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FUHRMAN & ZIMMERMAN’S
PEDIATRIC
CRITICAL CARE
SIXTH EDITION
FUHRMAN & ZIMMERMAN’S
PEDIATRIC
CRITICAL CARE
JERRY J. ZIMMERMAN, MD, PhD, FCCM ALEXANDRE T. ROTTA, MD, FCCM
Faculty, Pediatric Critical Care Medicine, Seattle Children’s Division Chief, Pediatric Critical Care Medicine Duke
Hospital, Harborview Medical Center, University of Children’s Hospital; Professor of Pediatrics; Duke University
Washington School of Medicine, Seattle, Washington School of Medicine, Durham, North Carolina
Robert S.B. Clark, MD Sapna Ravi Kudchadkar, MD, PhD, FCCM

Professor and Vice Chair, Critical Care Medicine, University Associate Professor, Anesthesiology and Critical Care
of Pittsburgh School of Medicine; Associate Director, Safar Medicine, Pediatrics, and Physical Medicine and
Center for Resuscitation Research, University of Pittsburgh, Rehabilitation, Charlotte R. Bloomberg Children’s Center,
Pittsburgh, Pennsylvania Johns Hopkins University School of Medicine, Baltimore,
Maryland
Bradley P. Fuhrman, MD, FAAP, MCCM

Professor of Pediatrics in Medical Education, Monica Relvas, MD, FAAP, FCCM, MSHA
Clinical Educator and Gold College Mentor, Paul L. Foster Medical Director, Pediatric Critical Care Medicine,
School of Medicine, Texas Tech University HSC El Paso, Covenant Children’s Hospital, Associate Clinical Professor,
El Paso, Texas Texas Tech University, Lubbock, Texas
Joseph D. Tobias, MD
Chair, Department of Anesthesiology and Pain Medicine,
Nationwide Children’s Hospital; Professor of Anesthesiology
and Pediatrics, The Ohio State University, Columbus, Ohio
Elsevier
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899
FUHRMAN AND ZIMMERMAN’S PEDIATRIC CRITICAL CARE,

SIXTH EDITION ISBN: 978-0-323-67269-6
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid ad-
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Previous editions copyrighted 2017, 2011, 2006, 1998, 1992 by Elsevier, Inc.
Library of Congress Control Number: 2020930336
Content Strategist: Michael Houston

Senior Content Development Specialist: Jennifer Ehlers
Publishing Services Manager: Catherine Jackson
Senior Project Manager/Specialist: Carrie Stetz
Design Direction: Patrick Ferguson
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors
Isaac Josh Abecassis, MD Ben D. Albert, MD

Resident Physician Program Director, Critical Care Medicine Fellowship
Department of Neurological Surgery Department of Anesthesiology, Critical Care, and Pain Medicine
University of Washington Boston Children’s Hospital
Seattle, Washington Boston, Massachusetts
Jayani Abeysekera, MD, FRCP Alicia Alcamo, MD, MPH

Assistant Professor Assistant Professor of Critical Care and Pediatrics
Department of Pediatrics Department of Anesthesiology and Critical Care Medicine
Division of Cardiology University of Pennsylvania Perelman School of Medicine
Dalhousie University/IWK Health Centre Children’s Hospital of Philadelphia
Halifax, Nova Scotia, Canada Philadelphia, Pennsylvania
P. David Adelson, MD, FAAP, FACS, FAANS Matthew N. Alder, MD, PhD
Diane and Bruce Halle Chair of Children’s Neurosciences Assistant Professor
Director, Barrow Neurological Institute at Phoenix Children’s Critical Care Medicine
Hospital Cincinnati Children’s Hospital Medical Center
Professor, Department of Child Health Cincinnati, Ohio
University of Arizona College of Medicine;
Professor, Department of Neurosurgery Omar Alibrahim, MD, FAAP
Mayo Clinic Chief, Pediatric Critical Care Division
Phoenix, Arizona John R. Oishei Children’s Hospital
Associate Professor of Pediatrics
Rachel S. Agbeko, FRCPCH, PhD Jacob’s School of Medicine
Consultant University of Buffalo
Paediatric Intensive Care Unit Buffalo, New York
Great North Children’s Hospital
Newcastle upon Tyne Hospitals NHS Trust Veerajalandhar Allareddy, MBBS, MBA
Newcastle upon Tyne, United Kingdom Section Chief, Pediatric Cardiac Intensive Care
Duke University Medical Center
Michael S.D. Agus, MD Professor of Pediatrics
Chief of Medical Critical Care Duke University School of Medicine
Department of Pediatrics Durham, North Carolina
Division of Medical Critical Care
Boston Children’s Hospital Melvin C. Almodovar, MD
Boston, Massachusetts The George E. Batchelor Chair in Pediatric Cardiology
Chief, Pediatric Cardiology
Mubbasheer Ahmed, MD University of Miami Miller School of Medicine;
Cardiac Intensive Care Unit Director, Children’s Heart Center
Texas Medical Center Director, Cardiac Intensive Care
Texas Children’s Hospital Hotz Children’s Hospital, Jackson Health System
Houston, Texas Miami, Florida
Alireza Akhondi-Asl, PhD Alexandra Aminoff, MD

Departments of Anesthesiology, Critical Care, and Pain Acting Assistant Professor
Medicine Department of Pediatric Rheumatology
Division of Critical Care Seattle Children’s Hospital
Boston Children’s Hospital Seattle, Washington
Boston, Massachusetts
v
vi Contributors
Catherine Amlie-Lefond, MD Adnan M. Bakar, MD

Professor Assistant Professor of Pediatrics
Department of Neurology Section Head, Pediatric Cardiac Critical Care
University of Washington Cohen Children’s Medical Center of Hofstra/Northwell
Seattle, Washington New Hyde Park, New York
Rajesh Aneja, MD Katherine Banker, MD

Clinical Chief, Division of Pediatric Critical Care Medicine Clinical Assistant Professor
Medical Director, Pediatric Intensive Care Unit Department of Pediatrics, Critical Care
Children’s Hospital of Pittsburgh of UPMC; Seattle Children’s Hospital
Professor Seattle, Washington
Department of Critical Care Medicine and Pediatrics
University of Pittsburgh School of Medicine Piers C.A. Barker, MD
Pittsburgh, Pennsylvania Professor of Pediatrics and Obstetrics/Gynecology
Department of Pediatrics
Abigail Apple, ARNP Duke University School of Medicine
Pediatric Critical Care Durham, North Carolina
Seattle Children’s Hospital
Seattle, Washington Lee M. Bass, MD
Andrew C. Argent, MD Departments of Gastroenterology, Hepatology & Nutrition
Professor Ann & Robert H. Lurie Children’s Hospital of Chicago
School of Child and Adolescent Health Northwestern University Feinberg School of Medicine
University of Cape Town; Chicago, Illinois
Medical Director
Paediatric Intensive Care Rajit K. Basu, MD, MS, FCCM
Red Cross War Memorial Children’s Hospital Associate Professor of Pediatrics
Cape Town, South Africa Emory School of Medicine;
Research Director
Joan C. Arvedson, PhD Division of Pediatric Critical Care Medicine
Program Coordinator, Feeding & Swallowing Services Children’s Healthcare of Atlanta
Speech Pathology and Audiology Atlanta, Georgia
Children’s Hospital of Wisconsin;
Clinical Professor Hülya Bayir, MD
Department of Pediatrics Safar Center for Resuscitation Research
Medical College of Wisconsin Department of Critical Care Medicine
Milwaukee, Wisconsin University of Pittsburgh School of Medicine
Children’s Hospital of Pittsburgh of UPMC
François Aspesberro, MD Pittsburgh, Pennsylvania
Pediatric Cardiothoracic ICU
Miller Children’s & Women’s Hospital Long Beach Lance B. Becker, MD
Long Beach, California Chair, Emergency Medicine
Donald and Barbara Zucker School of Medicine at
Nir Atlas, MD Hofstra/Northwell
Clinical Fellow Hempstead, New York
Division of Pediatric Critical Care
Children’s Healthcare of Atlanta–Egleston Jamie L. Bell, MD
Emory University School of Medicine Assistant Professor of Pediatrics
Atlanta, Georgia Department of Pediatrics
Children’s Hospital of Michigan
John E. Baatz, PhD Wayne State University School of Medicine
Professor Detroit, Michigan
Medical University of South Carolina Michael J. Bell, MD
Charleston, South Carolina Chief, Pediatric Critical Care Medicine
Harris P. Baden, MD Children’s National Medical Center
Professor and Chief Washington, DC
Pediatric Cardiac Critical Care
University of Washington
Seattle, Washington
Contributors vii
Melania M. Bembea, MD, MPH, PhD Naomi B. Bishop, MD

Associate Professor Assistant Professor
Department of Anesthesiology and Critical Care Medicine Department of Pediatric Critical Care Medicine
Johns Hopkins University School of Medicine Weill Cornell Medical College
Baltimore, Maryland New York, New York
M.A. Bender, MD, PhD Julie Blatt, MD

