ASSIGNMENT

ON
PEDIATRIC INTENSIVE CARE UNIT
(PICU)

"Happiness can be found even in the darkest of times, if only one remembers to
turn on the light." - J.K. Rowling

Submitted to, Submitted by,

Madam N. Saha Moumita Maity

Professor M. Sc Nursing , Part II

CON, RGKAR MCH, Kolkata CON, RGKAR MCH, Kolkata

Introduction

While neonatal and adult intensive care is well advanced, paediatric intensive care is still a
developing area. In tertiary care hospitals, 5-10% of total paediatric beds should be for ICU and this
should be greater if the hospital has surgical units.

Instability of homeostatic mechanisms, functional immaturity of vital organs and occurrence of

multiple problems simultaneously in critically ill children lead to a complex picture. In addition,
children have special needs. In order to optimize resource utilization, it is essential to understand
indications of admission into the PICU.

History

Goran Haglund is credited with establishing the very first pediatric ICU in 1955; this PICU was
located at Children’s Hospital of Goteburg in Sweden. The first PICU in the United States is a topic
often debated. Currently, Fuhrman’s Textbook in Pediatric Critical Care lists Pediatric Critical Care
Unit at the Children’s Hospital of District of Columbia in Washington, DC, dating back to 1965, as
the first pediatric critical care unit in the U.S.A. Medical Director was Dr. Berlin. As soon as 1966,
another well-documented early pediatric intensive care unit opened at Kings County Hospital in
Brooklyn, NY. It was caring for patients with open heart surgery and peritoneal dialysis under the
helm of Dr. Rodriguez-Torres. The PICU most commonly referred to as first is the Children’s
Hospital of Philadelphia in 1967 by John Downes. The PICU at Lurie Children's Hospital was also
established in 1967, the same year as the unit at the Children's Hospital of Philadelphia. The
establishment of these early units eventually led to hundreds of PICUs being developed across North
America and Europe.

There were a variety of factors that led to the development of PICUs. John Downes identified five
specialties of medicine that aided in the development. These specialties included adult respiratory
ICUs, neonatal intensive care, pediatric general surgery, pediatric cardiac surgery, and pediatric
anesthesiology.

Between 1930 and 1950 the poliomyelitis epidemic had created a greater need for adult respiratory
intensive care, including the iron lung. There were times when children would contract polio and
would have to be treated in these ICUs as well. This contributed to the need for a unit where critically
ill children could be treated. Respiratory issues were also increasing in children because neonatal
intensive care units were increasing the survival rates of infants. This was due to advances
in mechanical ventilation. However, this resulted in children developing chronic lung diseases, but
there was not a specific unit to treat these diseases.
Advancements in pediatric general surgery, cardiac surgery, and anesthesiology were also a driving
factor in the development of the PICU. The surgeries that were being performed were becoming
more complicated and required more extensive postoperative monitoring. This monitoring could not
be performed on the regular pediatric unit, which led to Children’s Hospital of Philadelphia’s
development of the first American PICU. Advancements in pediatric anesthesiology resulted in
anesthesiologist treating pediatric patients outside of the operating room. This caused pediatricians to
obtain skills in anesthesiology in order to make them more capable of treating critically ill pediatric
patients. These pediatric anesthesiologists eventually went on to develop run PICUs.

In the 2000s, the live discharging rate of child and adolescent patients in the USA and in the UK
become higher than 96%. As of 2003, in the same countries more than 250.000 children were
introduced to PICU (pediatric intensive care unit).

With the growth of hospitals with PICUs in the 1980s, the American Academy of Pediatrics (AAP)
and the pediatric section of the Society of Critical Care Medicine (SCCM) set forth guidelines in
1993 for PICUs. Since the establishment of those guidelines, both the number of PICUs and number
of PICU beds has been steadily increasing in the US. This growth could be attributed to the
advancement of medical care and the increased survival of children with chronic illnesses with the
need for higher level of support. With this increase, there has been variability in the distribution
across the US, mainly in areas with larger, specialized centers. Additionally, there was an expansion
of specialized PICUs, for example cardiac, trauma and neuroscience PICUs, seen in this time frame.

Characteristics

There are a variety of PICU characteristics that allow the healthcare providers to deliver the most
optimal care possible. The first of these characteristics is the physical environment of the PICU. The
layout of the unit should allow the staff to constantly observe the patients they are caring for. The
staff should also be able to rapidly respond to the patients if there is any change in the patient’s
clinical status.

Correct staffing is the next vital component to a successful PICU. The nursing staff is highly
experienced in providing care to the most critical patients. The nurse to patient ratio should remain
low, meaning that the nurses should only be caring for 1-2 patients depending on the clinical status of
the patients. If the patient's clinical status is critical, then they will require more monitoring and
interventions than a patient that is stable.

In most cases, the nurses and physicians are caring for the same patients for a long period of time.
This allows the providers to build rapport with the patients, so that all of the patient’s needs are
fulfilled. The nurses and physicians must work together as a collaborative team to provide optimal
care. The successful collaboration between nurses and physician has resulted in lower mortality rates
not just in PICUs, but all intensive care units.

Care team staff in addition to physicians, sub-specialists, and nurses include but are not limited
to physician assistants, nurse practitioners, respiratory therapists, pharmacists, physical
therapists, occupational therapists, speech therapists, nutritionists, dietitians, social
workers, clergy, child life specialists, palliative care, rapid response team, transport team, ethics
committee, and medical students.

Level of care

Since the 1993 AAP and SCCM guidelines were developed, and as medicine has matured over time,
the development of the pediatric intensive care unit has expanded to maintain a level I and a level II
PICU. These levels are defined by the resources available and the range of medical conditions
treated. These guidelines have been revised and updated in both 2004 and 2019 as medical care
advances and facilities grow.

