THE PICU SURVIVAL GUIDE

Website & Guidelines: www.GeorgesPICU.org.uk/pdf

Table of Contents

Introduction ..................................................................................................................................1
Airway ..........................................................................................................................................5
Breathing ......................................................................................................................................7
CIrculation.....................................................................................................................................8
Disability / Sedation ......................................................................................................................9
Electrolytes ................................................................................................................................. 10
Fluids .......................................................................................................................................... 11
Gastro / feeding .......................................................................................................................... 12
Haematology............................................................................................................................... 13
Infection...................................................................................................................................... 14
Lines............................................................................................................................................ 15

1st edition - March 2018 © St George’s PICU

By Mary Boullier, David Cohen & Nick Prince

2nd Edition: May 2019, Sukesh Mohta, Jonathan Round

Introduction
Welcome to PICU! This is a quick-reference booklet full of practical, essential information for anyone new to
PICU. It briefly covers some common clinical guidelines, and also a lot common practice in PICU that is not
written down, but has become the way things are done.

For the full and comprehensive guidelines for PICU go to:

http://www.georgespicu.org.uk/pdf

Organisation
The Paediatric Intensive Care Department at St George’s has 2 wards:

1) Paediatric Intensive Care Unit (PICU) – 1st floor Lanesborough wing

- 10 beds (2 cubicles / 4 semi cubicles / 4 open bay)
- Patients require either ICU or HDU support

2) Paediatric Step Down Unit (PSDU) – 5th floor Lanesborough wing

- 4 beds (3 open bay, 1 cubicle), non-ITU/HDU care / LTV
- PSDU is not an admission unit, however, in some special circumstances a patient may be admitted
directly to PSDU – this may include a patient who needs admission to hospital and is on home
ventilation, however does not need ICU support. Such admissions are consultant/Lead nurse
bespoke events.

There is a side-room policy (useful to help decide who to give priority for side-room to) available on St
George’s PICU guidelines

The Permanent Team

Board with staff photos is in the entrance to ward
Board with nurse’s names for the shift is next to Dr’s office (helpful for learning names)

Consultants
- Dr Caroline Davison – PICU Lead & Paediatric Anaesthetist
- Dr Linda Murdoch – PICU & Paediatric Anaesthetist
- Dr Jonathan Round – PICU & Reader in Clinical Education, Head of School LSoP
- Dr Soumendu Manna – PICU & Clinical Fellowship Programme Lead, Recruitment
- Dr Anami Gour – PICU, Global Child Health
- Dr Buvana Dwarakanathan – PICU – clinical governance lead, Recruitment.
- Dr Nick Prince – PICU, College Tutor for Paediatrics, Training Programme Director LSoP
- Dr Sukesh Mohta – Locum Consultant, PICU

Senior nurses
- Anita D’Souza – Matron
- Georgina Wilcock – Senior Sister
- Rachel Upton – Senior Sister
- Usha Chandran – Nurse Lecturer Practitioner
- Julie Geevarghese and Josephine – Nurse Practice Educator

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Sisters
- Sharmaine Monrose: Family Liaison Nurse
- Sophie Breen
- Sherly George
- Holly Price
- Josephine Rhodes
- Martin Makato
- Louise Mahon
- Jacopo Martero
- Sian Butler

Tech
- Mark Jenkins

Pharmacist
- Natasha Moore (bleep 7407)

Dietician
- Michelle Webber

Physiotherapists
- Claire-Louise Chadwick
- Caroline Shaw
- Maria Pinnington

PICU administrator: Stevie Burke

PICU Data Manager: Rachel Neal

Structure of the week

Daily timetable

0830 – 0900 Handover (in PICU seminar room during the week, coffee room on weekends)
Patients allocated to medical staff (2-4 patients per doctor, one doctor will cover PSDU)
0900 – 1100 Review patients allocated to you (notes/obs/results, examine, document, order tests)
1100 – 1300 sitting ward round – it’s a detail business round +/- teaching / MDT discussions (in PICU seminar room)
1300 – 1645 Lunch breaks / Ward jobs/ meetings etc..
1645 – 1700 Evening ward round + handover (short day team go home)
2030 – 2100 Handover to night team by long day team, in coffee room

