This document discusses caring for pediatric patients in an adult ICU in Geelong, Victoria. It notes barriers to caring for pediatric patients and differences compared to adult patients. It outlines the adult ICU team's skills and collaboration needed with pediatrics. Equipment, monitoring, medications, and resources required are reviewed. Education for nursing on a 3 stage program and courses like APLS are mentioned. Outcomes have improved since establishing a pediatric ICU liaison service for transfers and telehealth support. The goal is for most pediatric patients to be managed locally in Geelong rather than transferring to Melbourne.

1. Doing it for the kids
Caring for paediatric patients in an adult
ICU
Dr Claire Cattigan, University Hospital
Geelong

3. Geelong
• Largest Regional Centre in Victoria
• >16,000 paediatric presentations to ED per
year
• >2500 admission to paediatric ward per year

4. ICU - Barriers
• Unfamiliarity
• Underskilled
• Equipment/resources
• Centralisation of services
• Fear

5. Adult ICU team
Leadership and
Teamwork
Resuscitation
skills
Patient/Famil
y centred
Care
Crisis Resource
Management Medication
Knowledge
External
Collaboration
Effective
Communication
Airway Skills

6. Paediatrics
• Hospital Mortality 3.4%
• Top 5 admit dx
1. Bronchiolitis ?
2. Seizures ✔
3. Pneumonia/pneumonitis ✔
4. Asthma ✔
5. Adenoidectomy/tonsillecto
my ✔
Adult
• Hospital Mortality 8.6%
• Top 5 admit
1. CABG surgery
2. Orthopaedic surgery
3. GI surgery for neoplasm
4. Valvular heart surgery
5. Drug overdose
http://www.anzics.com.au/Downloads/CORE%20Annual%20Report%202013-14.pdf

7. Differences
• Diagnostic
– Congenital cardiac conditions
– Trauma and management
– Inborn errors of metabolism
– Cancers
• Physiological
– Vital sign ranges
– Fixed stroke volume, reduced respiratory reserve
– Transitional circulation
– Thermoregulation
– glucose/metabolism
• Risk
– PRISM/PIM vs APACHE
• Psychology
– Age appropriate interaction (4mo v 4y v 14y)
– Parents/Carers

8. AIRWAY

9. Cannula (birds) to 75.0 ETT (giraffe)
http://www2.pedsanesthesia.org/newsletters/2015fall/sessVI.html

10. Developed by Anaesthetics, Emergency Medicine, ICU and Paediatrics SIG - Barwon Health
Pre-
oxygenate
(bag/mask/T-
piece)
Positioning –
age appropriate
IV Access,
secured, with
flush
Consider
intraosseus if
unable to gain
IV
Airway
Assessment
MONITORING
ECG
BP
SpO2
CAPNOGRAPHY
Cuff Manometer
EQUIPMENT
Mask/Bag/T-piece
Guedel
ETT x 3
Laryngoscopes (2)
Bougie/Introducer
Suction
DRUGS
Induction
Paralysis
Maintenance
Atropine/
Adrenaline
Vasopressor
Is appropriate
TEAM present?
2x Consultant
(Anaes/ICU/Paed/
ED)
TEAM ROLES
Team Leader
First Intubator
Drugs/Second
Intubator
Intubator
Assistant
Cricoid
Scribe
(C-spine)
PLAN
DISCUSSED?
PLAN FOR
DIFFICULTIES
VENTILATION
Guedel/NPA
Bag/Mask or T-
Piece/Mask
Nasogastric
decompression
INTUBATION
Change position
Different
Laryngoscope
blade (+/-CMAC)
BURP
Frova
LMA
Fibreoptic
Bronchoscope
Surgical Airway
Pa#ent' Equipment' Team'
Difficult'
Intuba#on'
Plan'
AGE PREM NEO-
NATE
INFANT SMALL
CHILD
CHILD
WEIGHT' <1.5kg 1.563.5kg 3.566kg 7612kg 12616kg 16620kg 20624kg 24630kg
FACE%MASK 0"(white) 1"(pink) 2"(yellow) 3"(green)
GUEDEL 000"pink 00"orange 0"blue 1"purple 2"white
NP#AIRWAY 2.5 3.0 3.5 3.5 4.0 4.5 5.5 6.0
MILLER/MAC)
BLADE 0 1 2
ETT##(UNCUFFED) 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0
ETT#(CUFFED) 3.0 3.5 4.0 4.5 5.0 5.5
LMA 1"(<5kg) 1.5!(5!10kg) 2"(10!20kg) 2.5$(20!30kg)
STYLET 6Fr$(ETT$2.064.5) Adult&14&Fr&(ETT&>&4.5)
BOUGIE 5Fr$(pink)'ETT#2.063.5 10Fr% ETT#4.066.0 Adult&(blue)'ETT#>#4.5
FROVA xxx Paediatric!(yellow) Adult&(blue)
SUCTION(CATHETER ETT#363.5,%suction%catheter%6Fr ETT#464.5,%suction%catheter%8%Fr ETT#>5,#suction#catheter#10Fr

11. Breathing/Ventilation
Ventilation
Secured ETT (nasal >oral)
Sedation (beware propofol)
Monitoring (incl capnography), pulse
oximetry, ecg telemetry.
VT 6-8, RR 15-25, PEEP 5, PIP 20-25

12. Circulation

13. Medications

14. Resources
• Paediatric equipment (appropriate sized
airway equipment, monitoring, suction, cots,
breastmilk fridge)
• Paediatric resuscitation trolley
• Cognitive aides
• Paediatric medication chart
• Paediatric Check list (ward round, intubation)
• Age specific ICU chart with vital signs

15. Education
• Nursing
– In house 3 stage program
• RCH
• APLS, PLS
• APICS
• Beyond Paediatric Basic

16. Geelong ICU
Geelong
Paediatricians
Geelong Paed
and SCN
RCH PICU
Geelong
Anaesthetics
Geelong ED
Geelong/RCH
Radiology Geelong
Pharmacy
Mx
Cmt

17. Can this patient be managed at Geelong?

18. Pre 2011 2011
2012-
2015
Future
0
20
40
60
80
100
120
140
160
180
200
2010 2011 2012 2013 2014 2015 2016
ICU
MET
TF ICU
Ventilated