Admission Criteria in PICU for Children having COVID 19 & general care of a child in PICU

1. Admission Criteria in PICU forChildren having
COVID 19 & general care of a child in PICU

2. Admission Criteria in PICU forChildren having
COVID 19 & general care of a child in PICU
Speaker :
Dr Vivek Maheshwari
13th July 2021 3:00PM to 3:30PM

3. Pediatric patients who are critically ill and those who need advanced airway,
respiratory and hemodynamic support are admitted in PICU so that the outcome
is improved.
Objectives of admission in Picu:
to decrease the mortality.
to restore health of the child who is suffering from a life-threatening condition
to health with a minimum pain, anxiety and complications and
to provide comfort and guidance to the child’s family.
Jyothi AK et al. Int J Contemp Pediatr. 2019 Mar;6(2):757-760
Admission Criteria in PICU forChildren having COVID 19

4. Admission Criteria in PICU forChildren having COVID 19:
Requiring mechanical ventilation
Shock requiring vasopressor support
Worsening mental status
Multi-organ dysfunction syndrome

5. Evaluation
Initial assessment Primary assessment Secondary Assessment
Lethargic RR (repeat count if
elevated)
Fever, sore throat,
rhinorrhea, loose stool,
stomach ache
Fast RR (age cut
off)
SpO2 < 94% Redness& swelling of
tongue
Cyanosis/mottle
d/ ashen -grey
WOB- nasal flare,
chest indrawing,
grunting
Redness& swelling of
hand & feet
Tachycardia/hypotension Oral mucosa/sunken eyes
Cold extremities Skin pinch- very slow/slow
Urine output
Lethargic or unconscious

6. Redflags:Findings thatshould prompt immediateintervention
• Fever>100.4 for >3 days
• SpO2 <94%
• Cyanosis
• Respiratory rate > cut off for age
• Chest indrawing
• Features of MIS-C
General danger signs(2-
59mo)
• Not able to breastfeed/drink
• Vomits everything
• Convulsions
• Lethargy or unconscious

7. Triage-1:Screening
• Temperature
• SpO2
• Presence of recent/current confirmed COVID-19
cases
• Symptoms

8. Triage2: Symptomatic COVID19positive
Symptoms Mild Moderate Severe
Fever Yes Yes Yes
Respiratory rate Not fast Fast (age based
cut off)
Fast (age based
cut off)
Work of breathing Not increased Not increased Increased
Cyanosis No No May be present
Spo2 >95% 90-94% <90%
Circulatory
insufficienc
y
Not present Not present May be present
General
Danger signs
Not present Not present May be present

9. Co-morbidconditions
• Diabetes Mellitus Type I
• Cardiac disease/Congenital Heart
Disease
• Chronic Lung Disease
• Chronic kidney Disease/on HD
Dialysis
• Chronic Liver Disease
• Neurological disorders/psychiatric
illness
• Obesity/Severe malnutrition
• Steroid therapy/Chemotherapy

10. Types of FacilitybasedCare
Severity of illness Types of facility based care
Asymptomatic/Mild/
Absence of Co-morbid conditions
Quarantine facility/home isolation
Moderate illness COVID HDU
Severe illness COVID PICU
MIS-C PICU/HDU
• Assessment of vital signs is critical;age appropriate cut offs should be
known.
• Recognising a sick child can be done by structured approach.
• Evaluation comprises of Initial assessment, primary assessment and
secondary assessment.
• COVID 19 patients can be classified into mild, moderate and severe
cases based on the evaluation

11. General Care of a
Child in PICU
• Importance of the supportive care
• Components of general care of critically
ill child
• How to provide holisticgeneral care !