Director, Sickle Cell and Hemoglobinopathy Program Professor
Odessa Brown Children’s Clinic; Pediatric Hematology Oncology
Associate Professor University of North Carolina
Department of Pediatrics Chapel Hill, North Carolina
Seattle, Washington Lauren Bodilly, MD
Critical Care Fellow
Alexis L. Benscoter, DO Department of Pediatric Critical Care
Assistant Professor of Clinical Pediatrics Cincinnati Children’s Hospital
University of Cincinnati College of Medicine; Cincinnati, Ohio
Department of Cardiac Critical Care Medicine
Division of Cardiology Robert H. Bonow, MD
Cincinnati Children’s Hospital Medical Center Resident Physician
Cincinnati, Ohio Department of Neurological Surgery
Wade W. Benton, PharmD Seattle, Washington
Chief Development Officer
Eicos Sciences, Inc. E. Alexis Bragg, MD
San Mateo, California Assistant Professor of Anesthesiology and Pediatrics
Department of Anesthesia and Critical Care Medicine
Robert A. Berg, MD Children’s Hospital Los Angeles
Professor Keck School of Medicine–University of Southern California
Departments of Anesthesiology, Critical Care Medicine, Los Angeles, California
and Pediatrics
University of Pennsylvania Perelman School of Medicine; Barbara W. Brandom, MD
Division Chief, Critical Care Medicine Retired Professor
Departments of Anesthesiology and Critical Care Medicine Department of Anesthesiology
Children’s Hospital of Philadelphia University of Pittsburgh;
Philadelphia, Pennsylvania Retired Director
North American MH Registry of MHAUS
Emily Berkman, MD Pittsburgh, Pennsylvania
Assistant Professor
Departments of Pediatrics and Bioethics and Humanities Richard J. Brilli, MD
University of Washington School of Medicine; Chief Medical Officer
Division of Pediatric Critical Care Hospital Administration
Department of Pediatric Bioethics Nationwide Children’s Hospital;
Treuman Katz Center for Pediatric Bioethics Professor
Seattle Children’s Hospital Department of Pediatrics
Seattle, Washington Division of Critical Care Medicine
The Ohio State University College of Medicine
Carol Berkowitz, MD Columbus, Ohio
Chief, Division of General Pediatrics
Department of Pediatrics Thomas V. Brogan, MD
Harbor-UCLA Medical Center Professor
Torrance, California; Department of Pediatrics
Distinguished Professor of Pediatrics University of Washington School of Medicine
David Geffen School of Medicine at UCLA Seattle, Washington
Los Angeles, California
Ronald A. Bronicki, MD, FCCM, FACC
Katherine V. Biagas, MD Professor
Associate Professor Departments of Critical Care Medicine and Cardiology
Department of Pediatrics Texas Children’s Hospital and Baylor College of Medicine
Vice Chairman for Faculty Development Houston, Texas
Stony Brook Children’s and the Renaissance School of Medicine
Stony Brook, New York
viii Contributors
Samuel R. Browd, MD, PhD, FAANS, FAAP Michael P. Carboni, MD

Professor Medical Director, Pediatric Heart Failure & Transplant
Department of Neurological Surgery Department of Pediatrics
Seattle Children’s Hospital Duke Children’s Hospital
University of Washington Durham, North Carolina
Seattle, Washington
Joseph A. Carcillo, MD
Timothy E. Bunchman, MD Professor of Critical Care Medicine and Pediatrics
Professor and Director, Pediatric Nephrology Children’s Hospital of Pittsburgh
Children’s Hospital of Richmond University of Pittsburgh School of Medicine
Virginia Commonwealth University School of Medicine Pittsburgh, Pennsylvania
Richmond, Virginia
Antonio Cassara, MBChB
Jeffrey P. Burns, MD, MPH Associate Professor
Chief and Endowed Shapiro Chair of Critical Care Medicine Department of Anesthesia
Chair, Governance Committee of the Intensive Care Units Ruby Memorial Hospital
Boston Children’s Hospital Morgantown, West Virginia
Professor of Anesthesia
Harvard Medical School Nina Censoplano, MD
Boston, Massachusetts Attending physician
Pediatric Critical Care Medicine
David F. Butler, MD INOVA Fairfax Medical Center
Fellow Falls Church, Virginia
Division of Critical Care Victoria Chadwick, PharmD, BCCCP
Seattle Children’s Hospital Critical Care Pharmacist
Seattle, Washington Seattle Children’s Hospital
Seattle, Washington
Derya Caglar, MD
Fellowship Director, Pediatric Emergency Medicine Reid C. Chamberlain, MD
Associate Professor, Pediatrics Pediatric Cardiology Fellow
University of Washington School of Medicine Department of Pediatrics
Attending Physician Duke University Hospital
Division of Pediatric Emergency Medicine Durham, North Carolina
Seattle, Washington Anny Chan, PharmD
Hematopoietic Stem Cell Transplant Clinical Pharmacist
Michael W. Camitta, MD Seattle Children’s Hospital
Associate Professor of Pediatrics Seattle, Washington
Duke University School of Medicine John R. Charpie, MD, PhD
Durham, North Carolina Amnon Rosenthal Professor & Director of Pediatric Cardiology
University of Michigan Medical School
M. Jay Campbell, MD, MHA Co-Director, University of Michigan Congenital Heart Center
Associate Professor of Pediatrics C.S. Mott Children’s Hospital
Department of Pediatrics Michigan Medicine
Duke University School of Medicine Ann Arbor, Michigan
Durham, North Carolina
Ira M. Cheifetz, MD
Sally Campbell, MBBS(Hons), FRACP, FRCPA Professor
Paediatric Haematologist Departments of Pediatrics and Anesthesiology
Royal Children’s Hospital Duke University Medical Center
Melbourne, Australia Durham, North Carolina
Karel D. Capek, MD Saurabh Chiwane, MD

Fellow Assistant Professor
Acute Burn, Critical Care, and Reconstruction Department of Pediatrics
Shriners Hospitals for Children Saint Louis University
Galveston and the University of Texas Medical Branch St. Louis, Missouri
Galveston, Texas
Contributors ix
Robert H. Chun, MD Craig M. Coopersmith, MD

Associate Professor Professor
Department of Pediatric Otolaryngology Department of Surgery
Medical College of Wisconsin Emory University
Milwaukee, Wisconsin Atlanta, Georgia
Jeff Clark, MD Seth J. Corey, MD, MPH

Staff Intensivist Professor
Pediatric Critical Care Medicine Departments of Pediatrics and Molecular Medicine
Vice Chair of Pediatrics Cleveland Clinic
Ascension St. John Children’s Hospital Cleveland, Ohio
Detroit, Michigan
Mary K. Dahmer, PhD
Jonna D. Clark, MD Associate Professor
Associate Professor Department of Pediatrics
Departments of Pediatrics and Critical Care Medicine Division of Critical Care
University of Washington; University of Michigan Medical School
Faculty Ann Arbor, Michigan
Treuman Katz Center for Pediatric Bioethics
Seattle Children’s Hospital Heidi J. Dalton, MD, MCCM, FELSO
Seattle, Washington Director of ECMO Program Development and Research
INOVA Fairfax Medical Center
Robert S.B. Clark, MD Falls Church, Virginia;
Professor and Vice Chair Professor of Pediatrics
Critical Care Medicine Virginia Commonwealth University
University of Pittsburgh School of Medicine; Richmond, Virginia;
Associate Director, Safar Center for Resuscitation Research Professor of Clinical Surgery
University of Pittsburgh George Washington University
Pittsburgh, Pennsylvania Washington, DC
April Clawson, MD Rahul C. Damania, MD, FAAP

Fellow Clinical Fellow
Pediatric Emergency Medicine Division of Pediatric Critical Care
University of Arkansas Medical Center Children’s Healthcare of Atlanta–Egleston
Little Rock, Arkansas Emory University School of Medicine
Atlanta, Georgia
Jason A. Clayton, MD, PhD
Assistant Professor Mihaela A. Damian, MD, MPH
Department of Pediatrics Clinical Assistant Professor
Rainbow Babies & Children’s Hospital Department of Pediatrics
Cleveland, Ohio Stanford University
Palo Alto, California
Thomas Conlon, MD
Assistant Professor Lauren Dartois, PharmD
Department of Pediatric Critical Care Medicine Critical Care Clinical Pharmacist
The Children’s Hospital of Philadelphia Seattle Children’s Hospital
Philadelphia, Pennsylvania Seattle, Washington
Carol Conrad, MD Peter J. Davis, MD, FAAP

Associate Professor Professor
Department of Pediatrics Departments of Anesthesiology and Pediatrics
Stanford University University of Pittsburgh School of Medicine;
Palo Alto, California Anesthesiologist-in-Chief
Department of Anesthesiology
Edward E. Conway Jr, MD, MS Children’s Hospital of Pittsburgh of UPMC
Chairman and Pediatrician-in-Chief Pittsburgh, Pennsylvania
Milton and Bernice Stern Department of Pediatrics
Beth Israel Medical Center;
Professor of Pediatrics
Icahn School of Medicine at Mount Sinai
New York, New York
x Contributors
Leslie A. Dervan, MD Allan Doctor, MD

Assistant Professor Professor of Pediatrics (Critical Care)
Department of Pediatrics Director, Center for Blood Oxygen Transport and Hemostasis
Seattle Children’s Hospital University of Maryland School of Medicine
University of Washington School of Medicine Baltimore, Maryland
Seattle, Washington
John J. Downes, MD
Clifford S. Deutschman, MS, MD, MCCM Professor Emeritus of Anesthesiology and Critical Care, and
Vice Chair, Research Pediatrics
Department of Pediatrics University of Pennsylvania Perelman School of Medicine
Professor of Pediatrics and Molecular Medicine Chair Emeritus of Anesthesiology and Critical Care Medicine
Donald and Barbara Zucker School of Medicine at Children’s Hospital of Philadelphia
Hofstra/Northwell Philadelphia, Pennsylvania
Hempstead, New York;
Cohen Children’s Medical Center Christine Duncan, MD
New York, New York; Associate Clinical Director of Pediatric HSCT
Professor, Elmezzi Graduate School of Molecular Medicine Senior Physician
Professor, Feinstein Institutes for Medical Research Dana Farber/Boston Children’s Cancer and Blood Disorders
Manhasset, New York; Center;
Emeritus Professor of Anesthesiology & Critical Care and Assistant Professor of Pediatrics
Surgery Harvard Medical School
Perelman School of Medicine at the University of Pennsylvania Boston, Massachusetts
Philadelphia, Pennsylvania
Christopher M. Edwards, MD
Cameron Dezfulian, MD, FAHA Assistant Professor
Director, Adult Congenital Heart Disease ICU Department of Anesthesiology
Critical Care Medicine Section University of Florida College of Medicine
Texas Children’s Hospital; Gainesville, Florida
Senior Faculty
Baylor College of Medicine Lauren R. Edwards, MD
Houston, Texas Assistant Professor
Pediatric Critical Care
André A.S. Dick, MD, MPH University of Arkansas for Medical Sciences/Arkansas Children’s
Associate Professor of Surgery Hospital
ASTS Transplant Fellowship Director Little Rock, Arkansas
Surgical Director, Pediatric Kidney Transplant
Department of Surgery Chinyere Egbuta, MD
Division of Transplantation Instructor
Seattle Children’s Hospital Department of Anesthesia
University of Washington School of Medicine Harvard Medical School;
Seattle, Washington Associate Professor
Anesthesia and Critical Care Medicine
Douglas S. Diekema, MD, MPH Boston Children’s Hospital
Professor Boston, Massachusetts
University of Washington; Howard Eigen, MD
Director of Education Professor of Pediatrics, Retired
Treuman Katz Center for Pediatric Bioethics Department of Pediatrics
Seattle Children’s Research Institute Indiana University School of Medicine
Seattle, Washington Indianapolis, Indiana
Michael Dingeldein, MD Hannah Laure Elfassy, MD, FRCP(c)

