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Case Studies in Pediatric Critical Care

Weldon, B. Craig, MD

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doi: 10.1213/ANE.0b013e3181f0b8c8
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Case Studies in Pediatric Critical Care is a collection of 27 cases that are intended for an international audience of both “novice and experienced intensivist[s].” Case studies have traditionally appealed to medical students and resident physicians because they are concise, clinically oriented, and relatively inexpensive books. This book offers more than just a series of interesting case descriptions. The reader will find detailed discussions of the major aspects of each case with a bulleted list of “learning points,” recent references, and review articles for “further reading.” This teaching format might also be helpful to more advanced trainees as part of case-based teaching conferences.

For North American readers, there are several aspects of the book that deter from its overall usefulness. The editors are from the United Kingdom (U.K.) and have selected cases for inclusion in the book that are no longer, or were never, common clinical problems in the United States (U.S.) (e.g., fulminant meningococcal sepsis, bacterial meningitis, sagittal sinus thrombosis, and tricyclic antidepressant overdosage). Endemic dengue hemmorrhagic fever, even with continued global warming, is not expected to penetrate North America for at least another 50 years. This lack of relevance for U.S. practitioners is compounded by the omission of clinical problems that are commonly managed in pediatric intensive care units (PICUs) in North America and other developed countries (e.g., brain death, hepatic failure/transplantation, and acute life threatening events). A major oversight is the absence of any cases involving the postoperative care of surgical patients in the PICU except for children with congenital heart disease. By combining essentially redundant cases (e.g., duplicate chapters on burns, traumatic brain injury, and septic shock), the authors would have created space for additional case studies without expanding the size of the book. Another challenge for the U.S. trainee is the use of laboratory values that have units that are unfamiliar. A few of the chapters use mm Hg to describe blood gas values, but most use kilo Pascals. The presentation of blood glucose, calcium, and urea values in mmol/L, and bilirubin and creatinine in μmol/L, necessitated the use of a conversion table. In future editions of this book, a conversion table could be included on the inside of the back cover of the book, along with a pediatric Glasgow Coma Scale (there are nearly identical Glasgow Coma Scale tables in three separate chapters) and a glossary of commonly used abbreviations.

The strongest aspect of the book is the discussion section that follows each case presentation. The authors provide evidence-based guidance for the management of each situation. However, definitive answers to many pediatric critical care questions are lacking, and the authors are forced to rely on their own personal anecdotal experience. As a result, there are discrepancies on some specific management issues (e.g., one chapter advocates the use of human albumin for volume resuscitation in pediatric septic shock, and another chapter on septic shock suggests that isotonic crystalloid solution is “likely adequate”).

The variance in medical practice between the U.K. and the U.S. is perhaps most evident in the discussion of steroids in the management of catecholamine-resistant septic shock. Low-dose steroids are an essential component of the current evidence-based treatment algorithm for both adults and children in septic shock. However, in the chapter on meningococcal sepsis, a condition long known to be associated with adrenal insufficiency (i.e., Waterhouse– Fredrickson syndrome), steroids were administered only after a lengthy resuscitation effort at the referring hospital with massive amounts of fluid and catecholamine administration. Steroids were finally administered after 2 hours in the PICU when the patient was in a moribund condition. This apparent deviation from “the standard of care” is not commented on in the discussion. The other chapter devoted to septic shock described a recent bone marrow transplant recipient treated with large doses of inotropes (i.e., dopamine at 10 μg/kg/min and epinephrine at 0.3 μg/kg/min). This patient never received steroids and eventually died of multi-organ system failure. Most bone marrow transplant patients have recent or ongoing exposure to steroids as part of the standard treatment regimen and would therefore be expected to have suppression of their pituitary–adrenal axis, rendering them “adrenal insufficient” in the face of a severe systemic infection. The need for a “stress-dose of steroids” in this critical situation is not adequately addressed in the discussion section. The “novice” intensivist might draw an erroneous conclusion regarding the role of steroids in pediatric septic shock from reading these two chapters.

Three topics that are mentioned several times but never thoroughly discussed include interfacility transport of critically ill children, rapid sequence intubation, and the use of extracorporeal membrane oxygenation in the PICU. If these interventions are not properly conducted, they can contribute to morbidity and mortality rather than fulfill their intended role as life-sustaining therapies. The use of these interventions in many different cases within the book illustrates their importance in the care of critically ill patients and warrants a more comprehensive discussion in the book.

In summary, Case Studies in Pediatric Critical Care provides medical students, pediatric and anesthesiology residents, and fellows in pediatric critical care medicine a useful glimpse into intensive care practices in the U.K.

B. Craig Weldon, MD

Duke University

Durham, North Carolina

© 2011 International Anesthesia Research Society