We are also providing best care of a critically ill child who needs ICU support with team of doctors like Paediatric intensivist and Neonatal intensivist in peerless hospital.

Intensive Care is defined as “a service for patients with potentially recoverable diseases who can benefit from more detailed observation and treatment than is generally available in the standard wards and Departments”.
Intensive care is usually reserved for patients with threatened or established organ failure, which may have arisen as a result of an acute
illness, trauma or a predictable phase in a planned treatment programme. 

 

1. A ventilator – a machine that helps with breathing; a tube is placed in the mouth, nose or through a small cut in the throat (tracheostomy)
2. Monitoring equipment – used to measure important bodily functions, such as heart rate, blood pressure and the level of oxygen in the blood
3. IV lines and pumps – tubes inserted into a vein (intravenously) to provide fluids, nutrition and medication
4. Feeding tubes – tubes placed in the nose, through a small cut made in the tummy or into a vein if a person is unable to eat normally
5. Drains and catheters – drains are tubes used to remove any build-up of blood or fluid from the body; catheters are thin tubes inserted into the bladder to drain pee

 

Ongoing Assessment and Support

 The components are Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention and Glucose control. While some components like thromboembolic prophylaxis, stress ulcer prevention are more suitable for adult patients, it still may be worthwhile to follow this or a similar strategy to improve care of children in PICU.

Similarly, for neonates the mnemonic ‘STABLE’ (Sugar, Temperature, Assisted Breathing, Blood Pressure, Lab Work, Emotional Support) has been recommended. This primarily focuses on post-resuscitation and pre-transport stabilization of sick newborns in order to ensure the detailed assessment of multiple issues and appropriate intervention for these problems.

Glucose Control

Strict glucose control has been driven,the strict blood glucose levels of 80–110 mg/dL may be difficult to adhere to in routine patient care, but it may be feasible to keep blood glucose levels below about 150 mg/dL. Another study by the same authors in medical ICU patients found somewhat increased mortality if the duration of stay was less than 3 days in the ICU suggesting that short-term hyperglycemia in the intial phase may be helpful but prolonged hyperglycemia may be detrimental. It has been documented that hyperglycemia is common in critically ill children and the peak blood glucose level and the duration of hyperglycemia are independently associated with mortality in PICU.studied the effect of targeting age-adjusted normoglycemia with insulin infusions in critically ill infants and children on outcome. Targeting age-adjusted normal blood glucose levels with insulin infusion improved morbidity. It protected the cardiovascular system, prevented secondary infections, and attenuated inflammatory response, reducing the length of stay in ICU. However, the risk of biochemical hypoglycemia was substantial in the intensive group. In view of the available evidence, it may be beneficial to monitor blood glucose regularly in critically ill children and maintain blood glucose levels less than 150 mg/dL; at the same time, it is essential to prevent hypoglycemia. If the blood glucose levels are consistently above 180 mg/dL despite reduction of glucose infusion rates, insulin infusion may be considered.

Pressure Sores

Pressure ulcers are common in children in PICU. In a prospective study, 27% of PICU patients developed pressure ulcers. The patients at risk included those supported on mechanical ventilation and those with hypotension. Malnutrition, sensory loss, dependent edema and length of stay above 96 h are other risk factors. The extrinsic risk factors involved in tissue damage are: pressure, shearing and friction. It is important to regularly examine the skin in all children admitted to the PICU. Children who are ‘at risk’ of pressure ulcer development should be repositioned and the frequency of reposition is determined by the results of skin inspection and individual needs and not by a ritualistic schedule. The preventive strategies include adequate nutrition, use of alternating pressure mattresses or other high-technology pressure redistributing systems.

Eye Care

Abnormalities of the cornea and conjunctiva occur in association with neurological diseases, nocturnal lagophthalmos, coma, infection, and mechanical ventilation. These have been reported in nearly a quarter of critically ill patients in ICU. The risk factors for corneal erosions include patient's inability to fully close eyes and use of neuromuscular blocking agents. It is beneficial to use lubricating ointments and artificial tears to keep the corneal and conjunctival surfaces wet. In addition, protective eyelid taping is effective in preventing and treating the corneal erosion.

