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CLASS PRESENTATION

ADMINISTRATION AND

MANAGEMENT OF PICU

SUBMITTED ON:14/12/18
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INTRODUCTION

A paediatric unit usually abbreviated to PICU is an area within a hospital specializing the

care of critically ill infants, children and teenagers. The Pediatric Intensive Care Unit (PICU) is a

specialized unit forming an important section of a hospital or nursing home, for the management

of children with lifethreatening or potentially life-threatening conditions. The PICU is the section

of the hospital that provides sick children with the highest level of medical care. It differs from

other parts of the hospital, like the general medical floors, in that the PICU allows intensive

nursing care and continuous monitoring of things like heart rate, breathing, and blood

pressureThe PICU also allows medical staff to provide therapies that might not be available in

other parts of the hospital. Some of these more intensive therapies include ventilators (breathing

machines) and certain medicines that can be given only under close medical supervision

Purposes

1. The provision of specialized care for children with critical illness which may best be provided

by concentrating these patients in areas under the supervision of skilled and specially trained

team of physicians and nurses.

2. The continuing education of health-care team members.

UNIT DESIGN

PICU should be a separate unit from the Neonatal and Adult ICU dedicated to infants and

children. Unit design should take into consideration future adaptability and expan-sion and must

maximize the resource of space, equipment, and personnel in a most affordable way for

individual institutions. No traffic to other departments should pass through the unit. The unit

should be located near lift with easy access to emergency department and operation theatre,

laboratory and radiology department.

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The doctor duty room as well as intensivist duty room/office should be close to PICU

with intercom facility. Other facilities nearby should include a staff area with locker cabinets, a

family waiting area to provide for at least one (preferably two) person per admitted patient with

bathroom, shower and telephone facility, as feasible.

Planning

The design team should include relevant medical and support personnel in planning a functional

plus friendly environment. Prior evaluation should consist of a survey that includes:

 Patient drainage area and number expected per year

 Services already available from local institutions

 Disease profile in the community and drainage area

 The design should be conducive to expansion and upgradation

Location

Any unit however small should be located independently in a separate area with its

separate access. Supply and professional traffic that is separate from patient and visitor traffic is

desirable. There should be easy accessibility via elevator or corridor to the pediatric ward, OT,

delivery room (where neonates are part of the patient population) and other areas of the hospital.

Design

8 beds are considered an ideal number for efficiency. More than 12 beds require other resources.

a) Central AC with a separate air handling unit with 4-6 air changes per hour.

b) May be open or modular but the open variety is more acceptable in PICUs

c) Adequate space around each bed for procedures, X-ray machines. PD/ ECHO etc

d) Enough space for a parent to sit

e) Separate extra lighting per bed

f) Enough electrical outlets per bed plus provision for extra equipment: 10 per bed
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g) Floor covering: non-skid heavy duty material with ease of cleaning

h) Walls: easy to wash down

i) 2 Oxygen with and 1 suction outlet at each bed. Compressed air outlets may be used in larger

units with several running ventilators.

j) Direct line of vision from the nursing station

k) Area for clerk, computer etc.

l) Separate medication preparation area

m) Separate medicine storing area

n) Rest area for nurses

o) Doctors’ room. May be combined with a conference room/library/ private patient conference

area

p) Area for Visitors

q) Mothers’ rest/feeding area

r) Storage of stationery, linen and small equipment

s) Storage of large equipment when not in use.

t) Crash cart area easily accessible and unhindered passage. Dressing trolley

u) Wash basins: easily accessible from all beds for hand washing only. Not for utensils etc.

v) Bed side: Cabinet for storage of patient’s effects. Shelves/racks for monitors, pulse oximeters,

infusion pumps, and sterile hand-rub solution.

w) Pantry area with refrigerator

x) Medication refrigerator

y) Patient bathrooms with adequate safety

z) Sharps containers at nursing station and bedside

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LAYOUT
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Size of PICU

The ideal PICU size can not be stated but six to ten beds is desirable. PICUs with less

than 4 beds risk inefficiency and PICUs with greather than 16 beds may be difficult to manage, if

not properly divided(2). For the total pediatric ward, beds up to 25 and a PICU of six to eight

beds is ideal. Additional beds may be required if specialized surgery such as heart surgery,

neurosurgery and trauma surgery cases are routinely expected.

Room Layout and Bed Area

Room layout should allow actual visualization of all patients from central station. PICU

cubicles should have sliding glass doors to allow full visibility. Patient area in open PICU should

be 150 to 200 sq ft. In a cubicle, the minimum area should be 200 to 250 square feet with at least

one wash basin for two beds. However, one for each bed is preferred. At least one, preferably

two rooms should have an isolation capability with an area of 250 square feet with an ante room

(separate area at least 20 square feet for hand washing and wearing mask and gown) and separate

ventilation. The area around the bed should allow enough space for performing routine ICU

procedures such as central lines, chest tube placement, as well as for easy access for portable X-

ray machine, portable ultrasound, electrocardiograph and portable electroencephalograph

machine.

An easy access to head end of the patient for emergency airway management is a must on

all beds. Wall and ceilings should be constructed of materials with high sound absorption

capabilities. Wall oxygen outlets (two), air outlet (one), two suction outlets, and at least ten

electrical outlets per bed are recommended for various equipments. In rooms, windows are

important to prevent a sense of isolation. Adequate lighting, child friendly wall papering or

paintings with soothing colors and curtains are desirable.

Power control and temperature control

Unit should preferably be centrally air conditioned and should have central heating for
temperature control. In case of lack of central heating system, over head warmers should be
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available. Unit should have an uninterrupted power supply by means of backup power sources
such as invertors and generators in accordance with load of various equipments.

Beds

Beds should have ability to manouver head end and foot end as well as availability of two

or more air/water mattresses to prevent bed sores. All beds must have a railing to prevent

accidental fall of the child. Each bed should have an emergency alarm button to activate code

system in case of cardiac arrest or other emergencies so that additional help can be immediately

mobilized. An intercom at each bed is desirable. A cart at the bedside is important to hold

personal belongings and required patient items.

Crash Cart

A crash cart with emergency drugs and portable monitor/defibrillator should be readily

accessible. Zones should be provided for medication preparation and cabinets should be

available for the storage of medications and supplies. A receptionist area is ideal to control

visitation so that all visitors must go by this area before entering. This area should be monitored

by security personnel.