Specialty meetings / Teachings

Wednesday 0900 DRUGGLE – Brief drug safety teaching by pharmacist Natasha. Discussion of any
drug errors in past week + short teaching on any relevant drugs
Wednesday 1400 Paediatric Infectious Disease ward round (in paediatric seminar room)
Thursday 0900 Case base discussion: short teaching by a PICU consultant

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Friday 0900 Case base discussion / short teaching facilitated by PICU consultant

Admission / discharge / handover

Transfer to Freddie Hewitt / Pinkney / Nicholls
Prior to the patient transfer
1. Transfer letter must be on iclip - a summary of admission and plan – save as a clinical note with title
‘PICU discharge summary’
2. Bleep paediatric registrar/SHO on 8152 and handover verbally. ANY patient discharged from PICU to
any Paediatric wards SHOULD be handed over to General Paediatric team.
3. Additionally, if patient is under a specialty team / surgical team; then the respective team should
also be informed of the transfer out as well.
4. Document on iClip who the verbal handover was given to and time.

Transfer to another hospital

1. On morning of planned transfer: call hospital and give medical handover to paediatric registrar
2. Complete discharge summary on iclip – go to ‘depart’ and complete document
3. When patient leaves click on ‘discharge patient from ward’ and tick box at the bottom of screen
‘patient carer understands discharge plan’

Referrals
Three sources of referral
1. STRS (South Thames Retrieval Service) / Children Acute Transport Service ( CATS) for North Thames
a. Complete referral form (found next to Stevie’s desk) for ALL referrals, even if not accepted.
b. Discuss referral with consultant on call and nurse in charge prior to accepting
2. Ward / ED
3. Surgical elective admissions – surgeon / anaesthetist will request a bed and these cases will be
discussed at morning handover and theatres will be updated

All referrals must be discussed with a PICU consultant before acceptance / refusal

Specialties in PICU

Oncology
SGH is both a primary treatment centre (PTC) and shared care centre (POSC). PICU at SGH provides the ICU
support for patients of paediatric oncology at the Royal Marsden.
Common reasons for admission to PICU include
4. New diagnosis with tumour lysis syndrome / bleeding / infections etc
5. Solid tumour – admission mostly postoperatively
6. Sepsis with febrile neutropenia
7. Respiratory failure post bone marrow transplant
8. Severe graft vs host disease

If an oncology patient is in PICU the oncology team will come to join main ward round

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Trauma
SGH is a trauma centre with a helipad – receiving trauma admission from across SE England.

Traumatic brain injury protocol is available on SGH PICU guidelines – a new updated guideline soon

http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2016/12/TBI-Traumatic-Brain-Injury-
Protocol-PICU-2008.pdf

Surgical specialties
Paediatric General Surgery
Neurosurgery
ENT

Medical specialties
Respiratory, Neurology, Endocrine, Gastro, Allergy, Paediatric Infectious Disease

Majority of admissions are general medical admissions requiring ventilation

https://www.fileformat.info/info/unicode/char/1f4a1/electric_light_bulb.png

TOP TIP!
Paediatric Emergency Drugs App
1. Drug doses and infusions
2. Tube and line sizes
3. Guidelines
4. Procedures (eg: how to tape ETT)

Download here:
http://bit.ly/STRS-App

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A
irway

Key calculations

ETT Tube size =

Term infants: 3 cuffed / 3.5 uncuffed ETT.
Age 6 -12 months: 3.5 cuffed / 4 uncuffed.
Age 1- 2 yr: 4 – 4.5 cuffed / uncuffed.
Child ≥ 2yr: (age/4) + 4mm (if airway swelling eg croup use 0.5-1mm smaller)
For cuffed ETT use 0.5 mm smaller size ETT.
Micro-cuffed ETT are preferred if available, these are high volume low pressure cuff ETT: which apply less
pressure to sub-glottis hence reduced risk of airway trauma.

Tube length = (age/2) +12cm (oral)

(age/2) + 15cm (nasal)
Preference is for nasal ETT, however oral ETT may be used first to stabilise patient
2 doctors with dependable airway competency / anaesthetic experience MUST be present at bedside for any
intubation done on PICU. Confirm position with ETCO2
Laryngoscopy blade: for young infants, straight laryngoscopy blade: Miller blade / Robert Shaw / Stuart.
Consider Stuart / Robert Shaw laryngoscopy blade (rather than Miller blade) when changing / doing nasal
ETT for young infant as this gives a ‘wider’ view of oral cavity.

