Resident’s Survival Guide
for
Paediatric Intensive Care Unit (PICU)
Introduction
Paediatric Intensive Care Unit (PICU) deals with some of the sickest of all children in
the region requiring organ support.
The critical care area, being one of the most stressful areas within the hospital, is
prone to mistakes, which can cause serious harm to the patients. Therefore safety
issues and safety checks are of paramount importance within this PICU. Any
heroic intervention or practice that is beyond the competence of the operator
and/or can be potentially unsafe and puts patients at unnecessary risk cannot
therefore be allowed or encouraged. The consultant must be kept informed at all
times about any changes in the patient’s condition and any new intervention done
on the patient.
Scope of this SOP
This Standard Operating Procedure provides the broader baseline for patient care in
this PICU within a framework of safety, and is meant to serve as a reference for the
nursing staff and the resident doctors who have a duty of care within this clinical
area. Individual variations in patient conditions will mandate deviation from this
SOP on a case-to-case basis to suit the clinical needs of individual patients.
Any deviation from this SOP must be authorized at all times by the consultant
intensivist in charge of the patient.
It is the responsibility of the Nurse-in-Charge of the unit to ensure that this
SOP is complied with at all times.
Admission Criteria (IAP-ICC Recommendations)
PICU (Level 3) Admission Criteria:
• All patients requiring mechanical ventilation
• Patients with impending respiratory failure
• Upper or lower airway obstructions; Unstable airway
• All Post cardiac / respiratory arrest pediatric patients
• Comatose patients; Meningitis, encephalitis; Hepatic encephalopathy; Cerebral
malaria; Head injury; Poisonings; Status epilepticus
• All types of shock/hemodynamic instability: (a) Septic shock; (b) Hypovolemic
shock; (c) Bleeding emergencies such as gastrointestinal bleeding, bleeding
diathesis, disseminated intravascular coagulation; (d) Cardiogenic shock;
myocarditis, cardiomyopathy, con-genital heart disease; (e) Neurogenic shock;
and (f) Multiple trauma
• Cardiac arrhythmias
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Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
•
•
•
•
•
•
•
•
Hypertensive Emergencies
Severe acid base disorders; Severe electrolyte abnormalities
Acute renal failure; Patients requiring acute hemodialysis, haemofilteration and
peritoneal dialysis
Post operative patients; (a) Requiring ventilation; (b) Unstable patients; and (c)
Post operative patients after open heart surgery, neurosurgery, thoracic surgery
and other patients after major general surgery with potential for
respiratory/haemodynamic instability
Patients requiring ECMO (Extra corporeal membrane oxygenation), nitric oxide
therapy (if available)
Malignant hyperpyrexia
Acute hepatic failure; and
All post transplant patients (if applicable).
HDU (Level 2) Admission Criteria:
• All ward patients requiring close monitoring due to potentially unstable
conditions
• Croup (laryngotracheobronchitis) requiring oxygen
• Asthma requiring hourly nebulization/getting tired with increasing oxygen
requirement/mental status change
• All patients requiring more than 50% oxygen to maintain saturations
• Closed head injury/skull fracture admitted for observation
• Diabetes ketoacidosis with pH <7.2
• Patients with episodes of apnea
• Patients with significant abdominal trauma with suspected
renal/splenic/hepatic injury
• Severe dehydration with mental status change
• Post operative patients after major surgery with significant post operative
pain/blood loss/stress
• Patients recovering from critical illness (level 3 care), but requiring close
monitoring
Admission Documentation
The resident doctor is required to do the admission clerking in the prescribed
proforma and put time, date and sign the document legibly. He should then inform
the Consultant under whom the child is admitted and formulate a plan with him.
The resident doctor is required to fill up FULLY the Emergency Drug List and sign
it at the time of admission. The same shall then be cross-checked by the Nursing
Shift-in-Charge who will sign it and file it as the FIRST PAGE of the patient’s medical
folder. Its is the duty of the Shift-in-Charge to ensure that the Emergency Drug
List is filled up correctly and completely, and the same should be checked by
the Shift-in-Charge at the start of every shift.