Central Station

A central station should provide visibility to all patient areas. It should have ample area

to have capacity for all necessary staff functions. Patient records should be easily available.

Adequate space for computer, printers and central monitor is essential. Ample space for doctors

to write on patient files and space for unit secretarial staff is essential. At least two telephoane

lines should be available. A cordless telephone instrument is desirable. If possible, a telephone

line dedicated to incom-ing calls only to facilitate critical care trans-port requests is desirable.

X-ray Viewing Area

A distinctive area in PICU should be chosen for viewing and storage of patient X-ray. An

illuminated viewing box should allow viewing of several films.

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Storage

Storage for vital supplies should be located within or closely adjoining to PICU. A refri-

gerator is essential for some pharmaceuticals. An area must be provided for storage of large

patient care equipment items not in active use. An area must be provided for stretchers and wheel

chairs.

Clean and Dirty Utility Room

Clean and dirty utility rooms must be separate. The clean utility room should be used for

the storage of clean linen. Dirty utility room must contain a separate sink. Covered bins must be

provided for soiled linen and waste materials. An area for emptying and cleaning bed pans and

urine bottles is also necessary.

Waste Disposal

Mechanism of disposal of contaminated waste (segregation of garbage and contami-nated

medical waste) and adequate disposal of needles and sharp objects needs to be as per standard

applicable pollution control guidelines.

Conference Room

A room for intensivist and staff for education, discussion of difficult cases and other

necessary meetings related to quality improvement is desirable. This room should have a small

library facility with ready access to important intensive care books, journals and policy manuals.

Stat Laboratory

A mini laboratory with arterial blood gas, electrolyte, blood sugar, urea, creat,inine,

prothrombin time, partial thromboplastin time, complete blood count and urine examination with

Gram stain should be considered adjacent to the PICU. Twenty four hour availability of on site

or in hospital arterial blood gas is essential. As an alternative to stat laboratory adjacent to PICU,

a central main laboratory facility with a turn around time (reporting time) of less than one hour

for stat laboratory test results is acceptable.

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Organization and Staffing

The level I and level II PICU will be a distinct, separate unit within the hospital that is

equal in status to all other special care units. There should be a distinct administrative structure

and staff for the PICU regardless of its location. A PICU Committee will be established as a

standing (interdisciplinary) committee within the hospital, with membership including

physicians, nurses, respiratory therapists, clinical pharmacists, social workers, child life

specialists, and others directly involved in PICU activities.

(a) Medical Director/Intensivist Incharge

A medical director will be appointed.A record of the appointment and acceptance should

be made in writing. Medical directors of level I and level II PICUs must meet one of the

following requirements:

1. Initially board certified in paediatrics and board certified or in the process of certification in

pediatric critical care medicine

2. Board certified in anesthesiology with practice limited to infants and children and with special

qualifications in critical care medicine

3. Board certified in pediatric surgery with added qualifications in surgical critical care medicine.

If the medical director is not a pediatrician, a pediatric intensivist will be appointed as co-

director. This is essential for level I PICUs and desirable for level II PICUs. Medical directors

must achieve certification within 5 years of their initial acceptance into the certification process

and must maintain active certification in critical care medicine.

The medical director, in conjunction with the nurse manager, should participate in

developing and reviewing multidisciplinary PICU policies, promote policy implementation,

participate in budget preparation, help coordinate staff education, maintain a database that

describes unit experience and performance, ensure communication between the intensivists and

referring primary care and/or subspecialty physicians, supervise resuscitation techniques, and in
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coordination with the nurse manager, lead quality improvement activities and coordinate medical

research. Others may supervise these activities, but the medical director shall participate in each.

The medical director/intensivist in charge should be a pediatrician trained and experienced in

critical care of children with following responsiblities:

(a) Establishing policies and protocols with the help of a group of experts including but not

limited to Pediatric consultants and subspecialists, nursing director, administration, laboratory

and blood bank representatives;

(b) Smooth functioning of PICU with implementation of policies and protocols including

admission and discharge criteria;

(c) Quality assurance and improvement (membership of hospital audit/quality improvement

committee)

(d) Advise administration regarding equipment needs;

(e) Establishing teaching and training system of medical, nursing and ancillary staff;

( f ) Maintaining PICU statistics for mortality and morbidity

(g) Being member of infection control committee.

(b) Staffing Requirements

1. Medical Staff

The medical staff should be round the clock post graduate level pediatrician in PICU with

good airway and pediatric advanced life support skills and active PALS certification.Studies

suggest that having a full-time pediatric intensivist in the PICU improves patient care and

efficiency (4–8). At certain times of the day, the attending physician in the PICU may delegate

the care of patients to a physician of at least the PICU, this physician must be assigned to the

PICU, and in a level II PICU, this physician must be available to the PICU) or to an advanced

practice nurse or physician’s assistant with specialized training in pediatric critical care. These

nonphysician providers must receive credentials and privileges to provide care in the PICU only
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under the direction of the attending physician, and the credentialing process must be made in

writing and approved by the medical director. An in-house physician at the postgraduate year 3

level or above in pediatrics or anesthesiology is essential for all level I PICUs. In addition, all

hospitals with PICUs must have a physician in house 24 hrs/day who is available to provide

bedside care to patients in the PICU. This physician must be skilled in and have credentials to

provide emergency care to critically ill children.

Depending on the unit size and patient population, more physicians at higher training

levels may be required. Other physicians, including the attending physician or his or her

designee, should be available within 30 mins to assist with patient management. For level I units,

available physicians must include a pediatric intensivist, a pediatric anesthesiologist, a pediatric

cardiologist, a pediatric neurologist, a pediatric radiologist, a psychiatrist or psychologist, a

pediatric surgeon, a pediatric neurosurgeon, an otolaryngologist (pediatric subspecialist desired),

an orthopedic surgeon (pediatric subspecialist desired), and a cardiothoracic surgeon (pediatric

subspecialist desired). For level II PICUs, pediatric subspecialists (with the exception of the

pediatric intensivist) are not essential but are desirable, a general surgeon and neurosurgeon are

essential, and an otolaryngologist and orthopedic surgeon are desirable (pediatric subspecialists

optional). For level II PICUs, a cardiovascular surgeon is also optional.