 A level I PICU is defined as a PICU that cares for the most critically ill child. Health care
team members must be capable of providing a wide variety of care that typically involves
intensive, rapidly changing, and progressive approach. This includes a medical director that is
board-certified in critical care medicine, a full range of sub-specialists that are available
within 1 hour, hemodialysis capabilities, a transport team and system, dedicated PICU
respiratory therapists, dedicated PICU nurses, capabilities for resuscitation in the emergency
department, and dedicated physicians covering in the PICU for all 24 hours per day.
 A level II PICU does not meet the criteria for level I. Typically; patients will present with
less complex acuity and will be more stable. Level II units have well-established relationships
with level I units that allow for timely transport for higher level of care as needed. Given the
growth of pediatric critical care and improvements in general PICUs, there has been a growth
in specialized PICUs like cardiovascular medicine, transplant, neurology, trauma, and
oncology. New recommendations for classification of units based on level of care are
community-based PICU, tertiary PICU, and quaternary or specialized PICU.
2019 AAP Guidance and Recommendations

Community-based PICUs were previously known as level II units and provide a broad range of
services. Tertiary PICUs were previously known as level I units and provide advanced care.
Quaternary or specialized PICUs serve large catchment areas and provide comprehensive care for
complex patients.

Indication for admission into PICU

 Hemodynamic instability, shock, cardiac arrhythmias or cardio-respiratory arrest.

 Severe anaemia or haemorrhage
 Acute poisoning
 Respiratory failure: Impending and established
 Altered sensorium, encephalopathies, and status epilepticus or raised intracranial pressure.
 Hepatic failure and complication
 Renal failure and complication
 Severe metabolic abnormalities such as severe hyper or hypokalaemia, severe hyper or
hyponatremia, hypoglycaemia or diabetic ketoacidosis.
 Severe infections like severe malaria
 For procedures such as peritoneal dialysis, exchange transfusion, central venous cannulation.
 For post operative monitoring and care.

Assessment/ identification of a serious ill child

In order to improve the survival of seriously ill children, it is mandatory to recognize a sick child at
the earliest. This early identification is required on arrival to the emergency services and also in
children already admitted in the hospital. Such an assessment will ensure provision of more intensive
care to these children, which should improve the survival.

Identification of a critically sick child relies on observation of the child, history and physical
examination. At first contact, the ABCS are quickly assessed- patency of Airway, adequacy of
Breathing and Circulation. If there is an abnormality in any of these, life support/ resuscitation must
be initiated.

The important symptoms in seriously ill children include:

 Drowsiness
 Seizure activity
 Excessive irritability
 Decrease activity
 Difficulty in breathing
 Cold extremities (particularly in the absence of cold environment).
 Decrease feeding/ decrease intake of fluids
 Decrease in urine output (less than 4 wet nappies in the previous 24 hours)
 Apnoeic episode/ cyanosis
 Bilious vomiting.

Design and layout

Space:

The size of the unit is related to the expected population intended to be served. In addition, if the
center is to serve as a referral unit for the infants born outside the hospital, allowance should be
‘erade from additional physical facilities & space.’ Ideally it should be 100 sq ft/child. There should
no comprise on space & its adequacy is crucial for reduction of nosocromial infections. The entry of
visitors to this area should be restricted. Facilities for maintaining asepsis & weighing the babies
should be available in the transitional care room. Now a big issue that is running is whether cubical
system or bed around the nursing station is better one.

Location:
The unit should be located near to the general paediatric ward and operation theatre, to facilitate
prompt transfer of sick & high risk child. The presence of elevator in close proximity is desirable for
transport of critically ill. Lift is nearby to facilitate transportation. The sunlight is mostly available in
the outside room where doctors are checking infants or maintaining their other official works but
inside the PICU there is no space for sunlight to enter.

Room:

The door should be provided with automatic door closers. In addition to the special care area,
minimal care & isolation rooms, the unit should be closely linked with x-ray room, and laboratory &
procedure room. The cleaning area is used for sterilization of equipment & for fumigation of
incubators in a specially designed vapour proof chamber. It should be in close proximity to x-ray,
laboratory, procedure room and laminar flow system. There should be cleaning area, sterilization;
fumigation unit .Isolation room is used to nurse potentially infected children. Nurses wash
instruments inside the PICU itself in the hand washing area.

Floor plan:

The unit facility preferably in a square so that abundant open unencumbered space is available. The
walls should be made of washable, tiles & window should have two layers of glass panes to ensure
some measure of heat & sound insulation. Adequate number of deep wash basins with elbow or foot
operated taps, having constant round- the-clock water supply should be provided. The door should be
provided with automatic door closers. In addition to the special care area, minimal care & isolation
rooms, the unit should be closely linked with formula room, x-ray room, and laboratory & procedure
room.

Physical set up

Here the space is more or less square or rectangular shape. Glass windows are covered with curtains
in some places which are mostly sound proof. The doors are automatically closed. The PICU is
closely associated with its laboratory.

Ventilation:

Effective air ventilation is essential to reduce nosocromial infection .The most satisfactory ventilation
is achieved with laminar air flow system. Centralized air conditioning can be used with minimum 12
air changes/hour. Provision of exhaust fan also should be used.
In PICU air conditioning system is used but it is not centralized. A top & ventilator facilities
continuous air exchange inside the PICU. Laminar flow system is there for the fluid & total
parenteral nutrition preparation.

Lighting:

The unit must be well illuminated & painted white or slightly off white to permit proper visualization
of child. Spot illumination can be used for various procedures. If electrical failure is frequent &
prolonged, the electrical system must be attached with generator. The unit light should be dimmed at
night to stimulate day-night pattern to promote hormonal surge & wellbeing of child.

Environmental temperature:

The temperature of the complex must be maintained around 26+2 ⁰ C. This can be achieved by
centralized air conditioning or by radiant heater or hot air blowers. A digital clock on the wall which
shows the measured environmental temperature continuously.

Communication:

The unit should be provided with an intercom system so that additional person can be called for help
in case of emergency without leaving sick children. A direct line external telephone is mandatory so
that parents have an access to enquire about their babies. Mobile phone should not be used near the
vicinity of nursery because electromagnetic waves are likely to interfere with the functioning of
telephone equipment.

Acoustic characteristics:

The sound inside the NICU should always below 45 db. There should be decibel meter for
measurement. There should be minimum sound production from the instrument used in care children
e.g provision of blinking telephone instead of ringing, blinking alarm of machine.

In this PICU it is always asked not to shout within PICU, speak in a low voice and somehow it is
being maintained. There is no provision of blinking alarm system. One desible meter is there to
measure the sound frequency.