LOCSIP: use LOCSIP document as safety check list and MUST fill it. A completed LOCSIP form should be left
in ‘scan folder’ near Stevie’s computer. These forms are scanned and attached on iClip as patient note.
Position of ETT on CXR – T2-3

Drugs for intubation

All patients should have STRS emergency drug calculator sheet at bedside, before start of induction.
Induction agent
IV Fentanyl - 1-2mcg/kg
IV Ketamine - 1-2mg/kg
IV Propofol – 2-4 mg/kg as a sole induction agent can be used in haemodynamically stable patient.
Muscle paralysing agent:
IV Rocuronium 1mg/kg OR
IV Suxamethonium: Infant (up to 1yr): 2mg/kg. Child: 1mg/kg.

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Loose or wet tapes / reposition tube
These need to be changed to maintain secure airway – need at least 2 people for the task
9. Ensure adequate sedation consider bolus of proprofol (1-2mg/kg)+/- muscle relaxant
⇒ REMEMBER to switch to FULL ventilation BEFORE administering Propofol +/- muscle relaxant
10. Check length of tube was secured at and prepare tapes and duoderm
11. Switch on ‘QRS Bleep sound’ before giving sedation and starting the procedure
12. 1 person holds tube, 2nd person replaces tapes
13. To see how to apply tapes - https://www.evelinalondon.nhs.uk/resources/our-
services/hospital/south-thames-retrieval-service/Securing-of-nasal-entdotracheal-tubes-ETT.pdf

Extubation
Checklist
14. The clinical condition of the patient is resolved for which he / she was put on ventilator
15. Optimised ventilation – low ventilator pressures, low FiO2, breathing spontaneously / reasonable
cough and gag reflex present
16. Suctioning / chest physio done if needed
17. Airway trolley available at the bedside with equipment prepared if reintubation needed
18. Set up NIV / CPAP / optiflow if likely to be needed
19. Check has been NBM 6 hrs prior to extubation and aspirate NGT
20. Double check / inform nurse incharge before actually pulling the tube out(none major is going on simultaneously)
21. Deflate cuff and ask patient to cough (if older child)
22. Remove ETT
23. Give facemask O2 – or other NIV as appropriate

If stridor post extubation

- Give adrenaline neb 1 in 1000 (1mg/ml): 0.5ml / kg, (max 5 ml - can be repeated)
- IV Dexamethasone 0.2mg/kg TDS for 24 hrs (consider changing to oral Prednisolone if on full feeds)

If ongoing upper airways obstruction re-intubate and give 48 hours dexamethasone 0.2mg/kg TDS
ü Use 0.5mm smaller / uncuffed ETT for reintubation with upper airway obstruction

Tracheostomy
If correct diameter was chosen then length should be appropriate
Long term traches are usually uncuffed but patient may require cuffed trache tube during acute illness

New trache (1st 7 days) will have stay sutures securing trachea to skin – these will be tapped to child’s chest
For more information about paediatric tracheostomy
http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/tracheostomy-care-and-management-
review

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B
reathing

Ventilation settings
There is a lot of different terminology and some terms mean the same thing

We use Dragger Evita Ventilator. BIPAP ventilator mode is mostly a default mode on the unit to begin

CMV – Continuous mandatory ventilation: PIP, PEEP and set rate. Not synchronised
SIMV PS / BIPAP ASB – Combination of a set rate with all additional patient triggered breaths also
supported. ASB – Assist Support Breath: PS above level of PEEP
SIMV – Synchronised intermittent mandatory ventilation: volume control + PS
PS – Pressure support. PS is set above PEEP and when patient triggers a breath the ventilator delivers the
additional pressure support to assist.
CPAP– Continuous positive airways pressure – can be via ETT or nasal cannula / face mask / hood
BiPAP – Bi-level Positive air way pressure - can be given non-invasively and may also be called SiPAP

Initial settings suggestion

PIP PEEP Rate# I Time ETCO2 Sats
Standard 15-20 5 -8 20-30 0.7-1.2 4-7 kPA >90%
Asthma* To move 5 12-20 0.7 – 1 6-10 kPA >90%
chest
*PIP initially to get just enough chest rise. Titrate to ET CO2 / paCO2, limit to prevent barotrauma
# Rate: set rate will also depend on patient’s age. iTime to adjust I:E ratio – 1: 2-3.
Asthma - low rate and long expiratory time; I:E – 1: 3-4.
Severe hypoxia in ARDS use recruitment manoeuvres, suction, increase PEEP
https://www.evelinalondon.nhs.uk/resources/our-services/hospital/south-thames-retrieval-service/Pre-transport-stabilisation.pdf