Trauma Medical Director Chief
Rainbow Babies & Children’s Hospital Department of Allergy and Clinical Immunology
Assistant Professor of Surgery Sacré Coeur Hospital
Case Western Reserve University Montreal, Quebec, Canada
Cleveland, Ohio
Contributors xi
Alison M. Ellis, MD, MBA Joseph T. Flynn, MD

Assistant Professor Chief, Division of Nephrology
Anesthesia and Perioperative Medicine Department of Pediatrics
Charleston, South Carolina Seattle Children’s Hospital;
Professor
Idris V.R. Evans, MD Department of Pediatrics
Assistant Professor University of Washington School of Medicine
Department of Critical Care Medicine Seattle, Washington
University of Pittsburgh
Pittsburgh, Pennsylvania Michael L. Forbes, MD, FCCM
Professor and Associate Chair
Reid W.D. Farris, MD Department of Pediatrics
Associate Professor Northeast Ohio Medical University;
Department of Pediatrics Director, Critical Care Research & Outcomes Analysis
Division of Critical Care Medicine Akron Children’s Hospital
University of Washington Akron, Ohio
Seattle, Washington
Joseph M. Forbess, MD
Jeffrey R. Fineman, MD Department of Surgery
Professor Northwestern University Feinberg School of Medicine
Department of Pediatrics Chicago, Illinois
University of California, San Francisco
San Francisco, California Deborah E. Franzon, MD
Clinical Professor
Ericka L. Fink, MD Department of Pediatric Medicine
Associate Professor of Critical Care Medicine Division of Critical Care Medicine
University of Pittsburgh School of Medicine University of California, San Francisco
Children’s Hospital of Pittsburgh of UPMC; San Francisco, California
Associate Director
Safar Center for Resuscitation Research W. Joshua Frazier, MD
University of Pittsburgh Medical Center Assistant Professor of Pediatrics
Pittsburgh, Pennsylvania Critical Care Medicine
Nationwide Children’s Hospital
Frank A. Fish, MD Columbus, Ohio
Professor
Department of Pediatrics Bradley P. Fuhrman, MD, FAAP, MCCM
Vanderbilt Medical Center Professor of Pediatrics in Medical Education
Nashville, Tennessee Clinical Educator and Gold College Mentor
Paul L. Foster School of Medicine
Tamara N. Fitzgerald, MD, PhD Texas Tech University HSC El Paso
Assistant Professor El Paso, Texas
Department of Surgery
Duke University Richard M. Ginther Jr, MBA, BS
Durham, North Carolina Pediatric Perfusionist
Pediatric Cardiothoracic Surgery
Gregory A. Fleming, MD, MSCI, FSCAI UT Southwestern Medical Center
Associate Professor Dallas, Texas
Duke University Nicole Glaser, MD
Durham, North Carolina Professor
Saul Flores, MD Section of Endocrinology and Diabetes
Assistant Professor University of California, Davis
Pediatrics/Critical Care Sacramento, California
Baylor College of Medicine;
Attending Physician Ana Lia Graciano, MD, FCCM
Texas Children’s Hospital Professor of Pediatrics
Houston, Texas Medical Director CICU
Pediatric Critical Care Medicine
University of Maryland Children’s Hospital
Baltimore, Maryland
xii Contributors
Megan M. Gray, MD Cary O. Harding, MD

Assistant Professor of Pediatrics Professor
Department of Pediatrics Department of Molecular and Medical Genetics
Division of Neonatology Oregon Health & Science University
Fellowship Program Director for Neonatal-Perinatal Medicine Portland, Oregon
University of Washington School of Medicine Mary E. Hartman, MD, MPH
Kristin C. Greathouse, CPNP-AC, PhD Washington University in St. Louis
Heart Center St. Louis, Missouri
University of Minnesota Masonic Children’s Hospital
Minneapolis, Minnesota Silvia M. Hartmann, MD
Assistant Professor
Bruce M. Greenwald, MD, FAAP, FCCM Critical Care Medicine
Professor of Clinical Pediatrics Seattle Children’s Hospital
Executive Vice-Chair, Department of Pediatrics Seattle, Washington
Division of Pediatric Critical Care Medicine
Weill Cornell Medical College Kevin M. Havlin, MD
New York, New York Assistant Professor
Matthew M. Grinsell, MD, PhD Division of Pediatric Critical Care
Associate Professor University of Louisville
Department of Pediatrics Louisville, Kentucky
University of Utah
Salt Lake City, Utah Kristen Hayward, MD
Associate Professor
Jocelyn R. Grunwell, MD Department of Pediatrics
Assistant Professor Division of Rheumatology
Department of Pediatrics Seattle Children’s Hospital
Division of Critical Care Medicine University of Washington School of Medicine
Emory University/Children’s Healthcare of Atlanta Seattle, Washington
Atlanta, Georgia
Patrick J. Healey, MD
Björn Gunnarsson, MD Professor
Department of Research Department of Surgery
Norwegian Air Ambulance Foundation University of Washington School of Medicine
Drøbak, Norway Division Chief, Pediatric Transplant Surgery
SAR Helicopter Seattle Children’s Hospital
Ørland Main Air Station, Norway Seattle, Washington
Marla Guzman, MD Christopher M.B. Heard, MBChB, FRCA

Fellow Clinical Professor
Pediatric Rheumatology Department of Anesthesiology
Cohen Children’s Medical Center-Zucker School of Medicine at Clinical Professor
Hofstra/Northwell Division of Pediatric Critical Care
New Hyde Park, New York Oishei Children’s Hospital
Buffalo, New York
Timothy Hahn, MD
Fellow Julia A. Heneghan, MD
Department of Pediatrics Assistant Professor
Penn State Children’s Hospital Pediatric Critical Care
Hershey, Pennsylvania University of Minnesota Masonic Children’s Hospital
Minneapolis, Minnesota
Mark W. Hall, MD
Chief, Division of Critical Care Medicine David N. Herndon, MD
Department of Pediatrics Editor, Burn Care and Research
Nationwide Children’s Hospital American Burn Association
Columbus, Ohio Chicago, Illinois
Contributors xiii
Lynn J. Hernan, MD Laura Marie Ibsen, MD

Associate Professor of Pediatrics Professor of Pediatrics
Pediatric Clerkship Director Division Chief, Pediatric Critical Care
Texas Tech University HSC El Paso Department of Pediatrics
Paul L. Foster School of Medicine Oregon Health and Sciences University
El Paso, Texas Portland, Oregon
Kevin D. Hill, MD, MSCI Hanneke Ijsselstijn, MD, PhD

Associate Professor Associate Professor of Pediatrics
Department of Pediatrics Department of Pediatric Surgery and Intensive Care
Duke University Medical Center Erasmus Medical Center, Sophia Children’s Hospital
Durham, North Carolina Rotterdam, The Netherlands
Julien I. Hoffman† Travis C. Jackson, PhD

Professor (Emeritus) Associate Professor of Molecular Pharmacology & Physiology
Pediatrics University of South Florida
University of California, San Francisco Morsani College of Medicine
San Francisco, California USF Health Heart Institute
Tampa, Florida
Paula Holinski, MD, FRCPC
Clinical Assistant Professor of Anesthesiology Shelina M. Jamal, MD
University of Alberta Clinical Assistant Professor
Pediatric Anesthesia and Pediatric Cardiac Intensive Care Pediatric Critical Care
Stollery Children’s Hospital Alberta Children’s Hospital
Edmonton, Alberta, Canada Calgary, Alberta, Canada
Sue J. Hong, MD Prashant Joshi, MD

Assistant Professor Associate Professor
Departments of Pediatrics and Neurology Department of Pediatrics
Northwestern University Texas Tech University Health Sciences Center El Paso
Lurie Children’s Hospital of Chicago El Paso, Texas
Chicago, Illinois
Emily L. Joyce, MD
Simon Horslen, MB ChB Assistant Professor
Professor Department of Pediatrics, Division of Nephrology
Department of Pediatrics UH Rainbow Babies and Children’s Hospital
University of Washington School of Medicine; Case Western Reserve University School of Medicine
Medical Director of Solid Organ Transplantation Cleveland, Ohio
Department of Gastroenterology, Hepatology & Nutrition
Seattle Children’s Hospital Tom Kallay, MD
Seattle, Washington Chief, Division of Pediatric Critical Care Medicine
Director, Simulation and Educational Resource Center for
Aparna Hoskote, MBBS, DCH, MRCP, MD Improved Patient Safety and Outcomes
Consultant in Cardiac Intensive Care Harbor-UCLA Medical Center
Honorary Senior Lecturer Torrance, California;
UCL Great Ormond Street Institute of Child Health Associate Professor of Clinical Pediatrics
Great Ormond Street Hospital for Children David Geffen School of Medicine
NHS Foundation Trust Los Angeles, California
London, United Kingdom
Pradip P. Kamat, MD
Justin C. Hotz, BSRT, RRT-NPS Medical Director, Sedation
Senior Research Associate Children’s Healthcare of Atlanta
Department of Anesthesia and Critical Care Medicine Atlanta, Georgia
Children’s Hospital Los Angeles
Los Angeles, California Jason M. Kane, MD, MS, FAAP, FCCM
Department of Pediatric Critical Care Medicine
University of Chicago Comer Children’s Hospital
Chicago, Illinois
†
Deceased.
xiv Contributors
Prince J. Kannankeril, MD Christa Jefferis Kirk, PharmD, BCCP

