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IAP Textbook of Pediatric ICU Protocols
Praveen Khilnani, Soonu Udani, Deepak Ugra, Bala Ramachandran, Suchita Khadse
CHAPTER 1:
Approach to Sick Child
CHAPTER 2:
Approach to Collapsed Child
CHAPTER 3:
Approach to Respiratory Distress
CHAPTER 4:
Airway Management Protocol
Laryngeal Mask Airway
Predictors of Difficult Intubation
Algorithm for Difficult Airway
Contents of Cricothyrotomy Kit
CHAPTER 5:
Rapid Sequence Intubation
Steps in Rapid Sequence Intubation
Step 1: Preparation
Step 2: Preoxygenation
Step 3: Pretreatment
Step 4A: Paralysis (with Induction)
Induction Agents
Step 4B: Paralysis: Neuromuscular Blocking Agents
Step 5A: Protection
Step 5B: Positioning—For Children below 2 Years Age
Step 6: Placement
Step 7: Proof (Confirmation of Endotracheal Tube Placement)
Step 8: Postintubation Management
Conclusion
CHAPTER 6:
Respiratory Failure
Definition
Etiology of Acute Respiratory Failure
Classification of Respiratory Failure
Hypoxemic Respiratory Failure (Type I)
Hypercapnic Respiratory Failure (Type II)
Approach to a Child with Acute Respiratory Failure
Indices used to assess lung as an oxygenator (Fig. 6.1)
Indications for Admission to the PICU
Indications for Mechanical Ventilation
Emergency Management of Few Important Clinical Problems
Upper Airway Obstruction
Acute Respiratory Distress Syndrome/Pneumonia
Tension Pneumothorax
Neuromuscular Disorders
Summary
Respiratory Failure: Mechanical Ventilation Algorithm
CHAPTER 7:
Basic and Disease Specific Mechanical Ventilation
Case Scenario 1
Ventilation for Acute Respiratory Distress Syndrome
Goals of Ventilation in Acute Respiratory Distress Syndrome
Case Scenario 2
Air Leak Syndrome
Pneumothorax, Bronchopleural Fistula
Ventilation Strategies
Other Modes Useful in Air Leak Syndrome
Postoperative Ventilation following Open Heart Surgery
General Principles
Chronic Lung Disease/Neuromuscular Weakness
Case Scenario 3
Raised Intracranial Pressure
Weaning
Spontaneous Breathing Trial
Extubation
Indications for HFOV
CHAPTER 8:
Weaning from Mechanical Ventilation
Weaning Strategy
Step 1
Step 2
Relative contraindications for weaning and extubation:
Step 3
Readiness for weaning and extubation:
Step 4
Step 5
Weaning mode of ventilation
Step 6
Suggested Weaning Strategy from Mechanical Ventilation
CHAPTER 9:
Noninvasive Ventilation
CHAPTER 10:
High Frequency Ventilation
CHAPTER 11:
Management of Pediatric Status Asthmaticus
Case Scenario
Steps in Management of Pediatric Status Asthmaticus
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7: Intubation and Ventilation
Step 8
CHAPTER 12:
Brief Protocol of Treatment of Bronchial Asthma in PICU
CHAPTER 13:
Brief Protocol for Managing Shock
Introduction
Step 1
Step 2
What Does Early Goal Directed Therapy Try To Do (Egdt)?
Early Goal Directed Therapy
First Hour Antibiotics and Source Control
Mechanical Ventilation and Sedation
Steroids When and At What Dose?
Glucose Control
Summary
Shock
Antibiotic
Consider Endotracheal Intubation and Ventilation with RSI and Lung Protective Strategies
CHAPTER 14:
IAP Sepsis Guidelines Summary
Shock Not Reversed?
40–60 Min
Shock Not Reversed?