SIMV - Volume control mode of ventilator is used in patients’ with traumatic brain injury to achieve
a tight control of EtCO2 and pCO2 of 4-5kPa

High Frequency Oscillator

HFOV – Siemens A / B – HFOV is used commonly is Paediatric patients population when struggling to
maintain Oxygenation and / or ventilation requiring high ventilator settings.

Siemens A – for patients’ ≤ 10 kgs, though company recommendation is up-to 30 Kgs

Siemens B – This is more powerful machine, high base flow make it easier to deliver high mean airway
pressure (MAP) and delta P (amplitude), should be used for patients ≥ 20 kgs

Ready to use HFOV is available is equipment store room / techs room, nurses can help in setting up.

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Consider switching from CV to HFOV early – ALWAYS discuss with consultant PICU

FiO2 and MAP : for oxygenation. For initial setup- Start with100% FiO2 and MAP around 5 cm higher of
calculated MAP (NOT PIP) achieved on Conventional Ventilator.

Frequency (Hz) and delta P / Amplitude – is for CO2 removal / ventilation. If CO2 wash out was an issue on
CV then start at higher delta P – neonate and infant usually 30-40, older children may need 50-60 to start.

Suggested staring Hz (1 Hz is 60 oscillation / second)

− Neonate / Infant – 10 - 12
− Toddler / young children 8-10
− Older children / adolescent 6 – 8.

Lower the Hz – more CO2 washout. Higher the amplitude – more CO2 wash out.

Get the HFOV ready to go, bag the patient with anaesthetic T-piece circuit and then switch to HFOV.

Amplitude - adjust it to get enough ‘wobble’ of trunk, (higher the amplitude – more wobble)

If not maintaining SpO2 – consider incremental of MAP by 1-2 cm H2O.

Get a blood gas done within 15-30 minute of starting HFOV.

GET CXR at the earliest possible once switched to HFOV – to rule out pneumothorax and to help deciding
optimum MAP. Lung expansion of 9-10 ribs is usually optimal MAP / PEEP.

Inhaled Nitric Oxide (iNO)

iNO is used when struggling for oxygenation and possible reason is pulmonary hypertension (PH).
PH is a common issue in young infant presenting with respiratory failure in the background of chronic lung
disease. This can be used with CV as well as HFOV. Nurse will help in set up..

Starting concentration is 20ppm. Always discuss with PICU consultant..

Troubleshooting – alarming ventilator – DOPES

Displaced ETT. Check ETCO2. Check ETT length – has it moved
Obstruction – suction and check suction catheter can pass full length ETT
Pneumothorax – clinical examination +/- CXR
Equipment – Hand ventilate with bag – if problem resolves on bag then check ventilator settings / tubings
Stomach – decompress by aspirating NGT

ALWAYS CHECK EtCO2 trace on the monitor

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Nebulisers
Nebs can be used to loosen secretions – most beneficial when used prior to chest physio
0.9% or 3% NaCl nebulisation.
6% NaCl can be used with Chest Physio advice and consultant’s approval.

DNase (Dornase alpha) may be used if problematic secretions with high ventilation requirement
(peak airway pressures >28)
http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2017/05/DNase-ECH-2014.pdf

Consider DNase neb with chest physiotherapy early in management of an Asthmatic Child

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C
irculation

Reference values for normal heart rate and blood pressure targets in Paediatric age group:

http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2016/12/blood-pressure-children-
pedccm-2007.pdf

Advisable minimal target Systolic blood pressure for children:

Age less than 1 month: ≥ 60mmHg

Age 1month to 1 yr: ≥ 70 mmHg

Age 1 - 10 yrs: (age X 2) + 70 mmHg

Age > 10yrs old: min target systolic Blood pressure: > 100mmHg

Advisable minimal Mean blood pressure for children: Age (in yrs) X 1.5 + 40 mmHg

For Premature Neonates: gestational age = mean Blood pressure

REMEMBER LOW BLOOD PRESSURE IS A LATE SIGN OF SHOCK: treat aggressively.

http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2016/12/Fluid-management-PICU-
2013.pdf

Fluid bolus: 0.9% NaCl fluid bolus in aliquots of 10-20ml/kg: reassess clinically after each fluid bolus – heart
rate, capillary refill time, peripheral and central temperature, liver size, Blood Pressure, consciousness level
and urine output..