Professor Heart Center Clinical Pharmacy Specialist
Department of Pediatrics Seattle Children’s Hospital;
Vanderbilt Children’s Hospital Clinical Associate Professor
Nashville, Tennessee School of Pharmacy
Oliver Karam, MD, PhD Seattle, Washington
Division Chief
John J. Mickell Endowed Associate Professor of Pediatrics Sonya Kirmani, MD
Department of Pediatrics Medical Instructor
Children’s Hospital of Richmond at VCU Department of Pediatrics
Richmond, Virginia Duke University
Katherine L. Kenningham, MD
Fellow, Neonatal-Perinatal Medicine Ruth Kleinpell, PhD, RN, APRN-BC
Department of Pediatrics Director, Center for Clinical Research and Scholarship
Division of Neonatology Assistant Dean for Clinical Scholarship
Seattle Children’s Hospital Vanderbilt University School of Nursing
University of Washington School of Medicine Nashville, Tennessee
Seattle, Washington
Patrick M. Kochanek, MD, MCCM
Hedieh Khalatbari, MD, MBA Ake N. Grenvik Professor in Critical Care Medicine
Assistant Professor of Pediatric Radiology Department of Critical Care Medicine
Department of Radiology University of Pittsburgh School of Medicine
Seattle Children’s Hospital and University of Washington Pittsburgh, Pennsylvania
Seattle, Washington
Keith C. Kocis, MD, MS
Robinder G. Khemani, MD, MsCI Director, Pediatric Cardiac ICU
Associate Director of Research Co-Director, Pediatric ECLS
Department of Anesthesiology and Critical Care Medicine Inova Children’s Hospital
Children’s Hospital Los Angeles; Inova Heart and Vascular Institute;
Associate Professor of Pediatrics Professor of Pediatrics
Keck School of Medicine VCU School of Medicine Inova Campus
University of Southern California Falls Church, Virginia
Los Angeles, California
Samuel A. Kocoshis, MD
Elizabeth Y. Killien, MD, MPH Professor
Acting Assistant Professor Department of Pediatrics
Department of Pediatrics University of Cincinnati College of Medicine;
Division of Pediatric Critical Care Medicine Medical Director, Intestinal Transplantation and Intestinal Care
Seattle Children’s Hospital Center
University of Washington Department of Gastroenterology, Hepatology, and Nutrition
Seattle, Washington Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio
Yun Kim, MS, OTR/L
Pediatric Rehabilitation Clinical Specialist Ildiko H. Koves, MD, FRACP
Department of Physical Medicine and Rehabilitation Associate Professor
Johns Hopkins Children’s Center Department of Endocrinology and Diabetes
Baltimore, Maryland Seattle Children’s Hospital
Seattle, Washington
Jenny Kingsley, MD
Fellow Sapna R. Kudchadkar, MD, PhD
Pediatric Critical Care Medicine Associate Professor of Anesthesiology and Critical Care
Treuman Katz Center for Pediatric Bioethics Medicine, Pediatrics, and Physical Medicine and
Seattle Children’s Hospital Rehabilitation
Seattle, Washington Charlotte R. Bloomberg Children’s Center
Johns Hopkins University School of Medicine
Baltimore, Maryland
Contributors xv
Thomas J. Kulik, MD John C. Lin, MD

Senior Associate in Cardiology Associate Professor
Department of Cardiology Department of Pediatrics
Boston Children’s Hospital Washington University School of Medicine
Associate Professor of Pediatrics St. Louis, Missouri
Harvard Medical School
Boston, Massachusetts Aline Maddux, MD
Assistant Professor of Pediatrics
Jacques Lacroix, MD Department of Pediatric Critical Care
Professor University of Colorado Anschutz Medical Campus
Department of Pediatrics Aurora, Colorado
Sainte-Justine Hospital
Montreal, Quebec, Canada Matthew P. Malone, MD
Assistant Professor
Ruth Lebet, PhD, RN, PCNS-BC, CCNS-P Pediatric Critical Care
Nurse Scientist University of Arkansas for Medical Sciences/Arkansas Children’s
Center for Pediatric Nursing Research & Evidence-Based Hospital
Practice; Little Rock, Arkansas
Program Director, Pediatric & Neonatal CNS Programs
University of Pennsylvania School of Nursing Mioara Manole, MD
Philadelphia, Pennsylvania Associate Professor of Pediatrics
University of Pittsburgh School of Medicine
Amy Lee, MD Children’s Hospital of Pittsburgh of UPMC;
Associate Professor Associate Director
Department of Neurological Surgery Safar Center for Resuscitation Research
University of Washington University of Pittsburgh Medical Center
Seattle, Washington Pittsburgh, Pennsylvania
Hallie Lenker, PT, DPT Anne Marsh, MD

Pediatric Rehabilitation Team Coordinator Associate Professor of Pediatrics
Department of Physical Medicine and Rehabilitation Department of Hematology/Oncology & Bone Marrow
Johns Hopkins Children’s Center Transplant
Baltimore, Maryland University of Wisconsin School of Medicine and Public Health
Madison, Wisconsin
Daniel L. Levin, MD
Professor Emeritus Richard J. Martin, MBBS
Departments of Pediatrics and Anesthesia Professor
Children’s Hospital at Dartmouth Departments of Pediatrics, Reproductive Biology, and Physiology
Lebanon, New Hampshire & Biophysics
Case Western Reserve University School of Medicine;
Emily R. Levy, MD Drusinsky-Fanaroff Professor and Director of Neonatal Research
Assistant Professor Pediatrics/Neonatology
Department of Pediatric and Adolescent Medicine Rainbow Babies & Children’s Hospital
Divisions of Pediatric Critical Care Medicine and Pediatric Cleveland, Ohio
Infectious Diseases
Mayo Clinic Mudit Mathur, MD, MBA, FAAP, FCCM, CPPS
Rochester, Minnesota Director, Pediatric Critical Care
Director, Patient Safety and Risk Management
Mithya Lewis-Newby, MD, MPH Kaiser Permanente Fontana Medical Center;
Associate Professor Associate Professor
Departments of Pediatrics and Bioethics and Humanities Department of Clinical Science
University of Washington School of Medicine; Kaiser Permanente Bernard J. Tyson School of Medicine
Division of Pediatric Cardiac Critical Care Pasadena, California
Treuman Katz Center for Pediatric Bioethics
Seattle Children’s Hospital Jennifer McArthur, MD
Seattle, Washington Associate Member
St. Jude’s Research Hospital
Pediatric Critical Care
Memphis, Tennessee;
Adjunct Associate Professor of Pediatrics
Medical College of Wisconsin
Milwaukee, Wisconsin
xvi Contributors
Christine McCusker, MD Ryan W. Morgan, MD, MTR

Associate Professor Assistant Professor of Anesthesia, Critical Care, and Pediatrics
Department of Pediatrics Department of Anesthesiology and Critical Care Medicine
McGill University; University of Pennsylvania
Director Philadelphia, Pennsylvania
Division of Allergy, Immunology and Dermatology
Montreal Children’s Hospital Peter F. Morgenstern, MD
Montreal, Quebec Assistant Professor
Department of Neurosurgery
Ruth A. McDonald, MD Icahn School of Medicine at Mount Sinai
Professor of Pediatrics New York, New York
Division of Nephrology
University of Washington Michael J. Morowitz, MD
Chief Medical Officer, Hospital Operations Associate Professor
Seattle Children’s Hospital Pediatric General and Thoracic Surgery
Seattle, Washington UPMC Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Nilesh M. Mehta, MD, FASPEN
Professor of Anesthesia Wynne Morrison, MD, MBE
Harvard Medical School; Ingerman Endowed Chair in Palliative Care
Director of Quality and Outcomes Attending Physician, Critical Care and Palliative Care
Director of Critical Care Nutrition Children’s Hospital of Philadelphia
Associate Medical Director Associate Professor of Anesthesiology and Critical Care
Division of Critical Care Medicine Perelman School of Medicine at the University of Pennsylvania
Chair, Critical Care Nutrition and Metabolism Philadelphia, Pennsylvania
Department of Anesthesiology, Critical Care, and Pain Medicine
Boston Children’s Hospital Raj Munshi, MD
Boston, Massachusetts; Associate Professor
Past President Department of Pediatrics
American Society for Parenteral & Enteral Nutrition Seattle Children’s Hospital
Seattle, Washington
Ann J. Melvin, MD, MPH
Professor Jennifer A. Muszynski, MD, MPH
Department of Pediatrics Assistant Professor of Pediatrics
Division of Infectious Disease Critical Care Medicine
Seattle Children’s Hospital Nationwide Children’s Hospital
University of Washington Columbus, Ohio
Seattle, Washington
Vinay M. Nadkarni, MD
Shina Menon, MD Professor
Assistant Professor Departments of Anesthesiology, Critical Care, and Pediatrics
Department of Pediatrics University of Pennsylvania Perelman School of Medicine
Division of Nephrology Philadelphia, Pennsylvania
University of Washington Jessica A. Naiditch, MD
Seattle, Washington Trauma Medical Director
Dell Children’s Medical Center of Central Texas;
Paul Monagle, MBBS, MD Assistant Professor of Surgery
Professor Department of Surgery & Perioperative Care
Department of Paediatrics Dell Medical School, University of Texas Austin;
University of Melbourne; Pediatric Surgeon
Haematologist Austin Pediatric Surgery
Royal Children’s Hospital; Austin, Texas
Group Leader
Haematology Research Thomas A. Nakagawa, MD, FAAP, FCCM
Murdoch Children’s Research Institute Professor
Melbourne, Victoria, Australia Department of Pediatrics
Division of Critical Care Medicine
University of Florida College of Medicine;
Medical Director, Pediatric Intensive Care
Wolfson Children’s Hospital
Jacksonville, Florida
Contributors xvii
Vu Nguyen, MD Todd Otteson, MD, MPH

