2 PEARLS starting in the 1970s This retrieval medicine holds great promise for future improvements in care • In pediatric critical care medicine, there have been remark able achievements in the abilit[.]
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 progress in anatomy, physiology, resuscitation and ventilation, anesthesiology, neonatology, pediatric general surgery, pediatric cardiac surgery, and pediatric cardiology The role of nursing is absolutely central to the evolution of critical care units Until the 1950s and 1960s, intensive care units were organized by grouping patients with similar diseases However, in the 1960s, neonatal intensive care units grouped children according to age and severity of illness, and pediatric intensive care units followed this example Sophisticated interhospital transfer services proved significant in reducing morbidity and mortality of critically ill children Evolution of Modern Medicine The evolution of pediatric critical care medicine (PCCM) reflects a long series of contributions from anatomy, physiology, resuscitation and ventilation, anesthesiology, neonatology, pediatric general surgery, pediatric cardiac surgery, pediatric cardiology, and the many individuals responsible for the discoveries and innovations.1,2 Intensive care units were originally organized by grouping together patients with the same or similar diseases However, when neonatologists grouped children according to age and severity of illness, pediatric intensive care units (PICUs) followed their example Transport, or retrieval medicine, developed and nurses took on a major role in providing care to critically ill and injured children Anatomy and Physiology What seems simple and obvious today took a great deal of time, effort, and insight to understand This section discusses some of the contributions that advanced the practice of medicine, enabled • • starting in the 1970s This retrieval medicine holds great promise for future improvements in care In pediatric critical care medicine, there have been remarkable achievements in the ability to understand and treat critical illness in children as well as progress in the organization of pediatric critical care medicine, education, and research in the field Increasing use of improved technology has advanced the care of critically ill children but has not eliminated errors, complications, or potentially long-term sequelae, and it is associated with a need for greater focus on establishing a humane, caring environment for the patients and their families the development of cardiorespiratory support, and eventually led to the establishment of intensive care Andreas Vesalius (1514–1564), the Flemish anatomist, corrected many previous mistakes in the understanding of anatomy and provided positive pressure ventilation via a tracheotomy tube to asphyxiated fetal lambs Michael Servetus of Spain (1511–1553) correctly described the pumping action of the heart’s ventricles and the circulation of blood from the right heart through the lungs to the left heart Matteo Realdo Columbo (1515–1559) described pulmonary circulation and the concept that the lungs added a spirituous element to the blood by the admixture of air William Harvey (1578–1657) confirmed the function of the heart and arterial and venous circulations through both animal experiments and observations in humans He published De Motu Cordis3 (On the Motion of the Heart) in 1628 Because he did not yet have the microscope, he could not see the capillaries and thus could not include the mechanism for transfer of blood from the arterial to the venous systems of the pulmonary circulation Capillaries were first described by Marcello Malpighi (1628–1694, Italian) in De Pulmonibus (On the Lungs) in 1661 Thomas Willis (1611–1675) CHAPTER 1 History of Pediatric Critical Care Medicine and, eventually, William Cullen (1710–1790) led the way to the understanding of the role of the nervous system as the site of consciousness and the regulation of vital phenomena Richard Lower (1631–1691) proved that it was the passage of blood through the lungs, ventilation of the lungs, and gas exchange with blood that vivified the blood and turned it red Stephen Hales (1677–1761) measured blood pressure with a brass tube connected to a 9-foot glass tube in a horse Joseph Black (1728–1799) identified carbon dioxide as a gas expired from human lungs Karl Wilhelm Scheele (1742–1786) isolated oxygen, as did Joseph Priestley (1733–1804), who named it “dephlogisticated air” and determined its vital role in supporting combustion Antoine-Laurent Lavoisier (1743–1794) identified oxygen as the vital element taken up by the lungs that maintains life and gave it its name (literally “acid generator”) Oxygen’s essential role in physiology and biochemistry was not clarified until the late 19th century when