Admission, discharge and triage guidelines for paediatric intensive care units in Spain

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improved drastically in the past 4 decades thanks to a growing understanding of the pathophysiology of life-threatening processes, technological advances in the monitoring, diagnosis and treatment of critically ill paediatric patients and the specialised training of the health care staff that manages critically ill paediatric patients.The paediatric intensive care unit (PICU) was defined in 1983 in the Guidelines for Paediatric Intensive Care<a class="elsevierStyleCrossRef" href="#bib0195">1</a> (updated in 2004<a class="elsevierStyleCrossRef" href="#bib0200">2</a>) as “a hospital unit that provides treatment to children with a wide variety of illnesses of a life-threatening nature, including children with highly unstable conditions and those requiring sophisticated medical and surgical intervention.” Randolph et al.<a class="elsevierStyleCrossRef" href="#bib0205">3</a> expanded this definition: “A PICU is a separate physical facility or unit specifically designated for the treatment of paediatric patients who, because of shock, trauma, or other life-threatening conditions, require intensified, comprehensive observation and care.”At the beginning of the new millennium, the board of directors of the European Union of Medical Specialists (UEMS) approved the definition of intensive care medicine for the European Union proposed by the Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM)<a class="elsevierStyleCrossRef" href="#bib0210">4</a>: “Intensive care medicine [e.g. paediatric intensive care] combines physicians, nurses and allied health professionals in the coordinated and collaborative management of patients with life-threatening single or multiple organ system failure, including stabilisation after severe surgical interventions. It is a continuous (i.e. 24h) management including monitoring, diagnostics, support of failing vital functions as well as the treatment of the underlying diseases.”The MJCICM<a class="elsevierStyleCrossRef" href="#bib0210">4</a> also underscored that “patient care should be provided continuously over a 24h period, by staff members (physicians) who have obtained special competence in intensive care medicine” (e.g. paediatric intensive care). Indeed, adequate training of physicians and nurses is essential to ensure the quality of intensive care and the safety of the patient in the PICU.<a class="elsevierStyleCrossRefs" href="#bib0210">4–7</a>Early diagnosis and treatment are essential to the survival of critically ill patients, especially those with neurologic decompensation, haemodynamic instability or signs of tissue hypoxia and organ dysfunction. Although these signs can be detected with clinical observation, advanced monitoring at the ICU may facilitate faster decision-making.<a class="elsevierStyleCrossRef" href="#bib0230">8</a> Furthermore, delays in PICU admission may increase the risk of death,<a class="elsevierStyleCrossRefs" href="#bib0235">9,10</a> while implementation of early intensive treatment in critically ill patients or patients that are quickly deteriorating outside the PICU is associated with decreased mortality.<a class="elsevierStyleCrossRefs" href="#bib0245">11–13</a>The Spanish Constitution recognises the right to health in Spain. The World Health Organization affirms that the right to health includes “access to timely, acceptable, and affordable health care of appropriate quality.”In 1990, the Spanish government approved and ratified the Convention on the Rights of the Child adopted by the United Nations General Assembly,<a class="elsevierStyleCrossRef" href="#bib0260">14</a> and article 24 of this instrument states “1. States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and the rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services. 2. States Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures: … (b) To ensure the provision of necessary medical assistance and health care to all children …” Furthermore, the European Charter for Children in Hospital<a class="elsevierStyleCrossRef" href="#bib0265">15</a> establishes, among others, the fundamental rights of children and adolescents to receive “the best possible medical treatment … to be cared for throughout their hospital stay by appropriately trained staff, fully aware of the physical and emotional needs of each age group … [and] to be cared for in hospital with other children, avoiding as far as possible admission to adult wards.”Therefore, we must remain aware that critically ill children with potentially life-threatening single or multiple organ or system impairment or failure, including the need of stabilisation after severe surgical intervention, should be, wherever possible, placed in units dedicated exclusively to children,<a class="elsevierStyleCrossRef" href="#bib0200">2</a> managed by staff specifically accredited in paediatric critical care capable of providing integral, comprehensive and continuous care, carrying out the specialised interventions required by severe organ or system dysfunction in children and adolescents, and implementing the specific care protocols required for monitoring, diagnosis, support of failing vital functions and treatment of underlying disases.<a class="elsevierStyleCrossRefs" href="#bib0210">4,6,16</a>With the aim of upholding the right of children to enjoy the highest attainable standard of health and services for the treatment of illness and the rehabilitation of health and guaranteeing the quality of care and the safety of paediatric critical patients, the boards of directors of the Asociación Española de Pediatría (Spanish Association of Paediatrics [AEP]), the Sociedad Española de Cuidados Intensivos Pediátricos (Spanish Society of Paediatric Intensive Care [SECIP]) and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]) created paediatric intensive care standards committees in their respective societies, which in turn developed and approved the guidelines for Spanish PICUs presented in this article. The members of the standards committees were selected by their respective societies based on their clinical practice and management expertise and their education among recognised experts in paediatrics and paediatric critical care (AEP, SECIP) and intensive medicine (SEMICYUC) in Spain, while seeking adequate representation of the involved societies and other institutions associated with the pertinent medical specialties.We have developed these guidelines on the basis of the guidelines published in 1999 by the Society of Critical Care Medicine in collaboration with the American College of Critical Care Medicine and the Committee on Hospital Care of the American Academy of Pediatrics,<a class="elsevierStyleCrossRef" href="#bib0270">16</a> which we completed and updated with information obtained through a literature search in MEDLINE (Ovid), Embase and PubMed for articles published between January 1999 and April 2017 with the search terms pediatric intensive care units, pediatric critical care, admission, triage, discharge, pediatric intensive care/critical care outreach programs, benefit, futility, rationing, quality assurance/quality improvement, timely and guidelines, guidelines published by scientific associations<a class="elsevierStyleCrossRefs" href="#bib0275">17–25</a> and updated editions of internationally known reference books on clinical practice in paediatric intensive care.<a class="elsevierStyleCrossRefs" href="#bib0320">26,27</a> The guidelines also include general criteria to guide PICU triage based on the recommendations published by the ICU Admission Discharge and Triage (ADT) Task Force<a class="elsevierStyleCrossRef" href="#bib0230">8</a> and the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine.<a class="elsevierStyleCrossRef" href="#bib0255">13</a> We were unable to establish levels of scientific evidence due to the scarcity of data in the paediatric age group.These guidelines are meant as a reference for practice and may facilitate decision-making regarding admission, discharge and triage of critically ill paediatric patients in Spanish PICUs, guiding the classification of patients into the most appropriate level of care based on the need for intensive care/monitoring and how likely they are to benefit or not from intensive care.<a class="elsevierStyleCrossRef" href="#bib0230">8</a> Due to the ongoing advances in paediatric intensive care, we recommend that these guidelines be updated at regular intervals.This document is not meant to replace the use of clinical judgement in individual cases. Paediatric intensivists may request admission to the PICU for patients at risk of deterioration, with clinical manifestations of severe illness or with intensive monitoring or observation needs not included in these guidelines. Whatever the circumstances, any decision regarding admission, discharge and triage and its justification must be documented in the health records of the patient.Criteria for admission to the paediatric intensive care unitIt is essential to weigh the potential risks and benefits of intensive care in patients considered for PICU admission. Ideally, admission to the PICU should be granted to all patients with reversible disease whose risk of death would decrease with the use of advanced technologies and delivery of medical care by a team with specialised training in paediatric critical care.<a class="elsevierStyleCrossRef" href="#bib0230">8</a> However, intensive treatment and monitoring may increase morbidity, so extremely ill patients with a low probability of survival may not ultimately benefit from admission to the PICU, while patients that only require monitoring for preventive purposes and who are not severely ill are unlikely to benefit from transfer to this level of care.Admission to the PICU must always be considered in patients that may benefit from intensive care. Decisions regarding the admission to the PICU of terminal patients with a low probability of survival or with irreversible diseases should be based on qualitative criteria regarding the potential benefit or lack thereof of intensive care.<a class="elsevierStyleCrossRef" href="#bib0230">8</a> We recommend using the term “potentially inappropriate” as opposed to “futile” to refer to treatment at the PICU level that has some chance to achieve the effect sought by the patient or family but which the intensivists or other professionals in charge of the patient are opposed to implementing on account of ethical considerations.<a class="elsevierStyleCrossRefs" href="#bib0330">28,29</a> In certain situations, the PICU may be the most appropriate setting to perform treatments and procedures aimed to prolong survival or improve quality of life in terminally ill patients with appropriate comfort, and there are also situations where the PICU may be the ideal setting for specially-trained physicians and nurses to provide appropriate end-of-life palliative care to terminally ill children and adolescents.Generally speaking, admission to the PICU should be granted to any paediatric patient—especially cancer patients or bone marrow transplant recipients—at risk of severe acute deterioration, neurologic decompensation, haemodynamic instability or failure or life-threatening dysfunction of at least one vital organ or system<a class="elsevierStyleCrossRefs" href="#bib0340">30,31</a> or multiple organ or system failure, requiring stabilisation following severe surgical intervention or with pre- or post-operative conditions potentially associated with severe or life-threatening dysfunction of at least one organ or system, or who due to the severity or potential severity of their condition require invasive and/or continuous monitoring, diagnosis and support of failing vital functions or treatment of underlying diseases by a team specifically trained in paediatric intensive care.We proceed to specify the conditions that require admission to PICU related to multiple organ involvement and with the organs or systems that are most frequently involved (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1–8</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia>Multiple organ or system involvementPatients with severe, life-threatening or unstable multiple organ or system disease. Conditions include, but are not limited to:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Multiple organ dysfunction syndrome or failure, regardless of aetiology.</li><li class="elsevierStyleListItem" id="lsti0010">2.Thrombocytopenia associated with multiple organ failure.</li><li class="elsevierStyleListItem" id="lsti0015">3.Severe systemic inflammatory states, such as macrophage activation syndrome or haemophagocytic lymphohistiocytosis associated with shock, coagulopathy or vital organ dysfunction, or requiring intensive treatment and/or invasive and/or continuous monitoring.</li><li class="elsevierStyleListItem" id="lsti0020">4.Post-transplantation lymphoproliferative disease associated with shock, coagulopathy or vital organ dysfunction, or requiring intensive treatment and/or intensive and/or continuous monitoring.</li><li class="elsevierStyleListItem" id="lsti0025">5.Need of immunotherapy that may cause severe cytokine release syndrome.</li><li class="elsevierStyleListItem" id="lsti0030">6.Suspected or documented malignant hyperthermia.</li><li class="elsevierStyleListItem" id="lsti0035">7.Change in body temperature associated with a risk of arrhythmia and/or requiring invasive and/or continuous monitoring and/or complex intervention.</li><li class="elsevierStyleListItem" id="lsti0040">8.Suspected or documented tissue hypoxia, systemic or in at least one vital organ.</li><li class="elsevierStyleListItem" id="lsti0045">9.Intra-abdominal hypertension and abdominal compartment syndrome.</li><li class="elsevierStyleListItem" id="lsti0050">10.Severe toxin-related diseases: toxic shock syndrome, malignant pertussis, tetanus, human botulism, diphtheria.</li></ul>Criteria for discharge from the paediatric intensive care unitPatients staying in the PICU will be assessed and considered for discharge when the disease, process or unstable physiological condition that led to their admission has resolved and the patient no longer requires invasive or continuous monitoring or complex interventions exceeding the care capabilities outside the PICU, or when they are no longer benefitting from intensive care.Patient discharge must be based on the following criteria:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055">1.Stable haemodynamic parameters.</li><li class="elsevierStyleListItem" id="lsti0060">2.Stable respiratory status in extubated patient with airway patency not requiring respiratory support or requiring non-invasive support that can be provided safely outside the PICU.</li><li class="elsevierStyleListItem" id="lsti0065">3.Minimal oxygen requirements.</li><li class="elsevierStyleListItem" id="lsti0070">4.The patient no longer requires inotropic support, vasodilators and antiarrhythmic drugs or otherwise requires them at low doses that can be safely administered outside the PICU.</li><li class="elsevierStyleListItem" id="lsti0075">5.Cardiac dysrhythmias are controlled.</li><li class="elsevierStyleListItem" id="lsti0080">6.Intracranial pressure monitoring equipment has been removed.</li><li class="elsevierStyleListItem" id="lsti0085">7.The patient is neurologically stable with control of seizures.</li><li class="elsevierStyleListItem" id="lsti0090">8.All haemodynamic monitoring catheters have been removed.</li><li class="elsevierStyleListItem" id="lsti0095">9.Chronically mechanically ventilated patients with invasive (tracheostomy) or non-invasive ventilation that remain stable and whose critical illness has been resolved or reversed and can be transferred to a unit that routinely manages chronically ventilated patients or to home.</li><li class="elsevierStyleListItem" id="lsti0100">10.Patients with routine peritoneal dialysis or haemodialysis with resolution of acute critical illness and who no longer require complex interventions, care or monitoring exceeding the care capabilities outside the PICU.</li><li class="elsevierStyleListItem" id="lsti0105">11.Patients with tracheostomies that no longer require frequent and intensive suctioning.</li><li class="elsevierStyleListItem" id="lsti0110">12.The health care team in charge of the patient and the patient's family, after a careful, joint and coordinated assessment, determine that there is no benefit in keeping the child in the PICU.</li></ul>Triage in paediatric intensive care unitsPaediatric intensive care is costly and there is a limited number of beds. When there are insufficient beds for severely ill patients that need them, refusal rates can be high and raise ethical dilemmas or lead to potential legal repercussions.<a class="elsevierStyleCrossRef" href="#bib0255">13</a>Triage is essential in the PICU to ensure the optimal and equitable use of resources and to guarantee the safety and early treatment of critical patients in situations where resources become scarce, such as epidemics or natural disasters.<a class="elsevierStyleCrossRefs" href="#bib0230">8,13</a> Not admitting patients who are likely to benefit from the PICU, or undertriage, can increase their risk of death or progressive deterioration and multiple organ failure. Admitting patients who are unlikely to benefit from intensive care, or overtriage, may lead to more invasive and potentially harmful interventions as well as inappropriate allocation of resources, diverting care from other patients that need it more.