Oral Hygiene

Oropharyngeal colonization is of significant importance in the pathogenesis of Ventilator associated pneumonia, and a targeted approach to prevent colonization at this site may be an effective method of infection prevention. Several studies have documented benefit of selective oral decontamination in adults. Surveys performed in the US and UK suggested that oral care methods were not consistent with current research and oral care protocols. Results of a prospective study in a British PICU revealed a highly significant increase in plaque accumulation and gingival inflammation between admission to the PICU and discharge. The authors concluded that the prevailing mouth care regimen was not effective in preventing the build up of plaque or maintaining gingival health, placing these children at unnecessary risk from local or systemic spread of oral microorganisms.

The preventive measures should include regular cleaning of the oral cavity especially in intubated children. Use of chlorhexidine based oral hygiene products may be beneficial. In our unit, nurses perform oral hygiene procedures once a day using anti-septic solution (Iodophor/chlorhexidine).

Prevention of Stress Ulcers

Critically ill patients are at risk of developing stress ulcers in the stomach. Prophylaxis against stress ulcers has been recommended for the prevention of UGI bleeding in critically ill adult patients. Pediatric studies have identified various risk factors for upper gastrointestinal bleeding in critically ill children: thrombocytopenia, prolonged partial thromboplastin time, organ failure, mechanical ventilation and high pressure ventilator setting and higher severity of illness.

Recently, a systematic review and meta-analysis found limited high-quality data to recommend routine use of stress ulcer prophylaxis. Till more evidence is available, stress ulcer prophylaxis using ranitidine, sucralfate, or proton-pump inhibitors may be instituted in children with multiple risk factors for development of stress ulcers.

Thromboembolic Prophylaxis

Venous thromboembolism is being increasingly recognized in the pediatric age group. Children in intensive care unit are exposed to multiple risk factors for venous thromboembolism— secondary to either the underlying disease or selected therapeutic interventions. Presence of central venous catheter is most common risk factor for venous thromboembolism. Various diagnostic tests exist, with venography remaining the gold standard and newer, less invasive methods such as ultrasonography and impedance plethysmography becoming increasingly popular.

Standard unfractionated heparin remains the mainstay of therapy and prophylaxis; low molecular weight heparins are being increasingly used. Thrombolytic therapy is reserved for severe, life-threatening, acute thrombosis. There is lack of data on pediatric ICU patients to define clearly the ‘at-risk’ group and to administer the most ‘effective medication’. Also, the benefit of prophylaxis must be weighed against the risk of bleeding complications. The Surviving Sepsis Campaign guidelines recommend the use of DVT prophylaxis in postpubertal children with severe sepsis.

Care of Intravenous lines, Central Lines, Chest Tubes, PD catheters

All patients with an IV cannula must be examined at least once per shift for signs of infusion phlebitis. The cannula site must also be observed when bolus injections are administered, IV flow rates are checked or altered and when solution containers are changed. A Visual Infusion Phlebitis (VIP) Scale has been devised for objective assessment of the IV sites and appropriate intervention. The peripheral IV cannula should be replaced at the first indication of infusion phlebitis.

Central venous lines and arterial lines are important adjuncts for monitoring and therapy of children in intensive care. They should also be monitored regularly for displacement, bleeding, patency, infection or for hematoma formation at the site. They should preferably be removed as soon as they are no longer necessary and always when a patient develops fever with no other obvious focus of infection.

Chest drains should be assessed periodically for movement of fluid column, amount of drainage and its nature, displacement, breath sounds, and for any evidence of subcutaneous emphysema.

Peritoneal dialysis catheters should be inserted following thorough asepsis routine, and during the peritoneal dialysis their patency and flow rate should be monitored regularly. After completion of dialysis, it should be removed as early as possible and the PD fluid and catheter tip should be sent for culture to screen for possible infection.

Care of Child with Special Needs— Neurologic and Neuromuscular Disorders

Children with neurologic and neuromuscular disorders have special needs as they are more prone to recurrent aspiration, have poor cough and airway clearance, may have respiratory muscle weakness requiring prolonged ventilatory support, and weaning them off ventilator may be quite challenging. They may require prolonged support even after extubation in the form of either nasal mask CPAP or Bi-PAP or tracheostomy and may need monitoring of respiratory muscle strength and lung function to identify them early before they reach the threshold of respiratory failure. They also require special emphasis on nutritional support and regular turning and physiotherapy for prevention of contractures and pressure sores