Personnel:

The highest priority in the organization of the PICU is the availability of sufficient number of
adequately trained personnel especially the nurses. The nursing Council of India has not yet outlined
any special guidelines for this purpose. It has been recommended by the American Academy Of
Paediatrics that one nurse is needed to give intermediate care to 3 babies or intensive care to one
baby. The National Neonatology Forum of India has recommended that at least one trained nurse
should be allocated to provide coverage to 4 babies at least. Therefore for 8 bedded NICU<8 nurses
should be sanctioned to ensure availability of 2 nurses in each shift along with one additional sister-
in-charge in the morning shift. There must be equal distribution of nurses in three shifts during 24
hours. A paediatrician should devote his full time to improve existing standard of care. The unit must
also have an independent senior & junior resident doctor round the clock for every 8 babies requiring
special care.

The working personnel of the PICU should consist of the following:

 Paediatrician.
 Senior resident doctor.
 Junior resident doctor.
 Intensive care unit in charge
 Sister In charge who has at least 1 year Intensive care working experience.
 Paediatric nurse.
 General staff nurses.
 Laboratory technician.
 Biomedical technician.
 Paediatric pathologist.
 Ophthalmologist
 Security guard
 Group-D staff

Electrical outlet:

8-12 electrical points should be there against each baby at a height of 4-5 ft. There should direct
connection with all instrument, no adapter or extension to be used. There should be routine checking
of the points and round the clock power supply or back up support.

Equipment used in PICU:

 All the resuscitation equipment along with ventilator, self-inflating neonatal resuscitation bag,
central supply of oxygen, central suction apparatuses
 Electronic thermometer
 Refractometer
 Decibel meter
 Oxygen concentrator
 Multiple parameter monitor
 Oxygen analyser
 Bili blanket
 Infusion pump
 X-ray
 ECHO machine
 Radiant warmer
 Phototherapy
 Suction machine
 Incubator
 Ventilator

Activities:

Several activities usual as well as important activities made the unit separate & social from all other
critical care unit in the city. The activities are in the following-

Clinical care to critically sick children

Ventilator support
Different type of invasive procedure like- central line, E/T tube insertion, vein section etc.
Act as referral care unit
Continuous training programme
Ongoing research

EQUIPMENTS OF PAEDIATRIC INTENSIVE CARE UNIT (PICU)

During the last 2-3 decades a large number of monitoring devices for diagnostic and therapeutic use
for the high risk newborn infants and critically ill children have been developed. These have
considerably improved their intact survival. The maintenance of the existing equipment in proper
working condition is more important than acquiring new and sophisticated gadgets.

Some of the equipments of the NICU are:

Bag and mask resuscitator: Self inflating bag of 250-500 ml capacity is ideal for resuscitation of
newborn baby and 500-750 for older children. Face masks (size 0, 1 and 2) should be rigid with a
cushioned rim to form a tight air seal fit on the face enclosing the mouth and nostrils.

Oxygen and suction facilities: A centralized source of oxygen, compressed air and suction outlet
consoles (50 psi) affix on the wall is ideal. The suction pressure is regulated with a pressure dial.
Facility should be available for intermittent suction because continuous suction may cause
bradycardia and mucosal damage.

Catheters, syringes and needles: Catheters, needles and syringes should be available liberally in the
unit. The availability of liberal supplies of disposables is crucial for reduction of nosocromial
infections.
Feeding equipment: Glass or stainless steel bowls of adequate size (120 ml) should be available in
the nursery for collection of expressed breast milk, mixing and preparing the formula. A hot air
autoclaving oven or a pressure steriliser should be provided for autoclaving feeding equipment.
Storage facility like a refrigerator should be available in the nursery.

Laminar flow system: It is useful for safe and aseptic formulation and mixing of drugs, parenteral
fluids and nutrients. Strict asepsis should be ensured by wearing mask, sterile gown and disposable
gloves while operating the laminar flow system.

Weighing machine: Accurate weighing record of babies is a sensitive index of their wellbeing and
availability of a sturdy and reliable weighing machine fulfils the fundamental need. A sensitive beam
type weighing scale with a precision of + or – 10gms is a useful equipment in the nursery.
Bassinets: A variety of bassinets should be available for routine use in the nursery. It is desirable to
use bassinets, which can be easily cleaned and are equipped with locker and head tilting mechanism.

Incubators: The incubators are essential to provide an ideal micro environment for high risk babies.
About one third of nursery beds should comprise of incubators. The main functions of an incubator
are isolation, maintenance of thermo neutral environment, desired humidity and administration of
oxygen. The incubator maybe of portable type for transport of sick babies or stationed in the nursery.

Radiant heat warmer: During various procedures, the infant loses body temperature, unless he is
kept warm by use of radiant heat warmer. A portable heat lamp with two 150 watt white ordinary or
bakery bulbs or infra-red bulb fixed on the wall about 2- 3 feet about the level of table or trolley is
necessary. The infrared heat is preferable because it directly warms the subject without affecting the
temperature of the intervening environment.

Thermometers: Low reading (30-40°C) rectal thermometer is essential to assess the severity of
hypothermia. Electronic or tele thermometers with skin sensors or rectal probes with an accuracy of +
or – 0.1°C are ideal for continuous atraumatic monitoring of body temperature.

Oxygen concentrator: Oxygen concentrators are being indigenously manufactured and they work
both on battery and mains. The atmospheric air is passed through a chemical which absorbs all gases
except oxygen. Depending on the flow rate various concentrations of oxygen can be delivered to the
patient.

Oxygen head box (oxygen hood): A square shaped box made of transparent plastic or perspex
which can enclose the head of the infant is useful for administration of higher concentration of
oxygen. It can be used whether the baby is nursed in an open cot or incubator.
Oxygen analyser: This is useful for monitoring ambient oxygen concentration in order to protect the
infant against oxygen toxicity. It helps in regulating the flow rate of oxygen so that desired
concentration of oxygen is delivered to the infant depending upon his clinical condition and oxygen
requirements.

Perspex heat shield: It is a simple and useful device to reduce the heat loss by radiation and
evaporation. It also reduces insensible water loss by about 25%.
Phototherapy unit: Phototherapy is now generally accepted as a safe and effective method for
treatment of neonatal hyperbilirubinemia. A light source designed to give irradiance or flux of 8-10
uw/cm2/nm between 400-500nm wavelength range at the mattress is ideal. Blue light is more
effective than the red light but former interferes with the observation of the infant.