Felix Hoppe-Seyler (1825–1895) described the transportation of oxygen in blood by hemoglobin Giovanni Morgagni (1682–1771) initiated the field of anatomic pathology in his classic book De sedibus et causis morborum per anatomen indagatis, published in 1761 He described in detail his observations of the diseased organs in more than 700 autopsies of persons with a wide variety of disorders and made correlations with the patient’s appearance and symptoms, the initial clinicalpathologic basis of medicine In 1842, Crawford Long in Georgia and in 1846, William Morton in Boston demonstrated the efficacy and safety of ether anesthesia, thereby opening the era of modern surgery Joseph Lister (1827–1912), one of the founders of modern surgery, reasoned that bacteria were the source of pus in rotten organic material and in 1865 used carbolic acid in surgical fields and in wound dressings to eliminate bacteria This technique dramatically improved patient outcomes after surgery Robert Koch (1843–1910) developed his postulates in 1882 in order to attribute the etiology of a disease to a particular microorganism in a logical, scientific manner He also identified the tubercle bacillus as the cause of tuberculosis and was awarded the Nobel Prize in 1905 Wilhelm Conrad von Röntgen (1845–1923) discovered x-rays in 1895 Scipione Riva-Rocci (1863–1937), in 1896, measured blood pressure using the sphygmomanometer, and Nikolai Korotkoff (1874–1920) introduced his auscultation method of determining systolic and diastolic pressure in 1905.1 Resuscitation and Ventilatory Support The key to understanding the present practice of intensive care for children lies in knowing the history of scientific study of cardiorespiratory anatomy and physiology and the discovery of techniques to support ill patients Although one could think that current practice suddenly emerged with the late 20th century, technical discoveries and accomplishments in the development of resuscitation and ventilation taken for granted today date back to the Bible, and numerous events and contributions led to current practice In a biblical story,1,4,5 Elisha resurrected a young boy who was dead when “he climbed onto the bed and stretched himself on top of the child, putting his mouth to his mouth, his eyes to his eyes, and his hands to his hands, and as he lowered himself onto him the child’s flesh grew warm Then the child sneezed and opened his eyes.” In 117 CE, Antyllus performed tracheotomies for patients with upper airway obstruction.6 Paracelsus, a 16th-century Swiss alchemist and physician, first provided artificial ventilation to both animals and dead humans using a bellows.6 Andreas Vesalius, the aforementioned Flemish professor of anatomy, in De Humani Corporis Fabrica, reported ventilating open-chest dogs, fetal lambs, and pigs using a tracheostomy and fireplace bellows in 1543.7–9 The French obstetrician Desault, in 1801, described how to successfully resuscitate apneic or limp newborns by digital oral tracheal intubation with a lacquered fabric tube and then blowing into the tube.1 In 1832, Dr John Dalziel in Scotland developed a bellows-operated intermittent negative pressure device to assist ventilation.8 In 1864, Alfred F Jones, of Lexington, Kentucky, built a body-enclosing tank ventilator; in the 1880s, Alexander Graham Bell developed a so-called vacuum jacket driven by hand-operated bellows.8 In 1876 in Paris, Woillez built what was probably the first workable cuirass ventilator, which was strikingly similar to the “iron lung” respirator introduced by McKhann and Drinker in 1929 and manufactured for widespread use by Emerson in 1931.10 Braun developed an infant resuscitator, as described by Doe in 1889, which was used successfully in 50 consecutive patients A respirator developed by Steuart in 1918 in Cape Town, South Africa, apparently successfully treated a series of polio patients, but he did not report it.8 In 1888, Joseph O’Dwyer, a physician working at the New York Foundling Hospital who was concerned about the high death rate in croup and laryngeal diphtheria, instituted the manual method of blind oral laryngeal intubation using short, tapered brass tubes that entered the subglottic lumen Despite severe criticism, he persisted in developing a series of various-diameter tubes for the palliation of severe adult and pediatric laryngeal edema due to infections, including diphtheria They were used until the 1930s George Fell, another New York physician, devised a method of ventilation with a foot-operated bellows and exhalation valve connected by rubber tubing to the O’Dwyer tube.8 In 1898, Rudolph Matas of New Orleans adapted the FellO’Dwyer technique to ventilate patients’ lungs during chest wall surgery In the early 1900s, George Morris Dorrance of Philadelphia used the technique to perform resuscitations.8 