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Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
PICU Admission Checklist for Nurses
This must be completed by the bedside nurse at the start of every shift and crosschecked by the shift-in-charge. They must check that the Emergency Drug List is
complete and signed and is filed as the first page of the patient folder. The Ambu bag
size (appropriate for the child) must be circled on the checklist and at every shift
checked to make sure it is assembled properly and working. The Paediatric Bagging
Circuit (Mapleson F) or Adult Bagging Circuit (Mapleson C) whichever is
appropriate must be checked and kept attached to the oxygen port at all times.
Appropriately sized mask must be kept at the bedside and the size must be
mentioned on the checklist and checked in every shift. Appropriate size ET tube
with one size above and below must be kept at the bedside. Appropriately sized
Suction catheters (Size = 2xETT Size) must be available on the bedside at all times
and suction apparatus must be checked in every shift. Appropriately sized LMA and
Bougie and Elastoplast for Melbourne strapping must be kept at hand and their
availability in the in the designated location must be checked in every shift.
Medication dosing
All drug dosing should be in accordance with the British National Formulary for
Children (BMFc), hard copy of which can be found on the PICU. For renal dose
adjustment of medications in case of renal impairment, the PICU Quick Reference
Folder and the Great Ormond Street Hospital Paediatric Drug Dosage Adjustments
should be followed.
The Shift-in-Charge must cross-check that the prescriptions are in accordance with
the BNFc. If there is a discrepancy, both the Shift-in-charge as well as the Bedside
Nurse has the full authority to raise a query with the resident doctor on the shift,
and if the nurse is not satisfied, she is empowered to escalate it to the Consultant
under whom the child is admitted. Under no circumstances shall the nurse
administer a medication whose dosing he/she is not comfortable with.
All infusions should be prepared according to the infusion preparation charts
provided in the PICU Quick Reference Folder. Infusion Sticky Labels should be filled
completely including the Bolus volume and pasted on the syringe in a manner so
that the label remains visible at all times.
Sedations and muscle relaxants for procedures should be drawn up in the exact
amount in a 1ml syringe. Dilution of drugs can lead to confusion over doses and only
needs to be considered if the child is very small (e.g. a premature neonate) or if 1ml
syringes are unavailable.
Thames Valley Y-site Intravenous Drug Compatibility Chart
When administering two infusions or drugs through a single lumen via a Yconnection, it is the nurse’s responsibility to check the compatibility of the two
medications using the Thames Valley Y-site Drug Compatibility Chart provided in
first page of the PICU Quick Reference Folder.
3
Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
Airway
Intubation
Intubation is a life saving procedure but may be associated with significant risk.
Cardiovascularly unstable children are at risk of Cardiac Arrest during this
procedure.
Intubation therefore must always be a 2-operator procedure with 2 persons
competent in intubation skills being present at the bedside throughout the
procedure. It is advisable to solicit the support of the anaesthetist on-call. The
consultant intensivist must be informed about the decision to intubate. Parents
must be informed beforehand.
Intubation checklist must be completed prior to induction at all times.
The Crash Trolley must be at hand.
Unanticipated difficult airway may be encountered; therefore all staff should
familiarize themselves with the Difficult Airway Society (DAS) Guidelines which can
be found in the PICU Quick Reference Folder.
Induction
Any child with significant airway problem (Severe Croup, Acute Epiglottitis, Acute
Bacterial Tracheitis) must be taken to the Theatre for Gas induction by an
anaesthetist.
For IV induction, the induction agents preferred in this unit are
• Morphine (as a single agent) for Neonates and
• Ketamine for children.
Ketamine can cause increased airway secretions and is a potential hallucinogen;
hence Atropine and Midazolam may be considered along with it.
Ketamine need not be avoided in children known or suspected to have increased
intracranial pressure.
• Fentanyl+Midazolam combination may also be used.
Suxamethonium is the muscle relaxant of choice due to its short duration of action,
but should be avoided in any child known or suspected to have hyperkalaemia
(Renal Failure), Muscle dystrophy or myotonia, Malignant hyperpyrexia, or 24 hours
after a major burn or spinal cord injury due to exaggerated hyperkalaemic response.