<a class="elsevierStyleCrossRef" href="#bib0350">32</a>Triage in PICUs must take into account the following key aspects<a class="elsevierStyleCrossRef" href="#bib0255">13</a>:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0115">-Triage requires careful weighing of the multiple benefits and risks involved in PICU admission.</li><li class="elsevierStyleListItem" id="lsti0120">-Final triage decisions regarding admission to the PICU must be made by paediatric intensivists with input from nurses, paediatric emergency medicine specialists and hospitalists, surgeons, and allied professionals.</li><li class="elsevierStyleListItem" id="lsti0125">-Triage algorithms and protocols can be useful but can never supplant the role of skilled paediatric intensivists basing their decisions on input from multidisciplinary teams.</li><li class="elsevierStyleListItem" id="lsti0130">-Infrastructures need to be organised efficiently both within individual hospitals and at the regional level.</li></ul>Timeliness and appropriateness of paediatric intensive care and patient safetyThe opportune (timely and appropriate) delivery of intensive care to critically ill patients is associated with decreases in mortality, length of stay and health care costs.<a class="elsevierStyleCrossRefs" href="#bib0245">11,12</a> Thus, we recommend for each PICU to develop specific policies with explicit criteria regarding admission, discharge and triage tailored to the needs of the patients served in the corresponding hospital and its catchment area. These criteria should be adapted in response to current scientific evidence taking into account ethical and legal aspects. The staff of medical and surgical departments and units serving paediatric patients must be aware of the policies regarding PICU admission and know how to recognise the warning signs of acute and severe deterioration in children and adolescents with high-risk diseases, as do the family members that care for these patients.<a class="elsevierStyleCrossRef" href="#bib0235">9</a> Furthermore, a paediatric rapid response systems (PRRS) or paediatric critical care outreach teams (CCOT) supported by a team of paediatric intensive care consultants can be established to assist paediatric inpatient care or surgical teams in the assessment and management of severely ill patients, facilitate the transition of patients into and out of the PICU, allow the early identification of patients that may benefit from admission and intensive care, prevent unnecessary PICU admission, reduce the rate of unexpected readmission to the PICU and reduce inpatient mortality.<a class="elsevierStyleCrossRefs" href="#bib0355">33–35</a>Whenever a patient meets any of the admission criteria specified in these guidelines, the physician in charge of the patient should consult with the PICU team or the paediatric intensivist that serves as a consultant for the PRRS or CCOT to plan the handover to the PICU.<a class="elsevierStyleCrossRef" href="#bib0370">36</a> Paediatric intensivists should be informed of potential PICU admissions at an early stage, as initial intensive treatment may differ significantly from standard treatment.In order to guarantee patient safety and the quality, timeliness, appropriateness and efficiency of paediatric intensive care, adherence to criteria for PICU admission, discharge and triage should be monitored and assessed periodically by a multidisciplinary team with use of quality indicators<a class="elsevierStyleCrossRef" href="#bib0375">37</a> (including the standardised mortality rate, the severity-adjusted length of stay, and an analysis of unexpected readmissions)<a class="elsevierStyleCrossRef" href="#bib0380">38</a> and with documentation and analysis of patient deaths, cases of cardiopulmonary arrest or shock outside the PICU, cases of denial of admission to the PICU or delayed PICU admission or discharge, cancellation of scheduled surgeries and triage decisions.Conflicts of interestThe authors have no conflicts of interest to declare" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1022435" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec980579" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1022436" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec980580" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Criteria for admission to the paediatric intensive care unit" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Multiple organ or system involvement" ] ] ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Criteria for discharge from the paediatric intensive care unit" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Triage in paediatric intensive care units" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Timeliness and appropriateness of paediatric intensive care and patient safety" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack345245" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-10" "fechaAceptado" => "2017-10-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec980579" "palabras" => array:10 [ 0 => "Paediatric intensive care unit" 1 => "Paediatric critical care" 2 => "Admission criteria" 3 => "Discharge criteria" 4 => "Triage" 5 => "Critically ill paediatric patient" 6 => "Patient safety" 7 => "Quality of care" 8 => "Timely access to care" 9 => "Benefits from paediatric intensive care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec980580" "palabras" => array:9 [ 0 => "Unidad de cuidados intensivos pediátricos" 1 => "Cuidados críticos pediátricos" 2 => "Criterios de ingreso" 3 => "Criterios de alta" 4 => "Paciente pediátrico crítico" 5 => "Seguridad del paciente" 6 => "Calidad de cuidados" 7 => "Acceso oportuno a la asistencia sanitaria" 8 => "Beneficios del cuidado intensivo pediátrico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "A paediatric intensive care unit (PICU) is a separate physical facility or unit specifically designed for the treatment of paediatric patients who, because of the severity of illness or other life-threatening conditions, require comprehensive and continuous intensive care by a medical team with special skills in paediatric intensive care medicine. Timely and personal intervention in intensive care reduces mortality, reduces length of stay, and decreases cost of care. With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation, as well as ensuring the quality of care and the safety of critically ill paediatric patients, the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC) have approved the guidelines for the admission, discharge and triage for Spanish PICUs. By using these guidelines, the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La unidad de cuidados intensivos pediátricos (UCIP) es una unidad física asistencial hospitalaria independiente especialmente diseñada para el tratamiento de pacientes pediátricos quienes debido su gravedad o condiciones potencialmente letales requieren observación y asistencia médica intensiva integral y continua por un equipo médico que haya obtenido competencia especial en medicina intensiva pediátrica. La aplicación oportuna de terapia intensiva a los pacientes críticos reduce la mortalidad, el tiempo de estancia y los costes asistenciales. Con los objetivos de respetar el derecho del niño al disfrute del más alto nivel posible de salud y a servicios para el tratamiento de las enfermedades y la rehabilitación de la salud y de garantizar la calidad asistencial y la seguridad de los pacientes pediátricos críticos, la Asociación Española de Pediatría (AEP), la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP) y la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) han desarrollado y aprobado las guías de ingreso, alta y triage para las UCIP en España. Mediante la aplicación de estas guías se puede optimizar el uso de las UCIP españolas de forma que los pacientes pediátricos reciban el nivel de cuidados médicos más apropiado para su situación clínica." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: de la Oliva P, Cambra-Lasaosa FJ, Quintana-Díaz M, Rey-Galán C, Sánchez-Díaz JI, Martín-Delgado MC, et al. Guias de ingreso, alta y triage para las unidades de cuidados intensivos pediátricos en España. Med Intensiva. 2018;42:235–246." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article has also been published in the journal Anales de Pediatria, 2017. <a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="https://doi.org/10.1016/j.anpedi.2017.10.008">https://doi.org/10.1016/j.anpedi.2017.10.008</a>" ] ] "multimedia" => array:8 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CO2, carbon dioxide; ECMO, extracorporeal membrane oxygenation; FiO2, fraction of inspired oxygen; PICU, paediatric intensive care unit; SaO2, arterial oxygen saturation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with severe, potentially life-threatening or unstable pulmonary or airway disease. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Endotracheal intubation or potential need for emergency endotracheal intubation and mechanical ventilation, regardless of aetiology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Need for non-invasive mechanical ventilation in cases of moderate or severe acute respiratory failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Acute paediatric respiratory distress syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Rapidly progressive severe pulmonary or upper or lower airway disease with risk of progression to respiratory failure and/or total obstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. High supplemental oxygen requirement (FiO2≥0.5 to maintain SaO2≥92%), regardless of aetiology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Recently placed tracheostomy with or without the need for mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Acute barotrauma compromising the upper or lower airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Foreign body aspiration associated with dyspnoea, laboured breathing, hypoxaemia or hypercapnia, or requiring continuous monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Requirement for more frequent nebulised or inhaled medications that can be administered safely outside the PICU based on institution guidelines \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. Requirement of extracorporeal respiratory support: veno-venous or veno-arterial ECMO, extracorporeal CO2 removal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11. Abnormal air, fluid or solid contents in the pleural cavity that compromises respiration or produces haemodynamically instability, requiring fluid therapy or vasopressor infusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12. Apnoea observed by a physician or nurse or described as cyanosis and/or loss of consciousness and/or decreased muscle tone \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737573.png" ] ] ] ] "descripcion" => array:1 [ "en" => "PICU admission criteria related to the respiratory system." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ECMO, extracorporeal membrane oxygenation; PICU, paediatric intensive care unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular system \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with cardiovascular disease that is severe, life-threatening or unstable, or requires continuous and/or invasive monitoring. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Shock, regardless of aetiology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Post-cardiopulmonary resuscitation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Dysrhythmias that are life-threatening or require continuous monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Suspected or documented cardiovascular syncope \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Unstable congestive heart failure, with or without need for mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Congenital cardiac disease with unstable cardio-respiratory status \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Post high-risk cardiovascular and intrathoracic procedures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Cardiovascular disease requiring invasive and continuous monitoring of arterial, central venous or pulmonary artery pressures, or cardiac output \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Need for temporary cardiac pacing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. High blood pressure requiring intravenous treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11. Pulmonary hypertension requiring inhaled nitric oxide or intravenous treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12. Need of extracorporeal circulatory support: ECMO, pulsatile-flow or continuous-flow ventricular assist device, or intra-aortic balloon pump counterpulsation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13. Current or impending cardiac tamponade \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14. Pulmonary embolism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15. Need of treatment that may cause a severe acute anaphylactic reaction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal system \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with severe, life-threatening or unstable renal disease. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Acute or chronic renal failure requiring invasive and/or continuous monitoring and/or complex intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Need for acute haemodialysis, peritoneal dialysis or other continuous renal replacement therapies, such as continuous haemofiltration or veno-venous haemodiafiltration in the unstable patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Rhabdomyolysis with acute renal failure \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737571.png" ] ] ] ] "descripcion" => array:1 [ "en" => "PICU admission criteria related to the cardiovascular and renal systems." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PICU, paediatric intensive care unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infectious \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with confirmed or suspected infection that is life-threatening or requires invasive and/or continuous monitoring. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Sepsis with cardiovascular dysfunction or acute respiratory distress syndrome or dysfunction of another 2 vital organs and/or with high-risk signs: bradycardia, tachycardia, tachypnoea, hypoxaemia, prolonged capillary refill time, altered mental status, hypotension, oliguria, hyperlactataemia/lactic acidosis, clotting disorder and/or newly developed thrombocytopenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Sepsis in immunosuppressed patient or associated with neutropenia or lymphopenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Infection or abscess which due to its location or extent or the clinical condition of the patient does or may severely compromise the function of at least one organ or system or the airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Severe infection in patient with immunosuppression of any cause \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Infectious diseases whose natural history and/or potential complications may be fatal or lead to severe dysfunction of at least one vital organ or system \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gastrointestinal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with severe, life-threatening or unstable gastrointestinal disease. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Severe gastrointestinal bleeding leading to respiratory and/or haemodynamic instability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. After emergency endoscopy for foreign body removal that carries a risk of haemorrhage or perforation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Acute liver failure that leads or may lead to coma or respiratory and/or haemodynamic instability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Gastrointestinal inflammation or distension with haemodynamic instability and/or severe fluid or electrolyte imbalance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Severe acute pancreatitis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737572.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for PICU admission related to infection and to the gastrointestinal tract." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PICU, paediatric intensive care unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with actual or potential neurologic disease that is severe, life-threatening or unstable or requires invasive and/or continuous monitoring. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Status epilepticus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Seizures that do not respond to treatment or require continuous infusion of anticonvulsant agents \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Seizures with instability in vital signs related to the airway, respiration or circulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Acute and/or severe change in mental status where neurologic impairment or central nervous system depression is probable or unpredictable, or coma that may compromise the airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. After surgical procedures requiring invasive monitoring or close, comprehensive and continuous clinical observation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Glasgow coma scale<13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Acute inflammation or infection of the spinal cord, meninges or brain accompanied by central nervous system depression, metabolic and hormonal alterations, haemodynamic or respiratory compromise or risk of raised intracranial pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Head trauma that is severe or with signs or symptoms of raised intracranial pressure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Any neurosurgical perioperative condition manifesting with neurologic deterioration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. Progressive neuromuscular dysfunction with or without altered sensorium requiring continuous observation or cardiovascular monitoring and/or intensive respiratory support \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11. Actual or impending spinal cord compression of any cause \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12. Placement of external ventricular drainage device \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">13. Acute intracranial bleeding or cerebral oedema on imaging \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">14. Structural brain abnormality evinced by neuroimaging and requiring continuous observation or cerebral blood flow monitoring and/or intensive respiratory support \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">15. Acute change in pupillary response or level of consciousness, or decline in Glasgow coma scale \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">16. Need for monitoring of intracranial pressure, brain tissue oxygenation, jugular venous oxygen saturation and/or cerebral blood flow \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">17. Suspected or diagnosed acute haemorrhagic or ischaemic stroke \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737574.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for PICU admission related to the patient's neurologic condition." ] ] 4 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PICU, paediatric intensive care unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with oncologic or haematologic disease that is severe, life-threatening or unstable, or associated with bleeding or a prothrombotic state that poses a risk of death or dysfunction of a vital organ. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Exchange transfusions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Plasmapheresis and leukapheresis with unstable clinical condition \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Severe coagulopathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Severe anaemia with red blood cells ≤4g/dL that may lead to haemodynamic compromise or tissue hypoxia due to the condition of the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Severe complications of sickle cell crisis, such as neurologic changes, acute chest syndrome or aplastic anaemia with haemodynamic instability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Initiation of chemotherapy, steroid therapy or immunotherapy with presence or risk of tumour lysis syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Tumours or masses compressing or threatening to compress vital blood vessels, organs or airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Superior vena cava syndrome secondary to mediastinal mass \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Hyperleukocytosis associated with or with high risk of hyperviscosity and pulmonary hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. Actual or potential complications of chemotherapy that pose a risk of death or failure of at least one vital organ \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11. Hyperviscosity syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737570.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for PICU admission in haematology/oncology patients." ] ] 5 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ECG, electrocardiogram; IV, intravenous; Na, sodium; K, potassium; PICU, paediatric intensive care unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Patients with severe, life-threatening or unstable endocrine or metabolic disease. Conditions include, but are not limited to: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Severe metabolic ketoacidosis requiring treatment that exceeds the institutional capabilities for patient care outside the PICU or with severe dehydration, haemodynamic instability or neurologic involvement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Severe dehydration with haemodynamic instability and/or requiring invasive monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Other severe electrolyte disturbances, such as: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Hyperkalaemia with K≥6mEq/L and/or associated with arrhythmias and/or renal failure and/or requiring continuous ECG monitoring and/or complex intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Hypokalaemia with K<3mEq/L and/or associated with arrhythmias and/or renal failure and/or requiring IV infusion of K≥0.15mEq/kg/h and/or continuous ECG monitoring \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Hyponatraemia Na≤125mEq/L or hypernatraemia with Na≥160mEq/L or associated with or with a potential risk of cerebral oedema or central pontine myelinolysis, or requiring complex intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Hypo- or hyperglycaemia requiring continuous monitoring and observation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Severe metabolic acidosis requiring bicarbonate infusion, continuous cardiovascular monitoring or complex intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Severe metabolic alkalosis requiring continuous monitoring or complex intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Clinical conditions presenting with or posing a risk of severe acute abnormalities in divalent ions, phosphorus, calcium or magnesium, requiring continuous or invasive monitoring and/or continuous IV therapy and/or complex intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Need of continuous and/or invasive monitoring and/or complex intervention to maintain adequate fluid balance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Severe hyperammonaemia associated with cerebral dysfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Inborn errors of metabolism with acute deterioration requiring invasive monitoring, respiratory support, acute dialysis, haemoperfusion, management of raised intracranial pressure or inotropic support \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Adrenal insufficiency of any aetiology accompanied by electrolyte abnormalities and/or cardiovascular dysfunction requiring vasopressor therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737568.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for PICU admission related to endocrine or metabolic conditions." ] ] 6 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at7" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PICU, paediatric intensive care unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Ingestion of toxic substances, medication overdose or poisoning by environmental agents that is life-threatening or that may cause acute decompensation of organs or systems, and/or presenting with severe manifestations described in other sections of this guideline, and/or requiring continuous and/or invasive monitoring, and/or associated with dysfunction or failure of at least one vital organ, and/or requiring complex intervention or advanced decontamination methods \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Near drowning \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Burns covering >10% of the body surface or whose depth or location pose a risk to the life or the stability of the patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Severe electrical injuries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Smoke inhalation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Heatstroke \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Severe hypothermia due to cold exposure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Injury caused by chemical, biological, radiological or nuclear agent. It may require admission to units equipped for patient isolation and contention of the agent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Non-accidental injury or injury due to abuse requiring continuous monitoring and/or intensive treatment, or where admission to the PICU would be convenient to carry out the patient care plan \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. Suicide attempt requiring continuous monitoring and/or intensive care, or where admission to the PICU would be convenient to carry out the patient care plan \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737569.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for PICU admission related to accidental injuries, poisoning and environmental injuries." ] ] 7 => array:8 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at8" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PICU, paediatric intensive care unit." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre- and postsurgical patients with severe diseases and/or sepsis and/or requiring invasive monitoring and/or with presence or risk of coagulopathy and/or haemodynamic instability during the perioperative period in the following situations: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Cardiovascular surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Thoracic surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Neurosurgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4. Abdominal surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5. Ear, nose, throat surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6. Craniofacial surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7. Orthopaedic or spinal surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8. Organ transplantation: cardiac, renal, hepatic, intestinal, multivisceral, pulmonary \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9. Multiple trauma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10. Massive blood loss during surgery or in the postoperative period \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11. Surgery resulting in actual or risk of total or partial ischaemia-reperfusion injury in at least one vital organ, or after surgery with extracorporeal circulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Organ donation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Brain death in organ donor \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Need for intensive care related to donation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Controlled donation after circulatory death \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Need for advanced technologies, invasive procedures or specialised treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Clinical conditions requiring specialised technologies or interventions, invasive monitoring, complex interventions or treatment, including medication, or sedoanalgesia, and where the risks or complexity of the care or the condition of the patient exceed the capabilities of the hospital for care outside the PICU \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Need for continuous observation, medical care and/or nursing care or exceeding the capabilities of the hospital for care outside the PICU \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1737575.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for PICU admission related to surgery, organ donation and invasive procedures or specialised treatments." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Guidelines for pediatric intensive care units" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "1983" "volumen" => "72" "paginaInicial" => "364" "paginaFinal" => "372" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6889042" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0200" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines and levels of care for pediatric intensive care units" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.I. 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Petersen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1748-5908-5-13" "Revista" => array:5 [ "tituloSerie" => "Implement Sci" "fecha" => "2010" "volumen" => "5" "paginaInicial" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20181129" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack345245" "titulo" => "Acknowledgements" "texto" => "These guidelines have been developed by: The Asociación Española de Pediatría (Spanish Association of Paediatrics [AEP]). Paediatric Intensive Care Standards Committee:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0135">-Pedro de la Oliva. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Chief of the Paediatric Intensive Care Unit, Hospital Universitario Infantil La Paz, Madrid. Associate Professor, Department of Paediatrics, School of Medicine, Universidad Autónoma de Madrid. Member of the Executive Board of the AEP in representation of the Sociedad Española de Cuidados Intensivos Pediátricos (Spanish Society of Paediatric Intensive Care [SECIP]).</li><li class="elsevierStyleListItem" id="lsti0140">-Corsino Rey-Galán. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Chief of the Paediatric Intensive Care Unit, Hospital Universitario Central de Asturias. Chair of the Department of Paediatrics, Universidad de Oviedo. Member of the Executive Board of the AEP in the position of President of the Sociedad de Pediatría de Asturias, Cantabria y Castilla y León (Paediatrics Society of Asturias, Cantabria and Castilla y León).</li><li class="elsevierStyleListItem" id="lsti0145">-Juan Carlos de Carlos-Vicente. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Chief of the Paediatric Intensive Care Unit, Hospital Universitario Son Espases, Palma de Mallorca. Member of the Executive Board of the AEP in the position of President of the Sociedad de Pediatría Balear (Paediatrics Society of Balearic Islands).</li><li class="elsevierStyleListItem" id="lsti0150">-Francisco Javier Pilar-Orive. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Chief of the Paediatric Intensive Care Unit, Hospital Universitario de Cruces, Bizkaia.</li><li class="elsevierStyleListItem" id="lsti0155">-Antonio Rodríguez-Núñez. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Adjunct physician in the Paediatric Intensive Care and Emergency Department of the Hospital Clínico Universitario, Santiago de Compostela. Chair of the Department of Psychiatry, Radiology, Public Health, Nursing and Medicine, Universidad de Santiago de Compostela. Member of the National Committee on the Specialty of Paediatrics and its Specific Subspecialties.</li></ul> Sociedad Española de Cuidados Intensivos Pediátricos (Spanish Society of Paediatric Intensive Care [SECIP]). Paediatric Intensive Care Standards Committee:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0160">-Francisco José Cambra-Lasaosa. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Chief of the Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, Barcelona. Associate professor, Universidad de Barcelona. President of the SECIP.</li><li class="elsevierStyleListItem" id="lsti0165">-Juan Ignacio Sánchez-Díaz. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Chief of the Jefe de la Paediatric Intensive Care and Emergency Department of the Hospital Universitario 12 de Octubre, Madrid. Associate professor, Department of Paediatrics, School of Medicine, Universidad Complutense de Madrid.</li><li class="elsevierStyleListItem" id="lsti0170">-Ramón Hernández-Rastrollo. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Chief of the Paediatric Intensive Care Unit of the Hospital Universitario Materno-Infantil, Badajoz. Associate professor of Paediatrics, Department of Biomedical Sciences, School of Medicine, Universidad de Extremadura. Member of the Executive Board of the SECIP.</li><li class="elsevierStyleListItem" id="lsti0175">-Esther Ocete-Hita. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Specialty physician, Paediatric Intensive Care unit, Hospital Virgen de Las Nieves, Granada. Associate professor of Paediatrics, Universidad de Granada. Secretary of the SECIP.</li><li class="elsevierStyleListItem" id="lsti0180">-Ana Serrano-González. Specialist in Paediatrics. Accredited for practice of Paediatric Critical Care. Doctor in Medicine. Chief of the Paediatric Intensive Care Unit, Hospital Niño Jesús, Madrid. Associate professor, Department of Paediatrics, School of Medicine, Universidad Autónoma de Madrid.</li></ul> Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]). Paediatric Intensive Care Standards Committee:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0185">-Manuel Quintana-Díaz. Specialist in Paediatrics. Doctor in Medicine. Specialist physician, medical staff of the Department of Intensive Care, Hospital Universitario La Paz-Carlos III, Madrid. Associate professor of Health Sciences, Universidad Autónoma de Madrid. Secretary of the SEMICYUC.</li><li class="elsevierStyleListItem" id="lsti0190">-María Cruz Martín-Delgado. Specialist in Intensive Care Medicine. Doctor in Medicine. Chief of the Department of Intensive Care, Hospital Universitario de Torrejón. Associate professor, Universidad Francisco de Vitoria. President of the SEMICYUC.</li><li class="elsevierStyleListItem" id="lsti0195">-María Soledad Holanda-Peña. Specialist in Intensive Care Medicine. Doctor in Medicine. Coordinator of the Mother's and Children's Intensive Care Unit, Hospital Universitario Marqués de Valdecilla, Santander.</li><li class="elsevierStyleListItem" id="lsti0200">-Lluis Blanch. Specialist in Intensive Care Medicine. Doctor in Medicine. Critical Care Centre, Corporació Sanitaria Parc Taulí, Sabadell. Biomedical Research Networking Centre consortium (CIBER) on Respiratory Diseases, Instituto de Salud Carlos III, Madrid. Instituto de Investigación e Innovación Parc Taulí, Sabadell. 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Special article