60 Min
Recognize catecholamine resistant shock
Beyond 60 Min
CHAPTER 15:
Dengue Fever and Shock Syndromes: WHO Guidelines
Classification and Clinical Course of Dengue
Clinical Manifestations and Phases
Clinical Phases of Dengue
Diagnosis
Laboratory Confirmation of Dengue
Management of Patients with Dengue
Management Priority 1: Replacement of Plasma Losses
Management Priority 2: Recognition and Management of Hemorrhage
Management Priority 3: Prevention and Management of Fluid Overload
Management Priority 4: Prevention of Iatrogenic Complications
CHAPTER 16:
New Fever in PICU: Nosocomial Infection
CHAPTER 17:
Pediatric HIV Algorithm
CHAPTER 18:
Empyema Algorithm
CHAPTER 19:
Comatose Child
CHAPTER 20:
Raised Intracranial Pressure Algorithm
CHAPTER 21:
Pediatric Head Trauma
Clinical Signs of Herniation
Central Transtentorial Herniation
Progressive Rostrocaudal Deterioration of Brainstem Function
Uncal Herniation (Lateral Transtentorial Syndrome)
Classically, a Stepwise progression
Clinical Presentation
Vomiting Without Nausea
Non-localizing Signs
CHAPTER 22:
Status Epilepticus
IAP Convulsive Status Epilepticus Management Algorithm (2008)
IAP Algorithm for the Management of Neonatal Seizure (2008)
CHAPTER 23:
Cardiovascular Drug Protocol
Inotropes and Vasopressors
Adrenergic Receptors
Major Hemodynamic Effects of Adrenergic Receptor Activation
Dopamine
Epinephrine
Norepinephrine
Dobutamine
Milrinone
Vasopressin
Digoxin
Doses (Infusion Rates in Mcg/Kg/Min)
Dilution
Selection of Agents for Different Hemodynamic Disturbances
Common Notes
CHAPTER 24:
Arrhythmias
Tachyarrhythmia (Also see Chapter 66)
Two Types
Management
A. With Adequate Perfusion (Stable)
B. With Poor Perfusion (Unstable) (Also see Chapter 66)
Search for Reversible Causes and Treat: 6H, 5T
Bradyarrhythmias
Rhythm Disturbances Algorithm
CHAPTER 25:
Diabetic Ketoacidosis Protocol
Diabetic Ketoacidosis: Management
Notes
CHAPTER 26:
Trauma in Children
Anatomic and Physiologic Differences
General Considerations
Size and Shape
Skeleton
Surface Area
Primary Survey
Goals
Airway with C-Spine Stabilization
Airway Assessment
Patency
Management
Noninvasive Airway Adjuncts
Invasive Airway Adjuncts
Method
Rapid Sequence Intubation
Breathing
Assessment
Management
Circulation
Hemodynamics
Circulation with Hemorrhage Control
Assessment
Management
Optimal Response to Resuscitation
Disability Assessment
Management
Exposure with Environmental Control
Assessment
Management
Psychosocial
Family/child needs: Determine if family wishes to be present at the resuscitation
Secondary Survey
Goals
Head Trauma
Neck
SCIWORA: spinal cord injury without radiological abnormality
Management
Chest
Clinical Features
Abdominal Trauma
Diagnostic Adjuncts
Indications for Surgery
Pediatric Multiple Trauma Algorithm
CHAPTER 27:
Approach to Gastrointestinal Bleeding
Approach to Upper Gastrointestinal Bleed
Step 1: Confirm its Gastrointestinal Bleed
Step 2: Confirm its Gastrointestinal
Step 3: Immediate Assessment and Hemodynamic Resuscitation
Step 4: Pharmacologic Therapy
Acid Suppression
Vasoactive Medications
Antibiotics
Step 5: Other Supportive Measures and Determination of the Cause
Step 6: Endoscopy
Step 7: Refractory Bleed
Step 8: Surgery
Step 9: Remember Uncommon Causes