In these cases Rocuronium is preferred but the intubator needs to be aware that its
effect lasts more than 40 minutes and may pose a problem if airway cannot be
secured.
Intubation checklist must be completed prior to induction at all times.
It is mandatory to make sure that the child can be bagged effectively prior to
administration of muscle relaxant.
Confirmation of Endotracheal Tube placement
End Tidal CO2 (ETCO2) monitoring is mandatory to confirm Endotracheal Tube
placement at the time of intubation.
4
Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
It is mandatory to have continuous ETCO2 monitoring at all times in any child
ventilated via Endotracheal tube or via Tracheostomy.
Chest X-ray is mandatory to confirm the position of the tip of the ET Tube. The ideal
position for ET tube tip T2 vertebra level, and above the carina. Tube may need to be
repositioned and re-taped in response to the chest X-ray.
Taping
Full Melbourne Strapping should be used to secure Endotracheal Tube. Elastoplast
trouser length for this purpose should be measured from tragus to tragus and cut
longitudinally as “trouser legs” along 2/3 of the length. Steps of Melbourne
Strapping can be found in the PICU Quick Reference Guide.
Trimming the ET tube
Extra length of ET tube creates a significant dead space which must be minimized by
trimming the ET Tube, but this should never be done until ET tube position has been
confirmed to be satisfactory on the Chest X-ray.
Ordinarily, ideal length at which the tube should be cut is the child’s fist width from
the lips. The tube should always be cut obliquely for ease of re-connecting the
adaptor.
ET Tube should NOT be cut in children with septic shock or facial burns or facial
trauma where significant facial swelling is anticipated, as this may require extra
length of tube.
Re-taping
For ET Tube repositioning and / or re-taping the ET Tube, it is mandatory to have a
doctor competent in intubation skills to be present at the bed side, and the Crash
Trolley must be kept at hand. Bag and mask must be ready and checked in
anticipation of accidental extubation. A bolus of sedation AND muscle relaxant must
always be used for re-positioning or re-taping the ET tube to minimize chances of
accidental extubation.
Oxygen administration
Oxygen is a potentially toxic substance and must be used extremely judiciously.
Oxygen should be administered to maintain oxygen saturation above 92% in all
children except children who have chronic lung conditions with compensated
respiratory acidosis whose oxygen saturation should be maintained between 8892%. For children with underlying cyanotic cardiac conditions, saturation targets
must be decided by the consultant intensivist/cardiologist on individual basis.
Basic Ventilation
Humidified circuits must be used at all times for all children on invasive mechanical
ventilation. Always check that the Fisher-Peckel humidifier has been switched on
5
Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
and filled with water. Only use distilled water (Never Saline) in the Humidifier.
Appropriately sized HME filters can be used only for short duration (e.g. during
transport).
Paediatric Mode and Paediatric Circuit should be used for all children < 30 Kg Adult
Mode and Adult circuit should be used for all children > 30Kg.
Mechanical ventilation (non-invasive or invasive) should aim to maintain
oxygenation and ventilation (ie CO2 clearance) while minimizing any form of
Ventilator induced Lung Injury (VILI) and patient discomfort.
In Children with respiratory conditions, and in general, Pressure controlled modes
like SIMV-PC/PS is preferred, while in children who are expected to have normal
lungs (e.g. neuroprotected children without pulmonary concerns) can be ventilated
in Volume controlled mode. Hybrid mode e.g. PRVC are now preferred in most units.
Target Tidal Volume should be between 6-8ml/kg and should under no
circumstances exceed 10ml/kg or be less than 4ml/kg. PIP (Peak Inspiratory
Pressure) in Pressure controlled mode should be adjusted to achieve this Expiratory
Tidal Volume (VTe). PIP should be kept below 30cm H2O. Children needing PIP > 30
cm H2O should be considered for High Frequency Oscillation Ventilation (HFOV) or
Airway Pressure Release Ventilation (APRV/ BiVent).
I-Time (Ti) should be adjusted in such a way that both the inspiratory and
expiratory flow scalars reach baseline. Ordinarily recommended Ti is 0.6-0.8s for
1mo-1yr; 0.8 – 1s for 1-5yrs; 1-1.2s for 5-12yrs and 1.5s for >12yrs. But care has to
be taken to ensure this does not lead to inverse ratio ventilation (Ti>Te).