Admission, discharge and triage guidelines for paediatric intensive care units in Spain

Guias de ingreso, alta y triage para las unidades de cuidados intensivos pediátricos en España

Pedro de la Olivaa,b,

Corresponding author

pedro.oliva@salud.madrid.org

Corresponding author.

, Francisco José Cambra-Lasaosac,d, Manuel Quintana-Díaze,f, Corsino Rey-Galáng,h, Juan Ignacio Sánchez-Díazh,i, María Cruz Martín-Delgadoj,k, Juan Carlos de Carlos-Vicentel, Ramón Hernández-Rastrollom,n, María Soledad Holanda-Peñao, Francisco Javier Pilar-Orivep, Esther Ocete-Hitaq, Antonio Rodríguez-Núñezr,s, Ana Serrano-Gonzálezt,b, Luis Blanchu,v,w, on behalf of the Spanish Association of Paediatrics (AEP), Spanish Society of Paediatric Intensive Care (SECIP) and Spanish Society of Critical Care (SEMICYUC)

a Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario Materno-Infantil La Paz, Madrid, Spain

b Universidad Autónoma, Madrid, Spain

c Servicio Área de Críticos Pediátricos, Hospital Sant Joan de Déu, Barcelona, Spain

d Universidad de Barcelona, Barcelona, Spain

e Servicio de Medicina Intensiva, Hospital Universitario La Paz-Carlos III, Madrid, Spain

f Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain

g Universidad de Oviedo, Oviedo, Asturias, Spain

h Sección de Cuidados Intensivos Pediátricos y Urgencias Infantiles, Hospital Universitario 12 de Octubre, Madrid, Spain

i Universidad Complutense, Madrid, Spain

j Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain

k Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain

l Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares, Spain

m Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Materno-Infantil, Badajoz, Spain

n Universidad de Extremadura, Badajoz, Spain

o Unidad de Cuidados Intensivos Materno-Infantil, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain

p Servicio de Cuidados Intensivos Pediátricos, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain

q Unidad de Cuidados Intensivos Pediátricos, Hospital Virgen de Las Nieves, Universidad de Granada, Granada, Spain

r Servicio de Críticos y Urgencias Pediátricas, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain

s Universidad de Santiago de Compostela, Santiago de Compostela, La Coruña, Spain

t Servicio de Cuidados Intensivos Pediátricos, Hospital Niño Jesús, Madrid, Spain

