2. Case - 1
• 11 yr old 40 kg , Fever 5
days,101°F, Cough 4 days, Fast
beathing 1 day.
• Covid-19 RT-PCR Positive
• RR – 38/min , SpO2 – 91% in RA
• HR – 96/min, BP- 110/76
• Sensorium Normal
• Where will you admit the patient?
• What treatment you want to start ?
• Any investigation you want to do ?
5. Case continue ..
• Started on Nasal Canula – 4l/min but
within 10 hrs escalated to NRBM –
10L/min
• Dexamethasone started 6 mg once
daily
• IV Fluid/Enteral feeding
• Paracetamol
• Hb 10.3 TLC- 10540 , N-88% L- 9%. Plt
1.32lac. CRP- 54.6mg /l . ESR – 34
What are the parameters you will
monitor and how frequently ?
9. When will you wean Oxygen and Stop oxygen ?
• The child should appear clinically well, vital signs within normal limits
Work of breathing should be mild, or no work of breathing.
Feeding adequate amounts orally, alert behaviour = normal
• Stop oxygen therapy and maintain line of sight for approximately 5 min
• If SpO2 falls below 92%, recommence oxygen therapy at the lowest flow rate.
• Continuous pulse oximetry for 30 minutes post cessation of oxygen
Perform vital sign observation, intermittent SpO2 monitoring 30 minutes later, then
hourly for 2 hours
Nursing Officer-in-Charge for Oxygen Management
10. • What are the equipment, consumables we would like to have
in your settings ?
11.
12.
13. In daily round besides patient care what are
the important issues you will check ?
• Check all equipments are working
• Check all important consumables have adequate stock
• Check necessary medicines have adequate stock
• Check resuscitation tray is ready
• Oxygen source are adequate and working
• Electrical points are working and safe
• COMMUNICATION with mother and Father
14. Case - 2
• 9 year old female, 24 kg
• Fever for 7days and cough and cold
• Respiratory distress for 2 days
• Covid-19 RT-PCR Positive
• No history of contact to covid.
• RR – 40/min, Moderate retraction
• Spo2- 85% in RA and with NRBM (15
L/min) – 90% .
• Hb9.2. TLC- 9000 N-78% L- 19%. Plt
1.62lac. CRP- 44.6mg /l . ESR - 40
Where will you admit the patient ?
Any further investigation you want to
perform ?
How will you treat the child ?
15. COVID HDU/ICU
BEST treatment option
1. Continue NRBM Oxygen and Start Dexa
2. Start HFNO and Dexa
3. Start HFNO, Dexa, LMWH
4. Start HFNO, Dexa, LMWH and Prone
the patient
5. Start HFNO, Dexa, LMWH, Prone the
patient and start Remdesivir
LFT, RFT
16.
17. High Flow Nasal Oxygen
• Which patient circuit ?
• Nasal canula size ?
• Flow – How much?
• Oxygen percentage ?
• Pediatric Circuit - upto 20-25 L
• Adult Circuit - upto 60 L flow
• Nasal Canula – Should not cover > 50% of
nostril
Flow - Flow rates @1.5-2L/kg/min up to
12kg, plus 0.5 L/kg/min for each kg
above 12kg (to a maximum of 50 LPM) ,
FiO2 - 21-50% .
FiO2 requirement > 60% and Flow 2
ml/kg - consider escalation to NIV
18.
19. Contraindications
• A history with spinal instability like spondylolisthesis, scoliosis,
injury, or trauma to the spine.
• Increased intracranial pressure
• Hemodynamically unstable conditions like hypertension and
cardiopulmonary diseases
• Abdominal open wounds
20. What are the things you will look in daily
round and ask to monitor daily ?
21.
22. Case continue….
• After 2 hrs
• Flow – 30 L/min
• FiO2 – 70 %
• SpO2 – 90-92 %
• Moderate work of breathing
• BP – 108/74
• HR – 120/Min
• What will you do now ?