12. SUPPORTIVE CARE
Monitoring
• Measure physiological indices intermittently to assess
the treatment and raise alarms & evaluate trends- charts
Prevention of nosocomial infections
• HAND HYGIENE
Ongoing assessment & support
• FAST HUGS BIDS -checklist
• Keep a track of key aspects of general care of critically
ill patients

13. Things to beremembered……………
1. Assisting in Intubation/Extubation
2. Tracheal suction
3. Coughing/Sneezing or any procedure inducing this.
4. Delivery of nebulized medications
5. Cardio pulmonary Resuscitation.
The viral load in covid-19 infection is highest in the nose and mouth.
Any aerosol-generating procedures are high risk and full personal protective
equipment (PPE) is required to be worn.
Aerosol generation events:
Airway management should
be SAS (safe, accurate, swift).
Safe for patient and staff,
Accurate, avoiding unfamiliar,
unreliable and repeated
techniques and Swift i.e timely
without rush or delay.

14. KEYCOMPONENTS- FAST HUGS BID
• F- Feeding
• A- Analgesia
• S- Sedation
• T- Thromboembolic prophylaxis
• H-Head of bed elevation
• U-stress Ulcer prevention
• G-Glucose control
• S-Spontaneous breathing trial
• B-Bowel regimen
• I-Indwelling catheter removal
• D-De-escalation of antibiotics

15. FEEDING/NUTRITIONAL
SUPPORT
• Improves wound healing
• Attenuates the loss due to metabolic stress response
• Improves GI function and integrity
• Reduces the complications & length of stay
• Reduces morbidity & mortality
• Caloric goal (sick)– Basal metabolic rates (BMR or REE) -
avoid complications of overfeeding (27-58 kcal/kg/day)
• Protein goal 1-5 gm per kg day

16. FEEDING
ENTERAL FEEDING (EF) PARENTERAL FEEDING
• Physiological
• Trophic effect on gut mucosa
• Prevent bacterial translocation (+ sepsis)
• Simple, Cheap
• Easy to administer
• Few metabolic complications
• Enteral C/I
• GI bleed
• Gut ischemia
• Intestinal perforation
• Obstruction
Disadvantages
• Risk of aspiration
• Feed intolerance
• NG tube displacement
• Non-physiological, Expensive
• Requires venous access
• Higher risk of sepsis
• Metabolic complications
• Frequent monitoring
Enteral feeding is superior to Parenteral
nutrition

17. Bolus feeding
Preferably continuous feeding
Nasogastric feeding
Post-pyloric feeding
(Nasojejunal/Nasoduodenal)
No contraindications to EF + Bowel sounds +
Start enteral feeds within 24-48 hours of admission
Head end elevation
ASSESSFOR RISKFACTORS FOR ASPIRATION
(Severe respiratory distress, recurrent vomiting, GER with H/O
aspiration, Delayed gastric emptying)
1-2 ml/kg/h (max 25ml/h)
↑ till target volume reached
<1 y: 5 ml/kg q4h
>1 y: 5-20 ml/kg q4h
START with 25% of target
volume (2-4 hrly)
gradually ↑ by 25% of start
vol q4h till targetachieved
Supplementation of vitamins and minerals (RDA)
Iv; oral
+ -

18. FEEDING STRATEGY
• ↑ calorie delivery (>50% increase from present value) when acute
phase of illness is over (7-10th day)- to avoid under-feeding
• Pre-feed gastric residual volume to be checked; If GRV>150 ml or 5
ml/kg or >1/2 previous feed v o l u m e  Hold next feed + Prokinetics
+ smaller volume frequent feeds
• Metoclopramide or Domperidone (0.2 mg/kg/dose 8h)
• Composition of feeds- meet needs of critically ill child
– Upto 6 mnths- breast milk/expressed breast milk/formula
– 1-10 years: milk based feeds; Other- dal, porridge
– Fortification- MCT oil, sugar, puffed rice (↑ calorie density)
– Supplementation of vitamins and minerals (RDA); Iv;oral
• Dietician - to take care of needs of children in PICU