Early use of blood products in patients of suspected meningococcal sepsis (FFP / Octaplas / platelets) and in
trauma patients (PRBC): Ensure group and cross matched samples are available.

Minimum two secured intravenous access MUST be achieved.

Broad spectrum IV antibiotics cover ASAP, MUST be within 1st hr of contact if sepsis is suspected.

Consider early IO access: if none CVL access present and patient is in Fluid Refractory shock.

Start Inotropes: if 40-60ml/kg fluid resus has been given (Fluid Refractory shock).

Common default initial inotropes in children: IV Dopamine @ 10 – 15 mcg/kg/min

IV Dopamine can be started through a secured peripheral venous access.

Consider an early start of inotropes and intubation in patients of septic shock.

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Start Inotropes before induction for intubation in patients of sepsis.

Be prepared for decompensation during induction and intubation – Fluid bolus available ready to be pushed

Continue on-going fluid resus with inotropes on board.

Achieve a secured central venous access: preferably US guided at earliest possible if patient is in fluid
refractory shock. Should have had an IO inserted by this stage if not done so.
Intubation takes precedence over CVL access.

Once CVL is achieved:

- Warm vasodilatory shock: on going fluid resus + Noradrenaline infusion

o a common scenario in febrile neutropenic oncology patient
o Febrile patients with indwelling devices: infected VP shunt / infected CVL

- Cold shock: cautious fluid resus + adrenaline infusion

o Cold shock is much more common in Paediatric age group than adults: Its usual presentation
of sepsis in young children

Advisable to have invasive arterial blood pressure monitoring if Shock is an active issue.

Fluid refractory + Inotropes Refractory shock (patient is on two inotropes)

ü Ensure drug infusions delivery

ü Replace and replenish losses
ü IV Hydrocortisone: 2mg/kg, max 50mg, 6 hrly
ü Consider Echocardiogram: to rule out cardiogenic shock and effusion
ü Rule out obstructive reasons of shock: i.e. large pleural effusion
ü Rule out intra-abdominal hypertension
ü Appropriate source control of sepsis
ü Escalate care appropriately: consider referral to ECMO early

https://www.evelinalondon.nhs.uk/resources/our-services/hospital/south-thames-retrieval-
service/Sepsis.pdf

http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2016/12/Septic-Shock-CATS-
2015.pdf

https://www.paediatricfoam.com/2017/05/inotropes-made-simple/

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D
isability / Sedation

Sedation
In invasively ventilated patients, usually start with IV morphine and IV midazolam infusion – then add in
clonidine and wean off midazolam
Step 1 – Morphine 50 -100mcg/kg bolus (max x2) then infusion 10-60mcg/kg/hr (inc by 10)
Step 2 – Midazolam 50 - 100mcg/kg bolus (max x2) then infusion 60 -240mcg/kg/hr (inc by 60)
Step 3 – Clonidine 1-5mcg/kg 8hrly PO, Need to give initial test dose of 1 mcg/kg; usual dose used is
3mcg/kg/dose every 8 hrs.
Or clonidine infusion: start at 1mcg/kg/hr – increase by 0.5mcg/kg/hr – up to max 2mcg/kg/hr if
cardiovascularly stable.

High infusion rate of Midazolam and clonidine can be used in patient with Dystonia.
Patient with Status Epilepticus may need high doses of midazolam infusion to gain control.

Prolonged sedation
Midazolam should be weaned and stopped by day 5 at the latest
Clonidine should be optimised and be the main sedative by day 5 unless contraindicated
Dexmetomidine / Levopromazine infusions – can be considered – needs PICU consultant approval

Add chloral hydrate 15-50mg/kg 3 -6 hrly (Max 200mg/kg/day) +/- Alimemazine 1-2mg/kg 8 hrly PO
See guideline for futher advice
http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2016/12/Sedation-Guideline-PICU-
2016.pdf

Neuromuscular blocker
A small proportion of children will require continuous infusion of a neuromuscular (NM) blocker when fully
invasively ventilated / on HFOV. Ensure patient is optimally sedated before commencing NM blocker agent.

