care
André A.S. Dick, MD, MPH University of Arkansas for Medical Sciences/Arkansas Children’s
Associate Professor of Surgery Hospital
ASTS Transplant Fellowship Director Little Rock, Arkansas
Surgical Director, Pediatric Kidney Transplant
Department of Surgery Chinyere Egbuta, MD
Division of Transplantation Instructor
Seattle Children’s Hospital Department of Anesthesia
University of Washington School of Medicine Harvard Medical School;
Seattle, Washington Associate Professor
Anesthesia and Critical Care Medicine
Douglas S. Diekema, MD, MPH Boston Children’s Hospital
Professor Boston, Massachusetts
University of Washington; Howard Eigen, MD
Director of Education Professor of Pediatrics, Retired
Treuman Katz Center for Pediatric Bioethics Department of Pediatrics
Seattle Children’s Research Institute Indiana University School of Medicine
Seattle, Washington Indianapolis, Indiana
Michael Dingeldein, MD Hannah Laure Elfassy, MD, FRCP(c)

Trauma Medical Director Chief
Rainbow Babies & Children’s Hospital Department of Allergy and Clinical Immunology
Assistant Professor of Surgery Sacré Coeur Hospital
Case Western Reserve University Montreal, Quebec, Canada
Cleveland, Ohio
Contributors xi
Alison M. Ellis, MD, MBA Joseph T. Flynn, MD

Assistant Professor Chief, Division of Nephrology
Anesthesia and Perioperative Medicine Department of Pediatrics
Charleston, South Carolina Seattle Children’s Hospital;
Professor
Idris V.R. Evans, MD Department of Pediatrics
Assistant Professor University of Washington School of Medicine
Department of Critical Care Medicine Seattle, Washington
University of Pittsburgh
Pittsburgh, Pennsylvania Michael L. Forbes, MD, FCCM
Professor and Associate Chair
Reid W.D. Farris, MD Department of Pediatrics
Associate Professor Northeast Ohio Medical University;
Department of Pediatrics Director, Critical Care Research & Outcomes Analysis
Division of Critical Care Medicine Akron Children’s Hospital
University of Washington Akron, Ohio
Seattle, Washington
Joseph M. Forbess, MD
Jeffrey R. Fineman, MD Department of Surgery
Professor Northwestern University Feinberg School of Medicine
Department of Pediatrics Chicago, Illinois
University of California, San Francisco
San Francisco, California Deborah E. Franzon, MD
Clinical Professor
Ericka L. Fink, MD Department of Pediatric Medicine
Associate Professor of Critical Care Medicine Division of Critical Care Medicine
University of Pittsburgh School of Medicine University of California, San Francisco
Children’s Hospital of Pittsburgh of UPMC; San Francisco, California
Associate Director
Safar Center for Resuscitation Research W. Joshua Frazier, MD
University of Pittsburgh Medical Center Assistant Professor of Pediatrics
Pittsburgh, Pennsylvania Critical Care Medicine
Nationwide Children’s Hospital
Frank A. Fish, MD Columbus, Ohio
Professor
Department of Pediatrics Bradley P. Fuhrman, MD, FAAP, MCCM
Vanderbilt Medical Center Professor of Pediatrics in Medical Education
Nashville, Tennessee Clinical Educator and Gold College Mentor
Paul L. Foster School of Medicine
Tamara N. Fitzgerald, MD, PhD Texas Tech University HSC El Paso
Assistant Professor El Paso, Texas
Department of Surgery
Duke University Richard M. Ginther Jr, MBA, BS
Durham, North Carolina Pediatric Perfusionist
Pediatric Cardiothoracic Surgery
Gregory A. Fleming, MD, MSCI, FSCAI UT Southwestern Medical Center
Associate Professor Dallas, Texas
Duke University Nicole Glaser, MD
Durham, North Carolina Professor
Saul Flores, MD Section of Endocrinology and Diabetes
Assistant Professor University of California, Davis
Pediatrics/Critical Care Sacramento, California
Baylor College of Medicine;
Attending Physician Ana Lia Graciano, MD, FCCM
Texas Children’s Hospital Professor of Pediatrics
Houston, Texas Medical Director CICU
Pediatric Critical Care Medicine
University of Maryland Children’s Hospital
Baltimore, Maryland
xii Contributors
Megan M. Gray, MD Cary O. Harding, MD

Assistant Professor of Pediatrics Professor
Department of Pediatrics Department of Molecular and Medical Genetics
Division of Neonatology Oregon Health & Science University
Fellowship Program Director for Neonatal-Perinatal Medicine Portland, Oregon
University of Washington School of Medicine Mary E. Hartman, MD, MPH
Kristin C. Greathouse, CPNP-AC, PhD Washington University in St. Louis
Heart Center St. Louis, Missouri
University of Minnesota Masonic Children’s Hospital
Minneapolis, Minnesota Silvia M. Hartmann, MD
Assistant Professor
Bruce M. Greenwald, MD, FAAP, FCCM Critical Care Medicine
Professor of Clinical Pediatrics Seattle Children’s Hospital
Executive Vice-Chair, Department of Pediatrics Seattle, Washington
Division of Pediatric Critical Care Medicine
Weill Cornell Medical College Kevin M. Havlin, MD
New York, New York Assistant Professor
Matthew M. Grinsell, MD, PhD Division of Pediatric Critical Care
Associate Professor University of Louisville
Department of Pediatrics Louisville, Kentucky
University of Utah
Salt Lake City, Utah Kristen Hayward, MD
Associate Professor
Jocelyn R. Grunwell, MD Department of Pediatrics
Assistant Professor Division of Rheumatology
Department of Pediatrics Seattle Children’s Hospital
Division of Critical Care Medicine University of Washington School of Medicine
Emory University/Children’s Healthcare of Atlanta Seattle, Washington
Atlanta, Georgia
Patrick J. Healey, MD
Björn Gunnarsson, MD Professor
Department of Research Department of Surgery
Norwegian Air Ambulance Foundation University of Washington School of Medicine
Drøbak, Norway Division Chief, Pediatric Transplant Surgery
SAR Helicopter Seattle Children’s Hospital
Ørland Main Air Station, Norway Seattle, Washington
Marla Guzman, MD Christopher M.B. Heard, MBChB, FRCA

Fellow Clinical Professor
Pediatric Rheumatology Department of Anesthesiology
Cohen Children’s Medical Center-Zucker School of Medicine at Clinical Professor
Hofstra/Northwell Division of Pediatric Critical Care
New Hyde Park, New York Oishei Children’s Hospital
Buffalo, New York
Timothy Hahn, MD
Fellow Julia A. Heneghan, MD
Department of Pediatrics Assistant Professor
Penn State Children’s Hospital Pediatric Critical Care
Hershey, Pennsylvania University of Minnesota Masonic Children’s Hospital
Minneapolis, Minnesota
Mark W. Hall, MD
Chief, Division of Critical Care Medicine David N. Herndon, MD
Department of Pediatrics Editor, Burn Care and Research
Nationwide Children’s Hospital American Burn Association
Columbus, Ohio Chicago, Illinois
Contributors xiii
Lynn J. Hernan, MD Laura Marie Ibsen, MD

Associate Professor of Pediatrics Professor of Pediatrics
Pediatric Clerkship Director Division Chief, Pediatric Critical Care
Texas Tech University HSC El Paso Department of Pediatrics
Paul L. Foster School of Medicine Oregon Health and Sciences University
El Paso, Texas Portland, Oregon
Kevin D. Hill, MD, MSCI Hanneke Ijsselstijn, MD, PhD

Associate Professor Associate Professor of Pediatrics
Department of Pediatrics Department of Pediatric Surgery and Intensive Care
Duke University Medical Center Erasmus Medical Center, Sophia Children’s Hospital
Durham, North Carolina Rotterdam, The Netherlands
Julien I. Hoffman† Travis C. Jackson, PhD

Professor (Emeritus) Associate Professor of Molecular Pharmacology & Physiology
Pediatrics University of South Florida
University of California, San Francisco Morsani College of Medicine
San Francisco, California USF Health Heart Institute
Tampa, Florida
Paula Holinski, MD, FRCPC
Clinical Assistant Professor of Anesthesiology Shelina M. Jamal, MD
University of Alberta Clinical Assistant Professor
Pediatric Anesthesia and Pediatric Cardiac Intensive Care Pediatric Critical Care
Stollery Children’s Hospital Alberta Children’s Hospital
Edmonton, Alberta, Canada Calgary, Alberta, Canada
Sue J. Hong, MD Prashant Joshi, MD

Assistant Professor Associate Professor
Departments of Pediatrics and Neurology Department of Pediatrics
Northwestern University Texas Tech University Health Sciences Center El Paso
Lurie Children’s Hospital of Chicago El Paso, Texas
Chicago, Illinois
Emily L. Joyce, MD
Simon Horslen, MB ChB Assistant Professor
Professor Department of Pediatrics, Division of Nephrology
Department of Pediatrics UH Rainbow Babies and Children’s Hospital
University of Washington School of Medicine; Case Western Reserve University School of Medicine
Medical Director of Solid Organ Transplantation Cleveland, Ohio
Department of Gastroenterology, Hepatology & Nutrition
Seattle Children’s Hospital Tom Kallay, MD
Seattle, Washington Chief, Division of Pediatric Critical Care Medicine
Director, Simulation and Educational Resource Center for
Aparna Hoskote, MBBS, DCH, MRCP, MD Improved Patient Safety and Outcomes
Consultant in Cardiac Intensive Care Harbor-UCLA Medical Center
Honorary Senior Lecturer Torrance, California;
UCL Great Ormond Street Institute of Child Health Associate Professor of Clinical Pediatrics
Great Ormond Street Hospital for Children David Geffen School of Medicine
NHS Foundation Trust Los Angeles, California
London, United Kingdom
Pradip P. Kamat, MD
Justin C. Hotz, BSRT, RRT-NPS Medical Director, Sedation
Senior Research Associate Children’s Healthcare of Atlanta
Department of Anesthesia and Critical Care Medicine Atlanta, Georgia
Children’s Hospital Los Angeles
Los Angeles, California Jason M. Kane, MD, MS, FAAP, FCCM
Department of Pediatric Critical Care Medicine
University of Chicago Comer Children’s Hospital
Chicago, Illinois
†
Deceased.
xiv Contributors
Prince J. Kannankeril, MD Christa Jefferis Kirk, PharmD, BCCP

Professor Heart Center Clinical Pharmacy Specialist
Department of Pediatrics Seattle Children’s Hospital;
Vanderbilt Children’s Hospital Clinical Associate Professor
Nashville, Tennessee School of Pharmacy
Oliver Karam, MD, PhD Seattle, Washington
Division Chief
John J. Mickell Endowed Associate Professor of Pediatrics Sonya Kirmani, MD
Department of Pediatrics Medical Instructor
Children’s Hospital of Richmond at VCU Department of Pediatrics
Richmond, Virginia Duke University
Katherine L. Kenningham, MD
Fellow, Neonatal-Perinatal Medicine Ruth Kleinpell, PhD, RN, APRN-BC
Department of Pediatrics Director, Center for Clinical Research and Scholarship
Division of Neonatology Assistant Dean for Clinical Scholarship
Seattle Children’s Hospital Vanderbilt University School of Nursing
University of Washington School of Medicine Nashville, Tennessee
Seattle, Washington
Patrick M. Kochanek, MD, MCCM
Hedieh Khalatbari, MD, MBA Ake N. Grenvik Professor in Critical Care Medicine
Assistant Professor of Pediatric Radiology Department of Critical Care Medicine
Department of Radiology University of Pittsburgh School of Medicine
Seattle Children’s Hospital and University of Washington Pittsburgh, Pennsylvania
Seattle, Washington
Keith C. Kocis, MD, MS
Robinder G. Khemani, MD, MsCI Director, Pediatric Cardiac ICU
Associate Director of Research Co-Director, Pediatric ECLS
Department of Anesthesiology and Critical Care Medicine Inova Children’s Hospital
Children’s Hospital Los Angeles; Inova Heart and Vascular Institute;
Associate Professor of Pediatrics Professor of Pediatrics
Keck School of Medicine VCU School of Medicine Inova Campus
University of Southern California Falls Church, Virginia
Los Angeles, California
Samuel A. Kocoshis, MD
Elizabeth Y. Killien, MD, MPH Professor
Acting Assistant Professor Department of Pediatrics
Department of Pediatrics University of Cincinnati College of Medicine;
Division of Pediatric Critical Care Medicine Medical Director, Intestinal Transplantation and Intestinal Care
Seattle Children’s Hospital Center
University of Washington Department of Gastroenterology, Hepatology, and Nutrition
Seattle, Washington Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
Yun Kim, MS, OTR/L
Pediatric Rehabilitation Clinical Specialist Ildiko H. Koves, MD, FRACP
Department of Physical Medicine and Rehabilitation Associate Professor
Johns Hopkins Children’s Center Department of Endocrinology and Diabetes
Baltimore, Maryland Seattle Children’s Hospital
Seattle, Washington
Jenny Kingsley, MD
Fellow Sapna R. Kudchadkar, MD, PhD
Pediatric Critical Care Medicine Associate Professor of Anesthesiology and Critical Care
Treuman Katz Center for Pediatric Bioethics Medicine, Pediatrics, and Physical Medicine and
Seattle Children’s Hospital Rehabilitation
Seattle, Washington Charlotte R. Bloomberg Children’s Center
Johns Hopkins University School of Medicine
Baltimore, Maryland
Contributors xv
Thomas J. Kulik, MD John C. Lin, MD

Senior Associate in Cardiology Associate Professor
Department of Cardiology Department of Pediatrics
Boston Children’s Hospital Washington University School of Medicine
Associate Professor of Pediatrics St. Louis, Missouri
Harvard Medical School
Boston, Massachusetts Aline Maddux, MD
Assistant Professor of Pediatrics
Jacques Lacroix, MD Department of Pediatric Critical Care
Professor University of Colorado Anschutz Medical Campus
Department of Pediatrics Aurora, Colorado
Sainte-Justine Hospital
Montreal, Quebec, Canada Matthew P. Malone, MD
Assistant Professor
Ruth Lebet, PhD, RN, PCNS-BC, CCNS-P Pediatric Critical Care
Nurse Scientist University of Arkansas for Medical Sciences/Arkansas Children’s
Center for Pediatric Nursing Research & Evidence-Based Hospital
Practice; Little Rock, Arkansas
Program Director, Pediatric & Neonatal CNS Programs
University of Pennsylvania School of Nursing Mioara Manole, MD
Philadelphia, Pennsylvania Associate Professor of Pediatrics
University of Pittsburgh School of Medicine
Amy Lee, MD Children’s Hospital of Pittsburgh of UPMC;
Associate Professor Associate Director
Department of Neurological Surgery Safar Center for Resuscitation Research
University of Washington University of Pittsburgh Medical Center
Seattle, Washington Pittsburgh, Pennsylvania
Hallie Lenker, PT, DPT Anne Marsh, MD