Target Saturation is > 92% in most instances and >88% in children with severe
ARDS or those who have Chronic Lung Conditions with compensated respiratory
acidosis.
Target oxygen saturation in Cardiac children MUST be discussed with the attending
intensivist and the cardiologist.
Children should not be ventilated with zero PEEP under any circumstances. A
minimum PEEP of 5cm H2O must be used at all times.
If FiO2 > 40%, PEEP should be increased by 1, and similarly if FiO2 < 40%, PEEP can
be weaned by 1. PEEP adjustments should be done no more frequently than hourly.
In between PEEP changes, if oxygenation is a problem try to only adjust FiO2. This
allows time for the PEEP changes to take effect (recruitment).
Blood gas PCO2 should be correlated with ETCO2 at all times and ETCO2 trend may
be used to monitor ventilation but this does not eliminate the need for blood gas
monitoring from time to time.
Target PaCO2 should be maintained between 35 - 45mm Hg (4.5 - 6 kPa).
In neuro-protected children the target PaCO2 should be between 35 - 40mm Hg (4.5
- 5.2 kPa). [1 kPa = 7.5mm Hg]
Cardiovascular
In PICU, the Mean Arterial Pressure (MAP) is monitored as a) MAP provides the
perfusion pressure (PP = MAP – CVP) and b) Blood Pressure in PICU is measured by
oscillometric methods which measures the MAP and calculates Systolic and Diastolic
Blood Pressure values using an algorithm integrated within the machine.
6
Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
Target MAP (50th centile) = 55 + Age x 1.5
[ Newborn: 55 mm Hg; Infant (2 yrs): 58 mm Hg; Child (7 yrs): 65 mm Hg ]
(ACCM Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock 2017)
MAP (5th centile) = 40 + Age x 1.5
[ In children who are neuro-protected without an ICP bolt in-situ, MAP target is
decided to maintain age-appropriate Cerebral Perfusion Pressure (CPP).
CPP = MAP – ICP
MAP = CPP + ICP
As intervention threshold for Intracranial Pressure (ICP) is 20 mm Hg,
Target MAP = CPP + 20 mm Hg
CPP Threshold varies with age:
• Infants & Toddlers: 40-50 mmHg
• Children: 50-60 mmHg
• Adults: 60-70 mmHg
CPP must always be maintained > 40 mmHg. High CPP (> upper limit for age) should
always be avoided as it worsens vasogenic cerebral oedema.
In certain neurosurgical children where there is a risk of bleeding, the MAP (and
SBP) target will be dictated by the Neurosurgeon on a case to case basis. ]
Ordinarily a drop in MAP must be acted upon particularly if there is an associated
drop in urine output. Options are Fluid bolus and inotropes. Pressing on the liver
may be a useful bedside method to ascertain whether the child is volume responsive
or needs inotrope escalation. (There are many other measures of fluid
responsiveness including IVC size and compressibility on Bedside USG and Passive
Leg Raising Test, etc).
For children in septic shock, the Surviving Sepsis Campaign guidelines must be
followed at all times. Summary of this guideline can be found in the PICU Quick
Reference Folder.
Children without a central venous line (CVL) may be commenced on Dopamine
(peripheral strength) or Adrenaline (0.05-0.3mcg/kg/min) via a peripheral or an
Intraosseous (IO) access. A central venous access must be established in children
who need further escalation of inotropes. It is advisable to run Adrenaline infusion
via a Central Line. Noradrenaline should not be run peripherally under any
circumstances.
In Children without a Central Line, choice of inotropes should be Dopamine
(peripheral strength) or Adrenaline as mentioned above (for cold shock). In children
with central venous access, choice of inotropes should be Noradrenaline for warm
shock and Adrenaline for cold shock.
For changing Inotrope syringes running through the same lumen, the Quick Change
Method or the Double Pumping Method MUST ALWAYS be followed. For changing
the site of the Inotrope infusion, the Double Pumping Method MUST be followed at
all times.
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Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
Vascular Access
Arterial Line
Any child needing a central inotrope must have an arterial line.