Assistant Professor Chief
Department of Pediatric Critical Care Division of Pediatric Otolaryngology
Virginia Commonwealth University University Hospitals/Rainbow Babies and Children’s Hospital
Richmond, Virginia Cleveland, Ohio
Jenna R. Nickless, PharmD Yves Ouellette, MD, PhD

Critical Care Pharmacist Assistant Professor
Inpatient Pharmacy Division of Critical Care Medicine
Seattle Children’s Hospital Department of Pediatrics
Seattle, Washington Mayo Clinic
Rochester, Minnesota
Akira Nishisaki, MD
Associate Director, Clinical Implementation Program, ICU Daiva Parakininkas, MD
Department of Anesthesiology and Critical Care Medicine Associate Professor
The Children’s Hospital of Philadelphia Department of Pediatrics
Philadelphia, Pennsylvania Medical College of Wisconsin
Milwaukee, Wisconsin
Victoria F. Norwood, MD
Robert J. Roberts Professor of Pediatrics Robert I. Parker, MD
Chief of Pediatric Nephrology Professor Emeritus
Department of Pediatrics Department of Pediatrics
University of Virginia Stony Brook Children’s Hospital
Charlottesville, Virginia Stony Brook University Renaissance School of Medicine
Stony Brook, New York
Daniel A. Notterman, MA, MD
Professor Katherine Ratzen Peeler, MD
Department of Molecular Biology Department of Pediatrics
Princeton University Division of Medical Critical Care
Princeton, New Jersey Boston Children’s Hospital
Peter Oishi, MD
Professor of Pediatrics Francisco A. Perez, MD, PhD
University of California, San Francisco; Assistant Professor of Pediatric Radiology
Executive Medical Director Department of Radiology
Inpatient Services and Regional Access Seattle Children’s Hospital and University of Washington
UCSF Beinoff Children’s Hospital Seattle, Washington
San Francisco, California
Melvin G. Perry Jr, MD
Jeffrey Ojemann, MD Pediatric Intensivist
Professor Department of Pediatrics
Department of Neurological Surgery Piedmont Henry Hospital
University of Washington Stockbridge, Georgia;
Seattle, Washington Pediatric Intensivist
Michelle L. Olson, MD WellStar Hospital
Department of Pediatric Critical Care Marietta; Georgia
Children’s Hospital of Richmond at VCU
Richmond, Virginia Mark J. Peters, MBChB, MRCP(UK), FRCPCH, PhD
Professor of Paediatric Intensive Care
Jessie O’Neal, PharmD, BCCCP Respiratory, Critical Care and Anaesthesia Unit
Critical Care Pharmacist UCL Great Ormond Street Institute of Child Health;
Seattle Children’s Hospital Honorary Consultant Paediatric Intensivist
Seattle, Washington Paediatric Intensivist Care Unit
Great Ormond Street Hospital for Children NHS Trust
Kirsten Orloff, MD London, United Kingdom
Pediatric Critical Care Medicine Fellow
Duke University Hospital
xviii Contributors
Brent J. Pfeiffer, MD, PhD Thomas M. Raffay, MD

Assistant Professor Assistant Professor
Department of Pediatrics Department of Pediatrics and Neonatology
Division of Critical Care Medicine Rainbow Babies and Children’s Hospital
University of Miami Cleveland, Ohio
Miami, Florida
Prakadeshwari Rajapreyar, MD, FAAP
Rachel Phelan, MD, MPH Pediatric Critical Care
Assistant Professor of Pediatrics Medical College of Wisconsin
Division of Hematology/Oncology/Blood and Marrow Milwaukee, Wisconsin
Transplant
Medical College of Wisconsin Lauren Rakes, MD
Milwaukee, Wisconsin Clinical Assistant Professor
Joseph Philip, MD, FAAP Division of Critical Care Medicine
Associate Professor University of Washington
Medical Director Seattle, Washington
Pediatric Cardiac ICU
Congenital Heart Center Rafael G. Ramos-Jimenez, MD
University of Florida Surgery Resident
Gainesville, Florida Department of General Surgery
UPMC Presbyterian Shadyside
Neethi Pinto, MD, MS Pittsburgh, Pennsylvania
Assistant Professor
Children’s Hospital of Philadelphia Samiran Ray, MBBChir, MA
Philadelphia, Pennsylvania Consultant
Department of Paediatric Intensive Care Medicine
Murray M. Pollack, MD, MBA Great Ormond Street Hospital NHS Foundation Trust
Professor of Pediatrics London, United Kingdom
George Washington University School of Medicine and Health Christopher R. Reed, MD
Sciences; Resident Physician
Director, Clinical Outcomes Research Department of Surgery
Department of Critical Care Duke University Medical Center
Children’s National Medical Center Durham, North Carolina
Washington, DC
James J. Reese Jr, MD
Thomas J. Preston, BS, CCP, FPP Associate Professor of Neurology
Innovative ECMO Concepts, Inc. Department of Neurology
Arcadia, Oklahoma University of New Mexico
Albuquerque, New Mexico
Parthak Prodhan, MD
Professor Kyle J. Rehder, MD
Pediatric Critical Care Associate Professor
University of Arkansas/Arkansas Children’s Hospital Department of Pediatrics
Little Rock, Arkansas Duke Children’s Hospital;
Physician Quality Officer
Lawrence Quang, MD Duke Center for Healthcare Safety and Quality
Professor Duke University Health System
Department of Pediatrics Durham, North Carolina
College of Medicine
University of Arkansas for Medical Sciences Kenneth E. Remy, MD, MSCI, FCCM
Little Rock, Arkansas Assistant Professor of Pediatrics and Internal Medicine
Adult and Pediatric Critical Care Medicine
Michael W. Quasney, MD Washington University in St. Louis
Associate Professor St. Louis, Missouri
Division of Critical Care Jorge D. Reyes, MD
University of Michigan Medical School Professor and Chief, Transplant Surgery
Ann Arbor, Michigan University of Washington School of Medicine
Seattle, Washington
Contributors xix
Eileen Rhee, MD, MS Ahmed Said, MD, PhD

Assistant Professor Assistant Professor of Pediatrics (Critical Care)
Division of Pediatric Critical Care Medicine Center for Blood Oxygen Transport and Hemostasis
Division of Bioethics and Palliative Care University of Maryland School of Medicine
Seattle Children’s Hospital Baltimore, Maryland
Seattle, Washington
Colin J. Sallee
Clare Richardson, MD Pediatric Critical Care Fellow
Fellow Seattle Children’s Hospital/Harborview Medical Center
Division of Pediatric Otolaryngology University of Washington
Seattle Children’s Hospital Seattle, Washington
University of Washington School of Medicine
Seattle, Washington Britt Julia Sandler, MD
Fellow, Pediatric Critical Care Medicine
Joan S. Roberts, MD University of Washington School of Medicine
Associate Professor Seattle, Washington
Department of Pediatrics and Critical Care
Seattle Children’s Hospital Jhuma Sankar, MD
Luciana Rodriguez Guerineau, MD All India Institute of Medical Sciences
Staff Physician New Delhi, India
Division of Cardiac Critical Care Medicine
The Hospital for Sick Children; Ajit A. Sarnaik, MD
Assistant Professor of Paediatrics Associate Professor
Department of Paediatrics Department of Pediatrics
University of Toronto Wayne State University
Toronto, Ontario Detroit, Michigan
Canada
Ashok P. Sarnaik, MD
Stephen Rogers, PhD Professor of Pediatrics
Assistant Professor of Pediatrics Department of Pediatrics
Center for Blood Oxygen Transport and Hemostasis (CBOTH) Children’s Hospital of Michigan
University of Maryland School of Medicine Wayne State University School of Medicine
Baltimore, Maryland Detroit, Michigan
Alexandre T. Rotta, MD, FCCM Robert Sawin, MD

Division Chief Surgeon-in-Chief
Pediatric Critical Care Medicine General Surgery, Oncology, and Transplantation
Duke University Medical Center Professor of Surgery
Professor of Pediatrics Seattle Children’s Hospital
Duke University School of Medicine University of Washington
Durham, North Carolina Seattle, Washington
Mark E. Rowin, MD Kenneth A. Schenkman, MD, PhD

Associate Professor of Pediatrics Associate Professor
University of Tennessee College of Medicine Department of Pediatrics
Chattanooga, Tennessee University of Washington
Seattle, Washington
Randall Ruppel, MD
Assistant Professor Stephen M. Schexnayder, MD
Department of Pediatrics Professor and Chief
Virginia Tech Carilion School of Medicine Pediatric Critical Care
Roanoke, Virginia University of Arkansas for Medical Sciences/Arkansas Children’s
Hospital
Rita M. Ryan, MD Little Rock, Arkansas
Professor of Pediatrics (Neonatology)
UH Rainbow Babies & Children’s Hospital Charles L. Schleien, MD, MBA
Case Western Reserve University Philip Lanzkowsky Professor and Chair of Pediatrics
Cleveland, Ohio; Cohen Children’s Medical Center
Adjunct Professor of Pediatrics Hoftstra Northwell School of Medicine
Medical University of South Carolina New Hyde Park, New York
Charleston, South Carolina
xx Contributors
Stephanie P. Schwartz, MD Katherine N. Slain, DO