In 1910, at the Trendelenburg Clinic in Leipzig, two thoracic surgeons A Lawen and R Sievers, developed a volume-preset, positive-pressure, electrically powered piston-cylinder ventilator with a draw-over humidifier It was used successfully with a tracheotomy tube during and after thoracic surgery and for a variety of disorders causing respiratory failure.1 Chevalier Jackson (1858–1955), a surgeon at Temple University in Philadelphia, developed a highly specific series of techniques for laryngoscopy, bronchoscopy, and tracheotomy.1 He revolutionized the procedure of tracheotomy and developed a detailed protocol of airway care His design of tubes, made of silver, for patients of all ages set the standard for tracheotomy tubes for more than the first half of the 20th century In 1958, Peter Safar, then at the Baltimore City Hospital, published studies proving that the long-standing pulmonary resuscitation technique of chest pressure and arm lift was virtually worthless In effect, he went back to Elisha and proved jaw thrust and mouth-to-mouth resuscitation superior.11 Soon after, W.B Kouwenhoven and James Jude at Johns Hopkins published work on the effectiveness of closed-chest cardiac massage.12 In 1946 Beck and his team demonstrated open-chest electrical defibrillation In 1952, Zoll and coworkers proved the efficacy of external defibrillation and, in 1956, the effectiveness of external cardiac pacing.13 S E C T I O N I Pediatric Critical Care: The Discipline Contributions of Specific Disciplines Pediatric Anesthesiology PCCM developed initially through the efforts of pediatric anesthesiologists, as well as pediatric general surgeons and pediatric cardiac surgeons and neonatologists In fact, most of the original PICUs were founded by pediatric anesthesiologists (Table 1.1).1,4,14–23 Before discrete, geographically separate, ICUs evolved, critically ill children often received close monitoring, intensive nursing care, and pulmonary support in the postanesthetic recovery room There, the anesthesiologists were the attending physicians In addition to those PICUs noted in Table 1.1, there were certainly others that were not as well documented Pediatric General Surgery and Pediatric Cardiac Surgery Dr William E Ladd (1880–1967) at Boston Children’s Hospital (BCH), the first full-time pediatric surgeon, pioneered the TABLE Some Early Pediatric Intensive Care Units and Programsa 1.1 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 G Huault Neonatology Neonatology 1963 Royal Children’s Hospital, Melbourne, Australia I.H McDonald J Stocks Ped Anesth Ped Anesth 1963 Adelaide Children’s Hospital, Adelaide, Australia T Allen I Stevens Ped Anesth 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 F Seleny J Cox Ped Anesth Ped Anesth 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 N Talner Ped Anesth Ped Cardiol 1970e Hospital for Sick Children, Toronto, Canada A Conn Ped Anesth 1971 Massachusetts General Hospital, Boston, Massachusetts D Shannon I.D Todres Ped Pulm 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 A Lamarre Ped 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 A Fields Ped Ped 1975 Children’s Medical Center, Dallas, Texas D Levin F Morriss Ped Ped & Ped Anesth 1976 Hospital Infantil La Paz, Madrid, Spain F Ruza Ped CHAPTER 1 History of Pediatric Critical Care Medicine TABLE Some Early Pediatric Intensive Care Units and Programsa—cont’d 1.1 Year Institution/Location Medical Director(s) Director(s) Specialtyb 1977 Johns Hopkins Medical Center, Baltimore, Maryland M.C Rogers S Nugent Ped & Ped Anesth 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 H van Vught Ped 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 congenital malformations His protégé, Dr Robert Gross, first successfully operated on patent ductus arteriosus in 1937 and later on other congenital cardiac lesions Dr C Crawfoord in Sweden and Dr Gross in Boston both successfully repaired a coarctation of the aorta in 1945 In the same year, at Johns Hopkins, Dr Alfred Blalock (surgeon) and Dr Helen Taussig (cardiologist) with Mr Vivien Thomas (laboratory assistant) created the subclavian-to-pulmonary artery shunt for tetralogy of Fallot Dr John Gibbon at Jefferson Medical College Hospital in Philadelphia performed the first successful open-heart surgery using cardiopulmonary bypass for closure of an atrial septal defect in an adolescent girl in 1953.1 These advances in pediatric surgery created the need for excellent and often complex postoperative care Dr C Everett Koop, who had completed surgical residency at the University of Pennsylvania in 1945, then trained in Boston with Dr Gross for months He returned to the University of Pennsylvania and the Children’s Hospital of Philadelphia (CHOP) in 1946 With the help of Dr Leonard Bachman, director of anesthesiology, and the