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 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.
“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)
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. , 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 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 Cordis (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) 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 clinical-pathologic 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.
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, , , 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. Paracelsus, a 16th-century Swiss alchemist and physician, first provided artificial ventilation to both animals and dead humans using a bellows. 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.
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. In 1832, Dr. John Dalziel in Scotland developed a bellows-operated intermittent negative pressure device to assist ventilation. 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. 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. 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.
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.
In 1898, Rudolph Matas of New Orleans adapted the Fell-O’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. 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.
Chevalier Jackson (1858–1955), a surgeon at Temple University in Philadelphia, developed a highly specific series of techniques for laryngoscopy, bronchoscopy, and tracheotomy. 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. Soon after, W.B. Kouwenhoven and James Jude at Johns Hopkins published work on the effectiveness of closed-chest cardiac massage. 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.
Contributions of specific disciplines
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 ). , , 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.
|Year||Institution/Location||Medical Director(s)||Director(s) Specialty b|
|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 |
|1963||Royal Children’s Hospital, Melbourne, Australia||I.H. McDonald |
|Ped Anesth. |
|1963||Adelaide Children’s Hospital, Adelaide, Australia||T. Allen |
|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 |
|Ped Anesth. |
|1968 c||Children’s Hospital District of Columbia, Washington, DC d||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 |
|Ped Anesth. |
|1970 e||Hospital for Sick Children, Toronto, Canada||A. Conn||Ped Anesth.|
|1971||Massachusetts General Hospital, Boston, Massachusetts||D. Shannon |
|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 |
|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 |
|1975||Children’s Medical Center, Dallas, Texas||D. Levin |
Ped. & Ped Anesth.
|1976||Hospital Infantil La Paz, Madrid, Spain||F. Ruza||Ped.|
|1977||Johns Hopkins Medical Center, Baltimore, Maryland||M.C. Rogers |
|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
|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.|
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 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. 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 6 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.
Pediatric critical care owes a great debt to neonatologists and their special care nurseries. , , 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 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).
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.”
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 4 to 14 days using tracheotomy and a modified Radcliff adult ventilator. 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 Delivoria-Papadopoulos, 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 care and emphasized the importance of a full-time 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.
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.
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. ,
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 the number of patients in respiratory failure exceeded the available number of iron lung ventilators, Bjorn Ibsen, the chief of anesthesiology at the hospital, with the help of his medical staff and nurse anesthetists, performed tracheal intubation and then tracheostomy along with manual positive pressure ventilation with 50% oxygen and tracheal suctioning. This treatment was carried out in 200 patients with respiratory failure. To provide continuous manual ventilation on a 24-hour basis, Ibsen recruited, trained, and used 200 nursing students and aides along with 200 medical students, each working 8-hour shifts to provide manual ventilation, as well as 27 technicians per day to care for the patients. The mortality in patients receiving this treatment decreased from 90% to 40%.
At that time, patients from outlying areas were transported to hospitals in ambulances without sufficient attendants or airway care and arrived moribund. Lassen and Ibsen started to send so-called retrieval teams in ambulances out to pick up the patients in the countryside, with marked improvements in status on arrival. They also started passing stomach tubes early on for nutrition, and the rubber-cuffed tracheostomy tubes were replaced with a silver cannula that caused less tracheal mucosal damage. Even with all of these improvements, Dr. Ibsen noted, “Naturally we ran into a lot of complications.”
Drs. Ibsen and Lassen also received help from other people who were focusing their efforts on treating polio. The clinical biochemist Dr. Poul Astrup developed a micro method to measure capillary arterialized pH and PCO 2 in infants, children, and adults. C.G. Engstrom, a Swedish anesthesiologist, designed and clinically tested the first modern volume-preset positive pressure mechanical ventilator. This spectacular and thrilling story culminated in a cohort of patients with respiratory failure being treated in a single geographic area and cared for by full-time physicians, nurses, and technicians: the first modern ICU. Although these units tended to disband after the summer-fall polio season, they led to the creation of full-time respiratory care units at the Radcliff Infirmary of Oxford University and elsewhere in Europe and North America in the 1950s.