• Flow gradually increased to 45
l/min
• Fio2 – 70%
• Spo2 – 87%
• Work of breathing moderate
• Patient irritable
• HR- 136/min
• BP – 110/74
What will do now ?
23. What are the Indication to transfer to ICU
Facility ?
• Moderate to Severe ARDS
• 2 or more organ involvement
• Requiring Invasive Ventilation
24. How will you transfer the patient ?
1. Recognize the need (Stay & pay; scoop & run concept)
2. Planning & Preparation : Checklist, equipment, team, ambulance
3. Stabilisation before transport
4. Communication
5. Team?
6. Equipment needed ?
25. • In between patient Furter deteriorated . Patient will need Intubation
and ventilation
• You got a communication that this patient is going to be transferred
to your hospital .
• How will you prepare your team, equipments and drugs ?
• Present Status – 9 years,24 kg
• Sp02 – 90%, WOB – Increased, Irritable, HR – 140/min, BP- 104/68,
CRT – 3sec
26. • Communication ?
Discuss about possible intubation , Inform your team(Doctor, Nurses, MT)
• Equipment:
i. Intubation (ET tube cuffed – 5.5, 6,6.5 )
ii. laryngoscope Macintosh (No-3,4)
iii. Stylate - Large size
iv. Functioning Suction apparatus
v. Bacteria and Viral filter, HME Filter, Closed Loop Suction catheter (no-12)
vi. Bain circuit with Filter and Face mask/ AMBU with Filter and face mask
vii. Artery forcep
viii. EtCo2
ix. Disposable Ventilator Circuit - Adult (15 mm)
x. Point of care blood gas analyser?
xi. Portable Xray Machine and CR (Preferable)
30. • Drugs :
i. Drugs for intubation
ii. Midazolam – 0.2 mg/kg
iii. Ketamine – 2 mg/kg
iv. Fentanyl – 1mcg/kg
v. Rocuronium – 0.3 mg/kg
vi. Epinephrine/norepinephrine
vii. NS bolus /maintenance fluid
• Staffing
• Paediatrician, EMT , registered nurse
• Infection control :
Airborne precautions with Full PPE and Face Shield
31. Safe Practice Guidelines for Medications
• Intravenous (IV) therapy - essential component of current
healthcare delivery.
• Errors involving IV medications can occur in all phases of the
medication use process and can be particularly dangerous.
• IV medications are associated with 54% of potential adverse drug
events (ADEs).
• 59% of these errors occurred during drug administration
32. Good Prescribing: What constitutes good
prescribing?
• Maximize effectiveness
• Minimize risks,
• Minimize costs, and
• Respect the patient‟s choices
33. SAFE DRUG PRACTICE
• Patient Information
• Drug Information
• Communication of Drug Information
• Drug Labeling, Packaging, and Nomenclature
• Drug Storage, Stock, Standardization, and Distribution
• Device Use
• Environment, Staffing, and Workflow
• Staff Education and Competency
• Management and Quality Improvement Challenges
34. DRUG DILUTIONS
• This section deals with the emergency drug doses and
their preparation
• The concept is to prepare the drugs in a standard way
• Advantage ??