Pediatric Rehabilitation Team Coordinator Associate Professor of Pediatrics
Department of Physical Medicine and Rehabilitation Department of Hematology/Oncology & Bone Marrow
Johns Hopkins Children’s Center Transplant
Baltimore, Maryland University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Daniel L. Levin, MD
Professor Emeritus Richard J. Martin, MBBS
Departments of Pediatrics and Anesthesia Professor
Children’s Hospital at Dartmouth Departments of Pediatrics, Reproductive Biology, and Physiology
Lebanon, New Hampshire & Biophysics
Case Western Reserve University School of Medicine;
Emily R. Levy, MD Drusinsky-Fanaroff Professor and Director of Neonatal Research
Assistant Professor Pediatrics/Neonatology
Department of Pediatric and Adolescent Medicine Rainbow Babies & Children’s Hospital
Divisions of Pediatric Critical Care Medicine and Pediatric Cleveland, Ohio
Infectious Diseases
Mayo Clinic Mudit Mathur, MD, MBA, FAAP, FCCM, CPPS
Rochester, Minnesota Director, Pediatric Critical Care
Director, Patient Safety and Risk Management
Mithya Lewis-Newby, MD, MPH Kaiser Permanente Fontana Medical Center;
Associate Professor Associate Professor
Departments of Pediatrics and Bioethics and Humanities Department of Clinical Science
University of Washington School of Medicine; Kaiser Permanente Bernard J. Tyson School of Medicine
Division of Pediatric Cardiac Critical Care Pasadena, California
Treuman Katz Center for Pediatric Bioethics
Seattle Children’s Hospital Jennifer McArthur, MD
Seattle, Washington Associate Member
St. Jude’s Research Hospital
Pediatric Critical Care
Memphis, Tennessee;
Adjunct Associate Professor of Pediatrics
Medical College of Wisconsin
Milwaukee, Wisconsin
xvi Contributors
Christine McCusker, MD Ryan W. Morgan, MD, MTR

Associate Professor Assistant Professor of Anesthesia, Critical Care, and Pediatrics
Department of Pediatrics Department of Anesthesiology and Critical Care Medicine
McGill University; University of Pennsylvania
Director Philadelphia, Pennsylvania
Division of Allergy, Immunology and Dermatology
Montreal Children’s Hospital Peter F. Morgenstern, MD
Montreal, Quebec Assistant Professor
Department of Neurosurgery
Ruth A. McDonald, MD Icahn School of Medicine at Mount Sinai
Professor of Pediatrics New York, New York
Division of Nephrology
University of Washington Michael J. Morowitz, MD
Chief Medical Officer, Hospital Operations Associate Professor
Seattle Children’s Hospital Pediatric General and Thoracic Surgery
Seattle, Washington UPMC Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Nilesh M. Mehta, MD, FASPEN
Professor of Anesthesia Wynne Morrison, MD, MBE
Harvard Medical School; Ingerman Endowed Chair in Palliative Care
Director of Quality and Outcomes Attending Physician, Critical Care and Palliative Care
Director of Critical Care Nutrition Children’s Hospital of Philadelphia
Associate Medical Director Associate Professor of Anesthesiology and Critical Care
Division of Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania
Chair, Critical Care Nutrition and Metabolism Philadelphia, Pennsylvania
Department of Anesthesiology, Critical Care, and Pain Medicine
Boston Children’s Hospital Raj Munshi, MD
Boston, Massachusetts; Associate Professor
Past President Department of Pediatrics
American Society for Parenteral & Enteral Nutrition Seattle Children’s Hospital
Seattle, Washington
Ann J. Melvin, MD, MPH
Professor Jennifer A. Muszynski, MD, MPH
Department of Pediatrics Assistant Professor of Pediatrics
Division of Infectious Disease Critical Care Medicine
Seattle Children’s Hospital Nationwide Children’s Hospital
University of Washington Columbus, Ohio
Seattle, Washington
Vinay M. Nadkarni, MD
Shina Menon, MD Professor
Assistant Professor Departments of Anesthesiology, Critical Care, and Pediatrics
Department of Pediatrics University of Pennsylvania Perelman School of Medicine
Division of Nephrology Philadelphia, Pennsylvania
University of Washington Jessica A. Naiditch, MD
Seattle, Washington Trauma Medical Director
Dell Children’s Medical Center of Central Texas;
Paul Monagle, MBBS, MD Assistant Professor of Surgery
Professor Department of Surgery & Perioperative Care
Department of Paediatrics Dell Medical School, University of Texas Austin;
University of Melbourne; Pediatric Surgeon
Haematologist Austin Pediatric Surgery
Royal Children’s Hospital; Austin, Texas
Group Leader
Haematology Research Thomas A. Nakagawa, MD, FAAP, FCCM
Murdoch Children’s Research Institute Professor
Melbourne, Victoria, Australia Department of Pediatrics
Division of Critical Care Medicine
University of Florida College of Medicine;
Medical Director, Pediatric Intensive Care
Wolfson Children’s Hospital
Jacksonville, Florida
Contributors xvii
Vu Nguyen, MD Todd Otteson, MD, MPH

Assistant Professor Chief
Department of Pediatric Critical Care Division of Pediatric Otolaryngology
Virginia Commonwealth University University Hospitals/Rainbow Babies and Children’s Hospital
Richmond, Virginia Cleveland, Ohio
Jenna R. Nickless, PharmD Yves Ouellette, MD, PhD

Critical Care Pharmacist Assistant Professor
Inpatient Pharmacy Division of Critical Care Medicine
Seattle Children’s Hospital Department of Pediatrics
Seattle, Washington Mayo Clinic
Rochester, Minnesota
Akira Nishisaki, MD
Associate Director, Clinical Implementation Program, ICU Daiva Parakininkas, MD
Department of Anesthesiology and Critical Care Medicine Associate Professor
The Children’s Hospital of Philadelphia Department of Pediatrics
Philadelphia, Pennsylvania Medical College of Wisconsin
Milwaukee, Wisconsin
Victoria F. Norwood, MD
Robert J. Roberts Professor of Pediatrics Robert I. Parker, MD
Chief of Pediatric Nephrology Professor Emeritus
Department of Pediatrics Department of Pediatrics
University of Virginia Stony Brook Children’s Hospital
Charlottesville, Virginia Stony Brook University Renaissance School of Medicine
Stony Brook, New York
Daniel A. Notterman, MA, MD
Professor Katherine Ratzen Peeler, MD
Department of Molecular Biology Department of Pediatrics
Princeton University Division of Medical Critical Care
Princeton, New Jersey Boston Children’s Hospital
Peter Oishi, MD
Professor of Pediatrics Francisco A. Perez, MD, PhD
University of California, San Francisco; Assistant Professor of Pediatric Radiology
Executive Medical Director Department of Radiology
Inpatient Services and Regional Access Seattle Children’s Hospital and University of Washington
UCSF Beinoff Children’s Hospital Seattle, Washington
San Francisco, California
Melvin G. Perry Jr, MD
Jeffrey Ojemann, MD Pediatric Intensivist
Professor Department of Pediatrics
Department of Neurological Surgery Piedmont Henry Hospital
University of Washington Stockbridge, Georgia;
Seattle, Washington Pediatric Intensivist
Michelle L. Olson, MD WellStar Hospital
Department of Pediatric Critical Care Marietta; Georgia
Children’s Hospital of Richmond at VCU
Richmond, Virginia Mark J. Peters, MBChB, MRCP(UK), FRCPCH, PhD
Professor of Paediatric Intensive Care
Jessie O’Neal, PharmD, BCCCP Respiratory, Critical Care and Anaesthesia Unit
Critical Care Pharmacist UCL Great Ormond Street Institute of Child Health;
Seattle Children’s Hospital Honorary Consultant Paediatric Intensivist
Seattle, Washington Paediatric Intensivist Care Unit
Great Ormond Street Hospital for Children NHS Trust
Kirsten Orloff, MD London, United Kingdom
Pediatric Critical Care Medicine Fellow
Duke University Hospital
xviii Contributors
Brent J. Pfeiffer, MD, PhD Thomas M. Raffay, MD

Assistant Professor Assistant Professor
Department of Pediatrics Department of Pediatrics and Neonatology
Division of Critical Care Medicine Rainbow Babies and Children’s Hospital
University of Miami Cleveland, Ohio
Miami, Florida
Prakadeshwari Rajapreyar, MD, FAAP
Rachel Phelan, MD, MPH Pediatric Critical Care
Assistant Professor of Pediatrics Medical College of Wisconsin
Division of Hematology/Oncology/Blood and Marrow Milwaukee, Wisconsin
Transplant
Medical College of Wisconsin Lauren Rakes, MD
Milwaukee, Wisconsin Clinical Assistant Professor
Joseph Philip, MD, FAAP Division of Critical Care Medicine
Associate Professor University of Washington
Medical Director Seattle, Washington
Pediatric Cardiac ICU
Congenital Heart Center Rafael G. Ramos-Jimenez, MD
University of Florida Surgery Resident
Gainesville, Florida Department of General Surgery
UPMC Presbyterian Shadyside
Neethi Pinto, MD, MS Pittsburgh, Pennsylvania
Assistant Professor
Children’s Hospital of Philadelphia Samiran Ray, MBBChir, MA
Philadelphia, Pennsylvania Consultant
Department of Paediatric Intensive Care Medicine
Murray M. Pollack, MD, MBA Great Ormond Street Hospital NHS Foundation Trust
Professor of Pediatrics London, United Kingdom
George Washington University School of Medicine and Health Christopher R. Reed, MD
Sciences; Resident Physician
Director, Clinical Outcomes Research Department of Surgery
Department of Critical Care Duke University Medical Center
Children’s National Medical Center Durham, North Carolina
Washington, DC
James J. Reese Jr, MD
Thomas J. Preston, BS, CCP, FPP Associate Professor of Neurology
Innovative ECMO Concepts, Inc. Department of Neurology
Arcadia, Oklahoma University of New Mexico
Albuquerque, New Mexico
Parthak Prodhan, MD
Professor Kyle J. Rehder, MD
Pediatric Critical Care Associate Professor
University of Arkansas/Arkansas Children’s Hospital Department of Pediatrics
Little Rock, Arkansas Duke Children’s Hospital;
Physician Quality Officer
Lawrence Quang, MD Duke Center for Healthcare Safety and Quality
Professor Duke University Health System
Department of Pediatrics Durham, North Carolina
College of Medicine
University of Arkansas for Medical Sciences Kenneth E. Remy, MD, MSCI, FCCM
Little Rock, Arkansas Assistant Professor of Pediatrics and Internal Medicine
Adult and Pediatric Critical Care Medicine
Michael W. Quasney, MD Washington University in St. Louis
Associate Professor St. Louis, Missouri
Division of Critical Care Jorge D. Reyes, MD
University of Michigan Medical School Professor and Chief, Transplant Surgery
Ann Arbor, Michigan University of Washington School of Medicine
Seattle, Washington
Contributors xix
Eileen Rhee, MD, MS Ahmed Said, MD, PhD

Assistant Professor Assistant Professor of Pediatrics (Critical Care)
Division of Pediatric Critical Care Medicine Center for Blood Oxygen Transport and Hemostasis
Division of Bioethics and Palliative Care University of Maryland School of Medicine
Seattle Children’s Hospital Baltimore, Maryland
Seattle, Washington
Colin J. Sallee
Clare Richardson, MD Pediatric Critical Care Fellow
Fellow Seattle Children’s Hospital/Harborview Medical Center
Division of Pediatric Otolaryngology University of Washington
Seattle Children’s Hospital Seattle, Washington
University of Washington School of Medicine
Seattle, Washington Britt Julia Sandler, MD
Fellow, Pediatric Critical Care Medicine
Joan S. Roberts, MD University of Washington School of Medicine
Associate Professor Seattle, Washington
Department of Pediatrics and Critical Care
Seattle Children’s Hospital Jhuma Sankar, MD
Luciana Rodriguez Guerineau, MD All India Institute of Medical Sciences
Staff Physician New Delhi, India
Division of Cardiac Critical Care Medicine
The Hospital for Sick Children; Ajit A. Sarnaik, MD
Assistant Professor of Paediatrics Associate Professor
Department of Paediatrics Department of Pediatrics
University of Toronto Wayne State University
Toronto, Ontario Detroit, Michigan
Canada
Ashok P. Sarnaik, MD
Stephen Rogers, PhD Professor of Pediatrics
Assistant Professor of Pediatrics Department of Pediatrics
Center for Blood Oxygen Transport and Hemostasis (CBOTH) Children’s Hospital of Michigan
University of Maryland School of Medicine Wayne State University School of Medicine
Baltimore, Maryland Detroit, Michigan
Alexandre T. Rotta, MD, FCCM Robert Sawin, MD

Division Chief Surgeon-in-Chief
Pediatric Critical Care Medicine General Surgery, Oncology, and Transplantation
Duke University Medical Center Professor of Surgery
Professor of Pediatrics Seattle Children’s Hospital
Duke University School of Medicine University of Washington
Durham, North Carolina Seattle, Washington
Mark E. Rowin, MD Kenneth A. Schenkman, MD, PhD

Associate Professor of Pediatrics Associate Professor
University of Tennessee College of Medicine Department of Pediatrics
Chattanooga, Tennessee University of Washington
Seattle, Washington
Randall Ruppel, MD
Assistant Professor Stephen M. Schexnayder, MD
Department of Pediatrics Professor and Chief
Virginia Tech Carilion School of Medicine Pediatric Critical Care
Roanoke, Virginia University of Arkansas for Medical Sciences/Arkansas Children’s
Hospital
Rita M. Ryan, MD Little Rock, Arkansas
Professor of Pediatrics (Neonatology)
UH Rainbow Babies & Children’s Hospital Charles L. Schleien, MD, MBA
Case Western Reserve University Philip Lanzkowsky Professor and Chair of Pediatrics
Cleveland, Ohio; Cohen Children’s Medical Center
Adjunct Professor of Pediatrics Hoftstra Northwell School of Medicine
Medical University of South Carolina New Hyde Park, New York
Charleston, South Carolina
xx Contributors
Stephanie P. Schwartz, MD Katherine N. Slain, DO

Assistant Professor Assistant Professor
Division of Critical Care Medicine Rainbow Babies & Children’s Hospital
University of North Carolina at Chapel Hill Cleveland, Ohio
Chapel Hill, North Carolina
Jodi M. Smith, MD, MPH
Steven M. Schwartz, MD, FRCPC Professor
Head, Division of Cardiac Critical Care Medicine Department of Pediatrics
The Hospital for Sick Children; University of Washington, Seattle
Professor of Paediatrics Seattle, Washington
Department of Paediatrics
University of Toronto Lincoln S. Smith, MD
Toronto, Ontario, Canada Associate Professor
Jay Shah, MD University of Washington
Medical Director, Aerodigestive Clinic Seattle, Washington
Division of Pediatric Otolaryngology
University Hospitals/Rainbow Babies and Children’s Hospital Anthony A. Sochet, MD, MSc, FAAP
Cleveland, Ohio Assistant Professor, Anesthesia and Critical Care Medicine
Associate Fellowship Program Director, Pediatric Critical Care
Sareen Shah, MD Medicine
Assistant Professor of Pediatrics Johns Hopkins University School of Medicine
Department of Critical Care Medicine Johns Hopkins All Children’s Hospital
Cohen Children’s Medical Center St. Petersburg, Florida
New Hyde Park, New York
Lauren R. Sorce, PhD, RN, CPNP-AC/PC, FCCM
Dennis W.W. Shaw, MD Founder’s Board Nurse Scientist
Professor of Pediatric Radiology Associate Director, Nursing Research
Department of Radiology Pediatric Critical Care Nurse Practitioner
Seattle Children’s Hospital and University of Washington Ann and Robert H. Lurie Children’s Hospital of Chicago;
Seattle, Washington Assistant Professor
Steven L. Shein, MD Northwestern University Feinberg School of Medicine
Associate Professor Chicago, Illinois
Chief of Pediatric Critical Care Medicine
Department of Pediatrics Linda E. Sousse, PhD, MBA
Rainbow Babies & Children’s Hospital Assistant Professor
Cleveland, Ohio Department of Surgery
University of Texas Medical Branch
Michael Shoykhet, MD, PhD Galveston, Texas
Attending Physician
Pediatric Critical Care Michael C. Spaeder, MD
Children’s National Medical Center Associate Professor
Principal Investigator Division of Pediatric Critical Care
Center for Neuroscience Research University of Virginia School of Medicine
Children’s National Research Institute Charlottesville, Virginia
Washington, DC
Richard H. Speicher, MD
Dennis W. Simon, MD Associate Professor
Assistant Professor Department of Pediatric Critical Care
Department of Critical Care Medicine Rainbow Babies & Children’s Hospital
University of Pittsburgh School of Medicine Cleveland, Ohio
Pittsburgh, Pennsylvania
Philip C. Spinella, MD
V. Ben Sivarajan, MD, MS, FRCPC Director, Translational Research Program
Division Head, Pediatric Cardiac Intensive Care Unit Department of Pediatrics
Pediatric Critical Care Medicine Professor of Pediatric Critical Care
Associate Professor of Pediatrics & Critical Care Medicine Washington University School of Medicine
Faculty of Medicine & Dentistry, University of Alberta St. Louis, Missouri
Stollery Children’s Hospital & University of Alberta Hospitals
Edmonton, Alberta, Canada
Contributors xxi
Erika L. Stalets, MD, MS Erik Su, MD