19. SEDATIONAND ANALGESIA
• Goal is to attain analgesia and anxiolysis and patient ventilator
synchrony
• Analgesia and sedation preferred over neuromuscular blockade-
quickly reversible and allows for neurological monitoring
• Sedation- use agents with minimal effect on BP
• Short acting BZDs(midazolam)- 0.1mg/kg bolus f/b infusion 1-
10 µg/kg/min
• Fentanyl for analgesia (1 µg/kg fb 1-5 µg/kg/h infusion)
• PARDS- targeted sedation with minimal dose

20. SEDATION AND ANALGESIA
• If sedatives not completely effective- NMB agents
• Vecuronium- 0.15 mg/kg f/b 15-25 µg/kg/min
• Inmoderate-severe ARDS-Neuromuscular blocking agents-
improve tolerance to M V andoptimize oxygen delivery
• NMB- minimal possible dose
• Daily NMB holiday- monitoring clinical movement&
development of critical illness polyneuropathy

21. GLUCOSE CONTROL
• Blood glucose abnormalities – common – stress hormone response
• Hyperglycemia, peak glucose and duration- independently
associated- mortality
• Monitor glucose in ICUs 12 hourly
• Frequently (2-4 hrly)- abnormal BGL
• Maintain BGLless than 150 mg/dl
• Prevent hypoglycemia
• BGL>180mg/dl despite reduction of glucose infusion rates-
warrants insulin infusion
• Tighter glucose control (80-110) has no added benefits

22. PRESSURESORES
• Common in PICU- Incidence of 26%
• Common sites- occipital region, nose, chin or neck,
heel and sacral (↑ age)
• Risk Factors
• MV, HFO, Hypotension
• Malnutrition
• Sensory loss
• Dependent edema
• Central line in neck
• LOS> 96 h

23. PREVENTION
• Regularly examine skin
• Keep repositioning
• frequency- needs (2-4 hrly)
• Adequate nutrition
• Keep sheets dry and wrinkle free
• Alternating pressure mattresses

24. Classification & treatment of Pressure sores
STAGES FEATURES MANAGEMENT
Stage I Intact skin with non-blanchable readness - Protective dressing
Stage II Shallow, open ulcer with red pink wound - Moist dressing such as transparent
film, hydrocolloid dressing,
hydrogel, foam, alginate dressing
etc.
- Clean the wound with saline/water
Stage III Full thickness tissue loss with visible
subcutaneous fat  No necrosis- moist to absorbent
dressing, clean the wound
 Necrotic tissue- perform
debridement f/b measures as for
‘non-necrotic ulcer’
Stage IV Full thickness tissue loss with exposed
muscle and bone
Unstageable Full thickness tissue loss with base of
ulcer covered with slough/eschar
Suspected
deep injury
Purple maroon localised area of
discoursed intact skin or blood filled
blister

26. EYECARE
• Abnormalities of cornea and conjuctiva occur in
neurological diseases, nocturnal lagophthalmos, coma,
infection and mechanical ventilation
• EXPOSUREKERATITIS, CORNEALULCERATION,
INFECTION
• Seen in quarter of patients
• Risk factors: inability to close eyes and use of
neuromuscular blockade

27. EYE CARE
• Use lubricating ointments,
artificial tears to keep cornea
and conjuctiva wet
• 1 drop every 6 hourly- each eye
• If eyelids are not fully closed-
Protective eye taping- effective-
prevents corneal erosion
• Antibiotic eye drops- in infection

28. ORAL HYGIENE
• Predisposed to oral colonization of DR organisms &
plaque formation (oral drying/↓salivary production)
• Source of Ventilator Associated Pneumonia
• Regular cleaning of oral cavity esp intubatedkids
• Antiseptic (Chlorhexidine) solutions - BD
• While cleaning, ensure the dislodged plaques and
secretions are not aspirated- head elevation, ETT cuff
inflated, closed suction on