• One acts faster in an emergency
• Chances of error minimized
• Improves team coordination
35. EMERGENCY DRUGS
S NO DRUG S NO DRUG
1 MIDAZOLAM 11 CALCIUM
GLUCONATE
2 FENTANYL 12 ATRACURIUM
3 KETAMINE 13 NORCURON
4 MORPHINE 14 DOPAMINE
5 PROPOFOL 15 DOBUTAMINE
6 THIOPENTAL 16 XYLOCARD
7 ADRENALINE 17 AMIODARONE
8 NORADRENALINE 18 PHENOBARBITONE
9 ATROPINE 19 DILANTIN
10 NAHCO3 20 ADENOSINE
36. COMMERCIAL PREPERATIONS
S NO NAME OF MEDICATION mg/ml VIAL/AMPULE
1 MIDAZOLAM 1 mg/ml 10 ml vial
2 FENTANYL 50 g/ml 2 ml ampoule
3 KETAMINE 50 mg/ ml 10 ml vial
4 ATRACURIUM 10 mg/ml Ampoule
5 MORPHINE 15 mg/ ml 1 ml ampoule
6 ATROPINE 0.6 mg/ml 1 ml ampoule
7 EPINEPHRINE 1 mg/ ml 1 ml ampoule
8 PROPOFOL 10 mg/ml 10 ml vial
9 THIOPENTAL 500 mg powder Vial
10 NAHCO3 7.5% solution 10 ml ampoule
11 CALCIUM GLUCONATE 10 mg/ml 10 ml ampoule
46. SEQUENCE OF DRUG PREPERATION
This will depend upon the type of emergency in the
NICU/ PICU
• Convulsions
• Respiratory Failure
• Shock
• Arrhythmias
• Cardiac Arrest
47. SEQUENCE OF DRUG PREPERATION IN
PICU
Convulsions
• Prepare midazolam, fentanyl, Rocuronium in that
order
• Ask and prepare Phenytoin/ Phenobarbitone as the
next drug to be given
• Dilantin is never diluted in dextrose containing I/V
fluids (precipitation occurs)
• If the patient goes in status epilepticus, would require
propofol or thiopentone as bolus followed by infusion
48. SEQUENCE OF DRUG PREPERATION IN
PICU
Respiratory Failure
• Patient might need ventilation so prepare midazolam,
fentanyl, Rocuronium as the first drugs
• Patient may require Ketamine as bolus followed by
infusion, if asthmatic
49. SEQUENCE OF DRUG PREPERATION IN
PICU
Shock
• Patient will require NS fluid boluses @ 10-20 ml/kg, so it should be
prepared first
• Prepare Dopamine infusion after asking the doctor, followed by
Dobutamine if required
• Prepare midazolam, fentanyl, Rocuronium if ventilation anticipated
• Prepare adrenaline, atropine if anticipating cardiac arrest
50. SEQUENCE OF DRUG PREPERATION IN PICU
Cardiac arrest
• Prepare adrenaline, atropine, calcium gluconate, soda bicarbonate,
morphine, atracurium in that order along with normal saline flush
• Ask the doctor and prepare dopamine and adrenaline infusions in
that order
51. RESUSCITATION TRAY CHECKLIST
S. No NAME OF THE
MEDICATION
Mg/ ml (vial or ampoule)
Quantity
1 MIDAZOLAM 1 mg/ml (10 ml vial) 1 vial
2 FENTANYL 50 g/ml (2 ml ampoule) 1 ampoule
3 KETAMINE 50 mg/ ml (10 ml vial) 1 vial
4 ATRACURIUM 10 mg/ml (5 ml ampoule) 3 ampoules
5 MORPHINE 15 mg/ ml (1 ml ampoule) 1 ampoule
6 ATROPINE 0.6 mg/ml (1 ml ampoule) 1 ampoule
7 EPINEPHRINE 1 mg/ ml (1 ml ampoule) 1 ampoule
8 PROPOFOL 10 mg/ml (10 ml vial) 1 vial
9 THIOPENTAL 500 mg vial 1 vial
10 NAHCO3 (10 ml ampoule) 1 ampoule
11 CALCIUM
GLUCONATE
9 mg/ml (10 ml ampoule)
1 ampoule
12 ADENOSINE 3mg/ml (2 ml vial) 1 vial
13 AMIODARONE
50 mg/ml(3 ml vial)
1 vial
52. DRUG INTERACTIONS
PHENYTOIN/DILANTIN
• Never diluted in dextrose containing fluids
NORADRENALINE
• Diluted in dextrose containing fluids (DNS)
NaHCO3
• Always dilute in distilled water (1:5)
53. Preparation and commencement of the
Infusion
• Exercise extreme caution in the calculating and preparing of the inotrope.
