NAAMA experience

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NAAMA experience

• By
• Yasser Elborai, MD
• Assisstent Lecturer of Pediatric Oncology
• NCI Cairo University

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• NAAMA National Arab American Medical
  Association is a Non Governmental Organization
  (NGO) composed of an Arabian doctors living in
  America
• They are trying to help doctors in Egypt and
  other Arabian countries by different ways like
  offering training courses and research work

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• Due to collaboration between National Cancer
  Institute (NCI) Egypt and National Arab
  American Medical Association (NAAMA) USA,
  there was a 3 months training course for
  Pediatric Intensive Care Unit (PICU)
• This training course was in DeVos childrens
  hospital Michigan USA

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Pediatric Intensive Care Unit(PICU)

• What is the aim of building PICU ?
• How do you construct PICU ?
• How do you manage PICU ?

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What is the aim of building PICU ?

• To give our critically ill patients a proper
  treatment
• To create a new subspecialty in our pediatric
  department
• To decrease the load of work on main ICU in our
  institute

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How do you construct PICU ?

• Number of rooms
• Number of beds
• Isolation rooms
• Equipments
• Supplies
• Aeration of the room
• Design of the room
• Character of walls and floor

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Comparison between PICU in DeVos childrens
hospital-Michigan and newly developing PICU in
NCI-Cairo
DeVos childrens hospital-Michigan
newly developed PICU in NCI-Cairo

• rooms 16 rooms 1 room
• beds 16 beds 4 beds
  
• Isolation 2 rooms No
  rooms

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newly developed PICU in NCI-Cairo
DeVos childrens hospital-Michigan

• Equipments

• Each room has all equipments to be an operative
  room for any minor or major procedures

• Each bed has monitor, infusion pump, syringe
  pump, common ECG apparatus and blood warmer
  apparatus for all beds

• Supplies

All types of syringes, lines, tubes, masks,
Air conditioned
Air conditioned

• Aeration

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newly developed PICU in NCI-Cairo
DeVos childrens hospital-Michigan

• Design of
• room

• The bed is in the center of the room to be
  accessible from all sides that facilitate the work

• The bed is only accessible from 3 sides as usual

The walls and floors are washable and can be
easily cleaned by anti septic measures

• Character of
• walls and floor

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How do you manage PICU ?

• Criteria of admission
• Nursing notes
• Doctors notes
• Multidisciplinary team to deal with the patient
• Computer based system
• Ratio between nurses and patients
• Criteria of discharge

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• Criteria of admission
• There are many indications for PICU admission but
  the most common cause here in our institute will
  be shock specially septic shock
• ? if the patient is hemodynamically unstable
• - Heart rate greater than
• 90 beats per minute at the age of puberty or
  more.
• 110 beats per minute at the age of 10 years.
• 120 beats per minute at the age of 4 years or
  less.

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• - Systolic arterial pressure lower than
• 90 mm Hg at the age of puberty or more.
• 70 mm Hg at the age of 10 years.
• 50 mm Hg at the age of 4 years or less.
• for at least 30 minutes despite adequate
  fluid replacement and more than 5 µg/kg of body
  weight of dopamine or current treatment with
  epinephrine or norepinephrine.
• Urinary output of less than 0.5 mL/kg of body
  weight for at least 1 hour
• Arterial lactate levels higher than 2 mmol/L

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Stages of shock

• 1- Early shock tachycardia, poor capillary
  perfusion
• cold extremities, but in septic shock may be
  worm extremities because ischemia of precapillary
  sphincter
• 2- Established shock clinical triad tachycardia,
  hypotension, peripheral hypoperfusion will be
  evident. The patient looks pale and anxious

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• 3- Advanced shock the blood flow will increase
  to more vital organs (brain, heart) at the
  expenses of the less vital organs (kidneys,
  lungs, GIT)
• kidneys acute renal failure (oliguria,
  metabolic acidosis)
• Lungs Adult Respiratory Distress Syndrome
  (ARDS)
• GIT Ischemia, stress ulcer, hemorrhage,
  ileus
• Blood Disseminated Intravascular Coagulation
  (DIC)
• Metabolic metabolic acidosis, electrolytes
  disturbance
• Brain Hypoxic ischemic encephalopathy
• Heart Myocardial ischemia, arrhythmia

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• 4- Irreversible shock irreversible cellular
  damage (mitochondria, cell membrane) clinically,
  serious arrhythmia, deep coma, pH below 7.0 in
  spite of vigorous correction with sodium
  bicarbonate
• So, our role is how to detect this
  hemodynamically unstable patient in his early
  stage of shock to give him the best supportive
  treatment and careful observation to get a better
  out come

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Septic Shock
SIRS/Sepsis/Septic shock
Mediator release exogenous endogenous
Maldistribution of blood flow
Cardiac dysfunction
Imbalance of oxygen supply and demand
Alterations in metabolism
Outcomes of mediator release in systemic
inflammatory response syndrome (SIRS), sepsis,
and septic shock
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Septic Shock Is Unique

• Cardiac output may be normal, increased, or
  decreased.
• Hypotension and poor end-organ perfusion may be
  present despite good skin perfusion.
  Hypotension is still a sign of decompensation.
• Early signs of sepsis/septic shock include
• Fever or hypothermia
• Tachycardia and tachypnea
• Leukocytosis, leukopenia, or increased bands

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Septic Shock Warm Shock

• Early, compensated, hyperdynamic state
• Clinical signs
• Warm extremities with bounding pulses,
  tachycardia, tachypnea, confusion.
• Physiologic parameters
• widened pulse pressure, increased cardiac output
  and mixed venous saturation, decreased systemic
  vascular resistance.
• Biochemical evidence
• Hypocarbia, elevated lactate, hyperglycemia

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Septic Shock Cold Shock

• Late, uncompensated stage with drop in cardiac
  output.
• Clinical signs
• Cyanosis, cold and clammy skin, rapid, thready
  pulses, shallow respirations.
• Physiologic parameters
• Decreased mixed venous sats, cardiac output and
  CVP, increased SVR, thrombocytopenia, oliguria,
  myocardial dysfunction, capillary leak
• Biochemical abnormalities
• Metabolic acidosis, hypoxia, coagulopathy,
  hypoglycemia.

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Septic Shock (cont)

• Cold Shock rapidly progresses to MOSF or death,
  if untreated
• Multi-Organ System Failure Coma, ARDS, CHF,
  Renal Failure, Ileus, hemorrhage, DIC
• More organ systems involved, worse the prognosis
• Therapy ABCs, fluid
• Appropriate antibiotics, treatment of underlying
  cause

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• Nursing notes
• the nurse should take a brief history about the
  patients illness and his previous vital signs
• Doctors notes
• The doctor should take a full detailed history
  about the present and past illness and
  medications
• Multidisciplinary team to deal with the patient
• Interactions between other department e.g.
  surgery, radiotherapy, radio diagnosis, and
  clinical pathology is extremely essential for the
  sake of the patient

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• Computer based system
• If the system is computer based that will
  facilitate detection of any deterioration of the
  patients clinical condition through the curves
  drawn temperature, blood pressures, urine
  output,..
• Ratio between nurses and patients
• nurse to patient ration should be 11 or at
  least 12
• Criteria of discharge
• If the patient is hemodinamically stable for at
  least 24 h, he can transferred to normal floor to
  continue his treatment

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Conclusions
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Thank You