Heart rate monitor: These are ideal to monitor high risk infants and are especially useful during
prolonged procedures such as exchange blood transfusion and surgery.

Respiratory rate and apnoea monitor: The respiratory monitor based on impedance technique
measures changes in the electrical resistance during breathing. The electrode is fixed on the chest
wall to pick up signals which are digitally displayed as respiratory rate. The conventional apnea
monitors are based on air mattress having plethysmography sensor. When infant stops breathing after
a variable interval of 10-20secs depending upon the preset lag, the instrument emit a beep and
displays red warning signals.

Blood pressure monitor: Doppler system based on the principle of ultrasound waves provides an
accurate and non-invasive means of recording blood pressure in new born babies. The blood pressure
reading maybe unreliable if baby is crying or moving.

Multi-channel vital sign monitor: The multi-channel complex monitors are available to display and
record all the vital signs on an oscilloscope. They are equipped to record temperature at different
sites, heart rate, respiratory rate with apnoea alarm, invasive and non-invasive blood pressure and
pulse oximetry.

Infusion pump: The infusion pump is a sophisticated electronic micro pump which displaces fluid
and a microprocessor or pressure transducer controls the rate of fluid delivery. The rate of infusion is
depicted as drops/minute or in terms of volume through a disposable cassette or plastic syringe. The
latest infusion pumps have inbuilt alarms to signal occlusion flow, air in the system, system failure,
low battery charge etc.
Bilirubin analyser: The instrument provides direct read out of total serum bilirubin which is reliable
for taking therapeutic decisions for the management of neonatal hyperbilirubinemia.

Transcutaneous bilirubinometer: The yellow discoloration of skin and subcutaneous tissues can be
quantities and equated to total bilirubin value with the help of a photo probe. The probe is pressed
against forehead or sternum. The light passes through inbuilt fiberoptics and reflectometer and is
analysed by computerised specro photometer to provide immediate digital display of total bilirubin. It
is a useful bed side screening method for the young resident doctor to assess the degree of jaundice.
Transcutaneous blood gas monitor: These are non-invasive devices used for continuous monitoring
of oxygen tension in vivo. Transcutaneous monitoring measures skin-surface PO 2 and PCO2 to
provide estimates of arterial partial pressure of oxygen and carbon dioxide (PaO 2 and PaCO2). The
devices induce hyper perfusion by local heating of the skin and measure the partial pressure of
oxygen and carbon dioxide electrochemically. Transcutaneous blood gas monitoring is appropriate
for continuous and prolonged monitoring (eg, during mechanical ventilation, CPAP, and
supplemental oxygen administration).

Pulse oximeter: A pulse oximeter is a medical device that indirectly monitors the oxygen saturation
of a patient's blood (as opposed to measuring oxygen saturation directly through a blood sample) and
changes in blood volume in the skin, producing a photoplethysmography. It is often attached to a
medical monitor so staff can see a patient's oxygenation at all times. Most monitors also display the
heart rate. A blood-oxygen monitor displays the percentage of arterial haemoglobin in the oxy-
haemoglobin configuration. Acceptable normal ranges are from 95 to 100 percent, although values
down to 90% are common.
Capnography: Capnography is the monitoring of the concentration or partial pressure of carbon
dioxide (CO2) in the respiratory gases. Its main development has been as a monitoring tool for use

during anesthesia and intensive care. It is usually presented as a graph of expiratory CO 2 plotted
against time, or, less commonly, but more usefully, expired volume. The plot may also show the
inspired CO2, which is of interest when rebreathing systems are being used. The capnogram is a
direct monitor of the inhaled and exhaled concentration or partial pressure of CO 2, and an indirect
monitor of the CO2 partial pressure in the arterial blood. Capnographs usually work on the principle
that CO2 absorbs infra-red radiation. A beam of infra-red light is passed across the gas sample to fall
on to a sensor. The presence of CO2 in the gas leads to a reduction in the amount of light falling on
the sensor, which changes the voltage in a circuit. The analysis is rapid and accurate, but the presence
of nitrous oxide in the gas mix changes the infra-red absorption via the phenomenon of collision
broadening.

Ventilators: A ventilator is a medical device used in paediatric intensive care units (PICU) to assist
children in maintaining proper blood gas levels. Although ventilation refers to the removal of carbon
dioxide from the blood, these devices also help deliver oxygen to the children. These devices are
typically used in a variety of forms, but all are usually short-term treatments until the lungs are
capable of regulating blood gasses properly. Ventilators must be carefully monitored and maintained.
A breathing device may be harmful if it is not working properly or is exchanging gasses at the wrong
time. It is also possible to over-ventilate an child with these devices, which may lead to chemical
imbalances such as alkalosis.
Cranial ultrasonography: Cranial ultrasonography is most often used in infants to diagnose
problems with the brain and the ventricles in the brain through which cerebrospinal fluid (the clear
fluid that circulates through the brain and spinal cord) flows. These abnormalities are often associated
with premature birth. Because ultrasound waves are poorly conducted through bones, cranial
ultrasonography must be performed on infants before the fontanel (gaps between the bones of the
cranium) have closed. In infants, cranial ultrasonography is most often used to diagnose two
complications. Intraventricular hemorrhage (IVH) occurs when there is bleeding in the brain. This
occurs more commonly in premature babies and is likely to happen within the first week of the
infant's life. Periventricular leukomalacia (PVL) occurs when the tissue around the ventricles in the
brain is damaged. This complication can occur within several weeks of birth. Both IVH and PVL are
associated with mental disabilities and developmental delays. Cranial ultrasonography can also be
used to evaluate brain abnormalities in babies, such as congenital hydrocephalus or tumors, or to
detect infection.
A devise implanted inside the skull, just above the brain, or into one of the brain's ventricles in order
to monitor second by second changes in intracranial pressure, or ICP in infants with hydrocephalous,
intracranial haemorrhage, meningitis and birth asphyxia to guide therapy and predict prognosis.
Caution is advised while placing the sensor on the anterior fontanels because excessive force can lead
to spuriously high values.