u Centro de Críticos, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain

v CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain

w Instituto de Investigación e Innovación Parc Taulí, Sabadell, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical practice in paediatric intensive care has improved drastically in the past 4 decades thanks to a growing understanding of the pathophysiology of life-threatening processes&#44; technological advances in the monitoring&#44; diagnosis and treatment of critically ill paediatric patients and the specialised training of the health care staff that manages critically ill paediatric patients&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The paediatric intensive care unit &#40;PICU&#41; was defined in 1983 in the Guidelines for Paediatric Intensive Care<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> &#40;updated in 2004<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a>&#41; as &#8220;a hospital unit that provides treatment to children with a wide variety of illnesses of a life-threatening nature&#44; including children with highly unstable conditions and those requiring sophisticated medical and surgical intervention&#46;&#8221; Randolph et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> expanded this definition&#58; &#8220;A PICU is a separate physical facility or unit specifically designated for the treatment of paediatric patients who&#44; because of shock&#44; trauma&#44; or other life-threatening conditions&#44; require intensified&#44; comprehensive observation and care&#46;&#8221;</p><p id="par0015" class="elsevierStylePara elsevierViewall">At the beginning of the new millennium&#44; the board of directors of the European Union of Medical Specialists &#40;UEMS&#41; approved the definition of intensive care medicine for the European Union proposed by the Multidisciplinary Joint Committee of Intensive Care Medicine &#40;MJCICM&#41;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a>&#58; &#8220;Intensive care medicine &#91;e&#46;g&#46; paediatric intensive care&#93; combines physicians&#44; nurses and allied health professionals in the coordinated and collaborative management of patients with life-threatening single or multiple organ system failure&#44; including stabilisation after severe surgical interventions&#46; It is a continuous &#40;i&#46;e&#46; 24<span class="elsevierStyleHsp" style=""></span>h&#41; management including monitoring&#44; diagnostics&#44; support of failing vital functions as well as the treatment of the underlying diseases&#46;&#8221;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The MJCICM<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> also underscored that &#8220;patient care should be provided continuously over a 24<span class="elsevierStyleHsp" style=""></span>h period&#44; by staff members &#40;physicians&#41; who have obtained special competence in intensive care medicine&#8221; &#40;e&#46;g&#46; paediatric intensive care&#41;&#46; Indeed&#44; adequate training of physicians and nurses is essential to ensure the quality of intensive care and the safety of the patient in the PICU&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#8211;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Early diagnosis and treatment are essential to the survival of critically ill patients&#44; especially those with neurologic decompensation&#44; haemodynamic instability or signs of tissue hypoxia and organ dysfunction&#46; Although these signs can be detected with clinical observation&#44; advanced monitoring at the ICU may facilitate faster decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> Furthermore&#44; delays in PICU admission may increase the risk of death&#44;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a> while implementation of early intensive treatment in critically ill patients or patients that are quickly deteriorating outside the PICU is associated with decreased mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#8211;13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The Spanish Constitution recognises the right to health in Spain&#46; The World Health Organization affirms that the right to health includes &#8220;access to timely&#44; acceptable&#44; and affordable health care of appropriate quality&#46;&#8221;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In 1990&#44; the Spanish government approved and ratified the Convention on the Rights of the Child adopted by the United Nations General Assembly&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a> and article 24 of this instrument states &#8220;1&#46; States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and the rehabilitation of health&#46; States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services&#46; 2&#46; States Parties shall pursue full implementation of this right and&#44; in particular&#44; shall take appropriate measures&#58; &#8230; &#40;b&#41; To ensure the provision of necessary medical assistance and health care to all children &#8230;&#8221; Furthermore&#44; the European Charter for Children in Hospital<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> establishes&#44; among others&#44; the fundamental rights of children and adolescents to receive &#8220;the best possible medical treatment &#8230; to be cared for throughout their hospital stay by appropriately trained staff&#44; fully aware of the physical and emotional needs of each age group &#8230; &#91;and&#93; to be cared for in hospital with other children&#44; avoiding as far as possible admission to adult wards&#46;&#8221;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore&#44; we must remain aware that critically ill children with potentially life-threatening single or multiple organ or system impairment or failure&#44; including the need of stabilisation after severe surgical intervention&#44; should be&#44; wherever possible&#44; placed in units dedicated exclusively to children&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a> managed by staff specifically accredited in paediatric critical care capable of providing integral&#44; comprehensive and continuous care&#44; carrying out the specialised interventions required by severe organ or system dysfunction in children and adolescents&#44; and implementing the specific care protocols required for monitoring&#44; diagnosis&#44; support of failing vital functions and treatment of underlying disases&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;6&#44;16</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">With the aim of upholding the right of children to enjoy the highest attainable standard of health and services for the treatment of illness and the rehabilitation of health and guaranteeing the quality of care and the safety of paediatric critical patients&#44; the boards of directors of the Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a &#40;Spanish Association of Paediatrics &#91;AEP&#93;&#41;&#44; the Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos &#40;Spanish Society of Paediatric Intensive Care &#91;SECIP&#93;&#41; and the Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#40;Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#91;SEMICYUC&#93;&#41; created paediatric intensive care standards committees in their respective societies&#44; which in turn developed and approved the guidelines for Spanish PICUs presented in this article&#46; The members of the standards committees were selected by their respective societies based on their clinical practice and management expertise and their education among recognised experts in paediatrics and paediatric critical care &#40;AEP&#44; SECIP&#41; and intensive medicine &#40;SEMICYUC&#41; in Spain&#44; while seeking adequate representation of the involved societies and other institutions associated with the pertinent medical specialties&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We have developed these guidelines on the basis of the guidelines published in 1999 by the Society of Critical Care Medicine in collaboration with the American College of Critical Care Medicine and the Committee on Hospital Care of the American Academy of Pediatrics&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> which we completed and updated with information obtained through a literature search in MEDLINE &#40;Ovid&#41;&#44; Embase and PubMed for articles published between January 1999 and April 2017 with the search terms <span class="elsevierStyleItalic">pediatric intensive care units</span>&#44; <span class="elsevierStyleItalic">pediatric critical care</span>&#44; <span class="elsevierStyleItalic">admission</span>&#44; <span class="elsevierStyleItalic">triage</span>&#44; <span class="elsevierStyleItalic">discharge</span>&#44; <span class="elsevierStyleItalic">pediatric intensive care&#47;critical care outreach programs</span>&#44; <span class="elsevierStyleItalic">benefit</span>&#44; <span class="elsevierStyleItalic">futility</span>&#44; <span class="elsevierStyleItalic">rationing</span>&#44; <span class="elsevierStyleItalic">quality assurance&#47;quality improvement</span>&#44; <span class="elsevierStyleItalic">timely</span> and <span class="elsevierStyleItalic">guidelines</span>&#44; guidelines published by scientific associations<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">17&#8211;25</span></a> and updated editions of internationally known reference books on clinical practice in paediatric intensive care&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">26&#44;27</span></a> The guidelines also include general criteria to guide PICU triage based on the recommendations published by the ICU Admission Discharge and Triage &#40;ADT&#41; Task Force<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> and the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> We were unable to establish levels of scientific evidence due to the scarcity of data in the paediatric age group&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">These guidelines are meant as a reference for practice and may facilitate decision-making regarding admission&#44; discharge and triage of critically ill paediatric patients in Spanish PICUs&#44; guiding the classification of patients into the most appropriate level of care based on the need for intensive care&#47;monitoring and how likely they are to <span class="elsevierStyleItalic">benefit</span> or not from intensive care&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> Due to the ongoing advances in paediatric intensive care&#44; we recommend that these guidelines be updated at regular intervals&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This document is not meant to replace the use of clinical judgement in individual cases&#46; Paediatric intensivists may request admission to the PICU for patients at risk of deterioration&#44; with clinical manifestations of severe illness or with intensive monitoring or observation needs not included in these guidelines&#46; Whatever the circumstances&#44; any decision regarding admission&#44; discharge and triage and its justification must be documented in the health records of the patient&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Criteria for admission to the paediatric intensive care unit</span><p id="par0065" class="elsevierStylePara elsevierViewall">It is essential to weigh the potential risks and benefits of intensive care in patients considered for PICU admission&#46; Ideally&#44; admission to the PICU should be granted to all patients with reversible disease whose risk of death would decrease with the use of advanced technologies and delivery of medical care by a team with specialised training in paediatric critical care&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> However&#44; intensive treatment and monitoring may increase morbidity&#44; so extremely ill patients with a low probability of survival may not ultimately benefit from admission to the PICU&#44; while patients that only require monitoring for preventive purposes and who are not severely ill are unlikely to benefit from transfer to this level of care&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Admission to the PICU must always be considered in patients that may benefit from intensive care&#46; Decisions regarding the admission to the PICU of terminal patients with a low probability of survival or with irreversible diseases should be based on qualitative criteria regarding the potential benefit or lack thereof of intensive care&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a> We recommend using the term &#8220;potentially inappropriate&#8221; as opposed to &#8220;futile&#8221; to refer to treatment at the PICU level that has some chance to achieve the effect sought by the patient or family but which the intensivists or other professionals in charge of the patient are opposed to implementing on account of ethical considerations&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">28&#44;29</span></a> In certain situations&#44; the PICU may be the most appropriate setting to perform treatments and procedures aimed to prolong survival or improve quality of life in terminally ill patients with appropriate comfort&#44; and there are also situations where the PICU may be the ideal setting for specially-trained physicians and nurses to provide appropriate end-of-life palliative care to terminally ill children and adolescents&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Generally speaking&#44; admission to the PICU should be granted to any paediatric patient&#8212;especially cancer patients or bone marrow transplant recipients&#8212;at risk of severe acute deterioration&#44; neurologic decompensation&#44; haemodynamic instability or failure or life-threatening dysfunction of at least one vital organ or system<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">30&#44;31</span></a> or multiple organ or system failure&#44; requiring stabilisation following severe surgical intervention or with pre- or post-operative conditions potentially associated with severe or life-threatening dysfunction of at least one organ or system&#44; or who due to the severity or potential severity of their condition require invasive and&#47;or continuous monitoring&#44; diagnosis and support of failing vital functions or treatment of underlying diseases by a team specifically trained in paediatric intensive care&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We