Approach to Lower Gastrointestinal Bleed
Step 1: Confirm its Gastrointestinal Bleed
Step 2: Initial Hemodynamic Stabilization
Step 3: First Episode of Lower Gastrointestinal Bleed
Step 4: Recurrent Lower Gastrointestinal Bleed
Role of Endoscopy in Lower Gastrointestinal Bleed
CHAPTER 28:
Acute Gastrointestinal Bleeding Algorithm
CHAPTER 29:
Pediatric Multiorgan Failure (Renal and Hepatic) and Support
Pediatric Multiorgan Failure (Liver and Kidney)
Case Scenario
Definitions
Acute Kidney Injury in Multiple Organ Dysfunction
Pediatric Modified RIFLE Criteria (Table 29.1)
Principles of Management in Renal Dysfunction
Investigation and Monitoring
Algorithm
Renal Replacement Therapy
Indications in Acute Kidney Injury
Types of Dialysis (Table 29.3)
Peritoneal Dialysis
Intermittent Hemodialysis
Continuous Renal Replacement Therapy
Hepatic Dysfunction in Pediatric Multiorgan Dysfunction
Laboratory Evaluation
Principles of Treatment
CHAPTER 30:
Acute Renal Failure Algorithm
CHAPTER 31:
Fulminant Hepatic Failure Algorithm
CHAPTER 32:
Hyperammonemia
Clinical Approach to a Newborn Infant with Symptomatic Hyperammonemia
Treatment of Acute Hyperammonemia in an Infant
CHAPTER 33:
Interpretation of Arterial Blood Gas
Importance of Arterial Blood Gas in PICU
Basics of Arterial Blood Gas
Interpretation of Arterial Blood Gas
Five Steps for ABG Analysis
Step 1
Step 2
Acidemia
Alkalemia
Step 3
Step 4
Metabolic Acidosis
Metabolic Alkalosis
Step 5 Clinical Correlation
Some Important Equations and Principles
CHAPTER 34:
Inborn Errors of Metabolism (Iem) Algorithm
Principles of Treatment
Metabolic Acidosis with Increased Anion Gap in Young Infant
CHAPTER 35:
Acidosis
Metabolic Acidosis
Causes of Metabolic Acidosis
Distinguishing Features of Hyperchloremic Acidosis
Treatment
Forms of Alkali Replacement
Approach to Child with Acidosis
CHAPTER 36:
Alkalosis
CHAPTER 37:
Hyponatremia
CHAPTER 38:
Hypernatremia
Causes of Hypernatremia
Diagnostic Approach to Hypernatremia
Treatment
Hypernatremia Algorithm
CHAPTER 39:
Hyperkalemia
CHAPTER 40:
Hypokalemia
CHAPTER 41:
Hypocalcemia
Definition
Clinical Manifestations of Hypocalcemia
Cardiovascular
Neuromuscular
Other
Causes of Hypocalcemia
Approach to Hypocalcemia
Treatment
CHAPTER 42:
Hypercalcemia
CHAPTER 43:
Hypomagnesemia
Signs and Symptoms
Common Symptoms
Uncommon Symptoms
Treatment
Complications of Parenteral Magnesium Therapy
CHAPTER 44:
Bleeding Child in the PICU
Medical History
Family History
Types of Bleeding Manifestations
Physical Examination
Investigations
Complete Blood Count and Peripheral Blood Smear
Coagulation Studies
Platelet Disorders in PICU
Management of Bleeding Child
Vitamin K
Fresh Frozen Plasma
Guidelines for Pediatric Fresh Frozen Plasma Transfusions
Platelets
Guidelines for Pediatric Platelet Transfusions
Clotting Factor Concentrates
Recombinant Factor VIIa Therapy
Off-Label Use
Closed-Space Bleeding
Rescue Therapy for Surgical Patients
Postpartum Period and After Hysterectomy
Treatment of Specific Disorders
CHAPTER 45:
Bleeding Child Algorithm
CHAPTER 46:
Approach to a Child with Poisoning
CHAPTER 47:
Paracetamol Poisoning
Dose and Pattern of Paracetamol Ingestion
Pathophysiology of Paracetamol Toxicity