For level I PICUs, it is desirable to have available on short notice a craniofacial plastic)

surgeon, an oral surgeon, a pediatric pulmonologist, a pediatric hematologist/oncologist, a

pediatric endocrinologist, a pediatric gastroenterologist, and a pediatric allergist or

immunologist. These physicians should be available for patients in level II PICUs within a 24-hr

period.

2. Nursing Staff

A ventilated patient needs one pediatric/ICU trained nurse by the bed side. A very

unstable patient (hypotensive/hypoxemic patient despite moderate support) may require two

nurses by the bed side. Other unventilated/relatively stable patients (such as post operative
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patients and ones admitted for overnight observation) may require only one nurse per 2-3

patients.

A nurse manager with substantial pediatric expertise should be designated for level I and

level II PICUs. A master’s degree in pediatric nursing or nursing administration is desirable. In

collaboration with the nursing leadership team, the nurse manager is responsible for assuring a

safe practice environment consisting of appropriate nurse staffing, skill level mix, and supplies

and equipment. The nurse manager shall participate in the development and review of written

policies and procedures for the PICU; coordinate multidisciplinary staff education, quality

assurance, and nursing research; and prepare budgets together with the medical director. These

responsibilities can be shared or delegated to advanced practice nurses, but the nurse manager

has responsibility for the overall program. The nurse manager shall name qualified substitutes to

fulfill his or her duties during absences.

An advanced practice nurse (clinical nurse specialist or nurse practitioner) should be

available to provide clinical leadership in the nursing care management of patients. This is

recommended for level I PICUs and optional for level II PICUs. The clinical nurse specialist

should possess a master’s degree in nursing,

Paediatric critical care nurse specialist certification, and clinical expertise in pediatric

critical care. The nurse practitioner should hold a master’s degree in nursing and national

pediatric nurse practitioner certification and have completed a preceptorship in the management

of critically ill pediatric patients. Expanded role components of the advanced practice nurse

should match the clinical needs of patients within the particular

PICU and health care system. The department of nursing or patient care services should

establish a program for nursing orientation, yearly competency review of high-risk low-

frequency therapies, core competencies based on patient population, and an ongoing educational

program specific for pediatric critical care nursing. Program content should match the diverse
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needs of each unit’s patient population. It is desirable that most nursing staff working in level I

and level II PICUs obtain pediatric critical care certification.

Patient care in level I and level II PICUs should be carried out or supervised by a

pediatric critical care nurse. All nurses working in level I and level II PICUs should complete a

clinical and didactic pediatric critical care orientation before assuming full responsibility for

patient care. Pediatric advanced life support(PALS) or an equivalent course should be required.

Nurse-to-patient ratios should be based on patient acuity, usually ranging from 2:1 to 1:3.

Respiratory Therapy Staff

The respiratory therapy department should have a supervisor responsible for performance

and training of staff, maintaining equipment, and monitoring multidisciplinary quality

improvement and review. Under the supervisor’s direction, respiratory therapy staff primarily

designated and assigned to the level I PICU shall be in house 24 hrs/day. Hospitals with level II

PICUs must have respiratory therapy staff in house at all times; however, this staff need not be

dedicated to the PICU (unless patient acuity so dictates).

All respiratory therapists who care for children in level I and level II PICUs should have

clinical experience managing pediatric respiratory failure and pediatric mechanical ventilators

and should have training in PALS or an equivalent course.

Ancillary Staff

All PICU must be regularly staffed by physiotherapists, dieticians and respiratory

technicians for enhancing patient care. An appropriately trained and qualified clinical pharmacist

should be assigned to the level I PICU; this is desirable for the level II PICU. Staff pharmacists

must be in house 24 hrs/day in hospitals with level I PICUs, and this is desirable in hospitals

with level II PICUs. Biomedical technicians must be available within 1 hr, 24 hrs/day for level I

and level II PICUs. For level I PICUs, unit secretaries (clerks) should have primary assignment

in the PICU 24 hrs/day. A radiology technician (preferably with advanced pediatric training)
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must be in house 24 hrs/day in hospitals with level I PICUs, and this is strongly recommended

for those with level II units. In addition, social workers; physical, occupational, and speech

therapists; nutritionists; child life specialists; clinical psychologists; must be available (this is

essential for level I and desirable for level II PICUs).

PEDIATRIC EQUIPMENT, SUPPLIES, AND MEDICATIONS REQUIRED IN THE

PICU

MONITORS IN THE PEDIATRIC ICU

Every patient admitted to the ICU is on continuous monitoring which are displayed on the

patient’s bedside monitor.

• Non-invasive monitoring: ECG, pulse-oximeter, respiratory rate measurement,blood pressure

• Invasive monitoring devices: Central venous pressure, continuous arterial pressure, right / left

atrial pressure.

Non-Invasive Monitoring

ECG

Patients have three electrodes placed: the right arm / right chest, left arm / left chest, and

left lower abdomen / left leg. The monitor can be adjusted to visualize either leads I, II, or III. A

rhythm strip can be printed from the monitor during any acute event. For patients that are having

active arrhythmias, a 12-lead ECG must be acquired to fully evaluate the abnormal rhythm.

Multiple days of patient’s vitals and ECG recordings are accessible from the central telemetry

system in essence acting as a holter monitor.

Pulse-Oximeter

The pulse-oximeter has dramatically improved patient care and often is considered the

fifth vital sign particularly in the ICU. A pulse-oximeter consists of a light source and a photo

detector that must be applied to a narrow enough portion of the body for light to traverse a

capillary bed. Light is emitted from the light source and absorbed by the various substances on
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route before being detected by the photo detector on the other side. The light absorbed by venous

blood, and other soft tissue is unchanged throughout the cardiac cycle. Oxygenated blood

increases in arteries during systole changing the absorbance of light that varies according to the

cardiac cycle. The pulse oxy measures the ratio of oxy-hemoglobin to deoxy-hemoglobin at two

wavelengths: 660nm (Red) and 940nm (Infrared). During the pulsation of systole, the amount of

absorption by oxy-hemoglobin at 940nm increases effecting the ratio. Through a complex

algorithm, the pulse-oximeter compares the ratio of absorbance at 660nm and 940nm to

determine an absolute saturation.

Despite the accuracy of modern pulse-ox technology, some drawbacks must be noted.

• The pulse-ox is dependent on arterial blood flow to determine the oxygen saturation. In patients

with shock and poor perfusion, the saturation may not be accurate due to poor arterial blood-flow

in the periphery.