proceed to specify the conditions that require admission to PICU related to multiple organ involvement and with the organs or systems that are most frequently involved &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1&#8211;8</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Multiple organ or system involvement</span><p id="par0085" class="elsevierStylePara elsevierViewall">Patients with severe&#44; life-threatening or unstable multiple organ or system disease&#46; Conditions include&#44; but are not limited to&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Multiple organ dysfunction syndrome or failure&#44; regardless of aetiology&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Thrombocytopenia associated with multiple organ failure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Severe systemic inflammatory states&#44; such as macrophage activation syndrome or haemophagocytic lymphohistiocytosis associated with shock&#44; coagulopathy or vital organ dysfunction&#44; or requiring intensive treatment and&#47;or invasive and&#47;or continuous monitoring&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Post-transplantation lymphoproliferative disease associated with shock&#44; coagulopathy or vital organ dysfunction&#44; or requiring intensive treatment and&#47;or intensive and&#47;or continuous monitoring&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Need of immunotherapy that may cause severe cytokine release syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Suspected or documented malignant hyperthermia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Change in body temperature associated with a risk of arrhythmia and&#47;or requiring invasive and&#47;or continuous monitoring and&#47;or complex intervention&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Suspected or documented tissue hypoxia&#44; systemic or in at least one vital organ&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Intra-abdominal hypertension and abdominal compartment syndrome&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Severe toxin-related diseases&#58; toxic shock syndrome&#44; malignant pertussis&#44; tetanus&#44; human botulism&#44; diphtheria&#46;</p></li></ul></p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Criteria for discharge from the paediatric intensive care unit</span><p id="par0140" class="elsevierStylePara elsevierViewall">Patients staying in the PICU will be assessed and considered for discharge when the disease&#44; process or unstable physiological condition that led to their admission has resolved and the patient no longer requires invasive or continuous monitoring or complex interventions exceeding the care capabilities outside the PICU&#44; or when they are no longer benefitting from intensive care&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Patient discharge must be based on the following criteria&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Stable haemodynamic parameters&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Stable respiratory status in extubated patient with airway patency not requiring respiratory support or requiring non-invasive support that can be provided safely outside the PICU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Minimal oxygen requirements&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">4&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">The patient no longer requires inotropic support&#44; vasodilators and antiarrhythmic drugs or otherwise requires them at low doses that can be safely administered outside the PICU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">5&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Cardiac dysrhythmias are controlled&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">6&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Intracranial pressure monitoring equipment has been removed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">7&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">The patient is neurologically stable with control of seizures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">8&#46;</span><p id="par0185" class="elsevierStylePara elsevierViewall">All haemodynamic monitoring catheters have been removed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">9&#46;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Chronically mechanically ventilated patients with invasive &#40;tracheostomy&#41; or non-invasive ventilation that remain stable and whose critical illness has been resolved or reversed and can be transferred to a unit that routinely manages chronically ventilated patients or to home&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">10&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Patients with routine peritoneal dialysis or haemodialysis with resolution of acute critical illness and who no longer require complex interventions&#44; care or monitoring exceeding the care capabilities outside the PICU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">11&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Patients with tracheostomies that no longer require frequent and intensive suctioning&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">12&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">The health care team in charge of the patient and the patient&#39;s family&#44; after a careful&#44; joint and coordinated assessment&#44; determine that there is no benefit in keeping the child in the PICU&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Triage in paediatric intensive care units</span><p id="par0210" class="elsevierStylePara elsevierViewall">Paediatric intensive care is costly and there is a limited number of beds&#46; When there are insufficient beds for severely ill patients that need them&#44; refusal rates can be high and raise ethical dilemmas or lead to potential legal repercussions&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Triage is essential in the PICU to ensure the optimal and equitable use of resources and to guarantee the safety and early treatment of critical patients in situations where resources become scarce&#44; such as epidemics or natural disasters&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">8&#44;13</span></a> Not admitting patients who are likely to benefit from the PICU&#44; or <span class="elsevierStyleItalic">undertriage</span>&#44; can increase their risk of death or progressive deterioration and multiple organ failure&#46; Admitting patients who are unlikely to benefit from intensive care&#44; or <span class="elsevierStyleItalic">overtriage</span>&#44; may lead to more invasive and potentially harmful interventions as well as inappropriate allocation of resources&#44; diverting care from other patients that need it more&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Triage in PICUs must take into account the following key aspects<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a>&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">Triage requires careful weighing of the multiple benefits and risks involved in PICU admission&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">Final triage decisions regarding admission to the PICU must be made by paediatric intensivists with input from nurses&#44; paediatric emergency medicine specialists and hospitalists&#44; surgeons&#44; and allied professionals&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">-</span><p id="par0235" class="elsevierStylePara elsevierViewall">Triage algorithms and protocols can be useful but can never supplant the role of skilled paediatric intensivists basing their decisions on input from multidisciplinary teams&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Infrastructures need to be organised efficiently both within individual hospitals and at the regional level&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Timeliness and appropriateness of paediatric intensive care and patient safety</span><p id="par0245" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">opportune</span> &#40;timely and appropriate&#41; delivery of intensive care to critically ill patients is associated with decreases in mortality&#44; length of stay and health care costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;12</span></a> Thus&#44; we recommend for each PICU to develop specific policies with explicit criteria regarding admission&#44; discharge and triage tailored to the needs of the patients served in the corresponding hospital and its catchment area&#46; These criteria should be adapted in response to current scientific evidence taking into account ethical and legal aspects&#46; The staff of medical and surgical departments and units serving paediatric patients must be aware of the policies regarding PICU admission and know how to recognise the warning signs of acute and severe deterioration in children and adolescents with high-risk diseases&#44; as do the family members that care for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> Furthermore&#44; a paediatric rapid response systems &#40;PRRS&#41; or paediatric critical care outreach teams &#40;CCOT&#41; supported by a team of paediatric intensive care consultants can be established to assist paediatric inpatient care or surgical teams in the assessment and management of severely ill patients&#44; facilitate the transition of patients into and out of the PICU&#44; allow the early identification of patients that may benefit from admission and intensive care&#44; prevent unnecessary PICU admission&#44; reduce the rate of unexpected readmission to the PICU and reduce inpatient mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">33&#8211;35</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">Whenever a patient meets any of the admission criteria specified in these guidelines&#44; the physician in charge of the patient should consult with the PICU team or the paediatric intensivist that serves as a consultant for the PRRS or CCOT to plan the handover to the PICU&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> Paediatric intensivists should be informed of potential PICU admissions at an early stage&#44; as initial intensive treatment may differ significantly from standard treatment&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">In order to guarantee patient safety and the quality&#44; timeliness&#44; appropriateness and efficiency of paediatric intensive care&#44; adherence to criteria for PICU admission&#44; discharge and triage should be monitored and assessed periodically by a multidisciplinary team with use of quality indicators<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> &#40;including the standardised mortality rate&#44; the severity-adjusted length of stay&#44; and an analysis of unexpected readmissions&#41;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> and with documentation and analysis of patient deaths&#44; cases of cardiopulmonary arrest or shock outside the PICU&#44; cases of denial of admission to the PICU or delayed PICU admission or discharge&#44; cancellation of scheduled surgeries and triage decisions&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A paediatric intensive care unit &#40;PICU&#41; is a separate physical facility or unit specifically designed for the treatment of paediatric patients who&#44; because of the severity of illness or other life-threatening conditions&#44; require comprehensive and continuous intensive care by a medical team with special skills in paediatric intensive care medicine&#46; Timely and personal intervention in intensive care reduces mortality&#44; reduces length of stay&#44; and decreases cost of care&#46; With the aim of defending the right of the child to receive the highest attainable standard of health and the facilities for the treatment of illness and rehabilitation&#44; as well as ensuring the quality of care and the safety of critically ill paediatric patients&#44; the Spanish Association of Paediatrics &#40;AEP&#41;&#44; Spanish Society of Paediatric Intensive Care &#40;SECIP&#41; and Spanish Society of Critical Care &#40;SEMICYUC&#41; have approved the guidelines for the admission&#44; discharge and <span class="elsevierStyleItalic">triage</span> for Spanish PICUs&#46; By using these guidelines&#44; the performance of Spanish paediatric intensive care units can be optimised and paediatric patients can receive the appropriate level of care for their clinical condition&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La unidad de cuidados intensivos pedi&#225;tricos &#40;UCIP&#41; es una unidad f&#237;sica asistencial hospitalaria independiente especialmente dise&#241;ada para el tratamiento de pacientes pedi&#225;tricos quienes debido su gravedad o condiciones potencialmente letales requieren observaci&#243;n y asistencia m&#233;dica intensiva integral y continua por un equipo m&#233;dico que haya obtenido competencia especial en medicina intensiva pedi&#225;trica&#46; La aplicaci&#243;n oportuna de terapia intensiva a los pacientes cr&#237;ticos reduce la mortalidad&#44; el tiempo de estancia y los costes asistenciales&#46; Con los objetivos de respetar el derecho del ni&#241;o al disfrute del m&#225;s alto nivel posible de salud y a servicios para el tratamiento de las enfermedades y la rehabilitaci&#243;n de la salud y de garantizar la calidad asistencial y la seguridad de los pacientes pedi&#225;tricos cr&#237;ticos&#44; la Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a &#40;AEP&#41;&#44; la Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos &#40;SECIP&#41; y la Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#40;SEMICYUC&#41; han desarrollado y aprobado las gu&#237;as de ingreso&#44; alta y <span class="elsevierStyleItalic">triage</span> para las UCIP en Espa&#241;a&#46; Mediante la aplicaci&#243;n de estas gu&#237;as se puede optimizar el uso de las UCIP espa&#241;olas de forma que los pacientes pedi&#225;tricos reciban el nivel de cuidados m&#233;dicos m&#225;s apropiado para su situaci&#243;n cl&#237;nica&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; de la Oliva P&#44; Cambra-Lasaosa FJ&#44; Quintana-D&#237;az M&#44; Rey-Gal&#225;n C&#44; S&#225;nchez-D&#237;az JI&#44; Mart&#237;n-Delgado MC&#44; et al&#46; Guias de ingreso&#44; alta y triage para las unidades de cuidados intensivos pedi&#225;tricos en Espa&#241;a&#46; Med Intensiva&#46; 2018&#59;42&#58;235&#8211;246&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article has also been published in the journal Anales de Pediatria&#44; 2017&#46; <a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="https://doi.org/10.1016/j.anpedi.2017.10.008">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;anpedi&#46;2017&#46;10&#46;008</a></p>"
