Pediatric emergency medicine trisk 2769 2769

pressures minimized Depending on the diagnosis, there may be other clinical indicators such as fever, vomiting, and sepsis that may affect fluid management In severely ill or complex patients, the measurement of central venous pressure may provide a more precise guide for monitoring fluid status Sedation is an important adjunct to efficient assisted ventilation to reduce anxiety and increase tolerance to the presence of a tracheal tube and assisted ventilation Morphine sulfate dosed 0.1 to 0.2 mg/kg every to hours or as a continuous infusion of 0.1 mg/kg/hr is often used This is frequently combined with a benzodiazepine, such as midazolam 0.1 to 0.2 mg/kg every to hours or as a continuous infusion Dexmedetomidine is increasingly being used in critical care units and some EDs It provides anxiolysis and sedation without adverse impact on respiratory drive, airway protection, and hemodynamic stability Muscle relaxants may help optimally ventilate intubated children with severe respiratory failure, such as those with stiff lungs (e.g., severe interstitial pneumonia) or stiff chest wall (e.g., status epilepticus), by improving compliance and reducing oxygen consumption Depolarizing agents may include repeated doses of rocuronium at to 1.2 mg/kg/dose Alternatively, vecuronium bromide can be administered starting at 0.1 mg/kg every to hours or as a drip at 0.1 to 0.2 mg/kg/hr Clinical Indications for Discharge or Admission Patients with acute respiratory failure require hospitalization If resuscitation efforts restore adequate oxygenation and ventilation and a stable trajectory has been established, admission to the inpatient floor for continued evaluation and management may be appropriate The level of inpatient care required for patients on HFNC and noninvasive ventilation varies by institution However, most patients with respiratory failure will require intensive care unit (ICU) admission, and prompt communication with the critical care team at one’s institution or an appropriate transfer facility should be an early priority in management (see Chapter 11 Interfacility Transport and Stabilization ) ASTHMA CLINICAL PEARLS AND PITFALLS