• Oxygen is transported to tissue by two methods: bound to hemoglobin (large component) and

dissolved in solution (small component). The pulse-oximeter measures the saturation, SaO2, of

the oxyhemoglobin, i.e. the amount of hemoglobin bound by oxygen is measured. The dissolved

oxygen content, PaO2, is not measured.

• Abnormal hemoglobins such as methemoglobin or carboxyhemoglobin may inaccurately

increase the measured saturation.

Respiratory Rate Measurement

Respiratory movement is measured by impedance pneumography using the ECG

electrodes already on the patient. This waveform also allows the patient’s respiratory pattern to

be evaluated.

Non-invasive Blood pressure:

Blood pressure is the blood flow and perfusion maintained to the various organs and

tissues. The traditional method of auscultating Korotkoff’s sounds by stethoscope is no longer

done in the ICU setting. Patients have their blood pressures measured by the Dinamap – device
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for indirect noninvasive automated mean arterial pressure. This method of acquiring blood

pressure provides an accurate trend of the patient’s blood pressure. The diastolic blood pressure

is often higher than values from an invasive arterial catheter.

Several factors should be considered in using a non-invasive blood pressure measurement

technique. An appropriate size cuff should be used since a cuff that is too big will provide

artificially low readings and a cuff that is too small will artificially elevate them. According to

the AHA, the cuff size should be approximately 20% wider than the diameter of the limb.

Especially in pediatric patients, providers must be vigilant to assure that each patient has an

appropriate size cuff (particularly if the blood pressures are not in conjunction with the

remainder of the patient’s physical exam.) In critically ill patients, often with poor distal

perfusion and potential DIC, frequently inflated cuff may cause skin avulsion, petechia, and

venous stasis. In such patients, an invasive arterial blood pressure catheter should be considered.

End Tidal CO2 Monitor (ETCO2):

Capnography monitor is placed at the end of endo-tracheal tube in intubated patients and

measures the partial pressure of CO2 in expired gas. A small amount of gas is sampled and

analyzed in a spectrophotometer to determine the CO2. Capnography is based on the principle

that the highest concentration of CO2 sampled in the respiratory circuit represent the alveolar

CO2 concentration, which should be close to the arterial CO2 concentration. This principle

assumes minimal lung pathology; in patients with significant pulmonary disease, the ETCO2 is

often markedly lower to the CO2 measured by the arterial blood gas due to ventilation-perfusion

mismatch. Even in such patients, however, the ET CO2 can be used as a trend of rising or falling

true CO2. This monitor can also be used to assure tracheal intubation. The CO2 of the stomach is

near zero. Therefore, if the esophagus is intubated or a patient’s ETT is dislodged, minimal to no

CO2 will be detected. This can be a powerful bedside tool in an acutely desaturating patient. If

an ETCO2 is not detected, the patient’s ETT has been dislodged into the esophagus and re-

intubation of the trachea is required.

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Near Infrared Spectroscopy (NIRS):

A small adhesive device, which contains a light source and two detectors, is attached to

the region of interest and connected to a monitor displaying the regional saturation. Light in the

near red spectrum (700-1000nm) is passed through the tissue of interest and returns to the

detector. The detector reflects deoxy- and total-hemoglobin from which the mixed venous

saturation of the local tissue is calculated. This technology is being evaluated in cardiac surgery

and some PICU patients. Data collected to date suggests that monitoring the CNS NIRS in

relation to the splanchnic NIRS may prove more effective.

Invasive Monitoring:

Indications for invasive monitoring include:

• Monitoring

• Diagnosis

• Treatment.

Applications for specific catheters are discussed below. Catheters placed directly into a

vessel or cardiac chamber allow for invasive pressure measurement from that location. The intra-

vascular catheter is connected via an uninterrupted fluid filled column to a transducer. This

mechanical transducer then converts the intra-vascular pressure changes to electrical signals that

are displayed as numerical values on the monitor. Any factors effecting the compliance,

impedance, or resistance of fluid in the tubing, e.g. air bubbles, can dampen (artificially depress)

the pressure reading. Once inserted, the catheter must be calibrated correctly to assure accurate

pressure measurements. The transducer is placed at the level of the heart, opened to air, and

zeroed to assure the appropriate baseline setting. Once zeroed, the transducer is opened to the

column of fluid connected directly to the intra-vascular catheter and pressure measurement

begins. A transducer below the level of the heart, e.g. a transducer that falls on the ground, will

read an artificially low pressure and a transducer elevated above the level of the heart will read a

high pressure.
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Complications: Complications from the invasive catheters are rare, but should be recognized.

Risks of greatest concern include:

•Significant bleeding: Any patient with a bleeding diathesis is prone to bleed from a line

insertion, particularly if a large catheter is being inserted. If correction of the coagulopathy prior

to line insertion is possible, it should be considered. A cannulation site where direct pressure can

be held over the site to control significant bleeding would be preferred, e.g. the femoral vessels.

• Infection: Line infections are associated with significant morbidity and are therefore an issue of

great concern in the ICU. Infections can occur at the insertion site, along the line tract, and can

eventually cause intra-vascular invasion with bacteremia or sepsis. Lines inserted under sterile

conditions, particularly central catheters, have a significantly decreased risk of infection. In

emergency situations, lines are often not placed in a sterile fashion and prophylactic antibiotics

should be considered for these patients.

•Clot: If a line tip clot is discovered, the patient is often started on heparin to prevent propagation

of the clot and the involved catheter is removed.

Central Venous Catheters (CVC)

• These are catheters placed into large central veins and can be used for infusion of inotropes,

medications toxic to peripheral veins, provide total parenteral nutrition, blood sampling, and to

monitor venous pressures.

• The femoral, internal jugular, and subclavian veins are cannulated for central access.

• The location of venous cannulation is determined based on urgency of acquiring access, patient

size, severity of illness, specific disease process, and previous sites of cannulation.

• The Central Venous Pressure (CVP) can be measured from any of these sites and is a reflection

of the right heart filling pressure, i.e. the preload to the right ventricle. A normal CVP is

considered 2-8 mmHg. A decreased CVP is seen with hypovolemic or septic shock.

Hypovolemia may occur secondary to dehydration, e.g. acute gastro-entiritis, trauma, with loss
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of blood volume, or third spacing as seen with burn or sepsis patients. An elevated CVP can

occur with over-hydration, right heart failure or pulmonary hypertension.