nursing staff, Dr Koop developed the first neonatal surgical ICU in 1962 Dr Bachman and his young associate, John J Downes, subsequently set up North America’s first PICU service with a full-time medical and nursing staff in 1967 at CHOP Neonatology Pediatric critical care owes a great debt to neonatologists and their special care nurseries.1,4,24 The first and most prominent of these was established in the 1880s in Paris by obstetrician Etienne Tarnier and his young associate Pierre Budin at the Hôpital la Charitre with a unit that had a full-time dedicated nursing staff, an antiseptic environment, incubators, and gavage feeding of breast milk The practices reduced hospital preterm infant mortality in less than a decade from 197 per 1000 live births to 46 per 1000 live births Their work presaged the development of modern neonatal intensive care in the 20th century In 1914, the first premature infant center in the United States was opened at Michael Reese Hospital in Chicago by Dr Julius Hess (1876–1955) Canadian pediatrician Dr Alfred Hart performed exchange transfusions involving peripheral artery cannulation in 1928 In 1932, Drs Louis Diamond, Kenneth Blackfan, and James Batey at BCH determined the pathophysiology of hemolytic anemia and jaundice of erythroblastosis fetalis In 1948, they described exchange transfusions using a feeding tube inserted into the umbilical vein In the 1950s and 1960s, Dr Geoffrey Dawes at the Nuffield Institute for Medical Research at Oxford University described for the first time the fetal and transitional circulation of mammalian newborns using fetal and newborn lambs In the late 1950s, Columbia University’s obstetrical anesthesiologist, Virginia Apgar, who had devised the Apgar score for assessing birth asphyxia, recruited Dr L Stanley James to develop animal and human investigation of transitional pulmonary-cardiovascular adaptation during labor, delivery, and the postnatal period Dr James and his team at Columbia and Dr Abraham Rudolph, a South African pediatric cardiologist, and his team at Albert Einstein Medical Center in New York City and subsequently at the Cardiovascular Research Institute in San Francisco, performed extensive studies S E C T I O N I Pediatric Critical Care: The Discipline in fetal lambs, rhesus monkeys, and term and preterm human newborns that defined the human cardiopulmonary adaptation to delivery and postnatal life They also determined the biochemical factors and time course of birth asphyxia and recovery In 1959, a research fellow at Harvard, Dr Mary Ellen Avery (with mentor Dr Jere Mead), discovered deficiency of alveolar surfactant in lungs of newborns dying from respiratory distress syndrome (RDS) This discovery led to a better understanding of neonatal pulmonary disorders and eventually led to the intratracheal instillation of surfactant in newborn preterm infants to prevent or mitigate the severity of RDS In the 1960s, state-of-the-art neonatal ICUs were established at Columbia-Presbyterian Hospital (Dr William Silverman), University of Pennsylvania (Dr Thomas Boggs), Vanderbilt University (Dr Mildred T Stahlman), Toronto Hospital for Sick Children (Dr Paul Swyer), and the University of California at San Francisco (Dr William H Tooley) Pediatric Cardiology As previously indicated, the vision of Dr Taussig in devising a method to treat “blue babies” and successful cardiac operations led to infants and children who survived surgery and needed postoperative intensive care Advances in technology, especially in imaging, have allowed clinicians to “see” into living patients with astounding accuracy Increased understanding of anatomy and physiology has led to improved surgical and nonsurgical care for children with complex cardiopulmonary problems Developments in cardiac catheterization and interventional radiology have enabled clinicians to treat many lesions without open-heart surgery and potentially difficult postoperative intensive care This concept was introduced in 1968 by Dr William Rashkind at the Children’s Hospital of Philadelphia (CHOP) with the introduction of the balloon atrial septostomy for infants with transposition of the great arteries Growth of techniques that allow effective intervention in many complex cardiac conditions, both nonsurgical and surgical, has resulted in many pediatric centers creating specific cardiac ICUs, often run by pediatric cardiac intensivists Cognitive impairment in some infants with complex lesions or chromosomal abnormalities and the occasional development of chronic respiratory failure with dependence on mechanical ventilation for months or years are two of the occasional major sequelae of these highly successful endeavors The value of PCCM for these cardiac patients and other critically ill children has been well documented by Dr Jacqueline Noonan, who noted, “Much