      ]
    ]
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            "identificador" => "at1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CO<span class="elsevierStyleInf">2</span>&#44; carbon dioxide&#59; ECMO&#44; extracorporeal membrane oxygenation&#59; FiO<span class="elsevierStyleInf">2</span>&#44; fraction of inspired oxygen&#59; PICU&#44; paediatric intensive care unit&#59; SaO<span class="elsevierStyleInf">2</span>&#44; arterial oxygen saturation&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients with severe&#44; potentially life-threatening or unstable pulmonary or airway disease&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&#46; Endotracheal intubation or potential need for emergency endotracheal intubation and mechanical ventilation&#44; regardless of aetiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&#46; Need for non-invasive mechanical ventilation in cases of moderate or severe acute respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&#46; Acute paediatric respiratory distress syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#46; Rapidly progressive severe pulmonary or upper or lower airway disease with risk of progression to respiratory failure and&#47;or total obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5&#46; High supplemental oxygen requirement &#40;FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;5 to maintain SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>92&#37;&#41;&#44; regardless of aetiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6&#46; Recently placed tracheostomy with or without the need for mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#46; Acute barotrauma compromising the upper or lower airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8&#46; Foreign body aspiration associated with dyspnoea&#44; laboured breathing&#44; hypoxaemia or hypercapnia&#44; or requiring continuous monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>9&#46; Requirement for more frequent nebulised or inhaled medications that can be administered safely outside the PICU based on institution guidelines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>10&#46; Requirement of extracorporeal respiratory support&#58; veno-venous or veno-arterial ECMO&#44; extracorporeal CO<span class="elsevierStyleInf">2</span> removal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>11&#46; Abnormal air&#44; fluid or solid contents in the pleural cavity that compromises respiration or produces haemodynamically instability&#44; requiring fluid therapy or vasopressor infusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>12&#46; Apnoea observed by a physician or nurse or described as cyanosis and&#47;or loss of consciousness and&#47;or decreased muscle tone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">PICU admission criteria related to the respiratory system&#46;</p>"
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      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ECMO&#44; extracorporeal membrane oxygenation&#59; PICU&#44; paediatric intensive care unit&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Cardiovascular system</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patients with cardiovascular disease that is severe&#44; life-threatening or unstable&#44; or requires continuous and&#47;or invasive monitoring&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Shock&#44; regardless of aetiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; Post-cardiopulmonary resuscitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; Dysrhythmias that are life-threatening or require continuous monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4&#46; Suspected or documented cardiovascular syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5&#46; Unstable congestive heart failure&#44; with or without need for mechanical ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>6&#46; Congenital cardiac disease with unstable cardio-respiratory status&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>7&#46; Post high-risk cardiovascular and intrathoracic procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>8&#46; Cardiovascular disease requiring invasive and continuous monitoring of arterial&#44; central venous or pulmonary artery pressures&#44; or cardiac output&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>9&#46; Need for temporary cardiac pacing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>10&#46; High blood pressure requiring intravenous treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>11&#46; Pulmonary hypertension requiring inhaled nitric oxide or intravenous treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>12&#46; Need of extracorporeal circulatory support&#58; ECMO&#44; pulsatile-flow or continuous-flow ventricular assist device&#44; or intra-aortic balloon pump counterpulsation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>13&#46; Current or impending cardiac tamponade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>14&#46; Pulmonary embolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>15&#46; Need of treatment that may cause a severe acute anaphylactic reaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Renal system</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patients with severe&#44; life-threatening or unstable renal disease&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Acute or chronic renal failure requiring invasive and&#47;or continuous monitoring and&#47;or complex intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; Need for acute haemodialysis&#44; peritoneal dialysis or other continuous renal replacement therapies&#44; such as continuous haemofiltration or veno-venous haemodiafiltration in the unstable patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; Rhabdomyolysis with acute renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">PICU admission criteria related to the cardiovascular and renal systems&#46;</p>"
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      2 => array:8 [
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            "identificador" => "at3"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">PICU&#44; paediatric intensive care unit&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Infectious</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patients with confirmed or suspected infection that is life-threatening or requires invasive and&#47;or continuous monitoring&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Sepsis with cardiovascular dysfunction or acute respiratory distress syndrome or dysfunction of another 2 vital organs and&#47;or with high-risk signs&#58; bradycardia&#44; tachycardia&#44; tachypnoea&#44; hypoxaemia&#44; prolonged capillary refill time&#44; altered mental status&#44; hypotension&#44; oliguria&#44; hyperlactataemia&#47;lactic acidosis&#44; clotting disorder and&#47;or newly developed thrombocytopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; Sepsis in immunosuppressed patient or associated with neutropenia or lymphopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; Infection or abscess which due to its location or extent or the clinical condition of the patient does or may severely compromise the function of at least one organ or system or the airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4&#46; Severe infection in patient with immunosuppression of any cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5&#46; Infectious diseases whose natural history and&#47;or potential complications may be fatal or lead to severe dysfunction of at least one vital organ or system&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Gastrointestinal</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Patients with severe&#44; life-threatening or unstable gastrointestinal disease&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&#46; Severe gastrointestinal bleeding leading to respiratory and&#47;or haemodynamic instability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&#46; After emergency endoscopy for foreign body removal that carries a risk of haemorrhage or perforation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&#46; Acute liver failure that leads or may lead to coma or respiratory and&#47;or haemodynamic instability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4&#46; Gastrointestinal inflammation or distension with haemodynamic instability and&#47;or severe fluid or electrolyte imbalance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>5&#46; Severe acute pancreatitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Criteria for PICU admission related to infection and to the gastrointestinal tract&#46;</p>"
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      3 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PICU&#44; paediatric intensive care unit&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients with actual or potential neurologic disease that is severe&#44; life-threatening or unstable or requires invasive and&#47;or continuous monitoring&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&#46; <span class="elsevierStyleItalic">Status epilepticus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&#46; Seizures that do not respond to treatment or require continuous infusion of anticonvulsant agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&#46; Seizures with instability in vital signs related to the airway&#44; respiration or circulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#46; Acute and&#47;or severe change in mental status where neurologic impairment or central nervous system depression is probable or unpredictable&#44; or coma that may compromise the airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5&#46; After surgical procedures requiring invasive monitoring or close&#44; comprehensive and continuous clinical observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6&#46; Glasgow coma scale<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#46; Acute inflammation or infection of the spinal cord&#44; meninges or brain accompanied by central nervous system depression&#44; metabolic and hormonal alterations&#44; haemodynamic or respiratory compromise or risk of raised intracranial pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8&#46; Head trauma that is severe or with signs or symptoms of raised intracranial pressure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>9&#46; Any neurosurgical perioperative condition manifesting with neurologic deterioration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>10&#46; Progressive neuromuscular dysfunction with or without altered sensorium requiring continuous observation or cardiovascular monitoring and&#47;or intensive respiratory support&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>11&#46; Actual or impending spinal cord compression of any cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>12&#46; Placement of external ventricular drainage device&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>13&#46; Acute intracranial bleeding or cerebral oedema on imaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>14&#46; Structural brain abnormality evinced by neuroimaging and requiring continuous observation or cerebral blood flow monitoring and&#47;or intensive respiratory support&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>15&#46; Acute change in pupillary response or level of consciousness&#44; or decline in Glasgow coma scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>16&#46; Need for monitoring of intracranial pressure&#44; brain tissue oxygenation&#44; jugular venous oxygen saturation and&#47;or cerebral blood flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>17&#46; Suspected or diagnosed acute haemorrhagic or ischaemic stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Criteria for PICU admission related to the patient&#39;s neurologic condition&#46;</p>"
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      4 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">PICU&#44; paediatric intensive care unit&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Patients with oncologic or haematologic disease that is severe&#44; life-threatening or unstable&#44; or associated with bleeding or a prothrombotic state that poses a risk of death or dysfunction of a vital organ&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&#46; Exchange transfusions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2&#46; Plasmapheresis and leukapheresis with unstable clinical condition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&#46; Severe coagulopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#46; Severe anaemia with red blood cells &#8804;4<span class="elsevierStyleHsp" style=""></span>g&#47;dL that may lead to haemodynamic compromise or tissue hypoxia due to the condition of the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5&#46; Severe complications of sickle cell crisis&#44; such as neurologic changes&#44; acute chest syndrome or aplastic anaemia with haemodynamic instability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6&#46; Initiation of chemotherapy&#44; steroid therapy or immunotherapy with presence or risk of tumour lysis syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#46; Tumours or masses compressing or threatening to compress vital blood vessels&#44; organs or airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>8&#46; Superior vena cava syndrome secondary to mediastinal mass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>9&#46; Hyperleukocytosis associated with or with high risk of hyperviscosity and pulmonary hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>10&#46; Actual or potential complications of chemotherapy that pose a risk of death or failure of at least one vital organ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>11&#46; Hyperviscosity syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Criteria for PICU admission in haematology&#47;oncology patients&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at6"
