Naama Experience

بسم ال الرحمن بسم ال الرحمن الرحيمالرحيم

NAAMA experienceNAAMA experienceBy By

Yasser ElboraiYasser Elborai, MD, MD Assisstent Lecturer of Pediatric Assisstent Lecturer of Pediatric

OncologyOncology

NCI – Cairo UniversityNCI – Cairo University

NAAMA “National Arab American Medical NAAMA “National Arab American Medical Association” is a Non Governmental Association” is a Non Governmental Organization (NGO) composed of an Arabian Organization (NGO) composed of an Arabian doctors living in America doctors living in America

They are trying to help doctors in Egypt and They are trying to help doctors in Egypt and other Arabian countries by different ways like other Arabian countries by different ways like offering training courses and research work offering training courses and research work

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

This training course was in DeVos children’s This training course was in DeVos children’s

hospital – Michigan – USA hospital – Michigan – USA

Pediatric Intensive Care UnitPediatric Intensive Care Unit(PICU(PICU((

What is the aim of building PICU ?What is the aim of building PICU ?

How do you construct PICU ?How do you construct PICU ?

How do you manage PICU ?How do you manage PICU ?

What is the aim of building PICUWhat is the aim of building PICU ? ?

To give our critically ill To give our critically ill patients a proper treatmentpatients a proper treatment

To create a new subspecialty in To create a new subspecialty in our pediatric department our pediatric department

To decrease the load of work To decrease the load of work on main ICU in our instituteon main ICU in our institute

How do you construct PICUHow do you construct PICU ? ?

Number of roomsNumber of rooms Number of bedsNumber of beds Isolation rooms Isolation rooms EquipmentsEquipments SuppliesSupplies Aeration of the roomAeration of the room Design of the roomDesign of the room Character of walls and floorCharacter of walls and floor

Comparison between PICU in DeVos Comparison between PICU in DeVos children’s hospital-Michigan and children’s hospital-Michigan and

newly developing PICU in NCI-Caironewly developing PICU in NCI-Cairo

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

DeVos children’s hospital-Michigan

newly developed PICU in NCI-Cairo

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

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



• Equipments

• Supplies All types of syringes, lines, tubes, masks,…All types of syringes, lines, tubes, masks,…

• Aeration Air conditioned Air conditioned Air conditioned Air conditioned

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

The bed is only The bed is only accessible from 3 accessible from 3 sides as usual sides as usual



• Design of room

• Character of walls and floor

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

How do you manage PICUHow do you manage PICU ? ?

Criteria of admissionCriteria of admission Nursing notesNursing notes Doctor’s notesDoctor’s notes Multidisciplinary team to deal Multidisciplinary team to deal

with the patientwith the patient Computer based systemComputer based system Ratio between nurses and Ratio between nurses and

patientspatients Criteria of discharge Criteria of discharge

Criteria of admission:Criteria of admission:There are many indications for PICU admission There are many indications for PICU admission

but the most common cause here in our but the most common cause here in our institute will be shock specially septic shockinstitute will be shock specially septic shock

► ► if the patient is hemodynamically unstable: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.

- 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

Stages of shockStages of shock

1- Early shock1- Early shock: : tachycardia, poor capillary perfusiontachycardia, poor capillary perfusion

cold extremities, but in septic shock may be worm cold extremities, but in septic shock may be worm extremities because ischemia of precapillary sphincterextremities because ischemia of precapillary sphincter

2- Established shock2- Established shock: clinical triad : clinical triad tachycardia, tachycardia, hypotension, peripheral hypoperfusionhypotension, peripheral hypoperfusion will be evident. will be evident. The patient looks The patient looks palepale and and anxiousanxious

3- Advanced shock3- Advanced shock: the blood flow will increase to more vital : the blood flow will increase to more vital organs (brain, heart) at the expenses of the less vital organs organs (brain, heart) at the expenses of the less vital organs (kidneys, lungs, GIT)(kidneys, lungs, GIT)

kidneys: acute renal failure (oliguria, metabolic acidosis)kidneys: acute renal failure (oliguria, metabolic acidosis)

Lungs : Adult Respiratory Distress Syndrome (ARDS)Lungs : Adult Respiratory Distress Syndrome (ARDS)

GIT : Ischemia, stress ulcer, hemorrhage, ileusGIT : Ischemia, stress ulcer, hemorrhage, ileus

Blood : Disseminated Intravascular Coagulation (DIC)Blood : Disseminated Intravascular Coagulation (DIC)

Metabolic: metabolic acidosis, electrolytes disturbanceMetabolic: metabolic acidosis, electrolytes disturbance

Brain : Hypoxic ischemic encephalopathyBrain : Hypoxic ischemic encephalopathy

Heart : Myocardial ischemia, arrhythmiaHeart : Myocardial ischemia, arrhythmia

4- Irreversible shock4- Irreversible shock: irreversible cellular damage : irreversible cellular damage (mitochondria, cell membrane) clinically, serious (mitochondria, cell membrane) clinically, serious arrhythmia, deep coma, pH below 7.0 in spite of arrhythmia, deep coma, pH below 7.0 in spite of vigorous correction with sodium bicarbonate vigorous correction with sodium bicarbonate

So, our role is how to detect this So, our role is how to detect this hemodynamically unstable patient in his early stage hemodynamically unstable patient in his early stage of shock to give him the best supportive treatment of shock to give him the best supportive treatment and careful observation to get a better out come and careful observation to get a better out come