Complications specific to CVCs include:

• Arrhythmias from the wire or line, air embolism, shearing of the vessel, intravascular loss of

the guide wire, and bleeding can occur in any location.

• Pneumothorax and hemothorax are complications specific to lines placed in the subclavian or

internal jugular vein.

• Venous congestion and edema of the lower extremity without a clot may occur with catheters

placed in the femoral vein in small infants, particularly <5kg, necessitating removal of the line.

Arterial Catheter

An arterial catheter placement should be considered in the following patients.

• Hemodynamic instability: The arterial line allows continuous blood pressure monitoring and

titration of vasoactive agents as required.

• Lung pathology: Arterial blood gases (ABGs) can help assess the severity and progression of

disease.

Cannulation sites include the radial, ulnar, dorsalis pedis, posterior tibial, axillary, and

femoral arteries. Peripheral arteries are preferred to central vessels, but are often difficult to

cannulate in patients presenting in shock with poor distal perfusion. An Allen test should be

performed prior to cannulating the wrist vessels to assure collateral blood flow to the hand.

The arterial pressure tracing consists of:

• Rapid upstroke due to ventricular systolic ejection,

Right Atrial Catheter

• Post-operative cardiac surgery patients often have a right atrial catheter, which is placed

directly into the right atrium intra-operatively.

• Normal right atrial pressures (RAP) range between 1-6 mmHg. This pressure is a measure of

right heart preload and should usually match the CVP.

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o Low right atrial pressures are noted with hypovolemia.

o Increased RAP is seen with tamponade, poor right ventricular compliance, volume overload,

tricuspid valve stenosis or regurgitation,

tachyarrhythmias, and cardiac tamponade.

Left Atrial Catheter

• Similar to right atrial catheters, left atrial catheters are placed intra-operatively in cardiac

surgery patients.

• Left atrial pressures (LAP) are slightly higher than RAP and are often 3-8 mmHg.

LA pressures reflect the preload to the left ventricle.

 LAP is decreased with systemic hypovolemia and during pulmonary hypertensive crisis.

 LAP elevated with left ventricular dysfunction, tamponade, mitral valve disease, volume

overload, large left-to-right shunts, and tachy arrhythmias.

The most common forms of monitoring used in the ICU are detailed above. Each monitoring

device should be used individually, and in conjunction to maximize diagnosis and treatment. For

example, a patient with an arrhythmia may have a heart rate of 200, but on the arterial line or

pulse-oximeter tracing only every third beat is providing systemic perfusion. This data can help

provide a diagnosis and direct therapy. The information from the various devices can be used

appropriately to monitor, diagnose, and manage patients.

GENERAL EQUIPMENT

Intensive care unit equipment includes patient monitoring, life support and emergency

resuscitation devices, and diagnostic devices.

Patient monitoring equipment

Patient monitoring equipment includes the following:

Acute care physiologic monitoring system—comprehensive patient monitoring systems that

can be configured to continuously measure and display a number of parameters via electrodes

and sensors that are connected to the patient. These may include the electrical activity of the
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heart via an EKG, respiration rate (breathing), blood pressure, body temperature, cardiac output,

and amount of oxygen and carbon dioxide in the blood. Each patient bed in an ICU has a

physiologic monitor that measure these body activities. All monitors are networked to a central

nurses' station.

Pulse oximeter—monitors the arterial hemoglobin oxygen saturation (oxygen level) of the

patient's blood with a sensor clipped over the finger or toe.

Intracranial pressure monitor—measures the pressure of fluid in the brain in patients with

head trauma or other conditions affecting the brain (such as tumors, edema, or hemorrhage).

These devices warn of elevated pressure and record or display pressure trends. Intracranial

pressure monitoring may be a capability included in a physiologic monitor.

Apnea monitor—continuously monitors breathing via electrodes or sensors placed on the

patient. An apnea monitor detects cessation of breathing in infants and adults at risk of

respiratory failure, displays respiration parameters, and triggers an alarm if a certain amount of

time passes without a patient's breath being detected. Apnea monitoring may be a capability

included in a physiologic monitor.

Life support and emergency resuscitative equipment

Intensive care equipment for life support and emergency resuscitation includes the following:

 Ventilator (also called a respirator)—assists with or controls pulmonary ventilation in patients

who cannot breathe on their own. Ventilators consist of a flexible breathing circuit, gas supply,

heating/humidification mechanism, monitors, and alarms. They are microprocessor-controlled

and programmable, and regulate the volume, pressure, and flow of patient respiration. Ventilator

monitors and alarms may interface with a central monitoring system or information system.

 Infusion pump—device that delivers fluids intravenously or epidurally through a catheter.

Infusion pumps employ automatic, programmable pumping mechanisms to deliver continuous

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anesthesia, drugs, and blood infusions to the patient. The pump is hung on an intravenous pole

placed next to the patient's bed.

 Crash cart—also called a resuscitation or code cart. This is a portable cart containing emergency

resuscitation equipment for patients who are "coding." That is, their vital signs are in a

dangerous range. The emergency equipment includes a defibrillator, airway intubation devices, a

resuscitation bag/mask, and medication box. Crash carts are strategically located in the ICU for

immediate availability for when a patient experiences cardiorespiratory failure.

 Intraaortic balloon pump—a device that helps reduce the heart's workload and helps blood flow

to the coronary arteries for patients with unstable angina, myocardial infarction (heart attack), or

patients awaiting organ transplants. Intraaortic balloon pumps use a balloon placed in the

patient's aorta. The balloon is on the end of a catheter that is connected to the pump's console,

which displays heart rate, pressure, and electrocardiogram (ECG) readings. The patient's ECG is

used to time the inflation and deflation of the balloon.

 Diagnostic equipment

The use of diagnostic equipment is also required in the ICU. Mobile x-ray units are used for

bedside radiography, particularly of the chest. Mobile x-ray units use a battery-operated

generator that powers an x-ray tube. Handheld, portable clinical laboratory devices, or point-of-

care

analyzers, are used for blood analysis at the bedside. A small amount of whole blood is required,

and blood chemistry parameters can be provided much faster than if samples were sent to the

central laboratory.