Clinical and Laboratory Manifestations
Phase I (First 24 Hours)
Phase II (24–48 Hours)
Phase III (72–96 Hours)
Phase IV (4 Days to 2 Weeks)
Management
Detoxification of Paracetamol Metabolite—NAPQI
*Management of Children (< 12 Years) Who Present within 8 Hours of Ingestion
Gastrointestinal Decontamination
** Management of all Patients Who Present 8–15 Hours after Ingestion or When Paracetamol Levels are not Available
Management of all Patients Who Present 15–24 Hours after Ingestion
Dosage for NAC Intravenous Infusion
CHAPTER 48:
Paracetamol Poisoning Algorithm
CHAPTER 49:
Iron Toxicity
Treatment
Iron Poisoning
CHAPTER 50:
Iron Poisoning Algorithm
CHAPTER 51:
Organophosphorus Poisoning
Pathophysiology
Diagnosis
Treatment
Algorithm
CHAPTER 52:
Salicylate Poisoning
Pathophysiology
Clinical Presentation
Laboratory Studies
Treatment
Criteria for Admission or Observation
Methods to Prevent Absorption
Algorithm
CHAPTER 53:
Hydrocarbon Ingestion
Treatment
CHAPTER 54:
Scorpion Sting Poisoning
Pathophysiology and Clinical Features
Investigations
Treatment
Pharmacotherapy
Doses of Medications
Algorithm
CHAPTER 55:
Mammalian Bites
Management
CHAPTER 56:
Snake Bite Management Algorithm
Antivenom Treatment of Snake Bite Cases Algorithm
Classification of Envenomation Severity
Antivenin
CHAPTER 57:
Approach to Pediatric Hypertension
CHAPTER 58:
Hypertensive Crisis in the PICU
Hypertensive Crisis: Management Protocol
Definitions
Hypertension
Stage I Hypertension
Stage II Hypertension
Protocol of Management
Clinical Evaluation: Goals
Treatment
CHAPTER 59:
Hypertensive Crisis Algorithm
CHAPTER 60:
Management of the Postoperative Pediatric Cardiac Surgical Patient
Pulmonary Hypertension
Treatment
Renal and Electrolyte Problems
Renal Dysfunction
Renal Replacement Therapy
Capillary Leak Syndrome
Features
Management
Common Arrhythmias seen in the PICU
Narrow Complex Tachyarrhythmia
Treatment Strategies for JET
Bradyarrhythmia
AV Block
Ventricular Ectopic Beats
Common Postoperative Cardiac Scenarios with Common Lesions
CHAPTER 61:
Lesion Specific Management of Pediatric Cardiac Patients
Approach to Acyanotic Heart Defects
Approach to Cyanotic Heart Defects
Postoperative Low Cardiac Output
Left Ventricular Dysfunction
RV Dysfunction
Pulmonary Hypertensive Crises
Arrhythmias
Interpretation of Various Invasive Pressures in a Postoperative Cardiac Patient with Low Cardiac Output
Algorithm for the Management of Low Cardiac Output after Fontan Procedure
CHAPTER 62:
PICU Rounds and Documentation
General Admitting Orders
Admission Notes
Progress Notes
SOAP Note—Subjective
SOAP note—Objective
SOAP Note—Assessment
SOAP Note—Plan
Problem Oriented Medical Record Format
Problem by System
Example
Note Heading
General Condition
Problem by System
Respiratory (Resp)
Assessment and Plan
Cardiovascular
Assessment and Plan
Gastrointestinal
Assessment and Plan
Fluid/Nutrition
Assessment and Plan
Hematological (Heme)
Assessment and Plan
Infectious Disease
Assessment and Plan
Renal (Renal)
Assessment and Plan
Metabolic
Assessment and Plan
Neurological
Assessment and Plan
Social
Important Points to Remember
Procedure Notes
Transfer Note
Discharge Summary
Summary
Appendix
Glossary
CHAPTER 63:
Transport Protocol
Who Should Be Transported Out?
