PICU Handbook

For outside providers

Admission & Transfer Center

319-384-5000 or 1-866-890-5969

PICU staff offices

319-356-1615
*** Please contact if interested in outreach education

PICU 

319-356-4135
*** Please contact for information regarding admitted patients

For internal providers

Pager numbers

3433 = PICU fellow
3924 = PICU resident on call
3210 = Transport team
3920 = In-house floor senior
5678 = Peds Chief resident
3205 = Radiology resident (nights)
3911 = Urgent airway/Anesthesia
3268 = Neurosurgery resident on call
3792 = Neonatology Fellow

Phone numbers

64300 – PICU Pharmacy
63527 – Core Lab
62591 – Microbiology Lab

NOTE: The pediatric critical care reference guide has been formatted for brevity. For more information, please review the PICU Charts.

Depth of ETT

• Newborn: 6 + weight (kg)
• Others: 3 X size of ETT

Size of ET tube

• Uncuffed tube: (Age/4) + 4
• Cuffed tube: (Age/4) + 3

Microcuff pediatric ETT (Green adapter) recommend size selection

Please see PICU Common Medications page for general guidelines for drug choices for rapid sequence intubation.

PT with spontaneous respirations

• Monitor clinical status closely (WOB, anxiety, single breath count, airflow, mental status, pulse pressure, pulsus paradoxus)
• Do NOT intubate based on blood gas

Ominous signs

• Silent chest - no air flow or pneumothorax
• Poor air movement - may be sign of impending respiratory failure
• Normal or high pCO2 in a tachypneic pt - may be sign of early muscle fatigue and impending respiratory failure

Intubated patient

• Allow permissive hypercarbia (pH > 7.25)
• Use low respiratory rates and short inspiratory times to minimize hyperinflation and air trapping
• Ensure each breath returns to baseline
• Maintain adequate oxygenation
• PEEP settings controversial - consider low PEEP (0-5) because pt is already hyper expanded versus matching pt's auto PEEP on the ventilator

General management principles

1. Hydration - pt will need fluid resuscitation because has been hyperventilating and has increased insensibles
2. Continuous albuterol - use 0.25-0.5 mg/kg/hr (usually 10-20 mg/hr). May need to do back-to-back nebs while waiting for pharmacy and RT to set up
3. Oxygen - use as carrier for nebulizer, will not suppress respiratory drive
4. Steroids - give 2 mg/kg methylprednisolone as a bolus, then start 0.5 mg/kg Q 6 hrs
5. My bolus - give 25-40 mg/kg bolus (over 30 minutes), may repeat if needed. Thought to help relax smooth muscle

Other considerations

• Sub-Q Epinephrine - Beta-agonist, often used if no IV access. Dose is 0.01 mg/kg of the 1:1000 soultion
• Terbutaline (Beta-agonist) - continuous infusion, typical dosing range 0.5-2 mcg/kg/min
• Ipratropium bromide (anti-cholinergic) - usually Atrovent 2 puffs Q 4-6 hrs
• Theophylline (methylxanthine) - give loading dose, followed by continuous infusion. Monitor levels (goal 10-20)
• Heliox - used to reduce air flow resistance in small airways, limited by degree of hypoxemia in pt. 70/30 or 80/20
• Ketamine - if sedation is needed, preferred drug due to bronchodilating properties, typical dosing range 0.1-2 mg/kg/hr
• Zithromax - most common infectious trigger for asthma is Mycoplasma or Chlamydia pneumoniae
• Anesthesia (inhaled anesthetics) and ECMO (VV) (for refractory cases)

1. Akcan-Arikan A, Zappitelli M, Loftis LL, Washburn KK, Jefferson LS, Goldstein SL. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney International (2007) 71, 1028-1035.
2. Annich, Lunch, MacLaren, Wilson, and Bartlett. ECMO Extracorporeal Cardiopulmonary Support in Critical Care. USA: Extracorporeal Life Support Organization, 2012.
3. Chang, Hanley, Wernovsky, and Wessel. Pediatric Cardiac Intensive Care. Baltimore: Lippincott Williams & Wilkins, 1998.
4. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Critical Care Medicine (2008) 36(4): 1394-6.
5. Helfaer, Nichols. Rogers' Handbook of Pediatric Intensive Care. Philadelphia: Lippincott Williams & Wilkins, 2009.
6. Gunn, Nechyba. The Harriet Lane Handbook. Philadelphia: Mosby, 2002.
7. Rollings, Robert. Facts & Formulas. USA: Rollings, 1984.