Assistant Professor Assistant Professor
Division of Critical Care Medicine Rainbow Babies & Children’s Hospital
University of North Carolina at Chapel Hill Cleveland, Ohio
Chapel Hill, North Carolina
Jodi M. Smith, MD, MPH
Steven M. Schwartz, MD, FRCPC Professor
Head, Division of Cardiac Critical Care Medicine Department of Pediatrics
The Hospital for Sick Children; University of Washington, Seattle
Professor of Paediatrics Seattle, Washington
Department of Paediatrics
University of Toronto Lincoln S. Smith, MD
Toronto, Ontario, Canada Associate Professor
Jay Shah, MD University of Washington
Medical Director, Aerodigestive Clinic Seattle, Washington
Division of Pediatric Otolaryngology
University Hospitals/Rainbow Babies and Children’s Hospital Anthony A. Sochet, MD, MSc, FAAP
Cleveland, Ohio Assistant Professor, Anesthesia and Critical Care Medicine
Associate Fellowship Program Director, Pediatric Critical Care
Sareen Shah, MD Medicine
Assistant Professor of Pediatrics Johns Hopkins University School of Medicine
Department of Critical Care Medicine Johns Hopkins All Children’s Hospital
Cohen Children’s Medical Center St. Petersburg, Florida
New Hyde Park, New York
Lauren R. Sorce, PhD, RN, CPNP-AC/PC, FCCM
Dennis W.W. Shaw, MD Founder’s Board Nurse Scientist
Professor of Pediatric Radiology Associate Director, Nursing Research
Department of Radiology Pediatric Critical Care Nurse Practitioner
Seattle Children’s Hospital and University of Washington Ann and Robert H. Lurie Children’s Hospital of Chicago;
Seattle, Washington Assistant Professor
Steven L. Shein, MD Northwestern University Feinberg School of Medicine
Associate Professor Chicago, Illinois
Chief of Pediatric Critical Care Medicine
Department of Pediatrics Linda E. Sousse, PhD, MBA
Rainbow Babies & Children’s Hospital Assistant Professor
Cleveland, Ohio Department of Surgery
University of Texas Medical Branch
Michael Shoykhet, MD, PhD Galveston, Texas
Attending Physician
Pediatric Critical Care Michael C. Spaeder, MD
Children’s National Medical Center Associate Professor
Principal Investigator Division of Pediatric Critical Care
Center for Neuroscience Research University of Virginia School of Medicine
Children’s National Research Institute Charlottesville, Virginia
Washington, DC
Richard H. Speicher, MD
Dennis W. Simon, MD Associate Professor
Assistant Professor Department of Pediatric Critical Care
Department of Critical Care Medicine Rainbow Babies & Children’s Hospital
University of Pittsburgh School of Medicine Cleveland, Ohio
Pittsburgh, Pennsylvania
Philip C. Spinella, MD
V. Ben Sivarajan, MD, MS, FRCPC Director, Translational Research Program
Division Head, Pediatric Cardiac Intensive Care Unit Department of Pediatrics
Pediatric Critical Care Medicine Professor of Pediatric Critical Care
Associate Professor of Pediatrics & Critical Care Medicine Washington University School of Medicine
Faculty of Medicine & Dentistry, University of Alberta St. Louis, Missouri
Stollery Children’s Hospital & University of Alberta Hospitals
Edmonton, Alberta, Canada
Contributors xxi
Erika L. Stalets, MD, MS Erik Su, MD

Associate Professor of Clinical Pediatrics Assistant Professor
University of Cincinnati College of Medicine Department of Pediatrics
Clinical Director, Division of Critical Care Medicine Division of Pediatric Critical Care Medicine
Cincinnati Children’s Hospital Medical Center McGovern Medical School
Cincinnati, Ohio Houston, Texas
Stephen Wade Standage, MD Corinne Summers, MD

Assistant Professor Assistant Member
Department of Pediatrics Clinical Research Division
Cincinnati Children’s Hospital Medical Center Fred Hutchinson Cancer Research Center;
Cincinnati, Ohio Assistant Professor
Rebecca Stark, MD University of Washington, Seattle Children’s Hospital
Assistant Professor Seattle, Washington
Department of Pediatric Surgery
Seattle Children’s Hospital; Robert M. Sutton, MD, MSCE
Assistant Professor Associate Professor of Anesthesia, Critical Care, and Pediatrics
Department of Surgery Department of Anesthesiology and Critical Care Medicine
University of Washington University of Pennsylvania
Seattle, Washington Philadelphia, Pennsylvania
Michelle C. Starr, MD, MPH Jordan M. Symons, MD

Assistant Professor Professor
Division of Nephrology University of Washington School of Medicine;
Indiana University and Riley Children’s Hospital Attending Nephrologist
Indianapolis, Indiana Division of Nephrology
David M. Steinhorn, MD Seattle, Washington
Department of Critical Care Nathaniel R. Sznycer-Taub, MD
Children’s National Medical Center Assistant Professor of Pediatrics
Washington, DC Division of Pediatric Cardiology
University of Michigan
Kurt R. Stenmark, MD Ann Arbor, Michigan
Professor of Pediatrics and Medicine
Department of Pediatric Critical Care Robert T. Tamburro Jr, MD
University of Colorado Anschutz Medical Campus Professor
Aurora, Colorado Department of Pediatric Critical Care Medicine
Janet Weis Children’s Hospital
Claire A. Stewart, MD, MEd Danville, Pennsylvania
Division of Critical Care Medicine
Department of Pediatrics Christian Tapking, MD, MMS
Nationwide Children’s Hospital Fellow
The Ohio State University College of Medicine Department of Surgery
Columbus, Ohio University of Texas Medical Branch
Galveston, Texas;
Lindsay M. Stollings, MD Resident
Assistant Professor Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn
Department of Anesthesiology and Perioperative Medicine Trauma Center
Children’s Hospital of Pittsburgh of UPMC BG Trauma Center Ludwigshafen
Pittsburgh, Pennsylvania University of Heidelberg
Ludwigshafen, Germany
Casey Stulce, MD
Assistant Professor Robert C. Tasker, MBBS, MD
Department of Pediatrics Professor of Anesthesia (Pediatrics)
University of Chicago Harvard Medical School;
Chicago, Illinois Department of Neurology
Departments of Anesthesia (Pediatrics), Pain and Perioperative
Medicine
Division of Critical Care
Boston Children’s Hospital
xxii Contributors
Gregory H. Tatum, MD Marisa Tucci, MD

Associate Professor of Pediatrics Professor
Duke University School of Medicine Sainte-Justine Hospital
Durham, North Carolina University of Montreal
Montreal, Quebec, Canada
Ann H. Tilton, MD
Professor of Neurology and Pediatrics David Tuggle, MD
Section Chair, Child Neurology Associate Trauma Medical Director
Louisiana State Health Sciences Center; Department of Surgery
Director, Children’s Hospital Rehabilitation Center Dell Children’s Medical Center of Central Texas
Children’s Hospital of New Orleans Austin, Texas
New Orleans, Louisiana
Jennifer L. Turi, MD
Matthew R. Timlin, DO Medical Director
Pediatric Intensivist Pediatric Cardiac Intensive Care Unit
Department of Pediatrics Duke University Medical Center
Madigan Army Medical Center Associate Professor of Pediatrics
Joint Base Lewis-McChord, Washington Duke University School of Medicine
Pierre Tissieres, MD, DSc
Professor David A. Turner, MD
Pediatric Intensive Care Associate Director
AP-HP Paris Saclay University Graduate Medical Education
Le Kremlin-Bicetre, France Duke University Health System;
Section Chief, Pediatric Intensive Care
Joseph D. Tobias, MD Associate Professor, Department of Pediatrics
Chair Division of Pediatric Critical Care
Department of Anesthesiology and Pain Medicine Duke Children’s Hospital and Health System
Nationwide Children’s Hospital; Durham, North Carolina
Professor of Anesthesiology and Pediatrics
The Ohio State University Alisa Van Cleave, MD
Columbus, Ohio Clinical Assistant Professor
Philip Toltzis, MD Division of Bioethics and Palliative Care
Professor Seattle Children’s Hospital
Department of Pediatrics Seattle, Washington
Rainbow Babies & Children’s Hospital
Cleveland, Ohio Meredith G. van der Velden, MD
Senior Associate of Critical Care Medicine
Alexis A. Topjian, MD, MSCE Boston Children’s Hospital
Associate Professor of Anesthesia, Critical Care, and Pediatrics Assistant Professor of Anesthesia
Department of Anesthesiology and Critical Care Medicine Harvard Medical School
University of Pennsylvania Boston, Massachusetts
Philadelphia, Pennsylvania
Adam M. Vogel, MD
Troy Torgerson, MD, PhD Associate Professor
Associate Professor Departments of Surgery and Pediatrics
Department of Pediatrics Texas Children’s Hospital;
University of Washington Associate Professor
Seattle, Washington Departments of Surgery and Pediatrics
Baylor College of Medicine
Chani Traube, MD, FAAP, FCCM Houston, Texas
Associate Professor of Clinical Pediatrics
Division of Pediatric Critical Care Medicine Christine Vohwinkel, MD, PhD
Weill Cornell Medical College Associate Professor of Pediatrics
New York, New York Department of Pediatric Critical Care
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Contributors xxiii
Amelie von Saint Andre-von Arnim, MD Scott L. Weiss, MD, MSCE

Associate Professor Associate Professor of Anesthesiology, Critical Care, and
Department of Pediatrics Pediatrics
Division of Pediatric Critical Care Medicine Department of Anesthesiology and Critical Care
Seattle Children’s Hospital The Children’s Hospital of Philadelphia
University of Washington University of Pennsylvania Perelman School of Medicine
Seattle, Washington Philadelphia, Pennsylvania
Surabhi B. Vora, MD, MPH Jesse Wenger, MD

Associate Professor Assistant Professor of Pediatrics
Department of Pediatric Infectious Disease Department of Pediatric Critical Care Medicine
Seattle Children’s Hospital University of Washington
Seattle, Washington Seattle Children’s Hospital
Seattle, Washington
Alpana Waghmare, MD
Assistant Professor Derek S. Wheeler, MD, MMM, MBA
Department of Pediatrics Professor of Pediatrics
Division of Infectious Disease Feinberg School of Medicine
Seattle Children’s Hospital Northwestern University
University of Washington Executive Vice President and Chief Medical Officer
Seattle, Washington Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, Illinois
Mark S. Wainwright, MD, PhD
Professor Beth Wieczorek, DNP, CRNP-AC
Department of Neurology Nurse Practitioner
University of Washington Anesthesia and Critical Care Medicine
Seattle, Washington Pediatric Intensive Care Unit
Johns Hopkins University
Jessica S. Wallisch, MD Baltimore, Maryland
Assistant Professor
Department of Pediatrics Michael Wilhelm, MD
Division of Pediatric Critical Care Associate Professor
University of Missouri–Kansas City Department of Pediatrics
Children’s Mercy Hospital University of Wisconsin, Madison
Kansas City, Missouri Madison, Wisconsin
R. Scott Watson, MD, MPH Hector R. Wong, MD