Associate Professor of Clinical Pediatrics Assistant Professor
University of Cincinnati College of Medicine Department of Pediatrics
Clinical Director, Division of Critical Care Medicine Division of Pediatric Critical Care Medicine
Cincinnati Children’s Hospital Medical Center McGovern Medical School
Cincinnati, Ohio Houston, Texas
Stephen Wade Standage, MD Corinne Summers, MD

Assistant Professor Assistant Member
Department of Pediatrics Clinical Research Division
Cincinnati Children’s Hospital Medical Center Fred Hutchinson Cancer Research Center;
Cincinnati, Ohio Assistant Professor
Rebecca Stark, MD University of Washington, Seattle Children’s Hospital
Assistant Professor Seattle, Washington
Department of Pediatric Surgery
Seattle Children’s Hospital; Robert M. Sutton, MD, MSCE
Assistant Professor Associate Professor of Anesthesia, Critical Care, and Pediatrics
Department of Surgery Department of Anesthesiology and Critical Care Medicine
University of Washington University of Pennsylvania
Seattle, Washington Philadelphia, Pennsylvania
Michelle C. Starr, MD, MPH Jordan M. Symons, MD

Assistant Professor Professor
Division of Nephrology University of Washington School of Medicine;
Indiana University and Riley Children’s Hospital Attending Nephrologist
Indianapolis, Indiana Division of Nephrology
David M. Steinhorn, MD Seattle, Washington
Department of Critical Care Nathaniel R. Sznycer-Taub, MD
Children’s National Medical Center Assistant Professor of Pediatrics
Washington, DC Division of Pediatric Cardiology
University of Michigan
Kurt R. Stenmark, MD Ann Arbor, Michigan
Professor of Pediatrics and Medicine
Department of Pediatric Critical Care Robert T. Tamburro Jr, MD
University of Colorado Anschutz Medical Campus Professor
Aurora, Colorado Department of Pediatric Critical Care Medicine
Janet Weis Children’s Hospital
Claire A. Stewart, MD, MEd Danville, Pennsylvania
Division of Critical Care Medicine
Department of Pediatrics Christian Tapking, MD, MMS
Nationwide Children’s Hospital Fellow
The Ohio State University College of Medicine Department of Surgery
Columbus, Ohio University of Texas Medical Branch
Galveston, Texas;
Lindsay M. Stollings, MD Resident
Assistant Professor Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn
Department of Anesthesiology and Perioperative Medicine Trauma Center
Children’s Hospital of Pittsburgh of UPMC BG Trauma Center Ludwigshafen
Pittsburgh, Pennsylvania University of Heidelberg
Ludwigshafen, Germany
Casey Stulce, MD
Assistant Professor Robert C. Tasker, MBBS, MD
Department of Pediatrics Professor of Anesthesia (Pediatrics)
University of Chicago Harvard Medical School;
Chicago, Illinois Department of Neurology
Departments of Anesthesia (Pediatrics), Pain and Perioperative
Medicine
Division of Critical Care
Boston Children’s Hospital
xxii Contributors
Gregory H. Tatum, MD Marisa Tucci, MD

Associate Professor of Pediatrics Professor
Duke University School of Medicine Sainte-Justine Hospital
Durham, North Carolina University of Montreal
Montreal, Quebec, Canada
Ann H. Tilton, MD
Professor of Neurology and Pediatrics David Tuggle, MD
Section Chair, Child Neurology Associate Trauma Medical Director
Louisiana State Health Sciences Center; Department of Surgery
Director, Children’s Hospital Rehabilitation Center Dell Children’s Medical Center of Central Texas
Children’s Hospital of New Orleans Austin, Texas
New Orleans, Louisiana
Jennifer L. Turi, MD
Matthew R. Timlin, DO Medical Director
Pediatric Intensivist Pediatric Cardiac Intensive Care Unit
Department of Pediatrics Duke University Medical Center
Madigan Army Medical Center Associate Professor of Pediatrics
Joint Base Lewis-McChord, Washington Duke University School of Medicine
Pierre Tissieres, MD, DSc
Professor David A. Turner, MD
Pediatric Intensive Care Associate Director
AP-HP Paris Saclay University Graduate Medical Education
Le Kremlin-Bicetre, France Duke University Health System;
Section Chief, Pediatric Intensive Care
Joseph D. Tobias, MD Associate Professor, Department of Pediatrics
Chair Division of Pediatric Critical Care
Department of Anesthesiology and Pain Medicine Duke Children’s Hospital and Health System
Nationwide Children’s Hospital; Durham, North Carolina
Professor of Anesthesiology and Pediatrics
The Ohio State University Alisa Van Cleave, MD
Columbus, Ohio Clinical Assistant Professor
Philip Toltzis, MD Division of Bioethics and Palliative Care
Professor Seattle Children’s Hospital
Department of Pediatrics Seattle, Washington
Rainbow Babies & Children’s Hospital
Cleveland, Ohio Meredith G. van der Velden, MD
Senior Associate of Critical Care Medicine
Alexis A. Topjian, MD, MSCE Boston Children’s Hospital
Associate Professor of Anesthesia, Critical Care, and Pediatrics Assistant Professor of Anesthesia
Department of Anesthesiology and Critical Care Medicine Harvard Medical School
University of Pennsylvania Boston, Massachusetts
Philadelphia, Pennsylvania
Adam M. Vogel, MD
Troy Torgerson, MD, PhD Associate Professor
Associate Professor Departments of Surgery and Pediatrics
Department of Pediatrics Texas Children’s Hospital;
University of Washington Associate Professor
Seattle, Washington Departments of Surgery and Pediatrics
Baylor College of Medicine
Chani Traube, MD, FAAP, FCCM Houston, Texas
Associate Professor of Clinical Pediatrics
Division of Pediatric Critical Care Medicine Christine Vohwinkel, MD, PhD
Weill Cornell Medical College Associate Professor of Pediatrics
New York, New York Department of Pediatric Critical Care
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Contributors xxiii
Amelie von Saint Andre-von Arnim, MD Scott L. Weiss, MD, MSCE

Associate Professor Associate Professor of Anesthesiology, Critical Care, and
Department of Pediatrics Pediatrics
Division of Pediatric Critical Care Medicine Department of Anesthesiology and Critical Care
Seattle Children’s Hospital The Children’s Hospital of Philadelphia
University of Washington University of Pennsylvania Perelman School of Medicine
Seattle, Washington Philadelphia, Pennsylvania
Surabhi B. Vora, MD, MPH Jesse Wenger, MD

Associate Professor Assistant Professor of Pediatrics
Department of Pediatric Infectious Disease Department of Pediatric Critical Care Medicine
Seattle Children’s Hospital University of Washington
Seattle, Washington Seattle Children’s Hospital
Seattle, Washington
Alpana Waghmare, MD
Assistant Professor Derek S. Wheeler, MD, MMM, MBA
Department of Pediatrics Professor of Pediatrics
Division of Infectious Disease Feinberg School of Medicine
Seattle Children’s Hospital Northwestern University
University of Washington Executive Vice President and Chief Medical Officer
Seattle, Washington Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, Illinois
Mark S. Wainwright, MD, PhD
Professor Beth Wieczorek, DNP, CRNP-AC
Department of Neurology Nurse Practitioner
University of Washington Anesthesia and Critical Care Medicine
Seattle, Washington Pediatric Intensive Care Unit
Johns Hopkins University
Jessica S. Wallisch, MD Baltimore, Maryland
Assistant Professor
Department of Pediatrics Michael Wilhelm, MD
Division of Pediatric Critical Care Associate Professor
University of Missouri–Kansas City Department of Pediatrics
Children’s Mercy Hospital University of Wisconsin, Madison
Kansas City, Missouri Madison, Wisconsin
R. Scott Watson, MD, MPH Hector R. Wong, MD

Professor Critical Care Medicine
Department of Pediatrics Cincinnati Children’s Hospital Medical Center
Division of Pediatric Critical Care Medicine Cincinnati, Ohio
University of Washington School of Medicine Charles R. Woods Jr, MD
Seattle, Washington Chair
Kevin Watt, MD, PhD University of Tennessee College of Medicine;
Associate Professor Chief Medical Officer
Department of Pediatrics Children’s Hospital
Chief Erlanger Health System
Division of Clinical Pharmacology Chattanooga, Tennessee
University of Utah
Salt Lake City, Utah George A. (Tony) Woodward, MD, MBA
Maria Weimer, MD Chief, Division of Emergency Medicine
Associate Professor of Clinical Neurology University of Washington School of Medicine
Department of Neurology Medical Director, Emergency and Transport Services
Louisiana State University Health Sciences Center Seattle Children’s Hospital
New Orleans, Louisiana Seattle, Washington
xxiv Contributors
Amy C. Yang, MD Jerry J. Zimmerman, MD, PhD, FCCM

Assistant Professor Faculty, Pediatric Critical Care Medicine
Department of Molecular and Medical Genetics Seattle Children’s Hospital
Oregon Health and Science University Harborview Medical Center
Portland, Oregon University of Washington School of Medicine
Seattle, Washington
Heidi Yu, PharmD
Critical Care Pharmacist Kanecia Zimmerman, MD, MPH
Seattle Children’s Hospital Assistant Professor
Seattle, Washington Department of Pediatrics
Duke University Medical Center
Nicole R. Zane, PharmD, PhD Duke Clinical Research Institute
Research Scientist Durham, North Carolina
Center for Clinical Pharmacology
Children’s Hospital of Philadelphia Matt S. Zinter, MD
Philadelphia, Pennsylvania Assistant Professor
Danielle M. Zerr, MD, MPH Division of Critical Care Medicine
Professor University of California, San Francisco
Department of Pediatrics San Francisco, California
University of Washington Athena F. Zuppa, MD, MSCE
Seattle, Washington Professor
Department of Anesthesia and Critical Care
Hui Zhang, MD, PhD The Children’s Hospital of Philadelphia
Instructor Philadelphia, Pennsylvania
Department of Pediatric Critical Care
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Hengqi (Betty) Zheng, MD

Acting Instructor
Department of Gastroenterology and Hepatology
Seattle, Washington
Preface
From our home working spaces, in the midst of the COVID-19 For pediatric critical care medicine fellows who may read the
pandemic, welcome to the sixth edition of Pediatric Critical Care. textbook cover to cover, and for others who need an updated
The world has finally been provided a realistic glimpse of intensive reference for anything related to pediatric critical care, the new
care units, the work that occurs there, and the dedicated providers edition will not disappoint. Each color-coded section provides
who provide critical care, sometimes at their own peril. This sixth best-evidence clinical approaches to pediatric critical care issues
edition, which now reflects a lifetime work product for many based on contemporary genetic, biochemical, and physiologic
contributors, is dedicated to the multidisciplinary team that infrastructure. Because authors typically want to include all rele-
makes critical care a reality. vant details in their discussion and a hard copy textbook has
What the pandemic has taught all of us is the importance of physical limitations, readers are encouraged to make use of the
being able to adapt to change. As readers page through this new expanded electronic content included with the sixth edition.
edition, many changes will become apparent. Brad Fuhrman, who Board review questions, composed for most chapters, will be
ultimately deserves the credit for creating this publishing adven- valuable for new and repeat readers and are also available in the
ture, decided to move from Co-editor to Section Editor. More electronic content.
than once, likely while sipping single malt scotch together, Brad Finally, all of us must honor the children and families who
noted that Pediatric Critical Care might be our most important provide the meaning for our life work. With the publishing of the
professional contribution. Quality and sustainability over six sixth edition of Pediatric Critical Care, we collectively acknowledge
editions prove his prediction correct. the clinical challenges that critical illness presents. However, these
Meanwhile, Alex Rotta, appropriately one of Brad’s early challenges facilitate curiosity and imagination, growth and experi-
apprentices, has provided outstanding organizational leadership ence, and ultimately personal enrichment. Hopefully the sixth
as Co-editor for the sixth edition. Thanks also to Section Editors edition of Pediatric Critical Care can serve as a valuable tool for
Bob Clark, Sapna Kudchadkar, Monica Relvas, and Joe Tobias. addressing longstanding as well as novel critical care challenges.
Perusing the list of contributors similarly ascertains established
and burgeoning pediatric critical care contributors. Accordingly, Jerry J. Zimmerman, MD, PhD, FCCM
the sixth edition is truly a multigenerational effort. Alexandre T. Rotta, MD, FCCM
xxv
Contents
Section I: Pediatric Critical Care: Section II: Pediatric Critical Care:

The Discipline 1 Tools and Procedures 75
1 History of Pediatric Critical Care Medicine 2 11 Essential Concepts in Clinical Trial Design and
Daniel L. Levin and John J. Downes Statistical Analysis 76
Leslie A. Dervan, R. Scott Watson, and Mary E. Hartman
2 High-Reliability Pediatric Intensive Care Unit:
Role of Intensivist and Team in Obtaining 12 Prediction of Short-Term Outcomes During Critical
Optimal Outcomes 16 Illness in Children 82
Claire A. Stewart, Derek S. Wheeler, and Richard J. Brilli Julia A. Heneghan, Michael C. Spaeder, and Murray M. Pollack
3 Critical Communications in the Pediatric 13 Pediatric Critical Care Transport 89

Intensive Care Unit 22 Lauren Rakes, Reid W.D. Farris, and George A. (Tony) Woodward
Shelina M. Jamal, Katherine Banker, and Harris P. Baden
14 Pediatric Vascular Access and Centeses 94
4 Professionalism in Pediatric Critical Care 26 Lauren R. Edwards, Matthew P. Malone, Parthak Prodhan, and
Bradley P. Fuhrman and Lynn J. Hernan Stephen M. Schexnayder
5 Leading and Managing Change in the Pediatric 15 Ultrasonography in the Pediatric Intensive Care
Intensive Care Unit 29 Unit 114
John C. Lin Erik Su, Akira Nishisaki, and Thomas Conlon
6 Evolution of Critical Care Nursing 36 Section III: Pediatric Critical Care:

Lauren R. Sorce and Ruth Lebet
Psychosocial and Societal 135
7 Fostering a Learning Healthcare Environment in 16 Patient- and Family-Centered Care in the
the Pediatric Intensive Care Unit 47 Pediatric Intensive Care Unit 136
Melvin G. Perry Jr and Jerry J. Zimmerman Jenny Kingsley and Jonna D. Clark
8 Challenges of Pediatric Critical Care in Resource- 17 Pediatric Critical Care Ethics 144
Poor Settings 51 Mithya Lewis-Newby, Emily Berkman, and Douglas S. Diekema
Amélie von Saint André–von Arnim, Jhuma Sankar, Andrew
Argent, and Ericka Fink 18 Ethical Issues Around Death and Dying 154
Meredith G. van der Velden and Jeffrey P. Burns
9 Public Health Emergencies and Emergency Mass
Critical Care 59 19 Palliative Care in the Pediatric Intensive Care
Katherine L. Kenningham and Megan M. Gray Unit 158
Alisa Van Cleave, Eileen Rhee, and Wynne Morrison
10 Lifelong Learning in Pediatric Critical Care 66
Stephanie P. Schwartz, Laura Marie Ibsen, and David A. Turner 20 Organ Donation Process and Management of the
Organ Donor 163
Thomas A. Nakagawa, Mudit Mathur, and Anthony A. Sochet
xxvii
xxviii Contents
21 Long-Term Outcomes Following Critical Illness in 35 Pediatric Cardiopulmonary Bypass 363

Children 175 Richard M. Ginther Jr and Joseph M. Forbess
Elizabeth Y. Killien, Jerry J. Zimmerman, François Aspesberro,
and R. Scott Watson 36 Critical Care After Surgery for Congenital Cardiac
Disease 380
22 Burnout and Resiliency 183 Paula Holinski, Jennifer Turi, Veerajalandhar Allareddy,
Ruth Kleinpell and Jason M. Kane V. Ben Sivarajan, and Alexandre T. Rotta
Section IV: Pediatric Critical Care: 37 Cardiac Transplantation 411

Sonya Kirmani and Michael Carboni
Cardiovascular 187
23 Structure and Function of the Heart 188 38 Physiologic Foundations of Cardiopulmonary
Luciana Rodriguez Guerineau, Jayani Abeysekera, V. Ben Resuscitation 420
Sivarajan, and Steven M. Schwartz Adnan M. Bakar, Kenneth E. Remy, Sareen Shah,
and Charles L. Schleien
24 Regional Peripheral Circulation 203
Peter Oishi, Julien I. Hoffman, Bradley P. Fuhrman, 39 Performance of Cardiopulmonary Resuscitation
and Jeffrey R. Fineman in Infants and Children 444
Ryan W. Morgan, Robert A. Berg, Alexis A. Topjian,
25 Endothelium and Endotheliopathy 218 Vinay M. Nadkarni, and Robert M. Sutton
Yves Ouellette
Section V: Pediatric Critical Care:
26 Principles of Invasive Cardiovascular Pulmonary 453
Monitoring 227
Matthew R. Timlin and Kenneth A. Schenkman 40 Structure and Development of the Upper
Respiratory System 454
27 Assessment of Cardiovascular Function 239 Robert H. Chun and Joan C. Arvedson
Nathaniel R. Sznycer-Taub, Thomas J. Kulik, John R. Charpie,
and Melvin C. Almodovar 41 Structure and Development of the Lower
Respiratory System 462
28 Cardiac Failure and Ventricular Assist John E. Baatz and Rita M. Ryan
Devices 248
Ana Lia Graciano, Joseph Philip, and Keith C. Kocis 42 Physiology of the Respiratory System 470
Robinder G. Khemani and Justin C. Hotz
29 Echocardiographic Imaging 270
M. Jay Campbell, Michael W. Camitta, Piers C.A. Barker, 43 Noninvasive Respiratory Monitoring and
and Gregory H. Tatum Assessment of Gas Exchange 483
David F. Butler and Kenneth A. Schenkman
30 Diagnostic and Therapeutic Cardiac
Catheterization 289 44 Overview of Breathing Failure 492
Reid C. Chamberlain, Kevin D. Hill, and Gregory A. Fleming Katherine V. Biagas, Michael Wilhelm, and Bradley P. Fuhrman
31 Pharmacology of the Cardiovascular System 300 45 Ventilation/Perfusion Inequality 503

Naomi B. Bishop, Bruce M. Greenwald, and Daniel A. Notterman Silvia M. Hartmann and Thomas V. Brogan
32 Cardiopulmonary Interactions 320 46 Mechanical Dysfunction of the Respiratory

Ronald A. Bronicki, Mubbasheer Ahmed, Saul Flores, and System 509
Bradley P. Fuhrman Jeff Clark, Saurabh Chiwane, and Ashok P. Sarnaik
33 Disorders of Cardiac Rhythm 329 47 Diseases of the Upper Respiratory Tract 524
Frank A. Fish and Prince J. Kannankeril Todd Otteson, Clare Richardson, and Jay Shah
34 Shock States 352 48 Pediatric Acute Respiratory Distress Syndrome

Lincoln Smith, Alicia Alcamo, Joseph A. Carcillo, and Rajesh and Ventilator-Associated Lung Injury 536
Aneja Colin J. Sallee, Robinder G. Khemani, and Lincoln S. Smith
Contents xxix
49 Acute Viral Bronchiolitis 546 64 Status Epilepticus 779

Katherine N. Slain and Steven L. Shein Edward E. Conway Jr and Robert C. Tasker
50 Asthma 552 65 Hypoxic-Ischemic Encephalopathy 793

Steven L. Shein, Richard H. Speicher, Howard Eigen, Ericka L. Fink, Mioara Manole, Robert S.B. Clark, Cameron
and Alexandre T. Rotta Dezfulian, and Patrick M. Kochanek
51 Neonatal Pulmonary Disease 568 66 Pediatric Stroke and Intracerebral

Thomas M. Raffay and Richard J. Martin Hemorrhage 811
Catherine Amlie-Lefond and Jeffrey Ojemann
52 Pneumonitis and Interstitial Disease 585
Daiva Parakininkas 67 Central Nervous System Infections and Related
Conditions 823
53 Diseases of the Pulmonary Circulation 608 Kevin M. Havlin, Charles R. Woods Jr, and Mark E. Rowin
Hui Zhang, Christine Vohwinkel, Aline Maddux,
and Kurt R. Stenmark 68 Acute Neuromuscular Disease and
Disorders 837
54 Mechanical Ventilation and Respiratory Maria Weimer, James J. Reese Jr, and Ann H. Tilton
Care 625
Kyle J. Rehder and Ira M. Cheifetz 69 Acute Rehabilitation and Early Mobility in the
Pediatric Intensive Care Unit 845
55 Noninvasive Ventilation in the Pediatric Hallie Lenker, Yun Kim, Beth Wieczorek,
Intensive Care Unit 644 and Sapna R. Kudchadkar
Omar Alibrahim and Katherine N. Slain
Section VII: Pediatric Critical Care: Renal 855
56 Extracorporeal Life Support 655
Heidi J. Dalton, Nina Censoplano, Tom Preston, 70 Renal Structure and Function 856
Hanneke Ijsselstijn, and Aparna Hoskote Matthew M. Grinsell and Victoria F. Norwood
57 Pediatric Lung Transplantation 679 71 Fluid and Electrolyte Issues in Pediatric Critical
Carol Conrad Illness 866
Idris V.R. Evans and Emily L. Joyce
Section VI: Pediatric Critical Care:
72 Acid-Base Disorders 882
Neurologic 689 Michelle C. Starr and Shina Menon
58 Structure, Function, and Development of the
Nervous System 690 73 Tests of Kidney Function in Children 896
Robert S.B. Clark and Michael Shoykhet Rajit K. Basu
59 Critical Care Considerations for Common 74 Glomerulotubular Dysfunction and Acute Kidney
Neurosurgical Conditions 710 Injury 907
Peter F. Morgenstern, Robert H. Bonow, Isaac Josh Abecassis, Timothy E. Bunchman, Vu Nguyen, and Michelle L. Olson
Samuel R. Browd, and Amy Lee
75 Pediatric Renal Replacement Therapy in the
60 Neurologic Assessment and Monitoring 720 Intensive Care Unit 923
Mark S. Wainwright and Sue J. Hong Raj Munshi and Jordan M. Symons
61 Neuroimaging 735 76 Pediatric Renal Transplantation 930

Francisco A. Perez, Hedieh Khalatbari, and Dennis W.W. Shaw Jodi M. Smith, André A.S. Dick, and Ruth McDonald
62 Coma and Depressed Sensorium 756 77 Renal Pharmacology 937

Neethi Pinto and Casey Stulce Jenna R. Nickless, Victoria Chadwick, and Heidi Yu
63 Intracranial Hypertension and Monitoring 768 78 Acute Severe Hypertension 945

Robert C. Tasker and Alireza Akhondi-Asl Joseph T. Flynn
xxx Contents
Section VIII: Pediatric Critical Care: Section X: Pediatric Critical Care:

Metabolic and Endocrine 959 Gastroenterology and Nutrition 1129
79 Cellular Respiration 960 94 Gastrointestinal Structure and Function 1130
Scott L. Weiss, Clifford S. Deutschman, and Lance B. Becker Lee M. Bass and David M. Steinhorn
80 Biology of the Stress Response 971 95 Disorders and Diseases of the Gastrointestinal
Stephen Wade Standage System 1141
Lauren Bodilly and Samuel A. Kocoshis
81 Inborn Errors of Metabolism 976
Cary O. Harding and Amy Yang 96 Acute Liver Failure 1155
Hengqi (Betty) Zheng, Mihaela A. Damian, and Simon Horslen
82 Progress Towards Precision Medicine in Critical
Illness 991 97 Hepatic Transplantation 1162
Mary K. Dahmer and Michael W. Quasney Patrick J. Healey, Britt Julia Sandler, Abigail Apple,
Thomas V. Brogan, and Jorge D. Reyes
83 Molecular Foundations of Cellular Injury 996
Jocelyn R. Grunwell and Craig M. Coopersmith 98 Acute Abdomen 1170
Robert Sawin, Rebecca Stark, and Derya Caglar
84 Endocrine Emergencies 1003
Katherine Ratzan Peeler and Michael S.D. Agus 99 Nutrition of the Critically Ill Child 1177
Ben D. Albert and Nilesh M. Mehta
85 Diabetic Ketoacidosis 1016
Ildiko H. Koves and Nicole Glaser Section XI: Pediatric Critical Care:
Immunity and Infection 1189
Section IX: Pediatric Critical Care:
Hematology and Oncology 1023 100 Innate Immunity 1190
Samiran Ray, Rachel S. Agbeko, and Mark J. Peters
86 Structure and Function of the Hematopoietic
Organs 1024 101 Adaptive Immunity 1199
Seth J. Corey and Julie Blatt Jennifer A. Muszynski, W. Joshua Frazier, and Kristin C. Greathouse
87 The Erythron 1033 102 Critical Illness and the Microbiome 1208
Allan Doctor, Ahmed Said, and Stephen Rogers Rafael G. Ramos-Jimenez, Dennis Simon,
and Michael J. Morowitz
88 Hemoglobinopathies 1040
M.A. Bender and Anne Marsh 103 Congenital Immunodeficiency 1215
Hannah Laure Elfassy, Troy Torgerson, and Christine McCusker
89 Coagulation and Coagulopathy 1052
Robert I. Parker 104 Acquired Immune Dysfunction 1229
Brent J. Pfeiffer
90 Thrombosis in Pediatric Critical Care 1073
Sally Campbell and Paul Monagle 105 Immune Balance in Critical Illness 1242
Mark W. Hall
91 Transfusion Medicine 1082
Jacques Lacroix, Marisa Tucci, Oliver Karam, 106 Pediatric Rheumatologic Disease 1249
and Philip C. Spinella Marla Guzman, Timothy Hahn, Alexandra Aminoff, and Kristen
Hayward
92 Hematology and Oncology Problems 1101
Jesse Wenger, Corinne Summers, and Joan S. Roberts 107 Bacterial and Fungal Infections 1263
Deborah E. Franzon, Emily R. Levy, and Matt S. Zinter
93 Critical Illness in Children Undergoing
Hematopoietic Progenitor Cell 108 Life-Threatening Viral Diseases and Their
Transplantation 1113 Treatment 1273
Prakadeshwari Rajapreyar, Jennifer McArthur, Surabhi B. Vora, Alpana Waghmare, Danielle M. Zerr,
Christine Duncan, Rachel Phelan, Robert T. Tamburro Jr and Ann J. Melvin
Contents xxxi
109 Healthcare-Associated Infections 1284 124 Adverse Drug Reactions and Drug-Drug
Alexis L. Benscoter, Richard J. Brilli, Derek S. Wheeler, Interactions 1464
and Erika L. Stalets Jessie O’Neal, Lauren Dartois, Anny Chan, Wade W. Benton,
and Christa Jefferis Kirk
110 Pediatric Sepsis 1293
Matthew N. Alder, Lauren Bodilly, and Hector R. Wong 125 Principles of Toxin Assessment and
Screening 1486
111 Multiple-Organ Dysfunction Syndrome 1310 April Clawson and Lawrence Quang
Pierre Tissieres and Melania M. Bembea
126 Toxidromes and Their Treatment 1496
Section XII: Pediatric Critical Care: Prashant Joshi
Environmental Injury and Trauma 1317

Section XIV: Pediatric Critical Care:
112 Bites and Stings 1318 Anesthesia Principles in the Pediatric
Kirsten Orloff and Kanecia Zimmerman
Intensive Care Unit 1509
113 Hyperthermic Injury 1327 127 Airway Management 1510
Jason A. Clayton and Philip Toltzis Chinyere Egbuta, E. Alexis Bragg, and Sapna R. Kudchadkar
114 Accidental Hypothermia 1332 128 Anesthesia Effects on Organ Systems 1535
Björn Gunnarsson and Christopher M.B. Heard Lindsay M. Stollings, Peter J. Davis, Alison M. Ellis,
and Antonio Cassara
115 Drowning 1337
Jamie L. Bell, Ajit A. Sarnaik, and Ashok P. Sarnaik 129 Anesthesia Principles and Operating Room
Anesthesia Regimens 1544
116 Burn and Inhalation Injury 1347 Joseph D. Tobias
Christian Tapking, Linda E. Sousse, Karel D. Capek,
and David N. Herndon 130 Malignant Hyperthermia 1560
Christopher M. Edwards and Barbara W. Brandom
117 Evaluation, Stabilization, and Initial
Management After Trauma 1363 131 Neuromuscular Blocking Agents 1567
Jessica A. Naiditch, Michael Dingeldein, and David Tuggle Joseph D. Tobias
118 Traumatic Brain Injury 1375 132 Sedation and Analgesia 1583
Patrick M. Kochanek, Michael J. Bell, Dennis W. Simon, Christopher M. B. Heard, Omar Alibrahim,
Hülya Bayır, Jessica S. Wallisch, Michael L. Forbes, and Alexandre T. Rotta
Randall Ruppel, P. David Adelson, Travis C. Jackson,
and Robert S.B. Clark 133 Tolerance, Dependency, and Withdrawal 1611
Joseph D. Tobias
119 Pediatric Thoracic Trauma 1401
Tamara N. Fitzgerald and Christopher R. Reed 134 Pediatric Delirium 1617
Chani Traube and Bruce M. Greenwald
120 Pediatric Abdominal Trauma 1408
Adam M. Vogel and Michael Dingeldein 135 Procedural Sedation for the Pediatric
Intensivist 1624
121 Child Abuse 1417 Nir Atlas, Rahul C. Damania, and Pradip P. Kamat
Tom Kallay and Carol Berkowitz
Section XV: Pediatric Critical Care:

Section XIII: Pediatric Critical Care:
Board Review Questions e1
Pharmacology and Toxicology 1425
136 Board Review Questions e2
122 Principles of Drug Disposition 1426
Nicole R. Zane and Athena F. Zuppa Index 1629
123 Molecular Mechanisms of Drug Actions 1446
Kevin Watt
SECTION I
Pediatric Critical Care: The Discipline