Other ICU equipment

Disposable ICU equipment includes urinary (Foley) catheters, catheters used for arterial

and central venous lines, Swan-Ganz catheters, chest and endotracheal tubes, gastrointestinal and

nasogastric feeding tubes, and monitoring electrodes. Some patients may be wearing a posey

vest, also called a Houdini jacket for safety; the purpose is to keep the patient stationary. Spenco
 23

boots are padded support devices made of lamb's wool to position the feet and ankles of the

patient. Support hose may also be placed on the patient's legs to support the leg muscles and aid

circulation.

General Equipment

 Blood pressure cuffs, neonate, infant, child, adult, obese

 Blood pump device

 Cervical collars, pediatric and adult sizes

 Chest tubes (10-28 FR)

 Crash Cart

 Length and weight tape for determining pediatric resuscitation dosages

 Monitor/defibrillator (0-400ws with peds paddles)

 Oxygen, portable

 Ophthalmoscope

 Otoscope

 Pacemaker

 Peritoneal dialysis equipment

 Quick reference drug dose chart or book on crash cart

 Scale, infant and sling

 Spinal immobilization device

 Suction devices, portable and bedside

 Thermometers (capable of measuring hypothermia)

 Thoracostomy drainage system

 Urinary catheters (8-22Fr)

General Airway Equipment

 Bag-valve mask device, child and adult

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 Bag-valve masks, neonate, infant, child, small and large adult

 Endotracheal tubes (2.5-8.0)

 Endotracheal tubes stylets

 Laryngoscope handle and blades, pediatric and adult

 Magill forceps, pediatric and adult

 Nasal cannulae, infant, child and adult

 Nasogastric tubes, (5-18Fr)

 Nasopharyngeal airways (4.5mm-9.0mm)

 Oropharyngeal airways (neonate, infant, child, and adult small, medium, large)

 Oxygen masks, standard and non rebreathing infant, child, and adult

 Suction catheters, (6-12 Fr)

 Trach tubes (00-4)

Vascular Access Equipment

 Central venous catheters (size 6-12 Fr)

 Infusion devices to regulate rate and volume

 Intraosseous needles

 IV administration sets with calibrated chambers

 Three way stopcock

 Umbilical vein catheters

Monitoring Equipment

 Arterial pressure

 Central venous pressure

 ECG and heart rate

 End tidal carbon dioxide

 Intracranial pressure
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 Pulmonary arterial pressure

 Pulse oximetry

 Respiration

 Temperature

 Simultaneous pressure monitoring capability, arterial, central venous, pulmonary arterial and

intracranial

 Transport monitor

Specialized Trays

 Central line trays (pediatric and adult catheter sizes)

 Cricothyrotomy tray with compatible apparatus for bag-valve mask or jet ventilation

 IV cutdown tray

 Lumbar puncture tray (pediatric with needles 22g 1-1/2)

 Peritoneal lavage tray

 Thoracostomy tray

 Thoracotomy tray with pediatric rib spreader and aortic clamp

 Tracheostomy tray with trach tubes (00-4)

Portable Equipment

 Air-oxygen blenders (21-100%)

 Bedside ECG (12lead)

 Bedside echocardiography

 Bedside ultrasound

 Bedside nuclear scan

 Bilirubin lights

 Blood warmer

 Compressors
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 Cribs

 Doppler ultrasound device

 Heating/cooling blankets

 Infusion pumps including micro fusion capability

 IV fuild warmer

 Incubators

 Metabolic bed scale

 Servo-controlled heating units (with or without open crib)

 Transcutaneous pO2 monitor

 Transcutaneous pCO2 monitor

 Portable EEG

 Tray for insertion of ICP monitor

Levels Of Pediatric Intensive Care Units

All units should comply with the laid down Government laws and regulations regarding

certification and licensing of doctors, nurses, pharmacists, laboratory personnel, physiotherapists

and any one concerned with patient care. Patient Records should also be maintained as laid down

by existing laws. The PICU cannot certify any unit that does not comply with legal requirements.

Level I

• Able to provide immediate resuscitation and support of a sick neonate, child, adolescent

• Able to provide short term cardio-respiratory support including short term mechanical

ventilation and basic monitoring

• Able to provide safe transport to a high level unit either by itself or in collaboration with a

transport team

Level II

 High standard of general supportive care and life support for at least a few days
 27

 Full monitoring capabilities with at least one invasive monitor

 Post-graduate allopathic doctors on call round the clock

 Renal replacement therapy at least for a short term

 Emergency surgical interventions and support of post-operative patients

 Audit or Quality assurance program

 Infection control program

Level II

Should be a separate part of a multispecialty general or pediatric Hospital of at least 200

beds*

• At least 300 admissions a year. Minimum 100 ventilated patients*

• Dedicated full time Intensivist plus at least one additional available intensivist

(adult unit, anaethetists)*

• Highest level of care

• Complex multi-system support services

• Specialised pediatric, neurosurgical and cardiac surgical support

• Full 24 hour back up of all services on the premises including pharmacy

• Post-graduate allopathic doctors on call round the clock

• Continuing medical education programs for doctors and nurses

• Audit or Quality assurance program (Standard scoring system for severity of

disease) +Infection control program

ADMISSION AND DISCHARGE

Any child requiring pediatric intensive care must be admitted to PICU. This is

accomplished by calling the PICU attending physician. If a bed is available the patient may be

admitted. If the PICU is full, and all beds are occupied, then the physician wishing to admit a

patient to the PICU must contact the PICU attending. The critical care attending will then make

the disposition regarding discharge of another patient from the PICU after appropriate
 28

consultation with the patients primary service and the PICU nursing staff, or other appropriate

disposition

Type of Patients admitted to the PICU

 Medical patients from the ED. The ED will contact the PICU attending. The intensivist is the

attending of record

 Medical patients from the floor. The floor attending or resident will contact the PICU attending

who will decide about transfer, then call the PICU charge RN and resident. The intensivist is the

attending of record

 Medical patients transported in for outside institutions. The PICU attending will contact the

PICU charge RN and resident about the admission.

 Cardiac patients may be admitted from the OR, the floor, the ED, or DNCC. If they are

immediately post or pre-operative, the primary service is Pediatric Cardiac Surgery, with

medical consultation. Functionally, these patients are managed on an hour-to-hour basis by the

PICU attendings. Pediatric residents are the primary residents for the pediatric cardiac surgery

patients.

 Surgical patients from the ED or the floor. The surgical attending or resident must contact the

PICU attending to admit a patient to the PICU. The surgical attending is the attending of record.

