Routine care in the PICU is important for several reasons: it facilitates the identification of clinical issues, encourages patient-centered care, and helps prevent hospital-acquired infections. The key elements of routine care in the PICU are known by the acronym FASTHUGS BID, and include feeding, analgesia, sedation, thromboembolic prevention, head of bed elevation, ulcer prevention, glucose control, spontaneous breathing trials, bowel care, and catheter/line care. Providing this routine care is essential for all patients in the PICU.

1. Routine Care in PICU

2. Objectives
• Outline the importance of routine care of children in
PICU
• Describe the elements of routine care and other care in
PICU

3. Team work is important

4. • What are the importance of routine
care in PICU?

5. Routine care of children in PICU
Importance:
• Facilitates identification of clinical issues
• Encourages patient centered care
• Prevents hospital acquired infections
• Ensures hygiene and comfort
• Reminds clinicians to ensure routine care and
treatment is applied to every patient

6. Elements of Care
FASTHUGS BID

7. Elements- FASTHUGS BID
• Feeding
• Analgesia
• Sedation
• Thromboembolic
prevention
• Head of bed
elevation
• Ulcer prevention
• Glucose control
• Spontaneous
Breathing Trial
• Bowel care
• Invasive device and
catheter
• De-escalation of
Drug

8. Feeding
• Malnutrition is linked to poor outcome
• Should start within 24-72 hrs
• Enteral feeding is preferred but parenteral feeding
as an alternative
• Monitor for intolerance to feeding
• Carbohydrate: 50-60%, (e.g. 38–120 kcal/kg/day)
• Protein: 1.5-3 gm/kg/day (15-30% lipids)

9. Analgesia

10. • Child should be monitored for:
– common signs of pain by using validated pain
assessment tool
• Use analgesic agents:
–to provide pain relief
–i.e. Paracetamol, Ibuprofen, Opioids
(fentanyl, morphine) etc.
• Reassess effect

11. Sedation
• Goal: patient to be awake and comfortable
• Sedative medications:
– midazolam, ketamine, propofol, opioids
• Level of sedation should be assessed using a
validated scoring tool
Thrombolytic Therapy
• Some ICU children are at an increased risk for
Thrombosis
• Consider pharmacological and non-pharmacological
methods of prophylaxis

12. Head of Bed Elevation
• Elevate HOB to 30-45 degree
• Reduce the incidence of:
- gastro-esophageal reflux (aspiration)
- ventilator acquired pneumonia (VAP)
Ulcer prophylaxis
• Risk of developing stress-related mucosal damage
• leads to increased mortality
• Consider H2 antagonists and PPI’s

13. Glycemic Control
 Blood sugar must be kept within normal range (60-
140mg/dl)
 Decreases rate of infection and minimizes the
hospital stay
Spontaneous Breathing Trial
• Should be performed everyday as child’s condition
improves

14. Bowel Care
• Defecation
Indwelling Catheters and Lines
Intravenous line, CVP line, A- line
• Inspect all invasive line insertion sites for:
- patency
- signs of infection
- security
- pressure areas
• Lines and dressings should be changed according to
hospital protocol or if soiled/damaged
• Catheter care

15. De-escalation of Antibiotic
• Does the child need antibiotic?
• Duration of antibiotic?

16. Other Nursing Care
• Mouth care
• Eye care
• Pressure Area Care
• Patient sponging
• Sleep promotion
• Tracheostomy care
• Care of children under mechanical ventilator
• Handover

17. Mouth care
• Clinically proven to reduce VAP
• Use chlorehexidine 0.12% especially for intubated
child
• Tooth brushing at least twice a day if child is able
to do

18. Eye care
• Perform 4 hourly
• Clean outer eye with normal saline and
gauze
• Use eye drops and/or ointment:
– to lubricate the eyes and to reduce the risk of
corneal abrasions as needed
• If patient cannot close eyelids properly:
– consider using barrier to promote eye closing

19. Pressure area care
• level of risk should be assessed using a validated
tool
• Patients should be repositioned and their skin
assessed at least 3 hourly
• Consider:
- pressure relieving mattress
- adequacy of nutrition/hydration
- mobilization

20. Sponge bathing
• Once a day or when required
• Reduces risk of infection and promotes comfort
• Use either water bath or disposable wipes
• Use clean to dirty approach (infection control)

21. Sleep promotion
• Limit visiting hours and promote rest periods
• Reduce stimuli (i.e. noise, lights)
– if needed use aids such as eye mask and ear
plugs
• Encourage a day/night routine

22. Tracheostomy care
• Stoma should be inspected for infection and wound
breakdown
• Clean daily/PRN with NaCl 0.9% soaked
gauze/cotton swab
• Use tapes to ensure security
• Make emergency airway management equipment
readily available

23. Care of Children Under Mechanical
Ventilation

24. Adequate oxygenation, ventilation and support for
work of breathing
• Assessment of the child receiving MV
• General observation: comfort of child, chest expansion,
color and consciousness
• Auscultation: breath sound
• Work of breathing
• Document cuff pressure every shift
• Volume and quality of secretions
• Continue monitoring
• Monitor gastric insufflation and remove air from
stomach

25. Correct position and patency of artificial airways
• Chest radiograph
• Auscultation for breath sounds
• ETCO2 monitoring
• Ensure artificial airway is secured and stabilized
• Suction only as needed: not according to a schedule
• Use close suction if available
• Hyper oxygenate the child before and after suctioning

26. Contd…
• Do not instill normal saline while suctioning
• Limit suction pressure to the lowest level to remove
secretions
– (60-100 in preterms and neonates, 80-120 mm of Hg in
children)
• Suction for the shortest duration

27. Maintenance of fluid and electrolyte balance
• Calculation and monitoring of all fluid intake
• Monitor urine output:1-2 ml/kg/hr
• Evaluation of lab value
• Daily weight
• Optimize nutrition through early initiation of
feeding via OG/NG tube

28. Child should remain free of nosocomial infection
• Minimize ventilator source of infection (VAP) by
emptying condensation in tubing
• Keep head of bed elevated at 30 degree unless
contraindicated
• Mobilize patient as far as possible
• Maintenance of oral hygiene
• Consider removal of additional potential source of
hospital acquired infection as a daily basis

29. Maintenance of skin integrity
• Asses skin integrity every 2-4 hrs
• Keep skin clean and dry
• Reposition child every 3 hourly
• Prone positioning for all ventilated children as far
as possible
• Maintenance of oral hygiene
• Moisture the lips every 2-4 hrs or as required

30. Acceptable level of comfort
• Assess child’s pain and sedation level
• Titrate pain and sedation medication as per
protocol
• Provide non-invasive comfort measure
• Parental presence
• Favorite blanket or toy
• Ear plug to reduce the noise level
• Dim lights
• Distraction technique

31. Points to be considered before handover
• Infusions refilled and lines correctly labeled
• Ensure patient is clean and comfortable
• Empty drainage bags emptied
• Ensure dressings intact and lines secured
• Check that room re-stocked, neat and tidy
• Ensure documentation completed

32. Handover of children

34. Summary
• Why routine care is important in PICU?
• What are the elements of routine care?