Professor Critical Care Medicine
Department of Pediatrics Cincinnati Children’s Hospital Medical Center
Division of Pediatric Critical Care Medicine Cincinnati, Ohio
University of Washington School of Medicine Charles R. Woods Jr, MD
Seattle, Washington Chair
Kevin Watt, MD, PhD University of Tennessee College of Medicine;
Associate Professor Chief Medical Officer
Department of Pediatrics Children’s Hospital
Chief Erlanger Health System
Division of Clinical Pharmacology Chattanooga, Tennessee
University of Utah
Salt Lake City, Utah George A. (Tony) Woodward, MD, MBA
Maria Weimer, MD Chief, Division of Emergency Medicine
Associate Professor of Clinical Neurology University of Washington School of Medicine
Department of Neurology Medical Director, Emergency and Transport Services
Louisiana State University Health Sciences Center Seattle Children’s Hospital
New Orleans, Louisiana Seattle, Washington
xxiv Contributors
Amy C. Yang, MD Jerry J. Zimmerman, MD, PhD, FCCM

Assistant Professor Faculty, Pediatric Critical Care Medicine
Department of Molecular and Medical Genetics Seattle Children’s Hospital
Oregon Health and Science University Harborview Medical Center
Portland, Oregon University of Washington School of Medicine
Seattle, Washington
Heidi Yu, PharmD
Critical Care Pharmacist Kanecia Zimmerman, MD, MPH
Seattle Children’s Hospital Assistant Professor
Seattle, Washington Department of Pediatrics
Duke University Medical Center
Nicole R. Zane, PharmD, PhD Duke Clinical Research Institute
Research Scientist Durham, North Carolina
Center for Clinical Pharmacology
Children’s Hospital of Philadelphia Matt S. Zinter, MD
Philadelphia, Pennsylvania Assistant Professor
Danielle M. Zerr, MD, MPH Division of Critical Care Medicine
Professor University of California, San Francisco
Department of Pediatrics San Francisco, California
University of Washington Athena F. Zuppa, MD, MSCE
Seattle, Washington Professor
Department of Anesthesia and Critical Care
Hui Zhang, MD, PhD The Children’s Hospital of Philadelphia
Instructor Philadelphia, Pennsylvania
Department of Pediatric Critical Care
University of Colorado Anschutz Medical Campus
Aurora, Colorado
Hengqi (Betty) Zheng, MD

Acting Instructor
Department of Gastroenterology and Hepatology
Seattle, Washington
Preface
From our home working spaces, in the midst of the COVID-19 For pediatric critical care medicine fellows who may read the
pandemic, welcome to the sixth edition of Pediatric Critical Care. textbook cover to cover, and for others who need an updated
The world has finally been provided a realistic glimpse of intensive reference for anything related to pediatric critical care, the new
care units, the work that occurs there, and the dedicated providers edition will not disappoint. Each color-coded section provides
who provide critical care, sometimes at their own peril. This sixth best-evidence clinical approaches to pediatric critical care issues
edition, which now reflects a lifetime work product for many based on contemporary genetic, biochemical, and physiologic
contributors, is dedicated to the multidisciplinary team that infrastructure. Because authors typically want to include all rele-
makes critical care a reality. vant details in their discussion and a hard copy textbook has
What the pandemic has taught all of us is the importance of physical limitations, readers are encouraged to make use of the
being able to adapt to change. As readers page through this new expanded electronic content included with the sixth edition.
edition, many changes will become apparent. Brad Fuhrman, who Board review questions, composed for most chapters, will be
ultimately deserves the credit for creating this publishing adven- valuable for new and repeat readers and are also available in the
ture, decided to move from Co-editor to Section Editor. More electronic content.
than once, likely while sipping single malt scotch together, Brad Finally, all of us must honor the children and families who
noted that Pediatric Critical Care might be our most important provide the meaning for our life work. With the publishing of the
professional contribution. Quality and sustainability over six sixth edition of Pediatric Critical Care, we collectively acknowledge
editions prove his prediction correct. the clinical challenges that critical illness presents. However, these
Meanwhile, Alex Rotta, appropriately one of Brad’s early challenges facilitate curiosity and imagination, growth and experi-
apprentices, has provided outstanding organizational leadership ence, and ultimately personal enrichment. Hopefully the sixth
as Co-editor for the sixth edition. Thanks also to Section Editors edition of Pediatric Critical Care can serve as a valuable tool for
Bob Clark, Sapna Kudchadkar, Monica Relvas, and Joe Tobias. addressing longstanding as well as novel critical care challenges.
Perusing the list of contributors similarly ascertains established
and burgeoning pediatric critical care contributors. Accordingly, Jerry J. Zimmerman, MD, PhD, FCCM
the sixth edition is truly a multigenerational effort. Alexandre T. Rotta, MD, FCCM
xxv
Contents
Section I: Pediatric Critical Care: Section II: Pediatric Critical Care:

The Discipline 1 Tools and Procedures 75
1 History of Pediatric Critical Care Medicine 2 11 Essential Concepts in Clinical Trial Design and
Daniel L. Levin and John J. Downes Statistical Analysis 76
Leslie A. Dervan, R. Scott Watson, and Mary E. Hartman
2 High-Reliability Pediatric Intensive Care Unit:
Role of Intensivist and Team in Obtaining 12 Prediction of Short-Term Outcomes During Critical
Optimal Outcomes 16 Illness in Children 82
Claire A. Stewart, Derek S. Wheeler, and Richard J. Brilli Julia A. Heneghan, Michael C. Spaeder, and Murray M. Pollack
3 Critical Communications in the Pediatric 13 Pediatric Critical Care Transport 89

Intensive Care Unit 22 Lauren Rakes, Reid W.D. Farris, and George A. (Tony) Woodward
Shelina M. Jamal, Katherine Banker, and Harris P. Baden
14 Pediatric Vascular Access and Centeses 94
4 Professionalism in Pediatric Critical Care 26 Lauren R. Edwards, Matthew P. Malone, Parthak Prodhan, and
Bradley P. Fuhrman and Lynn J. Hernan Stephen M. Schexnayder
5 Leading and Managing Change in the Pediatric 15 Ultrasonography in the Pediatric Intensive Care
Intensive Care Unit 29 Unit 114
John C. Lin Erik Su, Akira Nishisaki, and Thomas Conlon
6 Evolution of Critical Care Nursing 36 Section III: Pediatric Critical Care:

Lauren R. Sorce and Ruth Lebet
Psychosocial and Societal 135
7 Fostering a Learning Healthcare Environment in 16 Patient- and Family-Centered Care in the
the Pediatric Intensive Care Unit 47 Pediatric Intensive Care Unit 136
Melvin G. Perry Jr and Jerry J. Zimmerman Jenny Kingsley and Jonna D. Clark
8 Challenges of Pediatric Critical Care in Resource- 17 Pediatric Critical Care Ethics 144
Poor Settings 51 Mithya Lewis-Newby, Emily Berkman, and Douglas S. Diekema
Amélie von Saint André–von Arnim, Jhuma Sankar, Andrew
Argent, and Ericka Fink 18 Ethical Issues Around Death and Dying 154
Meredith G. van der Velden and Jeffrey P. Burns
9 Public Health Emergencies and Emergency Mass
Critical Care 59 19 Palliative Care in the Pediatric Intensive Care
Katherine L. Kenningham and Megan M. Gray Unit 158
Alisa Van Cleave, Eileen Rhee, and Wynne Morrison
10 Lifelong Learning in Pediatric Critical Care 66
Stephanie P. Schwartz, Laura Marie Ibsen, and David A. Turner 20 Organ Donation Process and Management of the
Organ Donor 163
Thomas A. Nakagawa, Mudit Mathur, and Anthony A. Sochet
xxvii
xxviii Contents
21 Long-Term Outcomes Following Critical Illness in 35 Pediatric Cardiopulmonary Bypass 363

Children 175 Richard M. Ginther Jr and Joseph M. Forbess
Elizabeth Y. Killien, Jerry J. Zimmerman, François Aspesberro,
and R. Scott Watson 36 Critical Care After Surgery for Congenital Cardiac
Disease 380
22 Burnout and Resiliency 183 Paula Holinski, Jennifer Turi, Veerajalandhar Allareddy,
Ruth Kleinpell and Jason M. Kane V. Ben Sivarajan, and Alexandre T. Rotta
Section IV: Pediatric Critical Care: 37 Cardiac Transplantation 411

Sonya Kirmani and Michael Carboni
Cardiovascular 187
23 Structure and Function of the Heart 188 38 Physiologic Foundations of Cardiopulmonary
Luciana Rodriguez Guerineau, Jayani Abeysekera, V. Ben Resuscitation 420
Sivarajan, and Steven M. Schwartz Adnan M. Bakar, Kenneth E. Remy, Sareen Shah,
and Charles L. Schleien
24 Regional Peripheral Circulation 203
Peter Oishi, Julien I. Hoffman, Bradley P. Fuhrman, 39 Performance of Cardiopulmonary Resuscitation
and Jeffrey R. Fineman in Infants and Children 444
Ryan W. Morgan, Robert A. Berg, Alexis A. Topjian,
25 Endothelium and Endotheliopathy 218 Vinay M. Nadkarni, and Robert M. Sutton
Yves Ouellette
Section V: Pediatric Critical Care:
26 Principles of Invasive Cardiovascular Pulmonary 453
Monitoring 227
Matthew R. Timlin and Kenneth A. Schenkman 40 Structure and Development of the Upper
Respiratory System 454
27 Assessment of Cardiovascular Function 239 Robert H. Chun and Joan C. Arvedson
Nathaniel R. Sznycer-Taub, Thomas J. Kulik, John R. Charpie,
and Melvin C. Almodovar 41 Structure and Development of the Lower
Respiratory System 462
28 Cardiac Failure and Ventricular Assist John E. Baatz and Rita M. Ryan
Devices 248
Ana Lia Graciano, Joseph Philip, and Keith C. Kocis 42 Physiology of the Respiratory System 470
Robinder G. Khemani and Justin C. Hotz
29 Echocardiographic Imaging 270
M. Jay Campbell, Michael W. Camitta, Piers C.A. Barker, 43 Noninvasive Respiratory Monitoring and
and Gregory H. Tatum Assessment of Gas Exchange 483
David F. Butler and Kenneth A. Schenkman
30 Diagnostic and Therapeutic Cardiac
Catheterization 289 44 Overview of Breathing Failure 492
Reid C. Chamberlain, Kevin D. Hill, and Gregory A. Fleming Katherine V. Biagas, Michael Wilhelm, and Bradley P. Fuhrman
31 Pharmacology of the Cardiovascular System 300 45 Ventilation/Perfusion Inequality 503