Extracorporeal membrane oxygenator: It refers to the delivery of oxygen by “extracorporeal”

measures, and literally means by mechanical bypass that takes place outside of the body. It is very
similar to a heart-lung machine that is used to continue the supply of blood and oxygen while the
heart is stopped, such as during open heart surgery. The blood is drawn from a catheter in the right
internal jugular vein or right atrium, it is oxygenated as it crosses the membrane and then returned to
the patient via the right common carotid artery or the femoral vein.

Placenta prototype: The ultimate objective of bioengineers is to fabricate a sophisticated “utero

placental unit” so that extra uterine survival of foetus which is born early is assured with least
hazards and greater certainty. Apart from passive transport of oxygen and urea, placenta actively
transports a variety of other substances including amino acids, calcium, glucose and maternal
antibodies.

PICU Local Infection Control Guidelines

These guidelines must be used as a support to the Trust infection control guidelines.

General principles on PICU

Each bed space is denoted by its own floor lines and has coloured plastic aprons (varying colour to
next bed space). Each bed space has its own sink for hand washing and personal protective
equipment available at that space. No equipment should be borrowed from another bed space without
the usual cleaning requirement being adhered to. Hand gel is provided at both sides of each bed space
for ease of hand decontamination in most circumstances. On entering the area around each bed space
this should be considered a room and therefore aprons and other personal protective equipment (PPE)
e. g gloves, goggles, removed and hands decontaminated before leaving the area. The only exception
to this rule is when transferring bodily fluids or waste water to the sluice, when all PPE is removed in
the sluice and hands decontaminated before leaving the sluice. Any MDT staff attending patients
must be “bare below the elbow” adhering to dress code including jewellery, hair, decontaminate
hands according to Trust policy and wear aprons before approaching the patient. All other PPE
(gloves masks goggles) must be worn according to trust policy. This includes the use of goggles for
any aerosol inducing procedures e. g suctioning, accessing arterial lines, central and peripheral lines,
removal of lines etc. Visitors to bed spaces should be restricted to 2 at any one time (unless special
circumstances which should be discussed with Nurse in charge/ Sisters/ Charge Nurse/ Matron /PICU
Consultant on for day). Patients with larger extended family should be asked to streamline visiting to
support this and ask for single point of contact for telephone enquiries within their extended family
outside of the hospital. Parents and visitors should be asked to wear aprons and decontaminate their
hands before when entering and leaving the bed areas. They should wear aprons if carrying out cares.
Parents and relatives of other patients on the ward should be discouraged from visiting at other
patients’ bed areas. Parents, visitors and staff attending any patient presenting with diarrhoea must
use soap and water for hand hygiene as the gel is less effective for some of the diarrhoeal
infections(see hand hygiene policy).

Blood gases and PPE

After removing PPE and carrying out hand decontamination at the bedside, the sample (syringe or
capillary tube) should be carried on a cardboard tray to the blood gas room. New gloves should be
worn whilst processing sample and removed once procedure complete. Hand hygiene should be
carried out as per trust policy before and after procedures.

Isolation

The patient requiring isolation and other patients who may be affected by being adjacent to the
patient requiring isolation should be risk assessed using following considerations:

 Patient safety
 Infectious status of patient
 Children with compromised immune system and/or children with other
Pathologies e. g chronic lung which may increase the severity of their initial presentation
condition of patients who may be in next bed spaces who may be affected adversely by
secondary infection
 Intubation status - non-intubated patients with infections that may be passed on through
droplet and contaminated hands.
  Previous infection isolated requiring further checks for clearance e. g MRSA
 Privacy and dignity. Trust policy to put children 12 years and over into single sex
accommodation unless they are a critically ill patient requiring constant one-to-one nursing
care.

Single Rooms

Whenever possible, patients with infections should be moved to either a side-room or cohorted in an
adjoining area. If patients have to remain on an open ward area this decision should be made in
discussion with the Infection Control Team where possible. There is a microbiology consultant on
call for support if required. Decisions should be documented in the patient notes alongside discourse
with next of kin regarding their child’s infection. If no single rooms are available discuss new
referrals to PICU requiring isolation with the PICU Consultant for the day.

Partitioned bed areas

These are the next beds of choice where a patient requires isolation according to the above criteria
(cubicles) and no cubicle is available. Discussion around decision making, involving the MD Team
as above, must be documented in the patients’ notes. Where a partitioned area is being used for a
patient requiring isolation source isolation signs MUST be arranged to the front or the bed area using
a bed table to ensure all staffs are aware of the type of isolation and PPE required.

Open bed spaces (2,3,4,5)

These beds should not be used for infectious patients unless all other options have been exhausted.
Discussion around decision making, involving the MD Team as above, must be documented in the
patients’ notes. As soon as a cubicle or partitioned area becomes available the patient must be moved
to the more appropriate area, condition and stability permitting ie partitioned bed or cubicle. Where
an open bed is being used for a patient requiring isolation source isolation signs MUST be arranged
to the front or the bed area using a bed table to ensure all staff are aware of the type of isolation and
PPE required. If at all possible a bed space should be left empty between the open bed area being
used for isolation and the next patient. Any incidences where patients are not able to be nursed in
appropriate isolation areas should be reported using datix. Protective isolation for patients must be
carried out according to Trust side room priority guideline.
Medication considerations

Drawing up drugs at bed spaces. Trolleys must be sprayed with hard surface spray (70% alcohol
spray) and wiped in a even motion from one side to the other to prepare clean surface. This should
also be carried out with blue/ white trays before preparing drugs. Blue/ white trays should be used to
carry drugs to the patients’ bedside for administration. NB. A patient’s drugs must not be prepared
outside the bed area they are occupying. Accessing and preparing for insertion of IV/IA lines and
chest drains. Clean non- touch technique (using non sterile gloves) to be used for accessing arterial
and ALL venous lines. When accessing lines including changes of syringe/ bag use PDI Sanicloths
(70% alcohol plus 2% Chlorhexidine) wipes, to clean area of access. Spray bottles of Chlorhexidine
Gluconate 2% in Isopropyl Alchohol 70% should only be used for cleaning the site for central line
insertion and should be discarded 24 hours after opening. Please refer to infection control and venous
access policy.