Soon after these events, in 1958, Peter Safar led development of the first multidisciplinary ICU in North America at Baltimore City Hospital. In 1960, Barrie Fairley and colleagues created the ICU at Toronto General Hospital, followed in 1962 by the ICU at Massachusetts General Hospital under Drs. Henning Pontoppidan and Henrik Bendixen.
Some of the difficulty in relating the history of PCCM is defining a PICU and pediatric intensivist. The current definitions are as follows.
Pediatric intensive care unit
An ad hoc committee of the American Academy of Pediatrics (AAP), Diseases of the Chest Section established Guidelines for the Organization of Children’s Intensive Care Units in July 1975. In 1983, the AAP and Society of Critical Care Medicine (SCCM) published Joint Guidelines for Pediatric Intensive Care Units, which were updated in 1993 and 2004 and then retired in 2013. The committee defined a PICU as “a hospital unit which provides treatment to children with a wide variety of illnesses of life-threatening nature including children with highly unstable conditions and those requiring sophisticated medical and surgical treatment.”
Randolph and coworkers defined a pediatric intensivist (in the United States) as “any one of the following: (a) a pediatrician with subspecialty training in PCCM and subspecialty certification from the American Board of Pediatrics (ABP); (b) a pediatric anesthesiologist with special competency in critical care with subspecialty certification from the American Board of Anesthesiology; (c) a pediatric surgeon with special competency in critical care with subspecialty certification from the American Board of Surgery; (d) a physician (as above) eligible for subspecialty certification by the appropriate respective board.” Similar requirements for training exist or are in development elsewhere in the world.
First pediatric intensive care units
In 1955 Dr. Goran Haglund at the Children’s Hospital of Göteborg, Sweden, developed the first PICU, which he called a pediatric emergency ward. The patient who inspired Dr. Haglund to organize the unit was a 4-year-old boy who was operated on in 1951 for a ruptured appendix. Postoperatively, he lapsed into a coma; his surgeon declared that he had done all he could and the boy would die of bacteriotoxic coma. The anesthesiologist offered to help and the boy was intubated, given manual positive-pressure respiration with generous oxygen, tracheostomized, and given a large blood transfusion. After about 8 hours, the boy’s bowels started to function, and 4 hours later he was out of coma. After 20 hours, he had spontaneous respiration and had been successfully treated for respiratory insufficiency and shock.
This new unit had seven acute care beds with full-time nurses and nursing assistants providing 24-hour coverage. In the first 5 years, the team treated 1183 infants and children, with a mortality rate of 13.6%. Haglund went on to state, “But what we did was something else. It was the application of the basic physiology to clinical practice. Our main purpose was not to heal any disease; it was to forestall the death of the patient. The idea was—and is—to gain time, time so that the special medical or surgical therapy can have desired effects.” Haglund was also careful to point out: “There are few jobs more exciting, demanding, and taxing than emergency nursing. Our nurses and nurse assistants are tremendous. They must be!”
Central role of critical care nursing
Although many sources emphasize the role of advanced technology in the creation of adult, neonatal, and pediatric critical care, , skilled nursing care was even more important in this evolving process. Porter and others remind us of the vital role of nursing in triage and organization of care for patients by degree of illness. Long before the organizational efforts of the 20th century, Florence Nightingale (1820–1910) organized a volunteer service with 20 nurses and created a clean environment at the British military hospital at Skutari, Turkey, in 1854 during the Crimean War. Although the care consisted mostly of hygiene and nutrition, within 6 months of her arrival the mortality rate dropped from 40% to 2%. Nightingale provided the definition of nursing as “helping the patient to live.” These efforts were continued in the United States by Dorothea Dix (1802–1887) and Clara Barton (1821–1912), the “angel of the battlefield” during the American Civil War. Barton also brought the Red Cross to America in 1882.
As the complexity of medical and surgical care evolved in the late 19th and early 20th century, the need to cohort sick patients and provide skilled nursing care became apparent, especially for premature newborns and victims of poliomyelitis, as cited earlier. Then, as now, the recovery of the critically ill pediatric or adult patient depended on the skilled nurse at the bedside who was trained to use the life support and monitoring equipment at hand but to remain focused on the stability and comfort of the person in the bed.