The PICU acts as a consultant for medical issues. Surgical residents write admission orders. The

degree to which the surgical services manage the medical issues of their patients will depend on

the service and the patient.

 Surgical patients from the OR. Surgical attending is the attending of record. The PICU acts as a

consultant for medical issues. Surgical residents write admission orders. The degree to which the

surgical services manage the medical issues of their patients will depend on the service and the

patient
 29

 Orthopedic patients from Shriners are admitted to the service of the Pediatric Intensivist if the

orthopedic surgeon does not have privileges. The pediatric residents write admitting orders for

most of these patients.

Routine Procedures

There are pre-printed orders for general PICU admits, CV surgery admits (track A and

general), and ECMO admits. If you use a pre-printed order and want to write more things, use

regular order paper. There are also pre printed orders for sedation drips, muscle relaxant drips,

cardiac patient ventilator weaning. Others are being added on an ongoing basis. Admitting orders

to the PICU should include the following categories:

 Diagnosis

 Attending physician

 Condition

 Vital sign frequency (routine is q2). If you want things documented more frequently, be specific.

(Hourly is reasonable for sick patients)

 Allergies

 Nursing—specific nursing requirements

 Dressing changes

 Chest tube orders

 CVP/A-line orders

 NG

 Foley

 Diet/NPO

 IVF (type/rate)

 Meds
 30

 Drips written in amount/kg/minute (vasoactive) or amount/kg/hour (sedation/narcotic); consult

with PICU MD or nursing staff about concentration to order.

 Labs—labs wanted on admission as well as lab schedule if needed.

 Ventilator settings along with weaning parameters (i.e., wean oxygen for O2 sat>???)

 Call HO orders. It is best to write these and also to speak with the RN caring for the patient about

specific issues you are worried about, to ensure accurate communication.

 There are special order sheets for muscle relaxants, sedation, and PCA. If you are unfamiliar

with them, ask the intensivist or the nurse to assist in using them.

 Post operative cardiac patients and ECMO patients have pre-printed orders. These will be

completed by the intensivist or the pediatric resident with attending supervision.

Verbal Orders

Verbal orders may be taken only when necessary. These must be written and signed as soon as

possible after having been executed.

Emergency Procedures

In the absence of a physician, if a child's condition changes while waiting for the

physician caring for the child, the nurse may do the following where appropriate:

 Draw blood gases, electrolytes and hematocrit, and send these to the lab for stat results.

 Call for chest x-ray or other appropriate x-ray.

 Administer oxygen.

 Institute cardio-pulmonary resuscitation with Ambu bag and external cardiac massage.

 The PICU attending should be called immediately for any sudden, unexplained change in a

patient’s condition. In the event of a cardio-respiratory or respiratory arrest where the PICU

attending is not immediately available, the Pediatric Code 99 team may be called.

 If an anesthesiologist is needed emergently, the pediatric on call anesthesiology number should

be paged. At the present time, the pediatric anesthesiologists are in house 24 hours/day.
 31

Discharge/Transfer Procedures

Decisions regarding transfer of patients from the PICU to the ward will be made in

conjunction with the primary service and RN staff. Confirmation of the availability of a ward

bed as well as an accepting physician must be made prior to transfer. The PICU attending will

contact the receiving attending for medical patients, the residents should contact the receiving

resident to give report.

For surgical patients, the surgery service will write transfer orders. For medical patients, the

PICU residents write transfer orders. On occasion, the PICU residents can help the flow of

patients by writing transfer orders on surgical patients (confirm with surgical service first).

On medical patients, the PICU resident should write a transfer summary prior to transfer to the

floor. Any patient discharged from the PICU (including Shriners patients going back to Shriners)

need a dictated summary.

Medical Record

Record of patient admissions, diagnoses, date of discharge, and attending physician will

be kept in the PICU.

Visiting Regulations

 Visitors other than parents may be present with parental permission.

 Visitors may be limited to two persons at a time at the discretion of the bedside RN.

 One immediate family member may stay with the patient 24 hours a day.

 Visitors must check at the desk outside PICU for permission to visit the child.

MEDICATIONS

Antibiotics in PICU

Before antibiotics are started cultures (blood, urine, tracheal aspirate +/- BAL) should be

taken. Consider an LP, especially in infants, but this should not be done if there is any reduction

in level of consciousness or any haemodynamic instability. Blood cultures should never be taken
 32

from a central line alone. Always take a clean peripheral sample (and a central line specimen if

CVC sepsis is being considered).

rd th
Widespread use of broad spectrum antibiotics (e.g. carbapenems, 3 /4 generation

cephalosporins) is associated with resistant Gram-negative bacteria and fungi. Currently Starship

does not have endemic spread of carbapenem resistant gram negatives (including NDM-1) but

broad use of carbapenems could promote their emergence for which there is no effective

antibiotic. Similarly the use of vancomycin provides selection pressure for vancomycin-resistant

enterococcus (VRE). Nystatin should be charted for all children receiving antibiotics.

Surgical prophylactic antibiotics are important at the time of skin incision and during

surgery. They should be given 30-60 minutes prior to skin incision. Continuing antibiotics does

not prevent infection and leads to resistance. The default dose for all antibiotic doses for children

in PICU is the severe infection dose in the “Drug Doses” handbook by Frank Shann. The two

commonest ICU-acquired infections are bacteraemia (which may be due to CVC related sepsis)

and ventilator associated pneumonia (VAP).

CVC related sepsis is very uncommon if the catheter is <5-7 days old. There is no role

for either guide wire changes of catheters or routine placement of new catheters as they do not

reduce the rates of sepsis. If CVC sepsis is suspected, peripheral and central cultures should be

taken. If the catheter is very old, if CVC sepsis is strongly suspected or if the cultures are

positive the catheter should be replaced at a new site or removed.

VAP is also very uncommon in the first 5-7 days. Indications for treatment are a

new/persistent infiltrate on CXR together with at least two of: altered secretions (purulent or

increased volume), fever/hypothermia, raised (>15) or low (<4) WCC, increased left shift in

WCC, deterioration in oxygenation or increased ventilation requirement.

Tracheal aspirates (TA) have low specificity due to frequent contamination with URT

organisms and colonisation in longer term patients. Never start antibiotics for a positive TA

alone. They can be used to guide therapy (especially if a gram negative organism is present) if
 33

there is an indication for treatment by clinical criteria for VAP. In immunocompromised and

longer term patients, a blind BAL is a better option.