Distal Pulses in the limb that has an arterial line must be checked regularly and
colour and capillary refill time monitored. It may be worth putting the saturation
probe on a digit of the limb that has the arterial line in-situ to ensure that there is a
normal pulsatile wave form in that limb.
If any concern about the limb, the consultant needs to be informed immediately; he
may advise removal of the arterial line and if concern about intra-arterial thrombus,
anticoagulation may be considered as per protocol.
Brachial Artery must NEVER be used for arterial lines, as this is an end artery.
Heparinized Saline must always be used to maintain arterial line patency.
For Children < 10 Kg body weight, 50 Units Heparin in 50 ml NS @ 0.5-1ml/hr
For Children > 10 Kg body weight, 500 Unit Heparin in 500 ml NS via Pressure Bag.
Arterial lines should not be flushed with Heparinised Saline following access, only
Normal Saline should be used for flushing. Care should be taken to keep Arterial
Line air free at all times and should be zeroed following every access.
Central Venous Line
Only dopamine (peripheral strength) and Adrenaline (0.05-0.3mcg/kg/min) can be
run through a peripheral line. It is advisable that this route be used only for a short
duration until a central venous access is established.
Preferred sites are Internal Jugular and Femoral Veins. Wherever possible Central
venous line insertion should be USG-guided.
It is mandatory to confirm the position of the tip of any neck line with a Chest Xray
before using the line. The CVL tip should be in the SVC or at the Cavo-Atrial Junction
(At the level of the 1st anterior intercostal space).
Subclavian CVLs should be avoided in children with deranged coagulation. Neck
lines (IJ CVLs) should be avoided in children who are neuroprotected. Femoral CVLs
have more chances of getting infected than IJ lines due to their location.
Central Lines: Suggested Length and Gauge
Weight (Kg)
Right Internal Jugular
<3
4Fr 5cm
3–5
5Fr 5cm
5 – 10
5Fr 6.5cm
10 – 30
5Fr 8cm
> 30
5Fr 12cm
For Glen or TCPC use shorter length if RIJ
Femoral
4Fr 5cm
5Fr 6.5cm or 5Fr 8cm
5Fr 8cm
5Fr 8cm or 5Fr 12cm
5Fr 12cm
All inotrope and sedation infusion must ALWAYS be connected using a 3-way tap in
order to allow “Quick change” or “Double pumping” of the infusions in a safe
manner.
8
Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
The Distal Lumen of the CVL should be kept free as far as possible to enable CVP
measurement and Blood sampling. Vasoactive agents should be run through the
Proximal Lumen to avoid accidental purge as a result of flush / bolus of other drugs.
Full aseptic precautions must be taken at all times while accessing a Central Venous
Line or an Arterial Line.
CVP Line should be maintained with plain (non-heparinized) Normal Saline @ 0.51ml/hr.
Sedations and Analgesia
Sedation and Analgesia are not synonymous and interchangeable terms. Having an
Endotracheal Tube in the throat is painful and therefore awake ventilation should
never be allowed in children. Physically restraining children (e.g. by tying their
limbs to cot rails) is unacceptable in this PICU. Therefore adequate sedation and
adequate analgesia both should always be administered to any child on invasive
mechanical ventilation.
The standard combination used in this unit is Morphine (Analgesia) and Midazolam
(Sedation) infusions. Children needing a more potent opioid can be started on
Fentanyl infusion. Morphine should not be used in asthmatics as it causes histamine
release; Fentanyl is preferred in these children. Fentanyl being more potent, has
higher propensity for causing withdrawal.
Oversedation increases the risk of ventilator associated pneumonia (VAP) and
therefore sedation should be titrated to maintain the Comfort Score between 17 26. Comfort Score must be included in the nursing folder of all children who are on
invasive mechanical ventilation and can be found in the PICU Quick Reference
Folder. Daily Sedation Holiday is standard for all ventilated children, except those
who are on active neuroprotection. Sedation should be stopped every morning to let
the child wake up, move and cough, following which the child should be re-sedated
until ready for extubation. Sedation Holiday helps to decrease withdrawal, assess
neurology and helps clear secretions through coughing, thus is an integral part of
VAP Prevention Bundle.