Urinary catheterisation

Please refer to Marsden Manual on line (Trust internet). Local guideline is to use normal saline for
cleaning pre- insertion. Saving lives and other infection control related audits. Please refer to folder at
nurse’s station each shift to complete any relevant audits. Leave completed audits in plastic wallet at
back of folder for collection and transferring to l drive saving lives folder by non clinical staff. Hand
hygiene audits and decontamination of equipment audits are carried out on a monthly basis. The trust
expects 95% and 100% compliance respectively. Please maintain awareness and standard.

Ethical Considerations in Paediatric Intensive Care Unit: Indian Perspective

Due to rapid strides in medical technology over the years, the care of critically ill children with life
threatening disorders in the Paediatric Intensive Care Unit (PICU) has unfolded complex medical,
social, ethical, philosophical, moral and legal issues. Apart from tremendous financial cost of
paediatric intensive care to the parents and society, there is incalculable cost in terms of pain,
suffering, grief, anxiety, inadequacy, frustration and guilt not only to patients and their parents but
also for the treating medical and nursing team of PICU.

Basic Correlates of Ethical Decisions

Ethical decisions are based on the four principles of beneficence, non-maleficence, parental
autonomy and justice. Beneficence refers to the mandate that we should be the best advocates of our
patients and safeguard their "best interests" in accordance with the age old Hippocratic tradition. It
stipulates that physicians should be concerned with saving life and they should avoid doing any
wilful harm to their patients, i.e., they should be non-maleficence in their diagnostic and therapeutic
actions. The autonomy and wishes of parents should be honoured and they should be taken into
confidence while making a decision regarding the medical care of their children through a process of
informed consent. The principle of justice demands that we seek the morally correct distribution of
resources, ensure cost effectiveness of therapeutic interventions by balancing medical benefits and
burdens to the family and society. In what clinical situations, medical intervention is considered as
futile at present? Would the quality of life be worthwhile if the child survives with aggressive
management? How to assess the burdens and benefits of a therapy? Can the family afford expensive
management? Should we be concerned with the "best interests" of the patient alone or global interests
of the family, society and state? In what clinical situations intensive life support therapy should be
withheld? Should an unsalvageable child be hooked off the ventilator when a relatively better risk
child who needs assisted ventilation is admitted to the PICU? There are several other confounding
variables like cultural considerations, fertility of the parents, inter-parental harmony, gender of the
child, the concept of destiny or will of God, the doctor-knows-the-best attitude, education and
economic status of parents, available social support system and national priorities, etc. However,
whatever final decision is taken jointly by the medical team of experts and parents, it should be
without any ambiguity and recorded in the case file with full justifications.

The Need and Quality of Paediatric Intensive Care Facilities

It is not only justified but highly desirable to establish PICUs in all district and state level hospitals
both in the private and government sector in a phased manner throughout the country. It is mandatory
to ensure equitable development of health care services for children at all levels. In order to ensure
effectivity and credibility of the referral system, it is desirable to establish highly specialized medical
care facilities for children suffering from life-threatening critical disorders. If cardiac intensive care
units and cancer critical care units for adults are an accepted norm by the society, establishment of
PICUs should be more readily acceptable because they are more cost-effective. Saving the life of an
adult with stroke or cancer provides a lease of longevity for 2 to 5 years but saving the life of a child
is associated with a productive life of several decades. Moreover, it is easier to salvage the life of a
critically sick child due to their better reparative capabilities and lack of degenerative changes and
functional derangements in the body organs. The modern PICU should be equipped with the state-of-
the-art technology and run with business-like efficiency. It should be staffed with skillful, dedicated
and trained paramedics, nurses and resident doctors. But above all, they should be enthused and
equipped with qualities of human warmth, compassion and consideration. The general atmosphere of
PICU should exude overall optimism rather than the gloom of hopelessness despite all the odds. It is
desirable to maintain a balanced approach in various management protocols in order to avoid both
under and over treatment. The PICU procedure manual should outline details of admission policies
and indications for do not-resuscitate (DNR) and for withholding/withdrawing life support systems.

Parental Expectations in PICU

In view of the shortage of nurses and local cultural considerations, at least one of the parents should
be allowed to remain with the critically sick child and perform certain dedicated tasks and a routine
conventional parenting role. There should be one identifiable physician for regular interaction with
the family in a relaxed manner in a rest room located adjacent to the PICU. Above all, the parents
greatly honour the availability of a caring, credible, considerate and compassionate health team. They
need the assurance and transparency that every possible effort is being made to save the life of their
sick child.

Communication as the Vital Link

Most parental complaints in PICU originate due to lack of communication or because of abrasive
and callous attitude of the members of the health team rather than due to lack of skills or fruity
technical management of the patient. It is an amazing fact that most parents are grateful even when
we are unable to save the life of their child especially if one showed concern, care and compassion
and they were made to perceive that whatever was humanely possible was done for the care of their
child. It is crucial to listen and talk to the parents at least twice a day in a relaxed unhurried manner.
Humility, concern, empathy and compassion are crucial to generate faith and provide emotional
support to the family at this critical juncture. The paediatrician should be careful and tactful not only
in deciding what to tell the parents but also how to tell it. The parents should be told about the
condition of the child in a simple language. Try to be pragmatic and honest but always keep the hope
alive which has tremendous healing capabilities. Avoid creating confusion in the mind of parents due
to conflicting messages given by different physicians. In a critically sick child, always give a guarded
prognosis which can be tampered with hope and godly benevolence. The health team should not only
try to do their best, the family must perceive and appreciate that whatever was humanely possible in
the circumstances was actually done for their child. The parents should be encouraged to touch and
talk with their critically sick child, whether he is an infant or a child in coma, because it transmits
healing messages. The religious faith of the family should be honoured and if the parents wish they
may be allowed to use any mantras or charms to enhance the process of healing through faith. By and
large, efforts should be made to honour all the wishes of the parents of critically sick child if they are
not obviously harmful or contrary to the recommended therapies in a specific situation.

The Concept of Medical Futility

Despite tremendous advances in medical knowledge and technology in the recent past, medicine
cannot ever achieve immortality. Based on known medical facts when an intended therapy is likely to
fail in 100% cases, it is considered as futile to continue with aggressive management. The medical
therapy that merely prolongs life of a patient with permanent unconsciousness in a persistent
vegetative state (PVS) or when survival is likely to be associated with virtual or total lack of
cognition without any meaningful existence, the therapy becomes meaningless or futile effort.
However, in actual clinical practice these decisions are rather difficult as rightly said by Sir William
Osier, "medicine is a science of uncertainty and an art of probability".