Naomi B. Bishop, Bruce M. Greenwald, and Daniel A. Notterman Silvia M. Hartmann and Thomas V. Brogan
32 Cardiopulmonary Interactions 320 46 Mechanical Dysfunction of the Respiratory

Ronald A. Bronicki, Mubbasheer Ahmed, Saul Flores, and System 509
Bradley P. Fuhrman Jeff Clark, Saurabh Chiwane, and Ashok P. Sarnaik
33 Disorders of Cardiac Rhythm 329 47 Diseases of the Upper Respiratory Tract 524
Frank A. Fish and Prince J. Kannankeril Todd Otteson, Clare Richardson, and Jay Shah
34 Shock States 352 48 Pediatric Acute Respiratory Distress Syndrome

Lincoln Smith, Alicia Alcamo, Joseph A. Carcillo, and Rajesh and Ventilator-Associated Lung Injury 536
Aneja Colin J. Sallee, Robinder G. Khemani, and Lincoln S. Smith
Another random document with
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baciar la fossa che racchiudeva sua madre, riveder le sembianze del
padre suo. Poi... poi di nuovo in balìa del destino che lo sospingeva
verso l’isola fatale in cui era atteso da una Regina e in cui avrebbe
rivisto fredda e bianca la giovanetta del suo pensiero.
Uscì dal castello senza incontrar nessuno, neanche il vecchio
Carmine, e si diresse verso il paesello per un sentiero che usciva nei
pressi della chiesa parrocchiale. Vide da lungi che il corteo ne
tornava, onde si affrettò temendo di trovar chiusa la porta della
chiesa. La chiesa era anch’essa deserta, ma la porta ne era
socchiusa. Egli entrò. Nel mezzo della navata fra quattro ceri avevan
deposto la bara di suo padre il cui coperchio era sollevato.
Si avvicinò e stette per un pezzo immobile a contemplare il cadavere
che aveva nel viso bianco una grande serenità. Come lieta esser
doveva la donna che era stata di quell’uomo l’unico amore e che per
trent’anni lo aveva atteso in una fossa di quella chiesa; come era
lieta l’anima della madre sua che finalmente vedeva raccolti a sè
dappresso l’uomo del suo cuore e il figlio delle sue viscere! E lui
sarebbe andato lontano, lui li avrebbe lasciati in quella quiete, in quel
silenzio, in quell’ombra, in quella pace, per affrontar nuovi dolori, per
correre nuove avventure, per servire all’ambizione di una regina e
per vagheggiare un suo sogno? E lui li avrebbe lasciati per morire
chi sa dove, dopo nuove stragi e fors’anche nuovi delitti! E valeva la
pena, checchè offrir gli potesse la vita, lasciar soli in quel buio, in
quel silenzio, in quella pace coloro cui doveva la vita, quella donna le
cui ossa in quell’istante tremavano d’amore nella fossa mentre
l’anima gli aleggiava d’intorno, e quel vecchio che forse nel regno
degli spiriti godeva nell’amore di lei di quella gioia che aveva invano
chiesto alla terra?
In questo intese un rumore a sè vicino; si rivolse e vide Carmine, il
vecchio Carmine, che non osando di distoglierlo dal raccoglimento in
cui lo aveva visto, si teneva immobile aspettando che egli si
rivolgesse.
— Carmine, tu? — esclamò il giovane.
— Ho compreso che sareste venuto qui prima di lasciar forse per
sempre questi luoghi — rispose il vecchio che aveva gli occhi gonfi
di lacrime e la cui voce tremava.
— Grazie — rispose il giovane, commosso profondamente anche lui.
— Non sarei partito senza prender commiato da te a cui debbo
tanto.
— Lo so... ne ero certo, ma non si tratta di questo. Il maggiore mi ha
chiamato e mi ha detto, in verità con modi assai benigni, che fa
d’uopo partiate al più presto, stasera istessa. Egli s’impegna di non
farvi molestare finchè non v’imbarcate per la Sicilia. Dice che solo
questo può far per voi e in omaggio alla memoria del povero vostro
padre.
— È giusto — mormorò Riccardo — è giusto. Ma bisogna pure che
mi provvegga...
— Il signor maggiore ha pensato a tutto, a tutto. Fuori troverete uno
dei cavalli che portaste da Napoli e che erano caduti in potere dei
soldati, con la valigia, quella valigia nella quale ci è anche un po' di
danaro, delle vesti, della biancheria, insomma tutto ciò che ci era
quando i Francesi se ne impadronirono. In quanto alle armi, ha detto
che ne siete ben fornito e quindi...
— Mi si manda via, mi si scaccia — fece il giovane con voce amara
— ma fu questo il patto e devo essere grato al maggiore del cavallo
e della valigia. E tu, povero Carmine, tu...
— Io resterò nel castello come custode. È una concessione del
maggiore a cui, pare, io vado a verso.
— Hai sollevato di un gran peso l’anima mia, e dì al maggiore che lo
ringrazio non solo di quel che ha fatto per me osservando il patto e
restituendomi la mia roba e uno dei miei cavalli, ma anche della
bontà che ha per te. Ed ora aspettami fuori, buon Carmine, che io
sarò presto pronto a partire.
S’inginocchiò presso alla bara di suo padre, ne prese la mano fredda
ed inerte e mormorò con voce lenta e solenne:
— Addio, padre mio. Riposa in pace nella fossa dei tuoi avi ove forse
invano aspetterai che ti raggiunga, ma sta sicuro che io, qualunque
siano le vicissitudini della mia nuova vita, saprò custodire intatto
l’onore del nostro nome. Riposa in pace e prega per me, padre mio,
prega per me con la poveretta la cui anima ti accolse nel regno degli
spiriti.
Baciò la mano inerte e gelida che stringeva fra le sue, baciò il volto
bianco e sereno di suo padre, e dopo avergli rivolto un ultimo
sguardo uscì dalla chiesa.
Carmine l’aspettava tenendo per la briglia il cavallo insellato che
aveva in groppa la valigia.
— Carmine, mio buon Carmine! — esclamò il giovane aprendo le
braccia nelle quali il vecchio si precipitò.
Stettero un pezzo così abbracciati, poi Riccardo si disciolse, si
raddrizzò nella persona come per ripigliare possesso di sè e con un
salto balzò in sella.
— Addio — disse volgendosi al vecchio — addio!
E spronò il cavallo disparendo in breve fra gli alberi folti del bosco
vicino.
FINE.
Fa sèguito a questo romanzo:

«Sola contro tutti!».
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Last digit is the print number: 9 8 7 6 5 4 3 2 1

Isaac Josh Abecassis, MD Ben D. Albert, MD

Jayani Abeysekera, MD, FRCP Alicia Alcamo, MD, MPH

Alireza Akhondi-Asl, PhD Alexandra Aminoff, MD

Catherine Amlie-Lefond, MD Adnan M. Bakar, MD

Rajesh Aneja, MD Katherine Banker, MD

Melania M. Bembea, MD, MPH, PhD Naomi B. Bishop, MD

M.A. Bender, MD, PhD Julie Blatt, MD

Samuel R. Browd, MD, PhD, FAANS, FAAP Michael P. Carboni, MD

Karel D. Capek, MD Saurabh Chiwane, MD

Robert H. Chun, MD Craig M. Coopersmith, MD

Jeff Clark, MD Seth J. Corey, MD, MPH

April Clawson, MD Rahul C. Damania, MD, FAAP

Carol Conrad, MD Peter J. Davis, MD, FAAP

Leslie A. Dervan, MD Allan Doctor, MD

Michael Dingeldein, MD Hannah Laure Elfassy, MD, FRCP(c)

Alison M. Ellis, MD, MBA Joseph T. Flynn, MD

Megan M. Gray, MD Cary O. Harding, MD

Marla Guzman, MD Christopher M.B. Heard, MBChB, FRCA

Lynn J. Hernan, MD Laura Marie Ibsen, MD

Kevin D. Hill, MD, MSCI Hanneke Ijsselstijn, MD, PhD

Julien I. Hoffman† Travis C. Jackson, PhD

Sue J. Hong, MD Prashant Joshi, MD

Prince J. Kannankeril, MD Christa Jefferis Kirk, PharmD, BCCP

Thomas J. Kulik, MD John C. Lin, MD

Hallie Lenker, PT, DPT Anne Marsh, MD

Christine McCusker, MD Ryan W. Morgan, MD, MTR

Vu Nguyen, MD Todd Otteson, MD, MPH

Jenna R. Nickless, PharmD Yves Ouellette, MD, PhD

Brent J. Pfeiffer, MD, PhD Thomas M. Raffay, MD

Eileen Rhee, MD, MS Ahmed Said, MD, PhD

Alexandre T. Rotta, MD, FCCM Robert Sawin, MD

Mark E. Rowin, MD Kenneth A. Schenkman, MD, PhD

Stephanie P. Schwartz, MD Katherine N. Slain, DO

Erika L. Stalets, MD, MS Erik Su, MD

Stephen Wade Standage, MD Corinne Summers, MD

Michelle C. Starr, MD, MPH Jordan M. Symons, MD

Gregory H. Tatum, MD Marisa Tucci, MD

Amelie von Saint Andre-von Arnim, MD Scott L. Weiss, MD, MSCE

Surabhi B. Vora, MD, MPH Jesse Wenger, MD

R. Scott Watson, MD, MPH Hector R. Wong, MD

Amy C. Yang, MD Jerry J. Zimmerman, MD, PhD, FCCM