In the mid- to late 1970s, as pediatric cardiovascular surgery for more complex lesions in infants was developing, nurses provided postoperative care in designated units. Children with Reye syndrome suddenly appeared, requiring complex multisystem care. In addition, in the 1980s, emergency medical services systems began transporting severely injured children to hospitals, where they required rapid assessment and intervention by nurses and physicians and initiation of cardiorespiratory and neurologic support.
Pediatric critical care nurses joined the SCCM from its beginning in 1970 and the American Association of Critical Care Nurses emphasizing the care of children. In the mid-1990s, pediatric critical care nurses founded their own society and established a peer-reviewed journal. Also in the 1990s, advanced practice nurses and nurse practitioners began to specialize in pediatric critical care. They continue to function as important critical care team members to augment both physician and nursing care as well as conduct clinical research. ,
Role of pediatric anesthesiologists and pediatricians in founding pediatric critical care medicine
An important early physician-directed multidisciplinary PICU in North America was established at CHOP in 1967 as an outgrowth of a hospital-wide respiratory intensive care service. , The unit consisted of an open ward of six beds equipped with bedside electronic monitoring and respiratory support capabilities and an adjacent intensive care chemistry laboratory staffed 24 hours per day. The nurses were assigned full-time to the unit; most had previously served in the recovery room, infant ICU, or cardiac surgery postoperative ward. Dr. John Downes was the medical director and worked closely with two other anesthesiologists, Dr. Leonard Bachman, chief of anesthesiology, and Dr. Charles Richards, and a pediatric allergist/pulmonologist, Dr. David Wood. Four pediatric anesthesiology/critical care fellows provided 24-hour in-unit service. Dr. C. Everett Koop (chief of surgery), Dr. William Rashkind (the father of interventional pediatric cardiology), Dr. John Waldhausen (one of the nation’s few full-time pediatric cardiac surgeons), Dr. Sylvan Stool (a pioneer in pediatric otolaryngology), and other staff and residents provided close collaborative patient care, education, and clinical research. By 1975, with the establishment of the new CHOP building, the acute PICU was expanded to 20 beds with an adjacent 10-bed intermediate step-down unit.
In 1969, Dr. Peter Safar and his trainee, Stephen Kampschulte, developed a 10-bed PICU at the Children’s Hospital of Pittsburgh. That same year, James Gilman, a pediatric anesthesiologist, and Norman Talner, a pediatric cardiologist, established a six-bed PICU at the Yale–New Haven Medical Center.
In 1970, at the Hospital for Sick Children in Toronto, Dr. Alan Conn resigned as director of the Department of Anesthesiology to become director of a new multidisciplinary 20-bed PICU, by far the largest and most sophisticated unit in North America. During the prior decade, Dr. Conn and his colleagues had treated critically ill infants and children in a sequestered area of the postanesthesia care facility where they had developed considerable expertise in critical care. The new state-of-the-art PICU was the forerunner of units developed in major pediatric centers throughout North America spanning the 1970s and beyond. Dr. Geoffrey Barker, who went on to develop one of the largest multinational fellowship training programs in the world, followed Dr. Conn as director of the PICU.
Also in 1971, Dr. David Todres, an anesthesiologist and pediatrician, and Dr. Daniel Shannon, a pediatric pulmonologist, founded a 16-bed multidisciplinary unit for pediatric patients of all ages at the Massachusetts General Hospital. , The units in Philadelphia, Toronto, and Boston established vibrant training programs in critical care medicine and conducted clinical research. Among their numerous accomplishments, Dr. Conn became a noted authority on the management of near-drowning victims, and Dr. Todres and Dr. Downes pioneered long-term mechanical ventilation for children at home with chronic respiratory failure. These early PICUs and their training programs had a favorable impact on mortality and morbidity rates, particularly those associated with acute respiratory failure, leading to the development of similar units and programs in most major pediatric centers in North America, Western Europe, and Japan during the 1970s and early 1980s.