1. History of Pediatric Critical Care
6. Evolution of Critical Care Nursing, 36
Medicine, 2 7. Fostering a Learning Healthcare

2. High-Reliability Pediatric Intensive Care Environment in the Pediatric

Unit: Role of Intensivist and Team in Intensive Care Unit, 47
Obtaining Optimal Outcomes, 16 8. Challenges of Pediatric Critical Care in

3. Critical Communications in the Pediatric

Resource-Poor Settings, 51
Intensive Care Unit, 22 9. Public Health Emergencies and

4. Professionalism in Pediatric Critical Care, 26 Emergency Mass Critical Care, 59

5. Leading and Managing Change in the
10. Lifelong Learning in Pediatric Critical

Pediatric Intensive Care Unit, 29 Care, 66
1
1
History of Pediatric Critical Care
Medicine
DANIEL L. LEVIN AND JOHN J. DOWNES
“In critical care, it strikes one that the issues are three: realism, dignity, and love.”
Jacob Javitz, 1986 (Posthumous Inspirational
Award Honoree, Society Of Critical Care Medicine)
PEARLS
• The evolution of pediatric critical care medicine reflects long starting in the 1970s. This retrieval medicine holds great promise
progress in anatomy, physiology, resuscitation and ventilation, for future improvements in care.
anesthesiology, neonatology, pediatric general surgery, • In pediatric critical care medicine, there have been remark-
pediatric cardiac surgery, and pediatric cardiology. able achievements in the ability to understand and treat criti-
• The role of nursing is absolutely central to the evolution of cal illness in children as well as progress in the organization
critical care units. of pediatric critical care medicine, education, and research in
• Until the 1950s and 1960s, intensive care units were organized the field.
by grouping patients with similar diseases. However, in the • Increasing use of improved technology has advanced the care
1960s, neonatal intensive care units grouped children accord- of critically ill children but has not eliminated errors, complica-
ing to age and severity of illness, and pediatric intensive care tions, or potentially long-term sequelae, and it is associated
units followed this example. with a need for greater focus on establishing a humane, caring
• Sophisticated interhospital transfer services proved significant environment for the patients and their families.
in reducing morbidity and mortality of critically ill children
Evolution of Modern Medicine the development of cardiorespiratory support, and eventually led
to the establishment of intensive care.
The evolution of pediatric critical care medicine (PCCM) reflects Andreas Vesalius (1514–1564), the Flemish anatomist, cor-
a long series of contributions from anatomy, physiology, resuscita- rected many previous mistakes in the understanding of anatomy
tion and ventilation, anesthesiology, neonatology, pediatric gen- and provided positive pressure ventilation via a tracheotomy tube
eral surgery, pediatric cardiac surgery, pediatric cardiology, and to asphyxiated fetal lambs. Michael Servetus of Spain (1511–1553)
the many individuals responsible for the discoveries and innova- correctly described the pumping action of the heart’s ventricles and
tions.1,2 Intensive care units were originally organized by grouping the circulation of blood from the right heart through the lungs to
together patients with the same or similar diseases. However, the left heart. Matteo Realdo Columbo (1515–1559) described
when neonatologists grouped children according to age and sever- pulmonary circulation and the concept that the lungs added a
ity of illness, pediatric intensive care units (PICUs) followed their spirituous element to the blood by the admixture of air. William
example. Transport, or retrieval medicine, developed and nurses Harvey (1578–1657) confirmed the function of the heart and arte-
took on a major role in providing care to critically ill and injured rial and venous circulations through both animal experiments and
children. observations in humans. He published De Motu Cordis3 (On the
Motion of the Heart) in 1628. Because he did not yet have the
Anatomy and Physiology microscope, he could not see the capillaries and thus could not
include the mechanism for transfer of blood from the arterial to
What seems simple and obvious today took a great deal of time, the venous systems of the pulmonary circulation. Capillaries were
effort, and insight to understand. This section discusses some of first described by Marcello Malpighi (1628–1694, Italian) in De
the contributions that advanced the practice of medicine, enabled Pulmonibus (On the Lungs) in 1661. Thomas Willis (1611–1675)
2
CHAPTER 1 History of Pediatric Critical Care Medicine 3
and, eventually, William Cullen (1710–1790) led the way to the provided artificial ventilation to both animals and dead humans
understanding of the role of the nervous system as the site of con- using a bellows.6 Andreas Vesalius, the aforementioned Flemish
sciousness and the regulation of vital phenomena. Richard Lower professor of anatomy, in De Humani Corporis Fabrica, reported
(1631–1691) proved that it was the passage of blood through the ventilating open-chest dogs, fetal lambs, and pigs using a trache-
lungs, ventilation of the lungs, and gas exchange with blood that ostomy and fireplace bellows in 1543.7–9
vivified the blood and turned it red. Stephen Hales (1677–1761) The French obstetrician Desault, in 1801, described how to
measured blood pressure with a brass tube connected to a 9-foot successfully resuscitate apneic or limp newborns by digital oral
glass tube in a horse. Joseph Black (1728–1799) identified carbon tracheal intubation with a lacquered fabric tube and then blow-
dioxide as a gas expired from human lungs. ing into the tube.1 In 1832, Dr. John Dalziel in Scotland devel-
Karl Wilhelm Scheele (1742–1786) isolated oxygen, as did oped a bellows-operated intermittent negative pressure device
Joseph Priestley (1733–1804), who named it “dephlogisticated to assist ventilation.8 In 1864, Alfred F. Jones, of Lexington,
air” and determined its vital role in supporting combustion. Kentucky, built a body-enclosing tank ventilator; in the 1880s,
Antoine-Laurent Lavoisier (1743–1794) identified oxygen as the Alexander Graham Bell developed a so-called vacuum jacket
vital element taken up by the lungs that maintains life and gave it driven by hand-operated bellows.8 In 1876 in Paris, Woillez built
its name (literally “acid generator”). Oxygen’s essential role in what was probably the first workable cuirass ventilator, which
physiology and biochemistry was not clarified until the late 19th was strikingly similar to the “iron lung” respirator introduced by
century when Felix Hoppe-Seyler (1825–1895) described the McKhann and Drinker in 1929 and manufactured for wide-
transportation of oxygen in blood by hemoglobin. spread use by Emerson in 1931.10 Braun developed an infant
Giovanni Morgagni (1682–1771) initiated the field of ana- resuscitator, as described by Doe in 1889, which was used suc-
tomic pathology in his classic book De sedibus et causis morborum cessfully in 50 consecutive patients. A respirator developed by
per anatomen indagatis, published in 1761. He described in detail Steuart in 1918 in Cape Town, South Africa, apparently success-
his observations of the diseased organs in more than 700 autopsies fully treated a series of polio patients, but he did not report it.8
of persons with a wide variety of disorders and made correlations In 1888, Joseph O’Dwyer, a physician working at the
with the patient’s appearance and symptoms, the initial clinical- New York Foundling Hospital who was concerned about the high
pathologic basis of medicine. death rate in croup and laryngeal diphtheria, instituted the man-
In 1842, Crawford Long in Georgia and in 1846, William ual method of blind oral laryngeal intubation using short, tapered
Morton in Boston demonstrated the efficacy and safety of ether brass tubes that entered the subglottic lumen. Despite severe
anesthesia, thereby opening the era of modern surgery. Joseph criticism, he persisted in developing a series of various-diameter
Lister (1827–1912), one of the founders of modern surgery, tubes for the palliation of severe adult and pediatric laryngeal
reasoned that bacteria were the source of pus in rotten organic edema due to infections, including diphtheria. They were
material and in 1865 used carbolic acid in surgical fields and in used until the 1930s. George Fell, another New York physician,
wound dressings to eliminate bacteria. This technique dramati- devised a method of ventilation with a foot-operated bellows
cally improved patient outcomes after surgery. Robert Koch and exhalation valve connected by rubber tubing to the
(1843–1910) developed his postulates in 1882 in order to at- O’Dwyer tube.8
tribute the etiology of a disease to a particular microorganism in In 1898, Rudolph Matas of New Orleans adapted the Fell-
a logical, scientific manner. He also identified the tubercle bacil- O’Dwyer technique to ventilate patients’ lungs during chest wall
lus as the cause of tuberculosis and was awarded the Nobel Prize surgery. In the early 1900s, George Morris Dorrance of Philadelphia
in 1905. Wilhelm Conrad von Röntgen (1845–1923) discov- used the technique to perform resuscitations.8 In 1910, at the
ered x-rays in 1895. Scipione Riva-Rocci (1863–1937), in 1896, Trendelenburg Clinic in Leipzig, two thoracic surgeons. A. Lawen
measured blood pressure using the sphygmomanometer, and and R. Sievers, developed a volume-preset, positive-pressure, elec-
Nikolai Korotkoff (1874–1920) introduced his auscultation trically powered piston-cylinder ventilator with a draw-over hu-
method of determining systolic and diastolic pressure in 1905.1 midifier. It was used successfully with a tracheotomy tube during
and after thoracic surgery and for a variety of disorders causing
respiratory failure.1
Resuscitation and Ventilatory Support Chevalier Jackson (1858–1955), a surgeon at Temple Univer-
sity in Philadelphia, developed a highly specific series of tech-
The key to understanding the present practice of intensive care for niques for laryngoscopy, bronchoscopy, and tracheotomy.1 He
children lies in knowing the history of scientific study of cardio- revolutionized the procedure of tracheotomy and developed a
respiratory anatomy and physiology and the discovery of detailed protocol of airway care. His design of tubes, made of
techniques to support ill patients. Although one could think that silver, for patients of all ages set the standard for tracheotomy
current practice suddenly emerged with the late 20th century, tubes for more than the first half of the 20th century.
technical discoveries and accomplishments in the development of In 1958, Peter Safar, then at the Baltimore City Hospital,
resuscitation and ventilation taken for granted today date back to published studies proving that the long-standing pulmonary re-
the Bible, and numerous events and contributions led to current suscitation technique of chest pressure and arm lift was virtually
practice. In a biblical story,1,4,5 Elisha resurrected a young boy worthless. In effect, he went back to Elisha and proved jaw thrust
who was dead when “he climbed onto the bed and stretched and mouth-to-mouth resuscitation superior.11 Soon after, W.B.
himself on top of the child, putting his mouth to his mouth, his Kouwenhoven and James Jude at Johns Hopkins published work
eyes to his eyes, and his hands to his hands, and as he lowered on the effectiveness of closed-chest cardiac massage.12 In 1946
himself onto him the child’s flesh grew warm....Then the child Beck and his team demonstrated open-chest electrical defibrilla-
sneezed and opened his eyes.” In 117 CE, Antyllus performed tion. In 1952, Zoll and coworkers proved the efficacy of external
tracheotomies for patients with upper airway obstruction.6 Para- defibrillation and, in 1956, the effectiveness of external cardiac
celsus, a 16th-century Swiss alchemist and physician, first pacing.13
4 SECTION I Pediatric Critical Care: The Discipline
intensive nursing care, and pulmonary support in the postanes-

Contributions of Specific Disciplines thetic recovery room. There, the anesthesiologists were the attend-
ing physicians. In addition to those PICUs noted in Table 1.1,
Pediatric Anesthesiology there were certainly others that were not as well documented.
PCCM developed initially through the efforts of pediatric anes-
thesiologists, as well as pediatric general surgeons and pediatric Pediatric General Surgery and Pediatric Cardiac
cardiac surgeons and neonatologists. In fact, most of the Surgery
original PICUs were founded by pediatric anesthesiologists
(Table 1.1).1,4,14–23 Before discrete, geographically separate, ICUs Dr. William E. Ladd (1880–1967) at Boston Children’s Hospi-
evolved, critically ill children often received close monitoring, tal (BCH), the first full-time pediatric surgeon, pioneered the
TABLE
1.1 Some Early Pediatric Intensive Care Units and Programsa
Year Institution/Location Medical Director(s) Director(s) Specialtyb

1955 Children’s Hospital, Goöteborg, Sweden G. Haglund Ped Anesth.
1961 St. Goran’s Children’s Hospital, Stockholm, Sweden H Feychting Ped Anesth.
1961 Great Ormond Street Children’s Hospital, London, England W. Glover Ped Anesth.
1963 Hospital St. Vincent de Paul, Paris, France J.B. Joly Neonatology
G. Huault Neonatology
1963 Royal Children’s Hospital, Melbourne, Australia I.H. McDonald Ped Anesth.
J. Stocks Ped Anesth.
1963 Adelaide Children’s Hospital, Adelaide, Australia T. Allen Ped Anesth.
I. Stevens Ped Anesth.
1964 Alden Hey Children’s Hospital Liverpool, England G.J. Rees Ped Anesth.
1967 Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania J.J. Downes Ped Anesth.
1967 Children’s Memorial Hospital, Chicago, Illinois D. Allen Ped Anesth.
F. Seleny Ped Anesth.
J. Cox Ped Anesth.
1968c Children’s Hospital District of Columbia, Washington, DCd C. Berlin Ped.
1968 Children’s Hospital Calvo Mackenna, Santiago de Chile E. Bancalari Ped.
1969 Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania S. Kampschulte Ped Anesth.
1969 Yale–New Haven Medical Center, New Haven, Connecticut J. Gilman Ped Anesth.
N. Talner Ped Cardiol.
1970e Hospital for Sick Children, Toronto, Canada A. Conn Ped Anesth.
1971 Massachusetts General Hospital, Boston, Massachusetts D. Shannon Ped Pulm.
I.D. Todres Ped & Ped Anesth.
1971 Long Island Jewish Hospital, New York B. Holtzmann Ped Pulm.
1971 Montefiore Hospital, New York R. Kravath Ped Pulm.
1972 Sainte Justine Hospital, Montreal, Canada M. Weber Ped.
A. Lamarre Ped Pulm.
1972 Children’s Hospital “Dr. R. Guiterrez,” Buenos Aires, Argentina J. Sasbon Ped.
1972 Children’s Hospital “Pedro Elizade,” Buenos Aires, Argentina C. Bonno Ped.
1972 Hospital for Sick Children, Edinburgh, Scotland H. Simpson Pulmonology
1974 Red Cross Children’s War Memorial Hospital, Cape Town, South Africa M. Klein Ped Pulm.
1975 Private Hospital, Uruguay M. Gajer Ped.
1975 Children’s National Hospital Medical Center, Washington, DC P.R. Holbrook Ped.
A. Fields Ped.
1975 Children’s Medical Center, Dallas, Texas D. Levin Ped.
F. Morriss Ped. & Ped Anesth.
1976 Hospital Infantil La Paz, Madrid, Spain F. Ruza Ped.
TABLE
1.1 Some Early Pediatric Intensive Care Units and Programsa—cont’d
Year Institution/Location Medical Director(s) Director(s) Specialtyb