success of the surgery can be attributed to a group of pediatric intensivists, pediatric intensive care units, improved ventilator support, and trained respiratory therapists.”25 Early Use of Mechanical Ventilation in Neonates and Children The first series of carefully observed infants and children treated for respiratory failure was published in 1959 In that year, Drs P.M Smythe (pediatrician) and Arthur Bull (anesthesiologist) reported the first real success in mechanical ventilation of a series of neonates with respiratory failure caused by neonatal tetanus These infants were paralyzed with curare to relax the tetanic muscle spasms and ventilated for to 14 days using tracheotomy and a modified Radcliff adult ventilator.26 Until that time, infants or children were rarely given ventilator support for more than a few hours, with either adult ventilators or manual ventilation Neither specifically designed pediatric ventilators nor small-volume blood gas analysis was available Dr Smythe had to overcome these obstacles by innovation Due to local cultural practices, Bantu children from tribal areas were particularly prone to develop tetanus On July 13, 1957, at Groote Schuur Hospital, he performed a tracheostomy and began intermittent positive pressure ventilation for these infants with the assistance of anesthesiologist Dr Bull This was truly a landmark event in the evolution of PCCM Although considered a success story in that it was the first time that infants survived up to weeks of positive-pressure mechanical ventilation, the first seven of nine patients died Eventually, their survival rate reached 80% to 90% Drs Smythe and Bull commented, “No praise can be too high for the nursing staff, who were all student nurses and without any special training.” David Todres, a medical student at that time, was giving curare to and observing these infants, sparking his interest in critical care In 1963 to 1964 in Toronto, Drs Paul Swyer, Maria DelivoriaPapadopoulos, and Henry Levison were the first to successfully treat a series of moribund premature infants with RDS and respiratory failure They used positive-pressure mechanical ventilation and supportive care27 and emphasized the importance of a fulltime team, including dedicated nurses and therapists as well as physicians In 1968 Dr George Gregory and colleagues at the University of California at San Francisco demonstrated improved survival with early use of continuous positive airway pressure without assisted ventilation or with positive end-expiratory pressure added to the mechanical ventilation regimen.28 An important contribution to the development of intensive care and long-term mechanical ventilation was the use of plastic endotracheal tubes for prolonged intubation and ventilation Dr Bernard Brandstater, an Australian working at the American Hospital in Beirut, Lebanon, reported prolonged nasotracheal intubation as an alternative to the tracheostomy at the First European Congress of Anesthesia in Vienna in 1962.29 Poliomyelitis and Creation of the First Intensive Care Units Poliomyelitis epidemics occurred worldwide in the early 20th century but seemed especially severe in Western Europe and North America There was no treatment and, until the late 1920s, no effective life support for those victims with respiratory failure Fortunately, the confluence of great scientific and clinical minds and the organizational efforts of physicians, nurses, and therapists addressing the needs of polio patients led to the creation of dedicated polio respiratory 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 negative pressure, body-enclosing mechanical ventilator, later termed the iron lung.10,30 Polio outbreaks occurred in the summer months worldwide in the 1930s and 1940s The polio epidemics of the early 1950s were very severe in Los Angeles and Copenhagen In 1952, Dr H.C Lassen, the chief epidemiologist at Blegdam Hospital in Copenhagen, described treating 2772 patients with polio Of these, 316 were in respiratory failure and initially received assisted ventilation with iron lungs in a large respiratory care unit During that summer, they had as many as 70 patients in respiratory failure in that unit Unfortunately, the mortality of patients supported by an iron lung ventilator was nearly 90%, with the cause of death frequently being unrecognized upper airway obstruction When ... and in 1865 used carbolic acid in surgical fields and in wound dressings to eliminate bacteria This technique dramatically improved patient outcomes after surgery Robert Koch (1843–1910) developed... anatomy and physiology and the discovery of techniques to support ill patients Although one could think that current practice suddenly emerged with the late 20th century, technical discoveries and... 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