IV rocuronium infusion is usual practice (300-600mcg/kg/hr).

Need for NM blocker should be reviewed regularly and should be discontinued as soon as possible.

Seizures
Patients may be on PICU for refractory seizure on midazolam infusion
EEG request form found on intranet – search EEG on intranet home page for form. Fax to 0208 725 4637.
Call ext 5290 to confirm receipt.

http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2016/12/Seizures-STRS-2015.pdf

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 TOP TIP!
Always prescribe drugs as per the nurses’
drugs prep guide on the intranet

This ALWAYS takes precedence over the

BNFC

13
E
lectrolytes

Potassium
Normal serum value: 3.5 to 4.5mmol/L
Usual daily maintenance 2-3mmol/kg/day – may need more if on diuretics

HYPOKALAEMIA (K+ ≤3.0)

⇒ If enteral route available: Give 1mmol/kg, check serum potassium after 1-2 hr.
⇒ Enteral route is preferable to Intra-venous route.
⇒ If enteral route not available: IV Potassium chloride 0.4 – 1mmol/kg can be given.
⇒ Infusion over 1-2 hrs thru central venous line.
⇒ Max dose 20mmol IV.
⇒ Rate of administration: 0.2mmol/kg/hr. NOT more than 0.5mmol/kg/hour.
⇒ RECHECK serum potassium in one hour after starting IV correction.

Target serum potassium levels of 4-5mmol/L in patients of cardiogenic shock /arrhythmia and paralytic ileus.

If on TPN discuss with pharmacist

HYPERKALEMIA: (K+ ≥ 5mmol/L). Excessively squeezed capillary sample can have falsely high potassium
values. If true hyperkalemia or patient at high risk of hyperkalemia / developing renal failure:
Ø STOP all potassium containing fluids, including TPN and drugs which can increase serum potassium
like Spironolactone (potassium sparing diuretics) and Captopril (any ACE inhibitor)
Ø Recheck / Send blood sample to labs for electrolytes, bone profile, urea and creatinine.
Make sure blood sample was not contaminated with potassium containing fluid.
Ø Salbutamol nebulisation: 2.5 – 5mg nebulisation – B1 adrenergic receptor stimulation by salbutamol
shifts intravascular potassium to intra-cellular and reduce serum potassium concentration.
Ø IV Sodium Bicarbonate: 0.5 – 1mmol/kg. (preferably by CVL)

SERUM POTASSIUM ≥ 6mmol/L IS A MEDICAL EMERGENCY: treat aggressively and seek advice.

Ø IV Calcium gluconate 0.5 ml / kg slow IV (preferably by CVL – remember Bicarb and Calcium are
incompatible and can cause precipitation: flush generously with IV 0.9% NaCl in between).
IV Calcium does not lower serum potassium but antagonises effects of high potassium on
myocardium (reduces cardio-toxicity of hyperkalaemia).
Ø IV Salbutamol 5mcg / kg.
Ø Repeat IV Sodium bicarbonate and hyperventilate: try to get blood pH > 7.35
Ø Consider IV Glucose + IV Insulin infusion, if serum potassium is persistent > 5.5mmol/L after above
measures.
Ø Actively look for causes of persistent hyperkalemia like tumour lysis / haemolysis / Rhabdomyolysis
Ø CRRT

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Magnesium
Aim 0.8-1.2mmol/L. If low prescribe IV replacement – see nurses prep guide for doses.
Aim for high Mg level (≥ 1mmol/L) in patients with bronchial asthma, pulmonary hypertension, arrhythmia
and status epilepticus.
Persistent low magnesium levels will cause refractory low potassium and low calcium levels.

Calcium:
Look for and target normal ionized calcium levels (1.2 – 1.4mmol/L), specifically in patients of arrhythmia /
shock / trauma / actively bleeding / massive transfusions.
Correct with IV Calcium through CVL: check for dose as per nurses guide / iClip.

Sodium
Usual maintenance = 2-4mmol/kg/day
If Na abnormality – assess fluid status
Hyponatraemia – follow PICU guidelines

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F
luids

For full guideline see St George’s PICU guidleines:

http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2016/12/Fluid-management-
PICU-2013.pdf

Fluid calculation

IV fluids should only be used if it is not possible to give feeds enterally. In PICU 80% maintenance fluids
should be given unless otherwise specified.