• Both syringe and administration set must be clearly labeled.
• Dedicate a lumen of the central line for inotrope use only.
• Avoid bolus administration by adding other non-inotropic drugs
• Primes the pump to avoid delay in drug therapy
• Start the infusion at the prescribed rate .
54. Managing the infusion
• Never administer non-inotropic drugs or bolus via this lumen.
• Never stop an inotrope without first weaning.
• The parameters for drug delivery and therapeutic goal must be known
and recorded.
• Continuously monitor heart rate, rhythm and blood pressure and record
hourly.
• Observe infusion site hourly for signs of extravasation
• Be aware of the volume left in the syringe.
55. Changing syringes
• Perform this procedure during the day shift
• Start procedure with at least 4 hours of available drug in syringe
• Load the new infusion into the spare syringe pump.
• Purge until the infusion drips.
• Organise work to facilitate minimal distraction for a maximum of 10 minutes
• Ensure the infusion you are about to disconnect the correct one.
• Double check the infusion rate.
56. ANTIBIOTICS
• No antibiotic should be pushed as a bolus
• All antibiotics should be diluted and given as infusion
over 30 min to 1 hr
• Volume of dilution varies with age and weight
• Up to 5 kg – dilute the drug in 10 ml of IV fluid
• 5 - 15 kg – dilute the drug in 20 ml of IV fluid
• 15 - 40 kg – dilute the drug in 30 ml of IV fluid
• Use above dilutions unless particular dilution is
specified
57. ANTIBIOTICS
• Hypersensitivity can occur with any drug so the rate
of infusion should be slow initially and if no reaction is
noted, it can be increased.
• All antibiotics once prepared can be stored in the
refrigerator at 2-8 C for not more than 24 hrs.
58. Case continue
• Present Status – 9 years,24 kg
• Sp02 – 90%, WOB – Increased,
Irritable, HR – 140/min, BP-
104/68, CRT – 3sec
• You have intubated
• MODE - ?
• Settings - ?
• Sedation - ?
• Target ?
• Monitoring - ?
• Bedside goal
• TV - 5–8 ml/kg
• PEEP - 8-12 cm H2O
• Pplat - <28 CmH2O
• Ph- 7.25 without a specific
target PaCO2),
• Permissive hypoxemia
• ( Moderate- SpO2 92-94% ,
• Severe – SpO2 – 88-92%)
59. Spo2 – 94%
BP- 100/54
HR - 130
CRT – 3sec
What do you want to do ?
Sedation –
Midazolam – 4
mcg/kg/min
Fentanyl – 2 mcg/kg/hr
60. Optimize circulation
• Assess volume status
• Vasodilated vs Vasoconstricted shock
• Assess cardiac function
• Check intake output chart
• May need cautious fluid bolus
• Inotrope – Which one / what dose ?
65. Daily Routine care ?
• A PICU nurse plays a crucial role in implimentation of quality critical
care to children.
• Nurses are the most directly involved in delivering health care to
critical ill child.
• Standard of nursing care reflect upon the overall quality of PICU.
66. General Care in PICU
• Care of the eyes
• Care of the oral cavity
• Care of the back
• Bladder/bowel care
• Care of the pressure point
• Care of the lines
68. After 4 DAYS …
• PRVC Mode
• TV – 150 ML
• RR – 20
• PEEP – 8
• Fio2 – 40%
• Ppeak - 20
• SpO2 – 96-98%
• BP- 120/74
• HR – 90
• CRT – 3 sec
• ABG –
• Ph – 7.39
• Pco2 – 45
• Pao2- 150
• HCO3 – 22
What will you do now ?