Persistent Vegetative State (PVS)

Ethics and Humanities Subcommittee of the American Academy of Neurology has provided clear
clinical guidelines for the diagnosis of PVS. The common etiologic syndromes of PVS in children
include near-drowning, hypoxic-ischemic encephalopathy, meningitis, encephalitis, encephalopathies
and degenerative CNS disorders. It is characterized by protracted coma with open eyes. There is no
voluntary action or behaviour of any kind though they do have periods of wakefulness and
physiological sleep. They are unable to experience any suffering, pain and pleasure. They lack
coordinated chewing and swallowing is usually absent. They are likely to have prolonged survival if
provided with fluids and nutrition. In view of their meaningless existence without any purpose, the
American Academy of Neurology has sanctioned the withdrawal of nutrition and fluids in patients
with PVS if agreed by their care providers and parents through the process of informed consent.
However, this approach is controversial on basic humanitarian grounds because feeding hungry
people is considered as a great act of compassion while starving a dependent person is viewed with
utmost abhorrence and disbelief.

Financial Considerations

The PICU care is highly cost-intensive and daily cost of care may be more than the monthly salary of
the family. Apart from out of pocket expenses for PICU care in private sector, there are additional
financial implications to the family due to lost wages, travel expenses, expenses on drugs, special
diets and disposables, etc. Lack of Medicare insurance coverage and profound economic disparities
and inequitable social justice in India further complicate the complex economic realities. The patients
are often completely drained off monetarily by private nursing homes and then referred to the
government hospitals when they are at the brink of bankruptcy and near the threshold of death. The
overall gloomy prognosis and outcome both in terms of immediate survival and quality of life after
survival, often makes economic drainage unbearable leading to several adverse consequences to the
family dynamics for several months and years.

The Decision Making Process

Ethical decisions are based on clear understanding of a large number of complex issues. The
underlying medical facts pertaining to the patient should be properly analyzed in the light of available
information and technology. Sound ethical decisions can only be based on correct medical facts. It
should be known with fair degree of confidence whether the intended therapy in a particular patient is
likely to be rewarding or futile. Carefully evaluate the burdens (suffering, death, disability) and
benefits of the proposed intervention to the child, family and society (value conflicts). A team
approach should be followed by taking into confidence all the medical and nursing experts for
identification of various options and for making a reasonable and right opinion. The issue should be
discussed with the parents to seek their opinion through a process of informed consent. The various
confounding conflicts should be resolved to arrive at a mutually acceptable option through a process
of consensus. The final decision should be recorded in the case file with full justifications and
endorsement by the parent/s.

Withholding/Withdrawing Life Support

Therapies there are no significant medical and moral distinction between withholding and
withdrawing treatment. When it is futile to treat because the condition is either irreversible or
terminal or patient is in PVS or brain dead, it is undesirable and unrealistic to continue with
overzealous aggressive therapy. The core consideration in making such a decision is evaluation of
burdens and benefits of a therapy to the Child, family and the society. Instead of continuation of life
prolonging therapy, it is desirable to provide palliative care to relieve pain and suffering. Humanistic
teachings in general and philosophies of all the major religions of the world recognize that there
comes a time in the care of every patient when it is appropriate for the doctor to stop further attempts
to prolong unnecessarily the process of dying. A policy of passive euthanasia is followed by
withholding CPR, lifesaving surgery, assisted ventilation, dialysis, vasopressors, blood and blood
products and expensive antibiotics, etc. The provision of fluids and nutrition is also a form of medical
therapy but its denial is controversial and often considered inhuman. Although switching off a
ventilator is an "act" of commission but active euthanasia (say by intravenous administration of
potassium chloride) is considered as morally and ethically unjust. There is a risk of error, possibility
of an abuse and likelihood of erosion of trust in the doctor-patient relationship. The sanctity and
dignity of life should not be sacrificed at any cost. However, unintended but foreseen consequences
of over dosage of conventional drugs in the management of terminally sick patient, e.g., overdose of
analgesic-sedative to a patient with cancer is practiced at times without raising any eyebrows. Cardio-
pulmonary resuscitation is withheld if a patient is terminally sick or it is believed that the available
therapies are likely to be futile and in the event of survival there will be virtual or total loss of
cognition for any meaningful existence. The decision should be taken after due deliberations among
various experts and by taking family into confidence through the process of informed consent. The
decision should be recorded in the case file along with full medical justifications and should be duly
signed by the parent/surrogate. This approach is duly approved by the leading professional and
academic bodies of the world. The policy is rational and logical and is aimed at reducing the
suffering and misery of both the dying patient and his close relatives but it lacks legal sanction and
protection. There is a need to accord legal sanctity to the act of passive euthanasia in order to avoid
unnecessary litigations.

Criteria for Death

Availability of advanced life support systems has posed practical difficulties in making the diagnosis
of death. When there is irreversible cessation of circulatory and respiratory functions and CPR efforts
diligently performed over a period of 30 minutes have failed, death can be certified. In patients
maintained on assisted ventilation, criteria of brain death are used for declaring the patient as dead.
They are based on absence of brain stem responses. There are no reliable clinical criteria of brain
death in preterm babies and term babies below the age of 7 days. In infants between the age of 7 days
to 2 months, the brain stem responses should be absent during an observation period of 48 h, between
2 months to 1 year for 24 h and children older than 1 year for 12 h. Due to increased potentialities for
recovery, the observation period is prolonged in children with narcotic poisoning, exposure to severe
cold, near drowning, head injury, neuromuscular blockade, etc. In view of the increasing importance
of early diagnosis of brain death due to the emerging possibilities of cadaveric organ donation for
transplant programmes, a large number of sophisticated laboratory procedures are available though
the lack of their portability undermines their practical utility.

How to Communicate the Death of the Child?