1977 Johns Hopkins Medical Center, Baltimore, Maryland M.C. Rogers Ped. & Ped Anesth.
S. Nugent
1977 Sheba Medical Center, Israel F. Barzilay Ped.
1977 Children’s Hospital of San Diego, San Diego, California B. Peterson Ped. & Ped Anesth.
1977 Hospital de Clinicas, Sao Paulo, Brazil A. Wong Ped.
1978 Hospital Sãa Lucas da PUCRS, Porto Alegre, Brazil P. Celiny Garcia Ped.
1978 Sophia’s Children’s Hospital, Rotterdam, Netherlands E. van der Voort Ped.
H. van Vught Ped.
1978 Children’s Hospital of Los Angeles, Los Angeles, California E. Arcinue Ped.
1979 University of Minnesota Hospital, Minneapolis, Minnesota B. Fuhrman Ped.
1979 Hospital de Clinicas de Porto Alegre, Brazil P.R. Carvalho Ped.
1980 Moffett Hospital, San Francisco, California G. Gregory Ped Anesth.
1980 Children’s Hospital Boston, Boston, Massachusetts R. Crone Ped. & Ped Anesth.
Ped., Pediatrics; Ped Anesth., pediatric anesthesiology; Ped Pulm., pediatric pulmonology.
a
This is not intended to be a complete list. It is primarily composed of units well documented in the literature and personally known to the authors.
b
Primary specialties (not all-inclusive).
c
Although conceptual development of unit started in 1965, Dr. Berlin states that the first year of operation of the present ICU was in 1969 (opened December 1968).
d
Columbia Hospital District of Columbia was a precursor of Children’s National Hospital Medical Center.
e
This 20-bed state-of-the-art unit followed an experience with four designated beds in the PACU beginning in 1964.
Data from references 1, 4, 14–23.
development of many techniques to operate on noncardiac con- was established in the 1880s in Paris by obstetrician Etienne
genital malformations. His protégé, Dr. Robert Gross, first suc- Tarnier and his young associate Pierre Budin at the Hôpital la
cessfully operated on patent ductus arteriosus in 1937 and later Charitre with a unit that had a full-time dedicated nursing staff,
on other congenital cardiac lesions. an antiseptic environment, incubators, and gavage feeding of
Dr. C. Crawfoord in Sweden and Dr. Gross in Boston both breast milk. The practices reduced hospital preterm infant mortal-
successfully repaired a coarctation of the aorta in 1945. In the ity in less than a decade from 197 per 1000 live births to 46 per
same year, at Johns Hopkins, Dr. Alfred Blalock (surgeon) and 1000 live births. Their work presaged the development of modern
Dr. Helen Taussig (cardiologist) with Mr. Vivien Thomas (labora- neonatal intensive care in the 20th century. In 1914, the first
tory assistant) created the subclavian-to-pulmonary artery shunt premature infant center in the United States was opened at Mi-
for tetralogy of Fallot. Dr. John Gibbon at Jefferson Medical chael Reese Hospital in Chicago by Dr. Julius Hess (1876–1955).
College Hospital in Philadelphia performed the first successful Canadian pediatrician Dr. Alfred Hart performed exchange trans-
open-heart surgery using cardiopulmonary bypass for closure of fusions involving peripheral artery cannulation in 1928. In 1932,
an atrial septal defect in an adolescent girl in 1953.1 These Drs. Louis Diamond, Kenneth Blackfan, and James Batey at
advances in pediatric surgery created the need for excellent and BCH determined the pathophysiology of hemolytic anemia
often complex postoperative care. and jaundice of erythroblastosis fetalis. In 1948, they described
Dr. C. Everett Koop, who had completed surgical residency at exchange transfusions using a feeding tube inserted into the
the University of Pennsylvania in 1945, then trained in Boston umbilical vein.
with Dr. Gross for 6 months. He returned to the University of In the 1950s and 1960s, Dr. Geoffrey Dawes at the Nuffield
Pennsylvania and the Children’s Hospital of Philadelphia (CHOP) Institute for Medical Research at Oxford University described for
in 1946. With the help of Dr. Leonard Bachman, director of an- the first time the fetal and transitional circulation of mammalian
esthesiology, and the nursing staff, Dr. Koop developed the first newborns using fetal and newborn lambs. In the late 1950s,
neonatal surgical ICU in 1962. Dr. Bachman and his young as- Columbia University’s obstetrical anesthesiologist, Virginia Apgar,
sociate, John J. Downes, subsequently set up North America’s first who had devised the Apgar score for assessing birth asphyxia,
PICU service with a full-time medical and nursing staff in 1967 recruited Dr. L. Stanley James to develop animal and human in-
at CHOP. vestigation of transitional pulmonary-cardiovascular adaptation
during labor, delivery, and the postnatal period. Dr. James and his
Neonatology team at Columbia and Dr. Abraham Rudolph, a South African
pediatric cardiologist, and his team at Albert Einstein Medical
Pediatric critical care owes a great debt to neonatologists and their Center in New York City and subsequently at the Cardiovascular
special care nurseries.1,4,24 The first and most prominent of these Research Institute in San Francisco, performed extensive studies
in fetal lambs, rhesus monkeys, and term and preterm human Neither specifically designed pediatric ventilators nor small-volume
newborns that defined the human cardiopulmonary adaptation to blood gas analysis was available. Dr. Smythe had to overcome
delivery and postnatal life. They also determined the biochemical these obstacles by innovation. Due to local cultural practices,
factors and time course of birth asphyxia and recovery. In 1959, a Bantu children from tribal areas were particularly prone to de-
research fellow at Harvard, Dr. Mary Ellen Avery (with mentor velop tetanus. On July 13, 1957, at Groote Schuur Hospital, he
Dr. Jere Mead), discovered deficiency of alveolar surfactant in performed a tracheostomy and began intermittent positive pres-
lungs of newborns dying from respiratory distress syndrome sure ventilation for these infants with the assistance of anesthesi-
(RDS). This discovery led to a better understanding of neonatal ologist Dr. Bull. This was truly a landmark event in the evolution
pulmonary disorders and eventually led to the intratracheal instil- of PCCM. Although considered a success story in that it was the
lation of surfactant in newborn preterm infants to prevent or first time that infants survived up to weeks of positive-pressure
mitigate the severity of RDS. In the 1960s, state-of-the-art neo- mechanical ventilation, the first seven of nine patients died. Even-
natal ICUs were established at Columbia-Presbyterian Hospital tually, their survival rate reached 80% to 90%. Drs. Smythe and
(Dr. William Silverman), University of Pennsylvania (Dr. Thomas Bull commented, “No praise can be too high for the nursing staff,
Boggs), Vanderbilt University (Dr. Mildred T. Stahlman), who were all student nurses and without any special training.”
Toronto Hospital for Sick Children (Dr. Paul Swyer), and the David Todres, a medical student at that time, was giving curare to
University of California at San Francisco (Dr. William H. Tooley). and observing these infants, sparking his interest in critical care.
In 1963 to 1964 in Toronto, Drs. Paul Swyer, Maria Delivoria-
Pediatric Cardiology Papadopoulos, and Henry Levison were the first to successfully
treat a series of moribund premature infants with RDS and respi-
As previously indicated, the vision of Dr. Taussig in devising a ratory failure. They used positive-pressure mechanical ventilation
method to treat “blue babies” and successful cardiac operations and supportive care27 and emphasized the importance of a full-
led to infants and children who survived surgery and needed time team, including dedicated nurses and therapists as well as
postoperative intensive care. Advances in technology, especially in physicians. In 1968 Dr. George Gregory and colleagues at the
imaging, have allowed clinicians to “see” into living patients with University of California at San Francisco demonstrated improved
astounding accuracy. Increased understanding of anatomy and survival with early use of continuous positive airway pressure
physiology has led to improved surgical and nonsurgical care for without assisted ventilation or with positive end-expiratory pres-
children with complex cardiopulmonary problems. Develop- sure added to the mechanical ventilation regimen.28
ments in cardiac catheterization and interventional radiology have An important contribution to the development of intensive
enabled clinicians to treat many lesions without open-heart sur- care and long-term mechanical ventilation was the use of plastic
gery and potentially difficult postoperative intensive care. This endotracheal tubes for prolonged intubation and ventilation.
concept was introduced in 1968 by Dr. William Rashkind at the Dr. Bernard Brandstater, an Australian working at the American
Children’s Hospital of Philadelphia (CHOP) with the introduc- Hospital in Beirut, Lebanon, reported prolonged nasotracheal
tion of the balloon atrial septostomy for infants with transposi- intubation as an alternative to the tracheostomy at the First
tion of the great arteries. Growth of techniques that allow effective European Congress of Anesthesia in Vienna in 1962.29
intervention in many complex cardiac conditions, both nonsurgi-
cal and surgical, has resulted in many pediatric centers creating
specific cardiac ICUs, often run by pediatric cardiac intensivists. Poliomyelitis and Creation
Cognitive impairment in some infants with complex lesions or of the First Intensive Care Units
chromosomal abnormalities and the occasional development of
chronic respiratory failure with dependence on mechanical venti- Poliomyelitis epidemics occurred worldwide in the early 20th century
lation for months or years are two of the occasional major se- but seemed especially severe in Western Europe and North America.
quelae of these highly successful endeavors. The value of PCCM There was no treatment and, until the late 1920s, no effective life
for these cardiac patients and other critically ill children has been support for those victims with respiratory failure. Fortunately, the
well documented by Dr. Jacqueline Noonan, who noted, “Much confluence of great scientific and clinical minds and the organiza-
success of the surgery can be attributed to a group of pediatric tional efforts of physicians, nurses, and therapists addressing the
intensivists, pediatric intensive care units, improved ventilator needs of polio patients led to the creation of dedicated polio respira-
support, and trained respiratory therapists.”25 tory care units for patients of all ages. In 1929, Philip Drinker, an
engineer—with pediatricians Louis Shaw and Charles F. McKhann at
BCH—published their experience with an electrically powered
Early Use of Mechanical Ventilation negative pressure, body-enclosing mechanical ventilator, later termed
in Neonates and Children the iron lung.10,30
Polio outbreaks occurred in the summer months worldwide in
The first series of carefully observed infants and children treated the 1930s and 1940s. The polio epidemics of the early 1950s were
for respiratory failure was published in 1959. In that year, Drs. very severe in Los Angeles and Copenhagen. In 1952, Dr. H.C.
P.M. Smythe (pediatrician) and Arthur Bull (anesthesiologist) re- Lassen, the chief epidemiologist at Blegdam Hospital in Copen-
ported the first real success in mechanical ventilation of a series of hagen, described treating 2772 patients with polio. Of these, 316
neonates with respiratory failure caused by neonatal tetanus. were in respiratory failure and initially received assisted ventila-
These infants were paralyzed with curare to relax the tetanic tion with iron lungs in a large respiratory care unit. During that
muscle spasms and ventilated for 4 to 14 days using tracheotomy summer, they had as many as 70 patients in respiratory failure in
and a modified Radcliff adult ventilator.26 Until that time, infants that unit. Unfortunately, the mortality of patients supported by
or children were rarely given ventilator support for more than a an iron lung ventilator was nearly 90%, with the cause of death
few hours, with either adult ventilators or manual ventilation. frequently being unrecognized upper airway obstruction. When
the number of patients in respiratory failure exceeded the avail- Pediatric Intensivist
able number of iron lung ventilators, Bjorn Ibsen, the chief of
anesthesiology at the hospital, with the help of his medical staff Randolph and coworkers40 defined a pediatric intensivist (in the
and nurse anesthetists, performed tracheal intubation and then United States) as “any one of the following: (a) a pediatrician with
tracheostomy along with manual positive pressure ventilation subspecialty training in PCCM and subspecialty certification
with 50% oxygen and tracheal suctioning. This treatment was from the American Board of Pediatrics (ABP); (b) a pediatric
carried out in 200 patients with respiratory failure. To provide anesthesiologist with special competency in critical care with
continuous manual ventilation on a 24-hour basis, Ibsen re- subspecialty certification from the American Board of Anesthesi-
cruited, trained, and used 200 nursing students and aides along ology; (c) a pediatric surgeon with special competency in critical
with 200 medical students, each working 8-hour shifts to provide care with subspecialty certification from the American Board of
manual ventilation, as well as 27 technicians per day to care for Surgery; (d) a physician (as above) eligible for subspecialty certifi-
the patients. The mortality in patients receiving this treatment cation by the appropriate respective board.” Similar requirements
decreased from 90% to 40%.31–33 for training exist or are in development elsewhere in the world.
At that time, patients from outlying areas were transported to
hospitals in ambulances without sufficient attendants or airway First Pediatric Intensive Care Units
care and arrived moribund. Lassen and Ibsen started to send so-
called retrieval teams in ambulances out to pick up the patients in In 1955 Dr. Goran Haglund at the Children’s Hospital of Göteborg,
the countryside, with marked improvements in status on arrival. Sweden,18 developed the first PICU, which he called a pediatric
They also started passing stomach tubes early on for nutrition, emergency ward. The patient who inspired Dr. Haglund to organize
and the rubber-cuffed tracheostomy tubes were replaced with a the unit was a 4-year-old boy who was operated on in 1951 for a
silver cannula that caused less tracheal mucosal damage. Even ruptured appendix. Postoperatively, he lapsed into a coma; his sur-
with all of these improvements, Dr. Ibsen noted, “Naturally we geon declared that he had done all he could and the boy would die
ran into a lot of complications.”33 of bacteriotoxic coma. The anesthesiologist offered to help and the
Drs. Ibsen and Lassen also received help from other people boy was intubated, given manual positive-pressure respiration with
who were focusing their efforts on treating polio. The clinical generous oxygen, tracheostomized, and given a large blood transfu-
biochemist Dr. Poul Astrup developed a micro method to mea- sion. After about 8 hours, the boy’s bowels started to function, and
sure capillary arterialized pH and PCO2 in infants, children, and 4 hours later he was out of coma. After 20 hours, he had spontane-
adults. C.G. Engstrom, a Swedish anesthesiologist, designed and ous respiration and had been successfully treated for respiratory in-
clinically tested the first modern volume-preset positive pressure sufficiency and shock.
mechanical ventilator. This spectacular and thrilling story culmi- This new unit had seven acute care beds with full-time nurses
nated in a cohort of patients with respiratory failure being treated and nursing assistants providing 24-hour coverage. In the first
in a single geographic area and cared for by full-time physicians, 5 years, the team treated 1183 infants and children, with a mor-
nurses, and technicians: the first modern ICU. Although these tality rate of 13.6%. Haglund went on to state, “But what we did
units tended to disband after the summer-fall polio season, they was something else. It was the application of the basic physiology
led to the creation of full-time respiratory care units at the to clinical practice. Our main purpose was not to heal any disease;
Radcliff Infirmary of Oxford University and elsewhere in Europe it was to forestall the death of the patient. The idea was—and
and North America in the 1950s. is—to gain time, time so that the special medical or surgical
Soon after these events, in 1958, Peter Safar led development therapy can have desired effects.”18 Haglund was also careful to
of the first multidisciplinary ICU in North America at Baltimore point out: “There are few jobs more exciting, demanding, and
City Hospital.34 In 1960, Barrie Fairley and colleagues created the taxing than emergency nursing. Our nurses and nurse assistants
ICU at Toronto General Hospital, followed in 1962 by the ICU are tremendous. They must be!”18
at Massachusetts General Hospital under Drs. Henning Pontop-
pidan and Henrik Bendixen. Central Role of Critical Care Nursing
Definitions Although many sources emphasize the role of advanced technol-
ogy in the creation of adult, neonatal, and pediatric critical
Some of the difficulty in relating the history of PCCM is defining care,1,19 skilled nursing care was even more important in this
a PICU and pediatric intensivist. The current definitions are as evolving process. Porter41 and others remind us of the vital role of
follows. nursing in triage and organization of care for patients by degree of
illness. Long before the organizational efforts of the 20th century,
Florence Nightingale (1820–1910) organized a volunteer service
Pediatric Intensive Care Unit with 20 nurses and created a clean environment at the British
An ad hoc committee of the American Academy of Pediatrics (AAP), military hospital at Skutari, Turkey, in 1854 during the Crimean
Diseases of the Chest Section established Guidelines for the Organi- War. Although the care consisted mostly of hygiene and nutrition,
zation of Children’s Intensive Care Units in July 1975.35 In 1983, within 6 months of her arrival the mortality rate dropped from
the AAP and Society of Critical Care Medicine (SCCM) published 40% to 2%.42 Nightingale provided the definition of nursing as
Joint Guidelines for Pediatric Intensive Care Units,36 which were “helping the patient to live.”42 These efforts were continued in the
updated in 199337 and 200438 and then retired in 2013.39 The com- United States by Dorothea Dix (1802–1887) and Clara Barton
mittee defined a PICU as “a hospital unit which provides treatment (1821–1912), the “angel of the battlefield” during the American
to children with a wide variety of illnesses of life-threatening nature Civil War. Barton also brought the Red Cross to America in 1882.
including children with highly unstable conditions and those requir- As the complexity of medical and surgical care evolved in the
ing sophisticated medical and surgical treatment.” late 19th and early 20th century, the need to cohort sick patients
and provide skilled nursing care became apparent, especially for America. During the prior decade, Dr. Conn and his colleagues
premature newborns and victims of poliomyelitis, as cited earlier. had treated critically ill infants and children in a sequestered area
Then, as now, the recovery of the critically ill pediatric or adult of the postanesthesia care facility where they had developed con-
patient depended on the skilled nurse at the bedside who was siderable expertise in critical care. The new state-of-the-art PICU
trained to use the life support and monitoring equipment at hand was the forerunner of units developed in major pediatric centers
but to remain focused on the stability and comfort of the person throughout North America spanning the 1970s and beyond.
in the bed.43 Dr. Geoffrey Barker, who went on to develop one of the largest
In the mid- to late 1970s, as pediatric cardiovascular surgery multinational fellowship training programs in the world, followed
for more complex lesions in infants was developing, nurses pro- Dr. Conn as director of the PICU.
vided postoperative care in designated units. Children with Reye Also in 1971, Dr. David Todres, an anesthesiologist and pedia-
syndrome suddenly appeared, requiring complex multisystem trician, and Dr. Daniel Shannon, a pediatric pulmonologist,
care. In addition, in the 1980s, emergency medical services sys- founded a 16-bed multidisciplinary unit for pediatric patients of
tems began transporting severely injured children to hospitals, all ages at the Massachusetts General Hospital.1,4 The units in
where they required rapid assessment and intervention by nurses Philadelphia, Toronto, and Boston established vibrant training
and physicians and initiation of cardiorespiratory and neurologic programs in critical care medicine and conducted clinical re-
support.44 search. Among their numerous accomplishments, Dr. Conn be-
Pediatric critical care nurses joined the SCCM from its begin- came a noted authority on the management of near-drowning
ning in 1970 and the American Association of Critical Care victims, and Dr. Todres and Dr. Downes pioneered long-term
Nurses emphasizing the care of children. In the mid-1990s, pedi- mechanical ventilation for children at home with chronic respira-
atric critical care nurses founded their own society and established tory failure. These early PICUs and their training programs had a
a peer-reviewed journal. Also in the 1990s, advanced practice favorable impact on mortality and morbidity rates, particularly
nurses and nurse practitioners began to specialize in pediatric those associated with acute respiratory failure, leading to the de-
critical care. They continue to function as important critical care velopment of similar units and programs in most major pediatric
team members to augment both physician and nursing care as centers in North America, Western Europe, and Japan during the
well as conduct clinical research.43,44 1970s and early 1980s.
The development of the PICU at Children’s Memorial Hospi-
Role of Pediatric Anesthesiologists tal (CMH), Northwestern University Medical School, Chicago,
illustrates how many of the early PICUs evolved. The unit was
and Pediatricians in Founding Pediatric first started as a four-bed area set in one of the postoperative care
Critical Care Medicine wards by pediatric anesthesiologists David Allen and Frank
Seleny. Anesthesiologist Dr. John Cox arrived in August of 1964
An important early physician-directed multidisciplinary PICU in and was named director. He has stated that the unit never for-
North America was established at CHOP in 1967 as an out- mally opened. It began in the four-bed unit in the postoperative
growth of a hospital-wide respiratory intensive care service.1,45 ward in 1964 and became a 14-bed separate designed unit in
The unit consisted of an open ward of six beds equipped with late 1967. Dr. Cox was the director until 1975, when he was
bedside electronic monitoring and respiratory support capabilities succeeded by Dr. Richard Levin. During this time, Dr. Hisashi
and an adjacent intensive care chemistry laboratory staffed Nikaidoh, who was a surgery resident from 1966 to 1967, re-
24 hours per day. The nurses were assigned full-time to the unit; members taking care of a renal transplant patient; the care was
most had previously served in the recovery room, infant ICU, or provided by nephrology, general surgery, and immunology
cardiac surgery postoperative ward. Dr. John Downes was the without a centralized PICU service. Dr. Zehava Noah, who was
medical director and worked closely with two other anesthesiolo- educated in Israel and trained in the United Kingdom, did a
gists, Dr. Leonard Bachman, chief of anesthesiology, and critical care fellowship in anesthesia at CMH, developed a closed
Dr. Charles Richards, and a pediatric allergist/pulmonologist, medical-surgical PICU in 1979, and was named the director in
Dr. David Wood. Four pediatric anesthesiology/critical care fel- 1981. There was also an associate surgical director.46–49
lows provided 24-hour in-unit service. Dr. C. Everett Koop (chief Some of the early PICUs were directed by pediatricians. In
of surgery), Dr. William Rashkind (the father of interventional 1966, Dr. Max Klein joined Drs. H. de V. Heese and Vincent
pediatric cardiology), Dr. John Waldhausen (one of the nation’s Harrison in a two-bed neonatal research unit at the Groote Shuur
few full-time pediatric cardiac surgeons), Dr. Sylvan Stool (a pio- Hospital in Cape Town. Their research resulted in many signifi-
neer in pediatric otolaryngology), and other staff and residents cant papers, not the least of which was “The Significance of
provided close collaborative patient care, education, and clinical Grunting in Hyaline Membrane Disease,”50 demonstrating that
research. By 1975, with the establishment of the new CHOP oxygen tensions fell when infants had tracheal intubation, elimi-
building, the acute PICU was expanded to 20 beds with an adja- nating the ability to grunt on exhalation. By 1969, at Red Cross
cent 10-bed intermediate step-down unit. War Memorial Children’s Hospital in Cape Town, South Africa,
In 1969, Dr. Peter Safar and his trainee, Stephen Kampschulte, pediatric patients with respiratory failure (e.g., Guillain-Barré
developed a 10-bed PICU at the Children’s Hospital of Pitts- syndrome) were ventilated on the general wards. Although out-
burgh. That same year, James Gilman, a pediatric anesthesiologist, comes improved, deaths were still common. Dr. Max Klein en-
and Norman Talner, a pediatric cardiologist, established a six-bed couraged Dr. Malcolm Bowie (consultant) to start a six-bed ICU,
PICU at the Yale–New Haven Medical Center. or “high-care ward.” After further training in South Africa and at
In 1970, at the Hospital for Sick Children in Toronto, the University of California San Francisco (UCSF), Dr. Klein re-
Dr. Alan Conn resigned as director of the Department of Anes- turned to Cape Town in 1974, where he combined the neonatal
thesiology to become director of a new multidisciplinary 20-bed tetanus ward of Dr. Smythe and the six-bed ICU of Dr. Bowie
PICU, by far the largest and most sophisticated unit in North into the first full-time PICU in South Africa.51
The path for pediatricians providing care for the sickest pa- training with Dr. Peter Safar in Pittsburgh, who welcomed him as
tients on a full-time basis remained unclear for an extended pe- a fellow in critical care medicine. In 1975, Dr. Holbrook and
riod. Subsequent early leaders in the field each carved out their pediatrician Dr. Alan Fields, who also trained in Pittsburgh, were
own path. Dr. Daniel Levin completed pediatric cardiology and recruited to the new, modern Children’s Hospital National Medi-
neonatology fellowships to learn the care of sick children. How- cal Center (Washington, DC) as pediatricians in the Department
ever, he found few Chairs of Pediatrics interested in hiring an of Anesthesia to direct the PICU.
“intensivist.” Then, in 1975, Drs. Levin and Frances Morriss Dr. Bradley Peterson,52 after pediatric and neonatology train-
(trained in pediatrics and pediatric anesthesia) were recruited to ing and an anesthesiology residency at Stanford University,
start a PICU at Children’s Medical Center of Dallas. became director of the new PICU at Children’s Hospital of
There were so few of this new breed of intensivists that many San Diego in 1977. Dr. Bradley Fuhrman, following pediatric
became directors upon completion of residency and fellowship. At cardiology and neonatology fellowships, started the first PICU at
the beginning, few other physicians wanted to be responsible for University of Minnesota Hospital in 1979.53
pediatric intensive care.23 Eventually, more pediatricians decided Dr. George Lister,54 after a pediatric residency at Yale and a
to devote their careers to being members of a multidisciplinary fellowship in cardiopulmonary physiology at UCSF, joined the
team taking care of the sickest children in hospitals on a full-time staff at the UCSF Moffitt Hospital San Francisco in 1977 as an
basis. In 1975, the CHOP program started to accept PCCM attending in its combined adult-pediatric ICU. Due to the direc-
trainees who were pediatricians without anesthesia training. tor’s illness, he quickly found himself the co-director of the unit.54
In 1967, Dr. Peter Holbrook as a medical student at the Uni- He eventually returned to Yale as an attending in the PICU.
versity of Pennsylvania began a part-time job in the PICU at Dr. Mark Rogers, after completion of a pediatric residency at
CHOP and developed a strong interest in PCCM. Informed at BCH, an anesthesiology residency at Massachusetts General
the time that one needed anesthesia training to successfully work Hospital, and a pediatric cardiology fellowship at Duke, became
in the PICU, Holbrook shelved the idea and entered pediatric director of the first PICU at Johns Hopkins Hospital in 1977.55
residency training at Johns Hopkins. When the PCCM idea Subsequently, in 1980, Dr. Rogers became chair of the Depart-
resurfaced, he found that many still felt a physician needed anes- ment of Anesthesiology and Critical Care Medicine at Johns
thesia training to function in the PICU. Disagreeing with the Hopkins and chief editor of a major textbook of pediatric inten-
reasoning behind such a requirement, he pursued critical care sive care (Table 1.2).
TABLE
1.2 Textbooks in Pediatric Critical Care Medicine
First Edition Title Editors Reference