Classification
Risks versus Benefits
Benefits
Risks
Mode of Transport
Skills Needed by Physician, Nurse and Technician
Counseling the Family
Ambulance Equipment
Do's and Don'ts
Do's
Don'ts
Documentation of Vital Signs and Physical Examination
CHAPTER 64:
Sedation in PICU
Introduction
Main Goals of Sedation
Procedures Requiring Sedation
Noninvasive Procedures
Invasive and Painful Procedures
Preprocedure Fasting and Risk of Aspiration
Sedation Eqipment
Physician Qualifications
Monitoring and Care of Child after Sedation
Documentation
CHAPTER 65:
Admission, Transfer and Discharge Criteria for Pediatric Intensive Care Unit (PICU)
Admission Criteria
Admission Criteria to Level 2 Care (Unventilated)
Criteria for Transfer/Discharge from the PICU (Level 3 or Level 2)
Minimum Criteria
CHAPTER 66:
Pediatric Advanced Life Support 2010 Guidelines
Pediatric Advanced Life Support
BLS Considerations During PALS
Simultaneous Actions
Monitored Patients
Respiratory Failure
Shock
Airway
Oropharyngeal and Nasopharyngeal Airways
Laryngeal Mask Airway (LMA)
Oxygen
Pulse Oximetry
Bag–Mask Ventilation
Precautions
Two-Person Bag–Mask Ventilation
Gastric Inflation
Ventilation with an Endotracheal Tube
Rapid Sequence Intubation (RSI)
Cricoid Pressure During Intubation
Cuffed Versus Uncuffed Endotracheal Tubes
Endotracheal Tube Size
Verification of Endotracheal Tube Placement
Exhaled or End-Tidal CO2 Monitoring
Esophageal Detector Device (EDD)
Transtracheal Catheter Oxygenation and Ventilation
Suction Devices
CPR Guidelines for Newborns With Cardiac Arrest of Cardiac Origin
Extracorporeal Life Support (ECLS)
Monitoring
Electrocardiography
Echocardiography
End-Tidal CO2 (PETCO2)
Vascular Access
Intraosseous (IO) Access
Venous Access
Endotracheal Drug Administration
Medications for Pediatric Resuscitation
Emergency Fluids and Medications
Estimating Weight
Medication Dose Calculation
Medications
Adenosine
Amiodarone
Precautions
Atropine
Precautions
Calcium
Epinephrine
Precautions
Glucose
Lidocaine
Precautions
Magnesium
Precautions
Procainamide
Precautions
Sodium Bicarbonate
Precautions
Vasopressin
Pulseless Arrest
Nonshockable Rhythm: Asystole/PEA (Step 9)
Shockable Rhythm: VF/Pulseless VT (Step 2)
Defibrillators
Paddle Size
Interface
Paddle Position
Energy Dose
AEDs
Integration of Defibrillation With Resuscitation Sequence
Torsades de Pointes
Treatment
Bradycardia
Tachycardia
Narrow-Complex (≤0.09 Second) Tachycardia
Supraventricular Tachycardia (Box 5)
Wide-Complex (>0.09 Second) Tachycardia (Box 9)
Special Resuscitation Situations
Septic Shock
Hypovolemic Shock
Trauma
Single Ventricle
Pulmonary Hypertension
Children with Special Healthcare Needs
Ventilation With a Tracheostomy or Stoma
Toxicological Emergencies
Local Anesthetic
Cocaine
Treatment
Tricyclic Antidepressants and Other Sodium Channel Blockers
Treatment
Calcium Channel Blockers
Treatment
Beta-Adrenergic Blockers
Treatment
Opioids
Treatment
Postresuscitation Stabilization (Post-Cardiac Arrest Care)
Respiratory System
Cardiovascular System
Drugs Used to Maintain Cardiac Output
Epinephrine
Dopamine
Dobutamine Hydrochloride
Norepinephrine
Sodium Nitroprusside
Inodilators
Neurologic System
Renal System
Interhospital Transport
Family Presence During Resuscitation
Termination of Resuscitative Efforts
Sudden Unexplained Deaths
Class of Evidence
Levels of Evidence (LOE)
CHAPTER 67:
Procedures in PICU
Intubation
Introduction
