Pediatric intensive care: an overview.

This issue and the following issue (Volume 57, Number 2) of The Yale Journal of Biology and Medicine are a compilation of papers dealing with diagnosis and management problems in pediatric intensive care. The number of contributors, as well as their varied backgrounds, provides a glimpse of the efforts involved in intensive care for children outside the newborn period. Pediatric intensive care originally grew out of the need to treat the multiple, severe problems of premature newborns. With the publication of the study by Gregory et al. [1] on positive airway pressure for the treatment of the respiratory distress syndrome of the newborn, intensive care of newborns rapidly expanded. With more infants surviving, larger units were needed. As the technology became accepted, the number of newborn intensive care units rapidly expanded. This expansion of services was also made possible because of the limited number of diseases that were being treated in newborn units. Most infants had respiratory distress syndrome, some were infected, and some had congenital heart disease. In this respect, newborn intensive care units were very much like their adult counterparts -delineated along narrow lines and often defined by specific disease or lesion -one intensive care unit for patients with myocardial infarcts, one intensive care unit for post-operative patients divided at times into surgical subspecialties, one intensive care unit for respiratory care. This division is not present in intensive care for children and markedly affects the organization and staffing of these units. To give an indication of the disparate diagnoses in pediatric intensive care, as I write, the pediatric intensive care unit at Yale-New Haven Hospital has children with the following diagnoses: meningitis, respiratory failure due to asthma, upper airway obstruction, congenital heart diseasepost-surgery, diabetic ketoacidosis, gunshot wound, and intermittent ventricular tachycardia. To deal with a population such as this requires a large number of specialists who are readily available. Conversely, no one person can adequately develop the expertise to manage all patients. Care must be shared. But this necessity, in itself, raises questions such as where pediatric intensive care units should be located and who should practice pediatric intensive care. The personnel for the intensive care unit need to be available 24 hours a day, seven days a week. Yet to maintain such a large pool of people at a high level of skill requires a critical mass of patients.