1971 Care of the Critically Ill Child R. Jones, J.B. Owen-Thomas 56
1971 Pediatric Intensive Care: Manual K. Roberts, J. Edwards 57
1972 Smith’s The Critically Ill Child: Diagnosis and Medical Management J. Dickerman, J. Lucey 58
1977 Pediatrie d’urgence G. Huault, H. Labrune 59
1979 through 1997 A Practical Guide to Pediatric Intensive Care, first and second editions D. Levin, F. Morriss, G. Moore 60–63
(and accompanying Essentials volumes)
1980 Tratado de Cuidados Intensivos Pediatrucos (Textbook of Pediatric F.J. Ruza 64
Intensive Care)
1980 Core Curriculum for Pediatric Critical Care Nursing M.C. Slota 65
1983 Pediatric Critical Care J. Bloedel Smith 66
1984 Nursing Care of the Critically Ill Child M.F. Hazinski 67
1984 Textbook of Critical Care W.K. Shoemaker, W.L. 68
Thompson, P.R. Holbrook
1984 Pediatric Intensive Care E. Nussbaum 69
1985 Temas em Terapia Intensiva (Critical Care Issues in Pediatrics) J. Piva, P. Carvalho, 70
P. Celiny Garcia
1985 Critical Care Pediatrics S. Zimmerman, J.H. Gildea 71
1987 Pediatric Intensive Care J.P. Morray 72
1988 Textbook of Pediatric Intensive Care M.C. Rogers 73
1992 Pediatric Critical Care B.P. Fuhrman, J.J. Zimmerman 74
1993 Textbook of Pediatric Critical Care P.R. Holbrook 75
1994 Urgences & Soins Intensif Pediatriques (Pediatric Emergency J. Lacroix, M. Gauthier, 76
and Critical Care) P. Hubert, et al.
Continued
TABLE
1.2 Textbooks in Pediatric Critical Care Medicine—cont’d
First Edition Title Editors Reference