29. NHSGGC Pediatric clinical guidelines

30. STRESSULCERSPROPHYLAXIS
• Critically ill children are at risk
• Lead to Upper GI bleeding
• Risk factors for UGIB:Thrombocytopenia, coagulopathy,
organ failure, MV and high pressures, shock, prolonged
surgery and STEROID
• Not routinely advised !May ↑ nosocomial infections
• Indication - gastrointestinal bleeding
• Be cautious and observe for nasogastric aspirates!
• Ranitidine, Sucralfate, PPI (Pantoprazole)

31. THROMBOEMBOLIC
PROPHYLAXIS
• Venous TE increasingly recognized-children
• Risk factors: secondary to illness, age (<1 y, >14y), recent surgery,
complex medical condition (malignancy, chronic cardiac or renal ds),
prolonged hospitalization, inherited or acquired thrombophilia
• Central venous catheter – most common RF
• Diagnosis- Ultrasound doppler
• Standard UFH or LMWH prophylaxis is not routinely advised
• BENEFIT SHOULD BE WEIGHED AGAINST RISK OF BLEEDING!!

32. Prevention of venous thromboembolism/DVT related toprolonged
immobilization.
Goal: To prevent the incidence of venous thromboembolism/ DVT.
Nursing Intervention:
1. Look for signs of DVT such as redness, swelling, warmth of surrounding skin and positive Homan’s sign.
2. Administer DVT prophylaxis consisting of low molecular weight heparin*.
3. Perform active or passive range of motion exercises to improve circulation.
4. Use mechanical prophylaxis including intermittent pneumatic compression devices, elastic stockings etc.
*consider use of thrombolytics like LMWH as per prescription of treating pediatrician

33. Homan’s
Sign
Technique
1.In performing this test the patient will
need to actively extend his knee.
2.Once the knee is extended the examiner
raises the patient’s straight leg to 10 degrees,
then passively and abruptly dorsiflexes the
foot and squeezes the calf with the other
hand.
3.Deep calf pain and tenderness may
indicate presence of DVT.

34. Severe COVID-19 & MISC
• Low molecular weight heparin (Enoxaparin): thrombosis or D-Dimer
≥ 5 ULN or giant aneurysm with absolute coronary diameter ≥ 8 mm
or ≥ 10 Z score (coronary aneurysm score ≥ 10) or LVEF < 30%
• C/I: Marked thrombocytopenia (platelet count <25000/μL), hypo-
fibrinogenemia (fibrinogen activity <100 mg/dL), End stage renal
disease, recent major bleeding
• Duration
– until at least 2 weeks after discharge from hospital
– longer outpatient therapeutic enoxaparin
• CAA with z-score >10.0 (indefinite treatment)
• documented thrombosis (for ≥3 months pending thrombus resolution)
• ongoing moderate to severe LV dysfunction

35. THROMBOEMBOLIC PROPHYLAXIS
• Therapeutic Enoxaparin dose regime
– Neonate
• 2mg/kg TWICE DAILY subcutaneously
– 1 month old
• 1.5mg/kg TWICE DAILY subcutaneously
– 2 months -17 years
• 1mg/kg TWICE DAILY subcutaneously
• Remove CVL associated with VTE as soon as possible
• Ensure follow-up ultrasound to screen for extension of VTE
• Early mobilisation and physiotherapy, Compression devices-stockings