SIRS/Sepsis/Septic shockSIRS/Sepsis/Septic shock

Mediator release:Mediator release:

exogenous & endogenousexogenous & endogenous

MaldistributionMaldistribution

of blood flowof blood flow

CardiacCardiac

dysfunctiondysfunction

Imbalance of Imbalance of oxygenoxygen

supply and supply and demanddemand

Alterations inAlterations in

metabolismmetabolism

Outcomes of mediator release in systemic inflammatory response Outcomes of mediator release in systemic inflammatory response syndrome (SIRS), sepsis, and septic shock syndrome (SIRS), sepsis, and septic shock

Septic ShockSeptic Shock

Septic Shock Is UniqueSeptic Shock Is Unique

Cardiac output may be normal, increased, Cardiac output may be normal, increased, or decreased. or decreased.

Hypotension and poor end-organ perfusion may be Hypotension and poor end-organ perfusion may be present despite “good” skin perfusion. present despite “good” skin perfusion. Hypotension Hypotension is still a sign of decompensationis still a sign of decompensation. .

Early signs of sepsis/septic shock includeEarly signs of sepsis/septic shock include— Fever or hypothermiaFever or hypothermia— Tachycardia and tachypneaTachycardia and tachypnea— Leukocytosis, leukopenia, or increased bandsLeukocytosis, leukopenia, or increased bands

Septic Shock: “Warm ShockSeptic Shock: “Warm Shock””

Early, compensated, hyperdynamic stateEarly, compensated, hyperdynamic state Clinical signsClinical signs

Warm extremities with bounding pulses, tachycardia, Warm extremities with bounding pulses, tachycardia, tachypnea, confusion.tachypnea, confusion.

Physiologic parametersPhysiologic parameters widened pulse pressure, increased cardiac output and widened pulse pressure, increased cardiac output and

mixed venous saturation, decreased systemic vascular mixed venous saturation, decreased systemic vascular resistance.resistance.

Biochemical evidence:Biochemical evidence: Hypocarbia, elevated lactate, hyperglycemiaHypocarbia, elevated lactate, hyperglycemia

Septic Shock: “Cold Shock”Septic Shock: “Cold Shock” Late, uncompensated stage with drop in cardiac Late, uncompensated stage with drop in cardiac

output.output. Clinical signsClinical signs

Cyanosis, cold and clammy skin, rapid, thready pulses, Cyanosis, cold and clammy skin, rapid, thready pulses, shallow respirations.shallow respirations.

Physiologic parametersPhysiologic parameters Decreased mixed venous sats, cardiac output and CVP, Decreased mixed venous sats, cardiac output and CVP,

increased SVR, thrombocytopenia, oliguria, myocardial increased SVR, thrombocytopenia, oliguria, myocardial dysfunction, capillary leakdysfunction, capillary leak

Biochemical abnormalitiesBiochemical abnormalities Metabolic acidosis, hypoxia, coagulopathy, hypoglycemia.Metabolic acidosis, hypoxia, coagulopathy, hypoglycemia.

� Cold Shock rapidly progresses to MOSF or Cold Shock rapidly progresses to MOSF or death, if untreateddeath, if untreated

� Multi-Organ System Failure: Coma, ARDS, Multi-Organ System Failure: Coma, ARDS, CHF, Renal Failure, Ileus, hemorrhage, CHF, Renal Failure, Ileus, hemorrhage, DICDIC

� More organ systems involved, worse the More organ systems involved, worse the prognosisprognosis

� Therapy: ABCs, fluidTherapy: ABCs, fluid� Appropriate antibiotics, treatment of Appropriate antibiotics, treatment of

underlying causeunderlying cause

Septic Shock (con’tSeptic Shock (con’t((

Nursing notes:Nursing notes:the nurse should take a brief history about the patient’s the nurse should take a brief history about the patient’s

illness and his previous vital signsillness and his previous vital signs

Doctor’s notes:Doctor’s notes:The doctor should take a full detailed history about the The doctor should take a full detailed history about the

present and past illness and medicationspresent and past illness and medications

Multidisciplinary team to deal with the patient:Multidisciplinary team to deal with the patient:Interactions between other department e.g. surgery, Interactions between other department e.g. surgery,

radiotherapy, radio diagnosis, and clinical pathology is radiotherapy, radio diagnosis, and clinical pathology is extremely essential for the sake of the patientextremely essential for the sake of the patient

Computer based system:Computer based system:If the system is computer based that will facilitate If the system is computer based that will facilitate

detection of any deterioration of the patients’ clinical detection of any deterioration of the patients’ clinical condition through the curves drawn temperature, condition through the curves drawn temperature, blood pressures, urine output,……..blood pressures, urine output,……..

Ratio between nurses and patients:Ratio between nurses and patients: nurse to patient ration should be 1:1 or at least 1:2nurse to patient ration should be 1:1 or at least 1:2

Criteria of discharge:Criteria of discharge:If the patient is hemodinamically stable for at least 24 h, If the patient is hemodinamically stable for at least 24 h,

he can transferred to normal floor to continue his he can transferred to normal floor to continue his treatment treatment

We are trying to create a new pediatric care unit similar to that we observed in DeVos children’s hospital-Michigan-USA

But as an initial step it will be a pediatric intermediate care unit and in the near future it will be a pediatric intensive care unit

Naama Experience

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