            "detalle" => "Table "
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ECG&#44; electrocardiogram&#59; <span class="elsevierStyleSmallCaps">IV</span>&#44; intravenous&#59; Na&#44; sodium&#59; K&#44; potassium&#59; PICU&#44; paediatric intensive care unit&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Patients with severe&#44; life-threatening or unstable endocrine or metabolic disease&#46; Conditions include&#44; but are not limited to&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1&#46; Severe metabolic ketoacidosis requiring treatment that exceeds the institutional capabilities for patient care outside the PICU or with severe dehydration&#44; haemodynamic instability or neurologic involvement</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2&#46; Severe dehydration with haemodynamic instability and&#47;or requiring invasive monitoring</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3&#46; Other severe electrolyte disturbances&#44; such as&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Hyperkalaemia with K<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mEq&#47;L and&#47;or associated with arrhythmias and&#47;or renal failure and&#47;or requiring continuous ECG monitoring and&#47;or complex intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Hypokalaemia with K<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mEq&#47;L and&#47;or associated with arrhythmias and&#47;or renal failure and&#47;or requiring IV infusion of K<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;15<span class="elsevierStyleHsp" style=""></span>mEq&#47;kg&#47;h and&#47;or continuous ECG monitoring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Hyponatraemia Na<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>125<span class="elsevierStyleHsp" style=""></span>mEq&#47;L or hypernatraemia with Na<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>160<span class="elsevierStyleHsp" style=""></span>mEq&#47;L or associated with or with a potential risk of cerebral oedema or central pontine myelinolysis&#44; or requiring complex intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Hypo- or hyperglycaemia requiring continuous monitoring and observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Severe metabolic acidosis requiring bicarbonate infusion&#44; continuous cardiovascular monitoring or complex intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Severe metabolic alkalosis requiring continuous monitoring or complex intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Clinical conditions presenting with or posing a risk of severe acute abnormalities in divalent ions&#44; phosphorus&#44; calcium or magnesium&#44; requiring continuous or invasive monitoring and&#47;or continuous IV therapy and&#47;or complex intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8211; Need of continuous and&#47;or invasive monitoring and&#47;or complex intervention to maintain adequate fluid balance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4&#46; Severe hyperammonaemia associated with cerebral dysfunction</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">5&#46; Inborn errors of metabolism with acute deterioration requiring invasive monitoring&#44; respiratory support&#44; acute dialysis&#44; haemoperfusion&#44; management of raised intracranial pressure or inotropic support</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">6&#46; Adrenal insufficiency of any aetiology accompanied by electrolyte abnormalities and&#47;or cardiovascular dysfunction requiring vasopressor therapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Criteria for PICU admission related to endocrine or metabolic conditions&#46;</p>"
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      6 => array:8 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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            "identificador" => "at7"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">PICU&#44; paediatric intensive care unit&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&#46; Ingestion of toxic substances&#44; medication overdose or poisoning by environmental agents that is life-threatening or that may cause acute decompensation of organs or systems&#44; and&#47;or presenting with severe manifestations described in other sections of this guideline&#44; and&#47;or requiring continuous and&#47;or invasive monitoring&#44; and&#47;or associated with dysfunction or failure of at least one vital organ&#44; and&#47;or requiring complex intervention or advanced decontamination methods&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&#46; Near drowning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&#46; Burns covering &#62;10&#37; of the body surface or whose depth or location pose a risk to the life or the stability of the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&#46; Severe electrical injuries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&#46; Smoke inhalation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&#46; Heatstroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&#46; Severe hypothermia due to cold exposure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&#46; Injury caused by chemical&#44; biological&#44; radiological or nuclear agent&#46; It may require admission to units equipped for patient isolation and contention of the agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&#46; Non-accidental injury or injury due to abuse requiring continuous monitoring and&#47;or intensive treatment&#44; or where admission to the PICU would be convenient to carry out the patient care plan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">10&#46; Suicide attempt requiring continuous monitoring and&#47;or intensive care&#44; or where admission to the PICU would be convenient to carry out the patient care plan&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">PICU&#44; paediatric intensive care unit&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pre- and postsurgical patients with severe diseases and&#47;or sepsis and&#47;or requiring invasive monitoring and&#47;or with presence or risk of coagulopathy and&#47;or haemodynamic instability during the perioperative period in the following situations&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2&#46; Need for intensive care related to donation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3&#46; Controlled donation after circulatory death</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Need for advanced technologies&#44; invasive procedures or specialised treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1&#46; Clinical conditions requiring specialised technologies or interventions&#44; invasive monitoring&#44; complex interventions or treatment&#44; including medication&#44; or sedoanalgesia&#44; and where the risks or complexity of the care or the condition of the patient exceed the capabilities of the hospital for care outside the PICU</span>&nbsp;\t\t\t\t\t\t\n
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        "identificador" => "xack345245"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0265" class="elsevierStylePara elsevierViewall">These guidelines have been developed by&#58;</p> <p id="par0270" class="elsevierStylePara elsevierViewall">The Asociaci&#243;n Espa&#241;ola de Pediatr&#237;a &#40;Spanish Association of Paediatrics &#91;AEP&#93;&#41;&#46; Paediatric Intensive Care Standards Committee&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Pedro de la Oliva&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Chief of the Paediatric Intensive Care Unit&#44; Hospital Universitario Infantil La Paz&#44; Madrid&#46; Associate Professor&#44; Department of Paediatrics&#44; School of Medicine&#44; Universidad Aut&#243;noma de Madrid&#46; Member of the Executive Board of the AEP in representation of the Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos &#40;Spanish Society of Paediatric Intensive Care &#91;SECIP&#93;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">Corsino Rey-Gal&#225;n&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Chief of the Paediatric Intensive Care Unit&#44; Hospital Universitario Central de Asturias&#46; Chair of the Department of Paediatrics&#44; Universidad de Oviedo&#46; Member of the Executive Board of the AEP in the position of President of the Sociedad de Pediatr&#237;a de Asturias&#44; Cantabria y Castilla y Le&#243;n &#40;Paediatrics Society of Asturias&#44; Cantabria and Castilla y Le&#243;n&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">Juan Carlos de Carlos-Vicente&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Chief of the Paediatric Intensive Care Unit&#44; Hospital Universitario Son Espases&#44; Palma de Mallorca&#46; Member of the Executive Board of the AEP in the position of President of the Sociedad de Pediatr&#237;a Balear &#40;Paediatrics Society of Balearic Islands&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Francisco Javier Pilar-Orive&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Chief of the Paediatric Intensive Care Unit&#44; Hospital Universitario de Cruces&#44; Bizkaia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">Antonio Rodr&#237;guez-N&#250;&#241;ez&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Adjunct physician in the Paediatric Intensive Care and Emergency Department of the Hospital Cl&#237;nico Universitario&#44; Santiago de Compostela&#46; Chair of the Department of Psychiatry&#44; Radiology&#44; Public Health&#44; Nursing and Medicine&#44; Universidad de Santiago de Compostela&#46; Member of the National Committee on the Specialty of Paediatrics and its Specific Subspecialties&#46;</p></li></ul></p> <p id="par0300" class="elsevierStylePara elsevierViewall">Sociedad Espa&#241;ola de Cuidados Intensivos Pedi&#225;tricos &#40;Spanish Society of Paediatric Intensive Care &#91;SECIP&#93;&#41;&#46; Paediatric Intensive Care Standards Committee&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">-</span><p id="par0305" class="elsevierStylePara elsevierViewall">Francisco Jos&#233; Cambra-Lasaosa&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Chief of the Paediatric Intensive Care Unit&#44; Hospital Sant Joan de D&#233;u&#44; Barcelona&#46; Associate professor&#44; Universidad de Barcelona&#46; President of the SECIP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0310" class="elsevierStylePara elsevierViewall">Juan Ignacio S&#225;nchez-D&#237;az&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Chief of the Jefe de la Paediatric Intensive Care and Emergency Department of the Hospital Universitario 12 de Octubre&#44; Madrid&#46; Associate professor&#44; Department of Paediatrics&#44; School of Medicine&#44; Universidad Complutense de Madrid&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">-</span><p id="par0315" class="elsevierStylePara elsevierViewall">Ram&#243;n Hern&#225;ndez-Rastrollo&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Chief of the Paediatric Intensive Care Unit of the Hospital Universitario Materno-Infantil&#44; Badajoz&#46; Associate professor of Paediatrics&#44; Department of Biomedical Sciences&#44; School of Medicine&#44; Universidad de Extremadura&#46; Member of the Executive Board of the SECIP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0320" class="elsevierStylePara elsevierViewall">Esther Ocete-Hita&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Specialty physician&#44; Paediatric Intensive Care unit&#44; Hospital Virgen de Las Nieves&#44; Granada&#46; Associate professor of Paediatrics&#44; Universidad de Granada&#46; Secretary of the SECIP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">-</span><p id="par0325" class="elsevierStylePara elsevierViewall">Ana Serrano-Gonz&#225;lez&#46; Specialist in Paediatrics&#46; Accredited for practice of Paediatric Critical Care&#46; Doctor in Medicine&#46; Chief of the Paediatric Intensive Care Unit&#44; Hospital Ni&#241;o Jes&#250;s&#44; Madrid&#46; Associate professor&#44; Department of Paediatrics&#44; School of Medicine&#44; Universidad Aut&#243;noma de Madrid&#46;</p></li></ul></p> <p id="par0330" class="elsevierStylePara elsevierViewall">Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#40;Spanish Society of Intensive and Critical Care Medicine and Coronary Units &#91;SEMICYUC&#93;&#41;&#46; Paediatric Intensive Care Standards Committee&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">-</span><p id="par0335" class="elsevierStylePara elsevierViewall">Manuel Quintana-D&#237;az&#46; Specialist in Paediatrics&#46; Doctor in Medicine&#46; Specialist physician&#44; medical staff of the Department of Intensive Care&#44; Hospital Universitario La Paz-Carlos <span class="elsevierStyleSmallCaps">III</span>&#44; Madrid&#46; Associate professor of Health Sciences&#44; Universidad Aut&#243;noma de Madrid&#46; Secretary of the SEMICYUC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">-</span><p id="par0340" class="elsevierStylePara elsevierViewall">Mar&#237;a Cruz Mart&#237;n-Delgado&#46; Specialist in Intensive Care Medicine&#46; Doctor in Medicine&#46; Chief of the Department of Intensive Care&#44; Hospital Universitario de Torrej&#243;n&#46; Associate professor&#44; Universidad Francisco de Vitoria&#46; President of the SEMICYUC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">-</span><p id="par0345" class="elsevierStylePara elsevierViewall">Mar&#237;a Soledad Holanda-Pe&#241;a&#46; Specialist in Intensive Care Medicine&#46; Doctor in Medicine&#46; Coordinator of the Mother&#39;s and Children&#39;s Intensive Care Unit&#44; Hospital Universitario Marqu&#233;s de Valdecilla&#44; Santander&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">-</span><p id="par0350" class="elsevierStylePara elsevierViewall">Lluis Blanch&#46; Specialist in Intensive Care Medicine&#46; Doctor in Medicine&#46; Critical Care Centre&#44; Corporaci&#243; Sanitaria Parc Taul&#237;&#44; Sabadell&#46; Biomedical Research Networking Centre consortium &#40;CIBER&#41; on Respiratory Diseases&#44; Instituto de Salud Carlos <span class="elsevierStyleSmallCaps">III</span>&#44; Madrid&#46; Instituto de Investigaci&#243;n e Innovaci&#243;n Parc Taul&#237;&#44; Sabadell&#46; Former President of the SEMICYUC&#46;</p></li></ul></p>"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2017.10.009

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