1995 Critical Heart Disease in Infants and Children D.G. Nichols, D.E. Cameron, 77
W.J. Greeley, et al.
1996 Critical Care of Infants and Children I.D. Todres, J.H. Fugate 78
1996 Critical Care Nursing of Infants and Children M.A. Curley, J. Bloedel-Smith, 79
P.A. Moloney Harmon
1997 Illustrated Textbook of Pediatric Emergency and Critical Care R.A. Dieckmann, D.H. Fiser, 80
Procedures S.M. Selbst
1997 Pediatric Intensive Care N.S. Morton 81
2003 Essentials of Pediatric Intensive Care C.G. Stack, P. Dobbs 83
2005 Medicinia Intensiva em Pediatria J. Piva, P. Celiny Garcia 84
2005 Cuidudo Intensivo Pediatrico y Neonatal J. Forero, J. Alarcon, G. 85
Cassalett
2006 Pediatric Critical Care Medicine A.D. Slonim, M.M. Pollack 86
2006 Manual de Cuidado Intensivo Cardiovascular Pediatrico G. Casselett, M.C. Patarroyo 87
2007 Pediatric Critical Care Medicine: Basic Science and Clinical Evidence D.S. Wheeler, H.R. Wong, T.P. 88
Shanley
2010 Critical Care of Children with Heart Disease R. Munoz, V. Monell, E. da 89
Cruz, C.G. Vetterly
2012 Comprehensive Critical Care: Pediatric Medicine Society of Critical Care 90
Medicine
2012 Pediatric Critical Care Study Guide S.E. Lucking, F.A. Maffei, R.F. 91
Tamburro, N.J. Thomas
2015 Pediatric Critical Care Nutrition P.S. Goday, N.M. Mehta 92
2017 Pediatric Intensive Care S. Watson, A. Thompson 93
Growth of Pediatric Critical Care Medicine American College of Graduate Medical Education (ACGME)
and for the subspecialty of PCCM by the American Board of
The field of PCCM grew rapidly in the late 1970s and 1980s. Pediatrics (ABP). Legitimization of the subspecialty was achieved
However, there was a struggle for authority in both adult and with establishment of a new subboard of Pediatric Critical Care
pediatric units. The culture of intensive care was changing from Medicine of the ABP in 1985 and the first certifying examination
one in which each specialty service cared for its part of the patient in 1987, at which time 182 subspecialists were certified.95 Certi-
to one in which a full-time critical care service cared for the whole fication provided a clear basis for hospital credentialing of
patient, with help of consulting specialties.2,94 PCCM physicians.96 In addition to certification by the ABP, the
For PCCM to achieve its full potential, it required several ele- American Board of Anesthesiology and the American Board of
ments: a national organization to provide a venue in which to Surgery confer subspecialty certification with special competency
meet and communicate, acceptance and validation of pediatric in critical care. In 1989, special requirements for training in
critical care as a subspecialty, nationally approved training require- PCCM were developed by the ACGME, with formally accred-
ments, and academic credibility with meaningful research. ited programs first recognized in 1990.97
A small group of interested physicians met at the SCCM Na-
tional Meeting in 1979 and decided to petition the SCCM to Growth in Numbers of Pediatric Intensive
form a section on pediatrics. The society had no subsections, but
the petition was successful. The pediatric section with Dr. Russell
Care Units
Raphaely as chair was formed in 1980.1 In 1983, a committee of In 1979, there were 150 PICUs of four or more beds identified,
the SCCM developed guidelines for organization of PICUs36 that and another 42 thought to exist.98 Most were just special care
were regularly updated37,38 until January 2013, after which time nursing units, and only 40% had a pediatric intensivist available
they were retired.39 at all times. Forty percent of the units had fewer than seven beds
In 1984, after petitions by pediatric intensivists, a Section and only one half had affiliated transport systems. Pediatric
of Critical Care Medicine was established in the AAP with ward beds decreased by 22.4% between 1980 and 1989—by
Dr. Russell Raphaely as chair.95 These organizations then 10.8% between 1990 and 1994 and by 15.7% between 1995
petitioned for recognition of PCCM fellowships from the and 2000. During the same three time periods, PICU beds
increased by 26.2%, 19.0%, and 12.9%, respectively.40 Between In April 2004, the Eunice Kennedy Shriver National Institute
2001 and 2016, the US pediatric population grew 1.9% to of Child Health and Human Development (NICHD) established
greater than 73.6 million children, and PICU hospitals de- funding for the first federally supported network for pediatric
creased 0.9% from 347 to 344 (58 closed and 55 opened). In critical care research, the Collaborative Pediatric Critical Care
contrast, PICU bed numbers increased 43% (4135 to 5908 Research Network. The network is a multicentered program de-
beds). Sixty-three PICU hospitals (18%) accounted for 47% signed to investigate the safety and efficacy of treatment and
of PICU beds.40a According to the FY2017 American Hospital management strategies to care for critically ill children as well
Association (AHA) survey database, there are 399 hospitals as the pathophysiologic basis of critical illness and injury in
in the United States and territories that have a PICU in their childhood.114–117
hospital.100 Although not all children’s hospitals are members The NICHD has also supported research in PCCM by devel-
of the Children’s Hospital Association, of the 155 children’s oping and supporting young investigators in the field through
hospitals that contribute data to the fiscal year 2017 Children’s the Pediatric Critical Care and Trauma Scientist Development
Hospital Association Annual Benchmark Report Survey, 128 Program (PCCTSDP), a K-12 research training program. The
(82%) stated they had staffed PICU beds.101 PCCTSDP has been funded since 2004 and is directed by
Dr. Heather Keenan at the University of Utah. Eligible applicants
are board-eligible or board-certified PCCM faculty, or pediatric
Growth in Training Programs and Education trauma surgery faculty.114
In 1983 to 1984, there were 32 PCCM training programs; the Perhaps most notably, in 2013 the NICHD created an inde-
ACGME accredited 28 of them in 1990. By 2018 to 2019, the pendent branch, the Pediatric Trauma and Critical Illness Branch,
number had increased to 68 accredited training programs with to further support research in pediatric critical illness and injury.
527 enrolled fellows, of whom 336 (63.8%) are women.99 Since The mission of the new branch is to prevent and reduce all aspects
its inception, the subboard has certified 2693 subspecialists.99 of childhood trauma and critical illness and to enhance health
Educational programs in PCCM have progressed consider- outcomes for all children across the continuum of care.114,116,117
ably at the annual SCCM, AAP, Pediatric Academic Societies, The growth of education and research in PCCM has coincided
American Thoracic Society, and American College of Chest with, and presumably resulted in, better care for children as re-
Physicians meetings, as well as at independent meetings such as flected in the decrease in mortality from septic shock. Between
the Pediatric Critical Care Colloquium and the World Federa- 1958 and 1966, in patients younger than 16 years of age at the
tion of Pediatric Intensive Critical Care Societies (WFPICCS). University of Minnesota, mortality in septic shock was 95%; now,
Dr. Barker envisioned the need to bring together pediatric inten- with PICU care, it is less than 10%.118 Drs. Murray Pollack and
sive care from many parts of the world. This led to his founding Timothy Yeh established the basis for studying severity-adjusted
directorship of the WFPICCS, which has done much to foster mortality in pediatrics and demonstrated that patients do better
development of pediatric critical care around the world, bringing when cared for by pediatric intensivists.119 Although many would
vital critical care skills and experience to benefit multiple coun- attribute these improvements to technology and scientific ad-
tries. Numerous textbooks on PCCM have appeared in many vances, Dr. Yeh and others remind us that the presence of a full-
languages (see Table 1.2), and the journal Pediatric Critical Care time nursing and medical team and attention to basic principles
Medicine was launched in 2000.102 rather than exotic high technology improve outcomes.120 This is
Academic credibility that results from meaningful scientific echoed by Dr. Shann’s two rules of PCCM: (1) “the most impor-
research has come slowly. In the early days, intensivists were tant thing is to get the basics exactly right all of the time,” and
mostly consumed by clinical care and research and administrative (2) “organizational issues are crucially important.”23 In addition,
responsibilities. High-quality basic science, epidemiology, and Yeh as well as Ibsen33 and Orr have emphasized the important
translational studies addressing a broad range of problems have contributions of regionalization and the quality of PCCM trans-
gradually emerged. Multiinstitutional organizations have allowed port teams in improving outcomes.121,122
studies that require more patients than can be drawn from a single Modern medical simulation originated in pediatrics and has
institution to be designed, funded, and completed. In the early made significant contributions to education. In 1960, shortly af-
1990s, the Pediatric Critical Care Study Group was formed.103 It ter resuscitating his 2-year-old son following a drowning, Asmun
was followed by the Pediatric Acute Lung Injury and Sepsis Inves- Laerdal, the owner of a Norwegian doll factory, partnered with
tigators (PALISI) network,104–106 which employed the successful the Red Cross to create the first medical simulation mannequin.
programming model of research developed by the Canadian In 1988, Laerdal partnered with the American Heart Association
Critical Care Trials Group.107–109 PALISI has grown and pros- and the AAP to create Pediatric Acute Life Support simulation-
pered through the voluntary collaboration of currently 94 mem- based training. Since that time, evolving pediatric residency and
ber PICUs110 and has supported more than 200 articles address- fellowship requirements, duty hour restrictions, and an increased
ing the spectrum of PCCM.111 focus on medical safety have catalyzed exponential growth in simu-
The virtual PICU was started in 1997 to bring data manage- lation training.123–125 The International Network for Simulation-
ment technologies to critical care. In 2004, Virtual PICU Based Pediatric Innovation Research and Education has docu-
Systems (VPS) was formed by Drs. Thomas Rice and Ramesh mented an increase in pediatric simulation centers from
Sachdeva (Children’s Hospital and Health System of Milwaukee) 50 to 268 in the past 7 years. A recent meta-analysis documented
and Dr. Randall Wetzell (Children’s Hospital Los Angeles) in 57 studies and over 3500 learners engaged in pediatric simula-
conjunction with the National Association of Children’s Hospi- tion education. Studies compared simulation education with no
tals and Related Institutions to develop a PICU registry to facili- intervention and found large effects for outcomes of knowledge,
tate quality improvement and research. VPS currently has more behavior with patients, and time to task completion.126
than 125 members and a massive database describing more than Dr. Elizabeth Hunt along with pioneers in simulation at Johns
1 million critical care admissions.112,113 Hopkins have been able to document progressive acquisition of
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in tabes dorsalis,
831
Stammering,
571
Starvation as a cause of cerebral anæmia,
781
condition of brain in,
781
782
Status epilepticus, prognosis of,
498
Vertiginosus, the,
426
Treatment of,
428
Stigmatization,
348-351
Theories concerning origin,
350
Stimulants, use, in heat-exhaustion,
388
in collapse in opium habit,
673
,
675
in thermic fever,
397
Stomach, disorders of and changes in, in chronic alcoholism,
600
Strabismus in chronic hydrocephalus,
743
in tubercular meningitis,
727
Strychnia, use, in alcoholism,
641
,
643
646
in chorea,
455
in infantile spinal paralysis,
1157
in intracranial hemorrhage and apoplexy,
978
in labio-glosso-laryngeal paralysis,
1175
in paralysis agitans,
438
in spinal hyperæmia,
805
in writers' cramp,
538
Myelitis, acute,
822
823
Stupor in tubercular meningitis,
727
728
Melancholia with,
158
Stuttering,
569
571
Suicidal insanity,
146
tendency, in general paralysis of the insane,
191
Sumbul, use, in hysteria,
278
Sun, exposure to, as a cause of acute meningitis,
716
Sunstroke (see
Thermic Fever
).
headache from,
390
404
Influence on causation of cerebral hyperæmia,
764
Superficial neuralgia,
1211
Supposed discharge as a cause of cerebral hyperæmia,
766
of spinal hyperæmia,
802
Supraorbital nerve, intermittent neuralgia of,
1233
Surgical treatment of abscess of the brain,
800
of facial neuralgia,
1234
of tumors of the brain,
1067
Sweating, absence of, in progressive unilateral facial atrophy,

696
in the opium habit,
657
658
Swedish movement, use, in hysteria,
280
in infantile spinal paralysis,
1157
Sympathetic cervical, diseases of,
1263
headache,
404
neuralgias,
1220
Symmetrical gangrene,
1257
Symptoms of abscess of the brain,
795
of acute alcoholism,
587
et seq.
of acute cerebral anæmia,
776
782
of acute myelitis,
816
of acute simple meningitis,
717
of acute spinal meningitis,
750
pachymeningitis,
747
of amyotrophic lateral sclerosis,
868
of angina pectoris,
1238
of apoplexy,
733
of athetosis,
459
of atrophy of the brain,
994
995
of Bell's palsy,
1203
of capillary embolism,
981
of catalepsy,
320
of cerebral anæmia,
782
of cerebral hyperæmia,
768
of cerebral meningeal hemorrhage,
712
of cerebral softening,
981
989
of cerebral syphilis,
1003
of chorea,
445
of chronic alcoholism,
598-633
of chronic cerebral meningitis,
721
of chronic hydrocephalus,
741
of chronic lead-poisoning,
682
of chronic spinal meningitis,
752
of chronic spinal pachymeningitis,
749
of combined forms of sclerosis,
870
of concussion of the brain,
908
of concussion of the spine,
915
of congestion of cerebral dura mater,
704
of spinal membranes,
747
of the pia mater,
716
of delirium tremens,
627
of diffuse spinal sclerosis,
888
of disease of cervical sympathetic,
1264
of disseminated (cerebro-spinal) sclerosis,
874
of ecstasy,
342
of epilepsy,
477
of external pachymeningitis,
704
of family form of tabes dorsalis,
871
of gastralgia,
1238
of general paralysis of the insane,
178
of hæmatoma of dura mater,
707
of headache,
402
of heat-exhaustion,
387
of hebephrenia,
172
of hypertrophy of the brain,
944-946
of hypochondriasis,
154
of hemiplegia,
954
of hypertrophy of the brain,
99
of hysteria,
229
of hystero-epilepsy,
293
of infantile spinal paralysis,
1114
of inflammation of the brain,
791
of injuries to nerves,
1183
1185
1186
of insanity,
120
of insomnia,
379-382
of intermittent neuralgia of supraorbital,
1233
of internal pachymeningitis,
706
of intracranial hemorrhage and apoplexy,
733
of labio-glosso-laryngeal paralysis,
1170
of melancholia,
155
156
of migraine,
407
1230
of moral insanity,
143-146
of multiple neuritis,

Fuhrman Zimmermans Pediatric Critical Care 6Th Edition Jerry J Zimmerman Full Chapter

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Fuhrman & Zimmerman's Pediatric

Critical Care 6th Edition Jerry J.

FUHRMAN & ZIMMERMAN’S

Robert S.B. Clark, MD Sapna Ravi Kudchadkar, MD, PhD, FCCM

Bradley P. Fuhrman, MD, FAAP, MCCM

FUHRMAN AND ZIMMERMAN’S PEDIATRIC CRITICAL CARE,

Copyright © 2022 by Elsevier, Inc. All rights reserved.

Library of Congress Control Number: 2020930336

Content Strategist: Michael Houston

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Isaac Josh Abecassis, MD Ben D. Albert, MD

Jayani Abeysekera, MD, FRCP Alicia Alcamo, MD, MPH

Alireza Akhondi-Asl, PhD Alexandra Aminoff, MD

Catherine Amlie-Lefond, MD Adnan M. Bakar, MD

Rajesh Aneja, MD Katherine Banker, MD

Melania M. Bembea, MD, MPH, PhD Naomi B. Bishop, MD

M.A. Bender, MD, PhD Julie Blatt, MD

Samuel R. Browd, MD, PhD, FAANS, FAAP Michael P. Carboni, MD

Karel D. Capek, MD Saurabh Chiwane, MD

Robert H. Chun, MD Craig M. Coopersmith, MD

Jeff Clark, MD Seth J. Corey, MD, MPH

April Clawson, MD Rahul C. Damania, MD, FAAP

Carol Conrad, MD Peter J. Davis, MD, FAAP

Leslie A. Dervan, MD Allan Doctor, MD

Michael Dingeldein, MD Hannah Laure Elfassy, MD, FRCP(c)

Alison M. Ellis, MD, MBA Joseph T. Flynn, MD

Megan M. Gray, MD Cary O. Harding, MD

Marla Guzman, MD Christopher M.B. Heard, MBChB, FRCA

Lynn J. Hernan, MD Laura Marie Ibsen, MD

Kevin D. Hill, MD, MSCI Hanneke Ijsselstijn, MD, PhD

Julien I. Hoffman† Travis C. Jackson, PhD

Sue J. Hong, MD Prashant Joshi, MD

Prince J. Kannankeril, MD Christa Jefferis Kirk, PharmD, BCCP

Thomas J. Kulik, MD John C. Lin, MD

Hallie Lenker, PT, DPT Anne Marsh, MD

Christine McCusker, MD Ryan W. Morgan, MD, MTR

Vu Nguyen, MD Todd Otteson, MD, MPH

Jenna R. Nickless, PharmD Yves Ouellette, MD, PhD

Brent J. Pfeiffer, MD, PhD Thomas M. Raffay, MD

Eileen Rhee, MD, MS Ahmed Said, MD, PhD

Alexandre T. Rotta, MD, FCCM Robert Sawin, MD

Mark E. Rowin, MD Kenneth A. Schenkman, MD, PhD

Stephanie P. Schwartz, MD Katherine N. Slain, DO

Erika L. Stalets, MD, MS Erik Su, MD

Stephen Wade Standage, MD Corinne Summers, MD

Michelle C. Starr, MD, MPH Jordan M. Symons, MD

Gregory H. Tatum, MD Marisa Tucci, MD

Amelie von Saint Andre-von Arnim, MD Scott L. Weiss, MD, MSCE

Surabhi B. Vora, MD, MPH Jesse Wenger, MD

R. Scott Watson, MD, MPH Hector R. Wong, MD

Amy C. Yang, MD Jerry J. Zimmerman, MD, PhD, FCCM

Hengqi (Betty) Zheng, MD

Section I: Pediatric Critical Care: Section II: Pediatric Critical Care:

3 Critical Communications in the Pediatric 13 Pediatric Critical Care Transport 89

6 Evolution of Critical Care Nursing 36 Section III: Pediatric Critical Care:

21 Long-Term Outcomes Following Critical Illness in 35 Pediatric Cardiopulmonary Bypass 363

Section IV: Pediatric Critical Care: 37 Cardiac Transplantation 411

31 Pharmacology of the Cardiovascular System 300 45 Ventilation/Perfusion Inequality 503

32 Cardiopulmonary Interactions 320 46 Mechanical Dysfunction of the Respiratory

34 Shock States 352 48 Pediatric Acute Respiratory Distress Syndrome

49 Acute Viral Bronchiolitis 546 64 Status Epilepticus 779

50 Asthma 552 65 Hypoxic-Ischemic Encephalopathy 793

51 Neonatal Pulmonary Disease 568 66 Pediatric Stroke and Intracerebral