 Group approach

 Bundle care
 Airways
 Breathing
 Circulation
 Radiological assessment
 E.t. care
 Oral care
 Eye care
 Skin care
 Biochemical monitoring
 Bedsore
 Nutrition
 Summary
 TEAM APPROACH INCLUDE:
 Physician
 Nursing staff
 Physiotherapist
 Respiratory physiotherapist (available in some selected tertiary center)

 CONCEPT OF BUNDLE:
- Bundle is a structured way of improving the processes of care and patient outcomes.
- A small straightforward set of evidence –based practices-generally 3-5 that performed
Collectively and reliably, have been proven to improve patient’s outcomes.
- Bundle were further described by Berenholtz and colleagues as a means of assessing of
QUALity of care have two main strands:
1. The interventions themselves.
2. The process of care of delivery.

 WHY BUNDLE IS SO SPECIAL:

- Science based.
- They were well established best practices, but they are often not performed uniformly, making
treatment unreliable.
- A bundle ties the changes together into a package of interventions that people know must be
followed for every patient, every single time.
- Bundle can be used to ensure the delivery of minimum standard care.
- Used as an audit tool to assess the delivery of interventions.
- Most utilized bundle is sepsis care bundle worldwide.

 BUNDLE WORK:
- Direct benefit to the patient
- Shorter intensive care unit stay
- Reduced financial cost
- Improve resource utilization, and therefore, benefit to other patients outside the scope of the care bundle
 TYPE OF BUNDLE:
1. VAP bundle
2. Sepsis care bundle
3. Central line care bundle
1. VAP bundle:
- Elevation of the head of the bed
- Sedation level assessment
- Oral hygiene
- Subglottic aspiration
- Tracheal tube cuff pressure
- Stress ulcer prophylaxis
2. Sepsis care bundle:
- To be completed within 3 hrs. Of time:
- Measure the lactate level
- Obtained blood culture prior to administration of antibiotics.
- Administer broad spectrum antibiotics.
- Administer 30ml/kg crystalloid for hypotension or lactate ≥4 mmol/l
- To be completed within 6 hours. Of time:
- Apply vasopressor (for hypotension that does not respond to initial fluid resuscitation) to
Maintain a mean arterial pressure (MAP ≥65 mm hg)
- In the event of persistent hypotension after initial fluid administration (MAP <65 mm hg)
Or if initial lactated was ≥4 mmol/L, reassess volume status and tissue perfusion.
- Re-measure lactated if initial lactated elevated
3. Central line care bundle:
- Check the clinical indication
- CVC dressing intact and changed
- CVC hub decontamination
- Hand hygiene performed before and after all CVC maintenance/ access procedures.
- Chlorhexidine gluconate 2% used for cleaning the insertion site during dressing changes.
 PHYSIOTHERAPY:
- Mobilize the secretions
- Prevent pneumonia
- Reduce hospital stay
- POSTIONING: Maintain upright or 45˚(contraindicated in shock)
 Mainly beneficial in child having;
 Obesity,
 Abdominal sx,
 Ascites,
 Taking feed (prevent aspiration)
- Increase drainage of secretion
- Improve ventilation perfusion matching
- Decrease work of breathing
- Increase functional residual capacity
- PRONE POSITION:
 Increase oxygenation in early stage of ARDS (by increasing FRC)
 Increase in V/Q matching
 Enabling the drainage of secretion
 Improve lymphatic drainage
- PERCUSSING AND VIBRATION:
 Manually by clamping the chest wall using cupped hand
 Mobilize the secretion from nondependent area to central airway
 From where suctioned easily
 Vibration mainly done in neonates to avoid to damage their fragile chest wall
- MANUAL HYPERINFLATION:
 Performed before and between the suctioning
 Prevent hypoxia while suctioning
 Recruitment of atelectasis segment
 Mobilize the secretions
- CONTINUOUS ROTATIONAL THERAPY:
 Specialized beds are used
 Turn the patient along longitudinal axis
 Not available in India
- FIBEROPTIC BRONCHOSCOPY:
 Consider in lobar atelectasis in patient not responding to vigorous physiotherapy
 Removal of retained secretions
 Thick tenacious plug
- COMPLICATION:
 Increase incidence of hemodynamic disturbance
 Higher incidence of gastroesophaseal reflux
 Increase risk of aspiration
 Risk of fracture in neonate and children
- HUMIDIFICATION:
 Normally upper airway of a person heats and humidifies the atmospheric air to body
temperature & 100% relative humidity.
 Upper airway is bypassed in intubated patient so humidification is required.
 DECREASE IN HUMIDIFICATION LEAD TO:
 Mucosal damage
 Tubal occlusion
 Atelectasis
 Decrease FRC
 hypoxia
 COMPLICATION OF OVER HYDRATION:
 Decrease nasociliary clearance
 Hyper hydration
 Loss of surfactant
  OBTAINED BY:
 Heated water humidifiers
 Heated wire circuit
 Heat and moisture Exchange(HMEs) (Have humidifying property, bacterial filtering property)
- AIRWAYS:
 Is the tracheal tube obstructed or displaced?
 Is there any peritubal leak?
 What is length of tube introduced?
 Is it fixed properly?
 Is the nasogastric tube in situ
- BREATHING:
 Check the rate of spontaneous respiration.
 Check whether the child is breathing in synchrony with ventilator.
 Is there a nasal flare or accessory muscle use?
 Identify the cause of respiratory distress
 Airway problem
 Improper ventilator setting
 Patient- ventilator dyssynchrony
- CIRCULATION:
 Assess the heart rate.
 Peripheral perfusion.
 BP
 Spo2 >95% (indicate good oxygenation)
 In ARDS aim -88-92%
- RADIOLOGICAL ASSESSMENT:
 Done after intubation
 After deterioration
 After extubation
 Very small infants, a daily chest x-ray required to verify ET position.
 The tip of tracheal tube should be between T2 & T4.