The development of the PICU at Children’s Memorial Hospital (CMH), Northwestern University Medical School, Chicago, illustrates how many of the early PICUs evolved. The unit was first started as a four-bed area set in one of the postoperative care wards by pediatric anesthesiologists David Allen and Frank Seleny. Anesthesiologist Dr. John Cox arrived in August of 1964 and was named director. He has stated that the unit never formally opened. It began in the four-bed unit in the postoperative ward in 1964 and became a 14-bed separate designed unit in late 1967. Dr. Cox was the director until 1975, when he was succeeded by Dr. Richard Levin. During this time, Dr. Hisashi Nikaidoh, who was a surgery resident from 1966 to 1967, remembers taking care of a renal transplant patient; the care was provided by nephrology, general surgery, and immunology without a centralized PICU service. Dr. Zehava Noah, who was educated in Israel and trained in the United Kingdom, did a critical care fellowship in anesthesia at CMH, developed a closed medical-surgical PICU in 1979, and was named the director in 1981. There was also an associate surgical director.
Some of the early PICUs were directed by pediatricians. In 1966, Dr. Max Klein joined Drs. H. de V. Heese and Vincent Harrison in a two-bed neonatal research unit at the Groote Shuur Hospital in Cape Town. Their research resulted in many significant papers, not the least of which was “The Significance of Grunting in Hyaline Membrane Disease,” demonstrating that oxygen tensions fell when infants had tracheal intubation, eliminating the ability to grunt on exhalation. By 1969, at Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, pediatric patients with respiratory failure (e.g., Guillain-Barré syndrome) were ventilated on the general wards. Although outcomes improved, deaths were still common. Dr. Max Klein encouraged Dr. Malcolm Bowie (consultant) to start a six-bed ICU, or “high-care ward.” After further training in South Africa and at the University of California San Francisco (UCSF), Dr. Klein returned to Cape Town in 1974, where he combined the neonatal tetanus ward of Dr. Smythe and the six-bed ICU of Dr. Bowie into the first full-time PICU in South Africa.
The path for pediatricians providing care for the sickest patients on a full-time basis remained unclear for an extended period. Subsequent early leaders in the field each carved out their own path. Dr. Daniel Levin completed pediatric cardiology and neonatology fellowships to learn the care of sick children. However, he found few Chairs of Pediatrics interested in hiring an “intensivist.” Then, in 1975, Drs. Levin and Frances Morriss (trained in pediatrics and pediatric anesthesia) were recruited to start a PICU at Children’s Medical Center of Dallas.
There were so few of this new breed of intensivists that many became directors upon completion of residency and fellowship. At the beginning, few other physicians wanted to be responsible for pediatric intensive care. Eventually, more pediatricians decided to devote their careers to being members of a multidisciplinary team taking care of the sickest children in hospitals on a full-time basis. In 1975, the CHOP program started to accept PCCM trainees who were pediatricians without anesthesia training.
In 1967, Dr. Peter Holbrook as a medical student at the University of Pennsylvania began a part-time job in the PICU at CHOP and developed a strong interest in PCCM. Informed at the time that one needed anesthesia training to successfully work in the PICU, Holbrook shelved the idea and entered pediatric residency training at Johns Hopkins. When the PCCM idea resurfaced, he found that many still felt a physician needed anesthesia training to function in the PICU. Disagreeing with the reasoning behind such a requirement, he pursued critical care training with Dr. Peter Safar in Pittsburgh, who welcomed him as a fellow in critical care medicine. In 1975, Dr. Holbrook and pediatrician Dr. Alan Fields, who also trained in Pittsburgh, were recruited to the new, modern Children’s Hospital National Medical Center (Washington, DC) as pediatricians in the Department of Anesthesia to direct the PICU.
Dr. Bradley Peterson, after pediatric and neonatology training and an anesthesiology residency at Stanford University, became director of the new PICU at Children’s Hospital of San Diego in 1977. Dr. Bradley Fuhrman, following pediatric cardiology and neonatology fellowships, started the first PICU at University of Minnesota Hospital in 1979.
Dr. George Lister, after a pediatric residency at Yale and a fellowship in cardiopulmonary physiology at UCSF, joined the staff at the UCSF Moffitt Hospital San Francisco in 1977 as an attending in its combined adult-pediatric ICU. Due to the director’s illness, he quickly found himself the co-director of the unit. He eventually returned to Yale as an attending in the PICU.