Use this method to calculate 100% maintenance – then give 80% of this volume over 24 hours

Example 22kg child

1st 10kg = 100ml/kg/day = 1000ml
2nd 10kg = 50ml/kg/day = 500ml
Subsequent kg = 20ml/kg/day = 40ml
100% maintenance = 1540ml/day = 64ml/hr
80% maintenance = 51ml/hr

Up to max of 2500ml/day for young adult male and 2000ml/day for female as 100% allowance.

Types of fluid

0.9% NaCl + 5 % Dextrose (+/- KCl 10mmol/500 ml bag) is a common fluid of choice
For neonatal age group: 0.45% NaCl + 10% Dextrose (+/- KCl – 10mmol/500ml bag)

Bolus – for hypovolaemia

If a bolus is required give 10-20ml/kg aliquots of 0.9% NaCl

Consider Ringer’s Lactate if hyperchloraemia (don’t use if metabolic condition)
Consider PRC if blood loss (trauma / post op)

Dehydration

Replace over 24 hours (48 hours if DKA – follow DKA fluid protocol)
If associated with serum Na derangements –then slow correction and follow serum Na closely

Fluid deficit (ml) = weight (kg) x % dehydration x 10

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G
astro – feeds

Michelle Webber (dietician) has put together a very thorough protocol regarding feeds

http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-manager/2017/09/Feeding-Enteral-Guide-
PICU-May-2017.pdf

Feed choice

Age Weight Feed

0-1 yrs <10kg Expressed Breast Milk
SMA first / Cow & Gate 1, Aptamil first
1-6 yrs 10-20kg Nutrini
7-12 yrs 20-45kg Tentrini
7+ yrs >45kg Nutrison

If already on a milk feed at home try to use the same feed in hospital

If the feed is not available – refer to feed protocol to find suitable alternative that is stocked

Gastric protection

If not receiving enteral feeds prescribe ranitidine for gastric protection

Prescribe gastric protection if patient is on systemic steroids

Bowel management

Patients on PICU are at risk of constipation: note to review bowel motion in patients’ PICU day review.

Regular movicol could be considered to prevent this, or suppositories such as glycerine.

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H
aematology

Blood products

Patient needs to have 2 blood group samples sent (labelled with different sampling times, 30 minutes apart,
preferably by 2 different health care professionals) before any blood product can be issued.

Usually samples should be 2-4mls in adult pink bottle

For small babies the lab will accept lilac (paediatric FBC) bottle – with handwritten label (on a sticker)

Blood can be requested by phone and should be prescribed on iclip.

PICU usually follow conservative blood product transfusion policy.

For oncology patients Hb and Platelets targets are usually agreed beforehand.

DISCUSS with Consultant PICU before transfusions.

Hb: Patients are usually not given packed red cells transfusion (PRBC) for Hb as low as 70gm/L on PICU,
if are stable / improving.

PRBC 10-15ml/kg over 2-4 hrs: can raise patients’ Hb by 10 – 30 gm/L.

FFP: Fresh Frozen Plasma / Octaplas: 10 – 20ml/kg over 1-2 hrs.

Platelets: 5-10ml/kg over 15-30 minutes. Transfuse platelets as soon they are received from blood bank.
Platelets denature rapidly when kept outside un-agitated.

Cryoprecipitate: it is used to replenish blood fibrinogen level; target plasma fibrinogen level > 1-1.5gm/L.

Dose of cryoprecipitate: 5ml/kg, given over 15-30min.

Human Albumin 4.5% and 20% are considered as blood products and should be requested in a similar
manner from blood bank.

Please DON’T waste blood products; round up infusions to the pack available and consider giving ‘higher’
side of recommended volume if needed and deemed safe.

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I
nfection

Principles
Identify source and organism by extensive and early collection.

Broad spectrum antibiotics rapidly, then narrow or stop as soon as possible.

Samples

Depends on cause of admission:

Seriously ill, apnoea, seizures+sepsis, hypotension – BC, CSF, BAL, NPA, Urine, CXR.

LRTI – BC, BAL, NPA

If any indwelling plastic culture this and consider removal.

Physiotherapists will be happy to teach you how to take a BAL (needs to be done by a Dr)

Antibiotics

Consider using max dose of antibiotics for the age and weight of a patient admitted to PICU

Ceftriaxone is NEVER used in PICU (due to possible incompatibilities with other infusions).