Step 1: When to intubate a child
Step 2: What are the contraindications
Step 3: Preparation
Preintubation Supplies
Step 4: Confirm tube palcement
Procedure
Step 5: Post-intubation Care
Step 6: Complications
Central Line Placement
Introduction
Step Wise Approach
Indication for Central Line Access
Rule Out Contraindications
Appropriate Site Selection
Appropriate Catheter Selection:
Know the Anatomy
Take Informed Consent
Keep Equipment Ready
Set up Pressure Transducing System
Central Line Placement
Subclavian Vein Cannulation (Fig. 67.14A)
Internal Jugular Vein Cannulation (Fig. 67.14B)
Femoral Vein Cannulation (Fig. 67.14c)
Ultrasound Use for Vascular Access
Transducer Selection
Technique
View
Procedure IJV
Confirm Central Line Location and Documentation of Procedure
Port Designation (for Multi-lumen Catheters)
Catheter Dressing
Complications
Removal of Line
Steps to Minimize CVC-Related Infection
Arterial Line Placement
Introduction
Conventions to Remember While Measuring Cardiovascular Pressures
Components of the System used for Measurement
Indications for Arterial Line Placement
Check for Relative Contraindications
Site Selection
Check Collateral Circulation
Keep Equipment Ready
Arterial Line Cannulation
Zero and Level The Transducer
Check if System is Optimally Damped
Check Arterial Waveform and Interpret (Figs 67.18 and 67.19)
Optimize Natural Frequency of System
Arterial Catheter Maintenance and Documentation
Watch for Complications
Treat Ischemia Complications (if they occur)
When to Remove Arterial Catheter
Intracranial Pressure Monitoring
Introduction
Step 1 : Indication for Monitoring
Step 2 : Monitoring Techniques of ICP
Step 3: Preperation for Invasive Intracranial Pressure Monitoring
Step 4: Preperation for ICP Catheter Insertion
Step V : Procedure
Step VI: Documentation of Insertion and Post-Insertion
Step VII : Interpretation of ICP Monitoring
Step 8 : EVD Removal
Chest Tube Placement
Introduction
Step 1: Understand Some Terms
Step 2: Indications for Insertion (Table 67.9)
Step 3: Rule Out Contraindications
Step 4: Pre-drainage Assessment
Step 5: Preparation
Step 6: Consent and Premedication
Step 7: Prepare Drainage System and Drain Size
Step 8: Patient Position (Figs 67.25A to C)
Step 9: Site Selection
Step 10: Procedure
Step 11: Fixing the Tube (Fig. 67.28)
Step12: Verification of Chest Tube Placement and Documentation
Step 13: Drainage Systems
Step 14: Care of Chest Tube
Step 15: Guidelines for Removal
Step 16: Complications
Intra-abdominal Pressure Monitoring
Introduction
Step I : Understand the Definition, Cause, Classification of Intra-abdominal Pressure
Step 2 : Measurement of Intra-abdominal Pressure
Step 3 : Preparation
Step 4 : Different Methods
Step 5: Interpreting the Result
CHAPTER 68:
Useful Information and Equations in the PICU
Alveolar Air Equation
Alveolar Arterial Oxygen Gradient
Airway Resistance Equation
Oxygen Content (CaO2)
Oxygen Delivery (DO2)
Oxygen Consumption (VO2)
Oxygen Extraction
Shunt Equation (Qs/Qt)
Systemic to Pulmonary Shunt (Qp/Qs)
Systemic Vascular Resistance Index (SVRI)
Pulmonary Vascular Resistance Index (PVRI)
Pharmacokinetics
Drip Calculation
Acid-Base/Renal/Fluids
Serum Osmolality
Anion Gap
Fractional Excretion of Na (FENa)
Renal Failure Index (RFI)
Maintenance Fluids
Temperature Conversion
Body Surface Area (BSA)
Biostatistics
CHAPTER 69:
PICU Drug List
INDEX
TOC
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