36. THROMBOEMBOLI
C PROPHYLAXIS
• Aspirin: thrombosis or coronary aneurysm score is >2.5 Z
• Dose: 3mg/kg/day to 5 mg/kg/day, max 81mg/day
• Duration: until normalization of platelet count and confirmed
normal coronary arteries at ≥4 weeks after diagnosis.
• C/I: active bleeding, significant bleeding risk, and/or plateletcount
≤80,000/µL
1. Comprehensive Guidelines for Management of COVID-19 in CHILDREN (below 18 years). DGHS. Ministry of health and family welfare. June 2021
2. Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, et al. American College of Rheumatology Clinical Guidance for Pediatric
Patients with Multisystem Inflammatory Syndrome in Children (MIS‐C) Associated with SARS‐CoV‐2 and Hyperinflammation in COVID‐19. Version
1. Arthritis Rheumatol 2020; 72; 1791-1805
3. Goldenberg NA, Sochet A, Albisetti M, et al. Pediatric/Neonatal Hemostasis and Thrombosis Subcommittee of the ISTH SSC. Consensus-based
clinical recommendations and research priorities for anticoagulant thromboprophylaxis in children hospitalized for COVID-19-related illness. J
Thromb Haemost. 2020 Nov;18(11):3099-3105. doi: 10.1111/jth.15073. PMID: 33174388

37. CARE OFLINES
• Intravenous lines, central lines, chest tubes, PD catheters
• IV cannula- examined ATLEAST once per shift for phlebitis
• Cannula site- observed- bolus injections ,iv flow rates are checked and
when solution containers are changed
• Visual infusion phlebitis (VIP)scale – objective assessment of iv
sites and intervention
• Peripheral iv cannula should be replaced at first indication of
infusion phlebitis (Stage 2)

38. VIP
scale
SCORE FEATURES INTREPRETATION ACTION
0 Site appears healthy No signs of phlebitis - Observe cannula
1 One of following present:
slight pain, slight redness
Possible first signs
of phlebilits
- Observe cannula
2 Two of the following evident:
pain at iv site, swelling, erythema
Early stage of
phlebitis
- Remove cannula
- Change site
3 All signs: pain along path of cannula,
induration, erythema
Intermediate stage
of phlebitis
- Remove cannula
- Change site
- Consider treatment
4 All signs evident and extensive: pain
along path, induration, palpable
venous cord, erythema
Advanced stage of
phlebitis
- Remove cannula
- Change site
- Consider treatment
5 All evident and extensive: pain along
path, induration, palpable venous cord,
erythema, pyrexia
Advanced stage of
phlebitis
- Remove cannula
- Change site
- Initiate antibiotics

39. CARE OFLINES
• Central venous line- monitored regularly for displacement,
bleeding, patency, infection or for hematoma formation at site
• Remove- as soon as no longer needed or fever with no obvious foci
develops
• Chest drains- assessed periodically for movement of fluid column,
amount and nature of drainage, displacement, breath sounds and
subcutaneous emphysema
• PDcatheter- monitor patency of dialysis catheter and flow rate
regularly
• Remove as early as possible afterPD
• PD fluid and catheter- send for culture

40. CHEST PHYSIOTHERAPY
• Increase drainage of
secretions
• Improve ventilation perfusion matching
• Decrease work of breathing
• Increase functional residual capacity

41. PRONEPOSITIONIN
VENTILATED CHILDREN
• Increase oxygenation in early stage of ARDS (by ↑ FRC)
• Increase in V/Q matching
• Enabling drainage of secretions
• Improve lymphatic drainage
• Indications
• SEVERE ARDS
• Pao2/Fio 2< 150 (PEEP>5cm, FiO2>0.6)
• OI ≥ 16; OSI ≥ 12.3

42. AWAKE PRONING
• Children with severe COVID
• Non-intubated children
• Its effectiveness - investigated in moderate cases

43. Thermoregulation(Temperature Management)
Goal: To bring down the body temperature to normal range.
Nursing Interventions:
1. Monitor the axillary body temperature of the child.
2. Remove extra clothing.
3. Keep the patient’s environment cool.
4. Keep the child hydrated.
5.Administer antipyretics (e.g. Acetaminophene 10-15 mg/kg/dose; may repeat
every 4-6 hours) as prescribed by the treating doctor.
6. Reassess the body temperature.

44. Bowel and BladderCare
Strict aseptic handling of urinary catheter.
Catheter trauma and blockage should be checked in every shift.
Spillage of urine should be avoided and soiled sheets should be removed as
early as possible.
Stretching of catheter should be avoided as it may damage urethra.
As far as babies are concerned, diaper should be used.
For any kind of rash …..keep the area dry and use a soothing agent.