Any patient who has been started on ceftriaxone should be changed to cefotaxime – they should receive the
first dose of IV Cefotaxime within 12 hours of the initial dose of ceftriaxone.

Follow the microguide for antibiotic choice

LRTI admitted to PICU requiring intubation and ventilation: usually receive IV Co-Amoxyclav.

Difficult cases are discussed with PID – ward round is on Wed afternoons.

IV aminoglycosides needs regular follow up of levels.

Vancomycin – take level pre 4th dose (0-30mins prior to dose). Dose should be given – do not delay pending
result.

For Vancomycin dosing guidance see http://www.georgespicu.org.uk/wp-content/uploads/bsk-pdf-

manager/2016/12/Vancomycin-Guideline-PICU-Nov-2016.pdf

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 TOP TIP!
Download MicroGuide app for St George’s
Paediatric micro guidelines

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L
ines

Invasive arterial lines: US guided, radial artery cannulation is most preferred option.

Advisable to have invasive arterial line on any critically sick patient like with shock / traumatic brain injury /
high ventilator settings / ARDS / DKA etc..

Infants: 24 Gauze, IV cannula (Jelco)

Young children: 22G, IV cannula (Jelco) or 22G, arrow, 4cm arterial line

Older children / Adolescents: 20G / 3 Fr, leadercath arterial line

Femoral arterial line: 20G leadercath 8 cm arterial line. In neonates 22G 8cm line can be used.

Vascular team: for children > 6-7kgs: a paediatric ward based specialist nurse service can help to put a mid-
line ( 22G, 8cm, arrow, single lumen venous access) on PICU patient. They can be contacted on bleep:

Central venous access: US guided femoral central venous access is preferred approach in children on PICU.
There is none evidence to show in children that femoral venous access has more chance of infection in
comparison to internal jugular venous access.

Femoral CVL access:

Infants: 4.5 Fr, triple lumen, 6 / 8cm lines

Young children: 5 Fr tipple lumen, 8 – 12 cm. 15cm length can be used in older children.

Older children (> 40 kgs) and adolescents: 7 fr, triple lumen, 15 cm line.

Internal Jugular venous access:

Infants: 5 Fr, triple lumen, 6cm / 5 Fr, triple lumen, 5 cm.

Young children: 4.5 Fr, triple lumen 6 cm / 5 Fr, triple lumen, 5-8 cm.

Older children: 5 Fr, triple lumen: 8-12cm.

Young Adolescents: 7 Fr, triple lumen: 12 cm

Young adults: 7 Fr, quadruple lumen: 15cm / 8.5 Fr, quadruple lumen.

Chest X-ray and document position of internal jugular CVL before being used.
For TPN and inotropes purposes ideal tip position is at right atrium and SVC junction. (at the level of tracheal
carina/ 5-6 vertebral body).

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 Age ETT size, in mm internal diamtr Length at Length at Suction NG tube Urinary Intercostal
teeth, nose catheter Catheter chest
Uncuffed ETT Cuffed ETT in cm in cm (Size of ETT X 2) Foley drain
Neonate 3 -- 8-9 10-11 6 6 6 Fr 6-8
≤3 Kgs
Term infant 3.5 3 9-10cm 11-12cm 6-7 fr 6 Fr 6 Fr 6-8
6 – 12 mnths 3.5-4 3.5 11-12 cm 12-14cm 7-8 6- 8 Fr 6 Fr 8-10
1- 2 years 4-4.5 4-4.5 12-13cm 13-15cm 8r 8fr 6-8 Fr 8-10
2 - 12 years (Age/4) + 4 0.5 smaller size (age / 2) + 12 (age / 2) + 15 Size of ETT X 2 10 -12Fr 8-12 Fr 10-12
Young adult 6.5 – 7 18-20cm 12 - 14 14 14-16 12-20
female
Young adult 7-7.5 20-22cm 14 - 16 14-16 12-14 12-20
male

NG tube: 10 Fr for young children. 12 Fr for older children / young adolescents. 14 – 16 Fr: for young adults.

NGT and urinary catheter are usually inserted by bedside nurses.

Nasal ETT is usually preferred in children < 8 yrs old.

There are few indications of swap of oral ETT to Nasal ETT in older children and adolescents.

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