Dr. Mark Rogers, after completion of a pediatric residency at BCH, an anesthesiology residency at Massachusetts General Hospital, and a pediatric cardiology fellowship at Duke, became director of the first PICU at Johns Hopkins Hospital in 1977. Subsequently, in 1980, Dr. Rogers became chair of the Department of Anesthesiology and Critical Care Medicine at Johns Hopkins and chief editor of a major textbook of pediatric intensive care ( Table 1.2 ).
|1971||Care of the Critically Ill Child||R. Jones, J.B. Owen-Thomas||56|
|1971||Pediatric Intensive Care: Manual||K. Roberts, J. Edwards||57|
|1972||Smith’s The Critically Ill Child: Diagnosis and Medical Management||J. Dickerman, J. Lucey||58|
|1977||Pediatrie d’urgence||G. Huault, H. Labrune||59|
|1979 through 1997||A Practical Guide to Pediatric Intensive Care , first and second editions (and accompanying Essentials volumes)||D. Levin, F. Morriss, G. Moore||60–63|
|1980||Tratado de Cuidados Intensivos Pediatrucos (Textbook of Pediatric Intensive Care)||F.J. Ruza||64|
|1980||Core Curriculum for Pediatric Critical Care Nursing||M.C. Slota||65|
|1983||Pediatric Critical Care||J. Bloedel Smith||66|
|1984||Nursing Care of the Critically Ill Child||M.F. Hazinski||67|
|1984||Textbook of Critical Care||W.K. Shoemaker, W.L. Thompson, P.R. Holbrook||68|
|1984||Pediatric Intensive Care||E. Nussbaum||69|
|1985||Temas em Terapia Intensiva (Critical Care Issues in Pediatrics)||J. Piva, P. Carvalho, P. Celiny Garcia||70|
|1985||Critical Care Pediatrics||S. Zimmerman, J.H. Gildea||71|
|1987||Pediatric Intensive Care||J.P. Morray||72|
|1988||Textbook of Pediatric Intensive Care||M.C. Rogers||73|
|1992||Pediatric Critical Care||B.P. Fuhrman, J.J. Zimmerman||74|
|1993||Textbook of Pediatric Critical Care||P.R. Holbrook||75|
|1994||Urgences & Soins Intensif Pediatriques (Pediatric Emergency and Critical Care)||J. Lacroix, M. Gauthier, P. Hubert, et al.||76|
|1995||Critical Heart Disease in Infants and Children||D.G. Nichols, D.E. Cameron, W.J. Greeley, et al.||77|
|1996||Critical Care of Infants and Children||I.D. Todres, J.H. Fugate||78|
|1996||Critical Care Nursing of Infants and Children||M.A. Curley, J. Bloedel-Smith, P.A. Moloney Harmon||79|
|1997||Illustrated Textbook of Pediatric Emergency and Critical Care Procedures||R.A. Dieckmann, D.H. Fiser, S.M. Selbst||80|
|1997||Pediatric Intensive Care||N.S. Morton||81|
|2003||Essentials of Pediatric Intensive Care||C.G. Stack, P. Dobbs||83|
|2005||Medicinia Intensiva em Pediatria||J. Piva, P. Celiny Garcia||84|
|2005||Cuidudo Intensivo Pediatrico y Neonatal||J. Forero, J. Alarcon, G. Cassalett||85|
|2006||Pediatric Critical Care Medicine||A.D. Slonim, M.M. Pollack||86|
|2006||Manual de Cuidado Intensivo Cardiovascular Pediatrico||G. Casselett, M.C. Patarroyo||87|
|2007||Pediatric Critical Care Medicine: Basic Science and Clinical Evidence||D.S. Wheeler, H.R. Wong, T.P. Shanley||88|
|2010||Critical Care of Children with Heart Disease||R. Munoz, V. Monell, E. da Cruz, C.G. Vetterly||89|
|2012||Comprehensive Critical Care: Pediatric Medicine||Society of Critical Care Medicine||90|
|2012||Pediatric Critical Care Study Guide||S.E. Lucking, F.A. Maffei, R.F. Tamburro, N.J. Thomas||91|
|2015||Pediatric Critical Care Nutrition||P.S. Goday, N.M. Mehta||92|
|2017||Pediatric Intensive Care||S. Watson, A. Thompson||93|