Although we are all destined to die and death is the greatest truth, it is always unacceptable especially
so when life is cut short in the bud without fulfilment of purpose of existence. It is easier to face
death when it is anticipated and family is adequately prepared for the eventuality. If death is sudden
and unexpected, the family should be prepared emotionally. The family should be informed with
compassion and utmost care but in no unmistakable terms that the child has died despite our best
intentions and efforts. A large number of emotions like anger, hostility, shock, grief, guilt, denial,
depression, etc. need to be handled with poise, sympathy, utmost care and compassion so that reality
is accepted with grace as a will of God or nature's ordain. While CPR is provided (if DNR not
applicable), the relative/attendant should be escorted to the rest room and allowed to ventilate his/her
feelings. Family's wishes for religious support and ceremonies or their desire that death should occur
in the familiar atmosphere of home rather than hospital, should be honored as far as possible. When a
child is conscious and dying, the family should be at his bed side and talk with him to allay his fears
and assist him to express his concerns, desires and emotions. Silent listening and support at this stage
is valued more than unnecessary talking. During their earlier career some resident doctors/nurses may
feel extremely frustrated and angry due to their inadequacy and inability to save life despite maximal
efforts. They also need emotional support, guidance and advice to avoid unnecessary identification
and attachment with the family. They should be assisted to learn the art of detachment,
imperturbability and poise at all odds. After taking relevant postmortem biopsies, family should be
approached with caution and tact to seek permission for autopsy. Do not give the impression that
autopsy is needed for making a diagnosis but for helping the medical science and family regarding
the prevention of disease among contacts and siblings and for possible genetic counselling. The
enaction of Human Organ Transplant Act by the Indian Parliament in 1994 has opened opportunities
for cadaveric transplant of heart, lungs, liver, kidneys, pancreas, etc. which should be fully exploited.
The possibility of a positive contribution through their tragedy that their child may be able to see the
world or live through somebody else's eyes and body, may be accepted with enthusiasm. The issue of
organ donation should not be broached if there are well recognized contraindications for donation of
organs. After completing urgent formalities, a detailed death certificate should be prepared. Provide
courtesy, compassion and conveyance to the family for a dignified journey of the dead child to the
mortuary or home. The coping of the death of a child in PICU is a painful and challenging experience
but one that can also provide profound respect for humanity and life. Death punctures our ego and
teaches us humility and provides strength to face the greatest reality and truth of life. Resurrection of
Medical Ethics The continuing process of erosion of doctor-patient relationship and trust due to
insensitive and commercialized attitude of upcoming physicians (especially due to exorbitant cost of
medical education in private sector) and over demanding attitude of better educated and well
informed patients need to be checked against further disintegration. In view of the fact that services
of doctors have been included in the purview of Consumer Protection Act for redressal of grievances
and grant of compensation by the consumer courts, it is essential for the doctors to be more cautious,
considerate and ethical in their dealings with their patients to avoid any unnecessary legal actions. It
is desirable that all medical colleges in the country should initiate regular education programme in
the field of behavioural sciences and medical ethics for graduate and postgraduate medical students.
Ethics committees should be established in all hospitals and they should serve as a watch dog to
monitor and maintain the sanctity of all ethical decisions. The physicians should be enthused and
imbued with the qualities of sensitivity, compassion and genuine concern towards their patients
through a process of role modelling by the teachers. If is nice to be a well-informed doctor but it is
much nicer to be a good human being in order to provide holistic care rather than mere cure to one's
patients.

NURSES ROLE IN THE PICU

Essential roles:

Under general nursing and medical direction, utilizing standard procedures, the Nurse Practitioner or
Physician Assistant functions within an organized system for the delivery of health care in
association with other members of the health care team and performs specialized nurse practitioner
duties in clinical settings. The functions of the nurse are:

 Managing patient care of newborns and pediatrics, assisting with the admission assessment
and discharge of these patients
 Providing health education and counseling to patients.
 Maintaining medical records.
 Participating in nursing and unit staff meetings and patient care conferences.
 Performing other related duties as assigned/required.

Infant care center essential duties:

Under general supervision of the Director of Perinatal Nursing, the NICU/Pediatric Nurse
Practitioner or Physician Assistant performs specialized clinical nursing duties and serves as the
clinical expert for the neonatal inpatient population. The essential job functions include:

 Functions as part of the NICU clinical team.

 Provides and/or manages the nursing plan of care for neonates with complex problems.

 Provides education, training, information, and consultation services to physicians, registered

nurses, and other members of the clinical team; Interprets, coordinates, and implements new
and existing policies, methods and procedures for neonatal nursing in the perinatal areas.
 Keeps informed of current practices and trends and incorporates them into practice.
 Works in cooperation with other members of the multidisciplinary health teams.
 Makes professional contacts with a variety of public, private and professional
institutions/organizations.
 Performs other related duties as assigned/required.
Other roles include:

 Providing emotional support to parents.

 Empowering parents.
 Providing a welcoming environment; and
 Giving parents the opportunity to practice new parenting skills with their infants in the NICU
with assistance from the nursing staff.

Conclusion

A paediatric intensive care unit (also paediatric), usually abbreviated to PICU, is an area within
a hospital specializing in the care of critically ill infants, children, teenagers, and young adults aged
0-12. A PICU is typically directed by one or more paediatric intensivists or PICU consultants and
staffed by doctors, nurses, and respiratory therapists who are specially trained and experienced in
paediatric intensive care. The unit may also have nurse practitioners, physician
assistants, physiotherapists, social workers, child life specialists, and clerks on staff, although this
varies widely depending on geographic location. The ratio of professionals to patients is generally
higher than in other areas of the hospital, reflecting the acuity of PICU patients and the risk of life-
threatening complications. Complex technology and equipment is often in use,
particularly mechanical ventilators and patient monitoring systems. Consequently, PICUs have a
larger operating budget than many other departments within the hospital.

Bibliography:

1. Pal P. Textbook of Paediatric Nursing. 2nd edition. Delhi: Jaypee Brothers Medical publisher
(p) ltd; 2010.25-30.

2. Wong’s. Essential of Paediatric Nursing. 8th edition. Nadia: Elsevier; 2009.644-645.

3. Ghai OP. Essential Pediatrics. 7th edition. CBS Publishers & Distributors Pvt Ltd; 2010.240-
241.

4. A Guide: PICU. Children’s health and care. June 2019;1-27.

5. Singh M. Care of the New Born. 7th Ed. New Delhi. Sagar Publication.2010. P. 208-212