Aspiration pneumonitis is not an indication for antibiotics.

In deciding about antibiotic use we need to consider five things:

1. Probability of bacterial infection (i.e.fever, temperature instability, increasing IT

ratio,/CRP/procalcitonin);

2. Community or hospital/PICU-acquired

3. Signs of severe sepsis (e.g. increased inotropic requirement with no other likely cause,

worsenig Hypoxaemia associated with new CXR infiltrates);

4. Likely pathogens;

5. Likely antimicrobial susceptibility.

Standard Treatment Antibiotics

 Septicaemia/septic shock, i.e. sick child

 Normal CSF - flucloxacillin and gentamicin

 CSF unknown - flucloxacillin and cefotaxime

 Central line present or suspected MRSA REPLACE - flucloxacillin with vancomycin

 Pneumonia (community acquired)

 Moderately unwell - cefuroxime

 Severely unwell - flucloxacillin and gentamicin ± erythromycin (if considering

mycoplasma) ± clindamycin (MRSA)

 Meningitis - cefotaxime PLUS amoxicillin if <3 months of age PLUS

vancomycin

 Encephalitis - acyclovir

 Peritonitis - amoxicillin, gentamicin, metronidazole

 Osteomyelitis/septic arthritis - flucloxacillin

 34

 Cellulitis/adenitis

 Limbs or torso - flucloxacillin

 Head, neck, bites - amoxicillin and clavulanic acid

 UTI (sick) - amoxicillin and gentamicin

 Pertussis - erythromycin

STANDARD SURGICAL PROPHYLAXIS

 Cardiac surgery cephazolin (50mg/kg pre-induction and at the end of bypass, extra 25mg/kg

during if >4hrs). No post-operative antibiotics

 Sternal closure/reopening vancomycin 15mg/kg (max 500mg) x 1 dose

 Abdominal surgery (variable due to the range of procedures)

 “Standard” risk cefoxitin

 “High risk”, perforation amoxicillin, gentamicin, metronidazole

 Spinal surgery/neurosurgery- cephazolin

STOPPING ANTIBIOTICS or SCALING DOWN ANTIBIOTICS

• All antibiotics should have a stop or review date charted

• Antibiotics should be ceased after 48-72 hours if cultures are negative.

• Antibiotics should be narrowed at 48-72 hours if cultures positive.

• “Possible” VAP is treated with antibiotics for 5 days; “definite/very likely” VAP is treated for

7 days.

• If it is not appropriate to stop antibiotics (because of a high probability of bacterial infection or

signs of severe sepsis), antibiotic therapy can be scaled down when 48 hour cultures are

negative.

Appropriate antibiotics to scale down to depend on the clinical context, but include amoxicillin

and gentamicin for culture-negative severe pneumonia or sepsis. When scaling down antibiotics,

the standard guidelines above can be followed for the treatment of focal infections.
 35

GENERAL ORDERING INFORMATION:

Medication orders written in the Paediatric Intensive Care Unit (PICU) will comply with

all existing PICU policies with the following additions: All medication orders must be written in

dose per kilogram of body weight (e.g. mg / kg / per day or per dose, mcg / kg / per day or per

dose) until the adult dosage is reached.

The following components are required for all medication orders:

 Date and time of order

 Drug name

 Dose and dose per kg of body weight or mg/m2 calculation

mg/kg/day or mg/kg/dose

Mcg/kg/day or mcg/kg/dose

Units/kg/day or units/kg/dose

 Route of administration

 Dosing interval

 Patient weight on order sheet containing medications, usually at top right hand corner

 Legible signature and legible pager number

Therapeutic Levels:

When ordering medications for a patient, make sure you know which ones need

therapeutic levels monitored. You can order the level at the time of initial drug ordering. Most

medications are at steady state within 3 doses. In most instances, in patients with normal renal

and hepatic function, obtaining only a trough prior to giving the 3rd dose will allow you to adjust

the dosing frequency up or down to get a therapeutic level. In patients with hepatic or renal

insufficiency or failure, ordering both a peak and trough around the 3rd dose will allow you to

adjust the frequency (if the trough is high or low) and/or the dose (if the peak is high or low).
 36

DRIPS

In the PICU, drips are often used for their vasoactive properties (post-operative heart

patients or patients in shock) or sedative/anxiolytic or pain-reducing properties. Some helpful

general information about drips and how to calculate them follows.

1. All medications must be ordered as “mg” or “mcg” mixed in some solution, i.e., NS or D5W.

This gives the concentration of the medication (mg/ml or mcg/ml.)

2. The orders for drips must include the drip dose (“mcg/kg/hr” or “mg/kg/min”) AND the drip

rate (“ml/hr”). TRA means “to run at.”

3. Some medications are ordered as milligrams in some volume of fluid and then run at

“mcg/kg/min” so you must make sure that the units have been properly converted.

4. The drips are run through an infusion pump and have a minimum rate of 0.2 ml/hr.

5. Many medications that are infused as drips come in standard concentrations and are written on

pre-printed order sheets. Sedative/narcotic/paralytic drips have their own order sheet. Vasoactive

medication drips are listed on the cardiac admission order sheets. If you don’t know the

appropriate standard drip concentration, ask the attending or RN.

CONCLUSION

The field of Pediatric Intensive Care is rapidly growing. The number of intensive care

units providing care to infants and children is also progressing at a rapid pace. Currently there

are no well defined guidelines for Pediatric Intensive Care Units (PICUs) in the Indian context,

regarding unit design, equipment, organization and staffing or admission and discharge criteria

for different levels of PICU care. Along with the scientific and technical advances has come the

evolution of the pediatric intensive care unit (PICU), in which special needs of critically ill or

injured children and their families can be met by pediatric specialists.

All critically ill infants and children cared for in hospitals, regardless of the physical setting, are

entitled to receive the same quality of care.

 37

REFERANCE

1. Marilyn J. Hockenberry. David Wilson, Wong’s Essentials of pediatric Nursing; First second

Asia Edition;

2. Datta parul, pediatric Nursing,1st edition,2007,Jaypee brother Medical publishers, New Delhi,.

3. Ghai OP & etall, Essential pediatrics,6th edition,2004,CBS publishes & Distributors ,NewDelhi.

4. A Parthasarathy, IAP Textbook of Pediatrics; 4 th Edition; Jaypee brother Medical publishers,

New Delhi