45. KEY MESSAGES
Holistic care needed for a critically ill child
FAST-HUGS-BID
Minimal sedation and early extubation to improve outcome
Nutritional support is equally important for earlyrecovery
Physiotherapy should be done regularly to preventsores
Always follow the dictum “First do no harm”
PRIMUM NON NOCERE

47. Take home messages
Always Protect yourself.
There are no emergencies in covid-19 infected patients – always donn PPE beforeintervening!
Consider every procedure you do – is it necessary? and how best can we do itsafely.
Work as a team.
Nurses are involved at each level of patient management including prevention and screening,
diagnosing and delivering direct care to patients with coronavirusdisease.
Being a new emerging disease condition, there exist a huge gap in the knowledge and
understanding about the nursing care of COVID 19 patients admitted under health care facilities.
Therefore Nurses needs adequate knowledge and skills to manage COVID 19 pediatriccases
effectively.

48. Suggested reading…..
• Nitin Dhochak, Rakesh Lodha, S K Kabra. Supportive Care of a Critically Ill child. In:S.K
Kabra, Rakesh Lodha. Pediatric Intensive care protocols of AIIMS. 7th edn. New Delhi; 2017:
416-426
• NHS GGC GUIDELINES .
www.clinicalguidelines.scot.nhs.uk/nhsggc-paediatric-clinical-guidelines/nhsggc-
guidelines/intensive-and-critical-care/eye-care/
• Orloff KE, Turner DA, Rehder KJ. The Current State of Pediatric Acute Respiratory Distress
Syndrome. Pediatr Allergy Immunol Pulmonol. 2019;32(2):35-44. doi:10.1089/ped.2019.0999
• Tume LN, Valla FV, Joosten K, Jotterand Chaparro C, Latten L, Marino LV, Macleod I, Moullet C,
Pathan N, Rooze S, van Rosmalen J,Verbruggen SCAT. Nutritional support for children during
critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism,
endocrine and nutrition section position statement and clinical recommendations. Intensive
Care Med. 2020 Mar;46(3):411-425. doi:10.1007/s00134-019-05922-5
• Praveen Narsaria, Rakesh Lodha. Nutrition in Critically Ill children. In:S.K Kabra, Rakesh
Lodha. Pediatric Intensive care protocols of AIIMS. 7th edn. New Delhi; 2017: 438-453
• Krishna Mohan Gulla, Rakesh Lodha. Sedation, Analgesia and Paralysis in critical care Unit.
In: S.K Kabra, Rakesh Lodha. Pediatric Intensive care protocols of AIIMS. 7th edn. New Delhi;
2017: 427-437

49. References and additional learningmaterial
• Recognition of Sick Child: A Structured approach.In:IAP ALS
Handbook
,1st edition.2018.
• Triage of the acutely ill child. In: Nelson Textbook of
Pediatrics,21st edition.
• WHO. Emergency Triage Assessment and Treatment (ETAT).
Geneva. WHO 2005. Available from https://aaps.who.int.
• American Heart Association and American Academy of
Pediatrics. Systematic Approach to the seriously ill or injured
Child.In: Pediatric Advanced Life Support Provider Manual
2015.

50. Reference
1.Tarika Sharma et. al. Managing Covid 19 Patients: Nurses Role and
Considerations, Journal of Perioperative care and Critical Intensive Care
Nursing, Spe 2 No: 158.
2. https://www.nanda.org/nanda-i-publications/nanda-internationalnursing-
diagnoses-definitions-and-classification-2018-2020/ 12.
3. https://www.mohfw.gov.in/ 13.
4. https://www.cdc.gov/coronavirus/2019-ncov/index.html
5. KGMU Pediatrics SARI protocol (Updated 30/03/2020).