Muscle relaxants infusions are not routinely used in children who are mechanically
ventilated. Use of muscle relaxants must be authorized by the Consultant intensivist
at all times. Vecuronium infusion is preferred in these cases. Atracurium causes
histamine release and therefore should be avoided in asthmatics. Children on
Vecuronium infuison must get a daily “Vec Holiday” whereby the infusion is stopped
until spontaneous movements are observed, and restarted thereafter if necessary.
Paralysing an awake child is unacceptable. Muscle relaxants should be administered
only after ensuring that the child is adequately sedated. Enterally fed children can
be given enteral sedation. Triclofos is preferred for this purpose.
For children who have been on opioids for more than 3 days it is important to
consider appropriate sedation weaning plan to prevent withdrawal symptoms. IV
sedations must be stopped 4 hours prior to extubation. Oral sedations must be
stopped atleast 6 hours prior to extubation.
9
Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
IV Maintenance Fluid
The standard maintenance fluid in the PICU is DNS (0.9%NaCl+5%Dextrose)+/- KCl
(10mmol in 500ml bag).
Potassium should be added to the maintenance fluid only once urine output has
been documented and/or Blood Gas / Lab Report shows potassium level within
normal range. It is important that the electrolytes on the Blood Gas correlate with
the Laboratory values.
Any deviation from the above has to be approved by the Attending Consultant.
Isolyte-P or Arolyte-P (1/5NaCl+5%Dextrose) must not be stocked within any
clinical area treating children and must not be used within the PICU.
As all the patients admitted in the PICU have conditions that predispose them to
SIADH, fluid allowance should be restricted to 80% in most children.
For Neurosurgical/Neuroprotected children and children in Liver failure, fluid
allowance should be restricted to 60-70%. Cardiac children should started on 50%
IV maintenance. These are however only starting points, actual maintenance fluid
volume is titrated to achieve adequate organ perfusion (as evidenced by CVP 8-12
mm Hg, UO > 1ml/kg/hr, optimum MAP, Capillary refill < 2 secs, Scvo2 > 70%),
Blood Sugar Level and target Fluid Balance. (Target CVP in Neuroprotected children
= 4 – 10 mm Hg, as per Brain Trauma Foundation Guidelines).
This fluid allowance includes all infusions and medications and feeds unless
explicitly specified otherwise by the attending consultant.
Enteral Feeds
Enteral feeds should be started as soon as possible once airway has been secured
and some degree of clinical stability has been achieved, unless there are contraindications to enteral feeding. Enteral Feeding Guidelines are available in the PICU
Quick Reference Folder.
Nasogastric feeds need to be stopped for procedures and for extubation. NICE
recommends the 2-4-6 fasting rules for this purpose.
Feeds should therefore be stopped 4 hours before extubation.
Unless contraindicated, feeds should be restarted 4 hours post extubation.
Naso-jejunal feeds do not need to be stopped for procedures or extubation. When
feeds are stopped for procedures and not for feed intolerance, feeds should be
recommenced at the same rate/volume as the child was on before stopping feeds.
Enterally fed children requiring Sodium supplementation may be given table salt
mixed with feed. 1 mEq of Na+ = 23 mg of Na+ = 60 mg of Table Salt (NaCl).
Sterile packed salt sachets (1 gram or 2 gram sachets) should be used.
Glycaemic Control
Critically ill children have unstable blood sugar levels and are prone to develop
hypoglycemia and hyperglycemia both of which affect outcome. Blood sugar should
therefore be monitored at least 6 hourly in all children who needs any form of organ
support. Normoglycaemia (72 – 180 mg/dl = 4.0 -10.0 mmol/L) should be
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Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
targeted in all patients in the PICU. More tighter control (Blood Sugar 71 – 126
mg/dl = 4.0 – 7.0 mmol/L) is not recommended any more following the CHiP Trial.
Threshold for treating hyperglycaemia with IV Insulin is Blood Sugar > 216
mg/dl (12 mmol/L) on 2 occasions 30 minutes apart. The Normal Control Arm
of the CHiP Protocol must be followed in these children. Insulin should be stopped
once Blood Sugar is below 180 mg/dl (10 mmol/L).
