Current controversies in paediatric intensive care

Abstract

There is controversy about how intensive care for children should be organised. It is clear that paediatric intensive care training and service provision in the United Kingdom are not organised properly. There are too many small units and many children are managed in adult units. Concentration of the service in larger centres is beneficial both in terms of improved outcome and costs. Centralisation of paediatric intensive care means that the transport of critically ill children should be undertaken by expert teams based upon each large centre. Training for medical and nursing staff in paediatric intensive care and in paediatric resuscitation should be based upon the large units which should be inspected and, if suitable, be recognised by the Colleges as being capable of training future consultants. Whether such units should be funded supraregionally or by funds moving with the patient is controversial. One worry is that the latter method may discourage referrals. However, unnecessary referrals may be minimised with district units having to define more carefully their criteria for referral. In this regard, a formal assessment of illness severity and prognosis could be used to help with decision making. Controversial aspects of clinical management of children in intensive care include: sedation techniques; steroid therapy; topical antiviral therapy; alternatives to conventional respiratory and circulatory support; the underuse of analgesia for painful procedures; measures to conserve blood and use of invasive monitoring. A scientific approach to these interventions needs to be adopted if paediatric intensive care is to progress as a specialty.