 Check for gastric tube or central line if inserted.

  Look for overall lung volume. (Lung over inflation is identified by wide intercostal space
& flat diaphragms).
 Check whether there is improvement or deterioration of primary pathology.
 Look for the atelectasis, pneumonia, pulmonary edema & congestion.
 Cardiac size.
- Check for the presence of air leaks
- ENDOTRACHEAL SUCTION:
 To maintain gas exchange.
 To obtained tracheal aspirate specimen.
 To prevent the effect of retained secretions.
 Suction carried out in three position of the head.
 Choose appropriate size catheter (lumen size is double of the ET tube)
 Pre-oxygenate patient by ventilating for 3-5 breaths with 100% oxygen
 Instil 0.5-1ml of NS into trachea.
 Suction up to the tip of ET
 Don’t apply the negative pressure during inserting the catheter
 Apply intermittent suction while slowly withdrawing catheter in rotating manner.
 Duration of intermittent suction should not exceed >5 sec. in neonate, and 10sec in pediatric
patient
 Re-oxygenate with the manual resuscitation bag for a minimum of 3-5 breaths at age
appropriate rate or until SaO2 returns to baseline for 30 seconds.
 Suction Pressure:
 100-120 mmHg in adult
 80-100 mmHg in children
 60-80 mmHg in infants and neonate
 Birth wt. (g) Endotracheal Suction
tube(size) catheter(fr)
<1000 2.5 5.0

1000-2000 3.0 6.5

2000-3000 3.5 6.5

>3000 4.0 8.0

- MUCOLYTICS:
 N-acetylcystine
 DNA-se (use in life threatening situations of mucus plug)
1. N-acetylcystine:
 Breaks disulphide bonds in mucus.
 Make less viscid mucus (easier to suction)
 PTR- may cause bronchospasm, which can be overcome by using beta2 agonist.
DNA-se:
 Used in patients with cystic fibrosis
 Expensive and not available in India
- ORAL CARE:
 Tooth brushing twice a day
 Chlorhexidine rinse twice a day.
- EYE CARE:
 Ventilated patient is often sedated & Increase the risk of (muscle relaxed)
 Exposure keratitis
 Corneal ulceration
 Infection
 TT. Passive closure of eyelid, use lubricants,
(Artificial tear. Prevention: eye packing, lubricating
ointments and artificial tears,
antibiotics eye drops).
- SKIN CARE:
 Skin of term baby have well developed epidermis.
 Stratum corium similar to adult(15-20 layer)
 In preterm it has fewer layer & lead to
 Increase permeability
 Increase Risk of toxicity substance applied to skin
 Increase Evaporative heat loss
 Moisturizers
 Skin disinfectants(cause skin necrosis, blistering, burns)
 Povidone-iodine proved better than 70% isopropyl alcohol in pediatric
patient.
- BIOCHEMICAL MONITORING:
 Blood gases: ABG checked 20-30 min after initial setting, then after or twice per day or
as per need.
 Need to perform frequent gases has been reduced by pulse oximeter & ETCO2
monitoring
 Other lab monitoring: Serum Electrolytes, RFT, LFT etc.
 Monitor Hb/PCV once every day.
 Septic shock target is 10gm%
- BACTERIOLOGICAL MONITORING: They are warranted only when there is sudden
Change in quantity & quality of tracheal tube secretion, along with development of fever & new
infiltrates in the chest X-ray
- BLOOD CULTURE: It indicated, before changing antibiotics appropriate culture should be sent.
- MONITOR SOME COMMON CONDITION:

1. Asthma or bronchiolitis: Peak alveolar pressure & mean airway pressure, Auto- PEEP,
presence of barotraumas, pulse- oximeter & ABG, HR & BP, CO2

2. CARDIOVASCULAR FAILURE: CVP, systemic hemodynamic, pulse-oximeter & blood gases,

Urine output & serum electrolytes
3. NEUROMUSCULAR DISEASE: Spontaneous tidal volume & respiratory rate,
Maximal inspiratory pressure, vital capacity, periodic ABG analysis.
4. PULMONARY DISEASE: Patient-ventilator synchrony, peak alveolar pressure,
Auto-PEEP, systemic hemodynamic, pulse oximeter & blood gases, clinical signs of
Cardiopulmonary distress.
 If cuffed ET is used, cuffs must be released every 4 hrly. for 5 min.

 Confirmation of all preset alarms for gas supply, airways pressure, apnea, inspired O2 concentration
 No change in ventilator setting should be done without recording the reason & the change.
 Filling up of humidifier with sterile water daily/continuously.
 Checking the humidifier traps, condensation &temperature.
 Wash compressor filter daily or as indicated
 Change of ventilator tubing periodically
 Provision of adequate calories-with nasogastric tube.
 In few patient parenteral feeding if enteral feeding not possible because of ileus or abdominal
pathology.
 Intake & output measurement & their calculation every 8 hrly.

- BED SORE/ DECUBITE ULCER

 Localized injuries to the skin or underlying tissue that usually occurs over bony prominence as
a result of pressure in a combination with shear and friction.
 Most common sites are skin overlying sacrum, coccyx heel or the hips
 Pressure ulcer occurs due to pressure applied to soft tissue resulting in completely or
partially obstructed blood flow to the soft tissue.
 Cause of pressure ulcer:
 Lying or setting in a same position

 Friction when a person is dragged and not lifted or lured in right manner.

 Poor blood circulation

 Poor nutrition

 Constant pressure over a particular area of body

 Prevention of bed sore:

 Changing in patient position frequently 2-4 hrly
 A period of stretching and moving the joint decrease bed sore as well as improve
Blood circulation and prevent joint stiffness.
 Support the surface by using anti-decubitus mattresses and cushions.
 Controlling the heat and moisture level of skin surface.
 Adequate intake of protein and calories and Vit-C.
 Treatment of Decubitus ulcer:
 Pressure redistributing support surface
 Nutritional support
 Repositioning
 Wound care
- NUTRITIONAL CARE
 Improve the wound healing
 Decreases the catabolic response to injury Improve the GI
function and structure Reduce the complication and length
of stay Reduce the morbidity and mortality
 Enteral feeding is always superior than parenteral feeding
 Initial illness: permissive hypo caloric nutritional support (20-30 kcal/kg/day)
 Later on: improved metabolism-norm caloric and then to hyper caloric
Support to promote tissue growth and healing
 Goal is BMR/REE to avoid complications of overfeeding
  ENTERAL FEED :
 Preferred over TPN
 Reduced risk of bacteremia and pneumonia
 C/In: severe GI hemorrhage, recent GI surgery, obstruction, NEC, severe vomiting or diarrhea
 milk
 Elemental formula: carbohydrates as oligosaccharides, maltodextrins or hydrolyzed corn starch;
nitrogen as peptides or free amino acids; lipids as oils or MCT
 Given via nasogastric tubes or orogastric tubes
 10-15 ml/kg/day and started gradually till target calories are achieved
 Vitamins and mineral supplementation
 Percutaneous endoscopic gastrostomy (PEG) tubes in case of facial or skull trauma
 Nasoduodenal or trans pyloric feeding in decreased gut motility
(Pts. on vasoactive agents, neuromuscular blockage, recent major insult)
 For long term use: silicone tubes.
 PARENTERAL FEED:
 Amino acid mixtures, lipids, glucose and trace mineral and vitamins

 Route: peripheral (osmolarity of infusate should be <700 mOs/L) or central vein

 Daily weight recording

 Complications: catheter related infections, liver dysfunction, hyperglycemia, hyperlipidemia,

and acidosis and electrolyte imbalances

 Shifted to enteral feeds as soon as gut function improves

 Growing evidences show that TPN I systemically immunosuppressive, suppression of GALT

and disuse atrophy of gut mucosa, suppression of immune protection at respiratory

and genitourinary surfaces

 IMMUNONUTRITION:
 Glutamine, arginine, w 3 fatty acids, nucleotides, taurine, cysteine and some complex
carbohydrates and probiotic bacteria
 Reduced length of hospital stay and decreased risk of infectious complications