Hypoglycaemia (Blood Sugar < 72 mg/dl) should be treated with 2ml/Kg bolus of
10% Dextrose. It may be necessary to consider increasing total fluid allowance or
glucose concentration in order to increase glucose delivery. Glucose concentration >
12.5% MUST NEVER be infused through peripheral venous lines, Central Venous
Line is mandatory for fluid containing such concentration of Glucose.
Critically ill children, particularly ones with Liver disorders, often have high Glucose
requirement. While preparing Non-standard concentrations of Glucose containing
fluids, it is essential to ensure that isotonicity of the fluid is maintained at all times.
Therefore unlike in NICUs where extra glucose is added to maintenance fluid, in
PICU Sodium is added to Glucose to maintain fluid isotonicity. Ideally 30% NaCl
solutions are used for this purpose, but due to its unavailability in India, 3% NaCl is
used instead, but due to the extra volume, Glucose concentration is always less than
the target. A rough guide can be found in the PICU Reference Folder. Children with
unstable Blood Sugar levels should have Blood Sugar monitored atleast 4 hourly,
and often more frequently if necessary.
Blood Products
Blood is a hazardous medicine and must be used judiciously.
Blood Transfusion threshold on PICU are as follows:
• Packed Red Blood Cells: Hb< 7g/dl
• Platelets: Platelet count ≤10,000/mm3 in absence of bleeding
≤ 20,000/mm3 if significant risk of bleeding
≤ 50,000/mm3 if active bleeding, surgery or any invasive
procedure.
• Cryoprecipitate: Fibrinogen < 1g/L
• Fresh Frozen Plasma: INR > 2; Current guidelines recommend that FFP
should NOT be used to correct INR in Acute Liver Failure unless there is
active bleeding or any invasive procedure need to be performed.
In children post-transplant, Hb should be kept between 6-9g/dl
Watch for Anaphylaxis and any other form of Transfusion reaction.
If fever à Stop transfusion, inform blood bank, monitor BP, Pulse, RR, watch for
abdominal pain and urine colour. If flank pain, red urine and pink plasma, suspect
Haemolytic reaction. Establish urine output 4-5ml/kg/hr, monitor for ARF,
hyperkalaemia and DIC.
Transfusion Related Acute Lung Injury (TRALI) can occur with any plasma
containing blood product, including albumin, and has to be watched out for. This
presents with pulmonary oedema and acute respiratory distress during or within 6
hours of the end of a transfusion, with bilateral pulmonary infiltrates on Chest Xray
11
Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care
with no sign of circulatory overload. They need respiratory support and usually
resolve within 48 hours.
Antibiotics
Any child commenced on IV antibiotics must have Blood Cultures taken prior to
starting antibiotics. Choice of antibiotics should ordinarily be guided by the hospital
antibiotic policy that reflects the current resistance pattern of the bacterial flora in
the region and should be led by the Microbiology team which should lead
Microbiology rounds on the unit on set days of the week with an aim to rationalize
antibiotics use. Empiric use of ultra-broad spectrum antibiotics may be justified only
in children presenting in septic shock and severe sepsis, as long as there is readiness
to review and de-escalate over the next 48 hours in consultation with the
Microbiology team.
Protocols
In the practice of Western Medicine, where our entire medical knowledge base is
derived from the western literatures and models, western protocols ordinarily
remain valid in the Indian context too. However where national protocols are
available (e.g. IAP protocols), these may be preferred. While following western
protocols, discretion is needed with regards to recommendations not deemed
relevant to the Indian context. The consultant in charge of the patient will decide
and specify which protocol to follow for specific medical conditions.
Referrals to Other Specialties
All subspecialty consultations must be documented in the medical notes and the
resident doctor must inform the Consultant intensivist about the outcome of such
referral as soon as possible. Changes to the patient management as suggested by the
referred subspecialty can be instituted only after obtaining approval of the
consultant intensivist under whom the child is admitted.
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Dr. Bichitrovanu Sarkar DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Accredited Teacher, IAP-ICC College of Pediatric Critical Care