69. Weaning
• Reduce/Stop sedation
• Sedation Holiday if prolonged
ventilation
• SIMV/ PS
• Extubate
• Wait for 30 min- 2 hrs in PS mode
• Monitor –
• SpO2 - > 94%
• RR – Increase not > 10 (5 for older)
• HR – Increase not > 20 ( 10 for older)
• BP – Maintained
• WOB – None or Mild
• No role of routine Dexa – Use if
traumatic intubation or duration > 4
days
70. Case history …
• 10 Yr old boy, 30 kg
• Referred on day 7 of fever as case of
Appendicitis ? Enteric fever?
• Severe abdominal pain/ tenderness
• Shock and respiratory distress at
admission –
• BP – 86/52, HR – 150, CRT – 5 sec,
Periphery cold
• RR – 34/min, Mild retraction
• TLC- 8600, N-82, L-12, CRP-172, ESR- 54,
Blood C/S send
• Tropical infection screening negative
• Family history of Covid – 6 wks back
• You are at Subdivision Hospital -
WHAT will do now ?
71. Continue …
• Stabilization –
• 0.9% NaCl bolus – 20 ml/kg
• Oxygen – NRBM Mask – 10l/min
• Start Inotrope - Which one ??
• Antibiotic
• Steroid – Methypred/Dexa
• Check CBG, Send blood for CBC,
Culture
• Reassess and intervene
• Talk about transfer
• Communicate
• Arrange safe transport
• Continue treatment during
transport
72. Now patient is transferred to Tertiary care…
• 10 Yr old boy, 30 kg
• Bolus – 20ml/kg
• Dopamine/Epinephrine/Norepi
• Oxygen NRBM
• Antibiotic
• Arrived in your emergency –
• BP – 90/56, HR- 148/min CRT – 5
sec, Periphery cold
• RR – 34/min, Mild retraction
• SpO2 – 92%
• Sensorium - Irritable
• TLC- 8600, N-82, L-12, CRP-172,
ESR- 54, Blood C/S send
73. How will prepare your team
• Discuss –
• Need of Respiratory support
• Need for Intubation
• Need for further Bolus
• Need for escalation of Inotrope
• Need of other drugs
• Communication to parents
• Need for Intubation
• Don’t be in hurry to intubate in a
patient with uncorrected shock.
• Start bolus
• Start Inotrope
• Start PPV/High flow oxygen
• Give low dose sedation
74. ALL 6 CRITERIA MUST BE MET
1.Age 0- 19 years
2.Fever for ≥3 days
3.Clinical signs of multisystem involvement (at least 2 of the following):
• Rash, bilateral nonpurulent conjunctivitis, or mucocutaneous inflammation signs (oral, hands, or feet)
• Hypotension or shock
• Cardiac dysfunction, pericarditis, valvulitis, or coronary abnormalities (including echocardiography
findings or elevated troponin/BNP)
• Evidence of coagulopathy (prolonged PT or APTT; elevated D-dimer)
• Acute gastrointestinal symptoms (diarrhoea, vomiting, or abdominal pain)
4.Elevated markers of inflammation (eg, ESR, CRP, or procalcitonin)
5.No other obvious microbial cause of inflammation.
6.Evidence of SARS-CoV-2 infection(Any one of the following)
– Positive SARS-CoV-2 RT-PCR
– Positive serology(SARS CoV-2 IgG positive)
– Positive antigen test
– Contact with an individual with COVID-19
78. Outcome
• Gradual clinical improvement
• Afebrile, no features of shock occurred
after IVIG and methyl prednisolone therapy
• Repeat ECHO showed – EF-55%, NO
features of myocarditis or effusion, no
coronary dilatation
• Repeat chest Xray showed no pleural
effusion
• Repeat CBC showed no lymphopenia and
descending trend of CRP value(10mg/l)
• Patient was discharged in stable
condition after 12 days of hospital
stay
79. Take Home Message
Be Intense in care of sick children…..not
necessarily Intensive
