Pediatric Intensive Care Units

What is the PICU: catheters, machines, sounds, and teams?

The intensive care unit (ICU) is the area where your child will likely go after being resuscitated from cardiac arrest. Time in the ICU can be overwhelming and can feel like stepping into a completely different world. Often, many things are going on at once, with different sounds and alarms. You may have questions about your child’s treatment plan, the machines in the room, who is on the medical team caring for your child, and the devices connected to your child.  

Most children will go to the Pediatric ICU (also called the “PICU”) after a cardiac arrest. Some children will go to the Cardiac or Cardiovascular ICU (also called the “CICU” or “CVICU”) if the cause of their cardiac arrest is their heart, or the Neonatal ICU (also called the “NICU”) if they are newborns. 

What are all these machines, tubes, and monitors in the room?

Machines and treatments are used if your child’s organs need extra support and to make sure your child is monitored closely. This helps the medical team to act quickly if your child has any medical changes. Here are some common machines or treatments you may see in the ICU: 

• Ventilator or “breathing machine”:  A mechanical ventilator, also known as a breathing machine, will be connected to a breathing tube. A breathing tube, also known as an endotracheal tube (ET tube), is a plastic tube that passes through your child’s nose or mouth into their windpipe. This tube and breathing machine will assist in breathing and keeping normal oxygen levels. It is extremely common after a cardiac arrest for children to need extra help breathing, particularly If your child remains unconscious. 

• You should know that both the breathing tube and ventilator are temporary and are removed once your child can safely breathe without the help of machines. If the lungs or brain don’t recover enough for your child to breathe without the help of machines, your child’s medical team will talk with you about the next steps of a temporary but longer-term option called tracheostomy.
• Vital signs monitor: A screen shows numbers known as “vital signs.” These usually are oxygen levels, heart rate, respiratory rate, and blood pressure. Your child’s medical team watches these numbers continuously. Medical teams are alerted if any of them move out of range. 
  • Heart monitor leads: Small, sticky pads with thin wires will be placed on the chest to monitor the heart rate and rhythm.  
  • Pulse oximeter: A sticky sensor that is attached to a finger, earlobe, or toe monitors the oxygen levels in the blood.
  • Blood pressure cuff (also called “BP cuff”): This device is placed on the arm or leg to measure your child’s blood pressure. Your child may hear or feel the cuff inflate every so often.
• Intravenous lines (also called “IVs” or “PIVs”): These are small catheters that go into the veins and are used to give medicines or fluids.
• Central venous line (also called a “central line”): A central, which includes a specific type called a peripherally inserted central catheter or “PICC line,” is larger than IV lines and is inserted into one of the large veins, usually in your child’s neck or groin. These are used to give medicines or fluids. For some medications used to support the heart and its ability to pump blood to the body, your child’s medical team will need a central venous line. The medications will reach the heart faster when given through the central venous line.
• Arterial line (also called an “A-line”): An arterial line is a small catheter inserted into an artery (usually in the wrist, groin, foot, or armpit). This measures blood pressure continuously and can be more precise than the blood pressure cuff. It also can be used to collect blood for blood tests.
• Electroencephalogram (also called an “EEG”): Your child’s medical team may use a tool called an EEG. This involves placing metal discs (electrodes) with thin wires onto the scalp (think of it as an EKG but for the brain). The brain activity is recorded and shows up on a computer as wavy lines. It will alert doctors, including a neurologist (brain doctor), if your child is having seizures, even if the body does not show any abnormal movements.
• Foley catheter: A Foley catheter is inserted through the urethra into the bladder. It helps to drain urine. The medical team may need to keep track of fluids going in and out of your child’s body and how much urine the kidneys are making, and this catheter will help them monitor that closely.
• Feeding tube: Your child may need a feeding tube to get enough nutrition and medicines. If your child has a breathing tube, is sedated, or is unconscious, your child will not be able to eat by mouth. Feeding tubes can be inserted through the nose or mouth to reach the stomach or intestines. They may be called nasogastric (“NG”) tubes, orogastric (“OG”) tubes, or nasoduodenal (“ND”) tubes. Once your child no longer needs the feeding tube, it can be removed. 
• Cooling blanket: It is important to avoid fever after a cardiac arrest. A cooling blanket or other device will be used to control your child’s body temperature. Your child may lay on or be wrapped in a cooling blanket or device. This helps to monitor your child’s temperature, maintain a target temperature,  and prevent fever. 
• Other machines: You may see many other machines in your child’s room. These may be to help monitor how your child’s body is recovering. Please ask your medical team about machines you notice in the room and want to know more about. They should be able to explain how they are using them. 

Your child’s medical team

You will meet many professionals in the ICU. We will introduce some of the common team members here. Please know you can ask anyone in the hospital who they are and what their role is on the care team. Even if you have met them before, it is a lot to remember. It is important to know who is interacting with your child. 

The ICU team is your child’s main medical team – they help to lead your child’s care. Some members of the ICU team can include:

• Attending Physician: a supervising doctor who has completed subspecialty training to work in the ICU. 
• Fellow Physician: a doctor who has completed residency training to be a pediatrician and is currently doing extra subspecialty training to work in the ICU. 
• Resident Physician: a doctor who graduated from medical school and is currently training to work in pediatrics, emergency medicine, or another specialty. 
• Medical Student: a student who is training to be a doctor. 
• Nurse Practitioner: a nurse who has completed special training to work in the ICU and make medical decisions. 
• Physician Assistant: a professional who has completed special training to work in the ICU and make medical decisions. 
• Nurses: professionals who provide bedside care, care coordination, health education, assessments, treatments, and support. 
• Respiratory Therapists: professionals who are experts in treatments and machines that help to support your child’s breathing.
• Pharmacists: professionals who have completed special training to help your child’s team use medicines safely in the ICU.

There are other members of the ICU team that help to support your child. These may include:

• Social Workers: professionals who have special training to support you and your family (in and out of the hospital). 
• Case Managers: professionals who work with you and your child’s insurance to make sure that they can get all the treatments they need (in and out of the hospital). 
• Physical, Occupational, and Speech Therapists: professionals who are experts in helping your child to rehab and recover. 
• Child Life Specialists: professionals who are trained to support children and their siblings adjust to illness and the hospital.
• Spiritual Care Team: professionally trained chaplains that represent a broad array of religious faiths and cultural backgrounds to help provide a compassionate presence

There will likely be more than one medical team caring for your child during the ICU stay. Other “consulting teams” are medical teams that are experts in certain medical issues – for example, problems with the kidneys or infections. These consulting teams will provide critical help for your child’s ICU team to make important decisions about their care.

The ICU daily routine

The daily routine in the ICU can sometimes vary. Usually, your child’s ICU team will “round” in the morning. This is where all members of the ICU team talk together about any updates on your child’s health. They will talk about updates or changes in the past day, any new test results, and recommendations from the consulting teams. They will then come up with a plan for the day. Most ICU teams will and should invite you to join rounds in the morning. Rounds can be overwhelming with a lot of medical words and a lot of people. Usually, the team will ask you if you have any questions. Many families also like to write down questions and ask them on rounds. Some families prefer someone from the medical team to come to update them after rounds. When families cannot make it to rounds, they sometimes ask the team to call them after rounds for updates.   

In the afternoon, you might see other consulting team members at your bedside. Your child may also have certain tests, procedures, or treatments.  

In the evening, the ICU team might have “night rounds.” This set of rounds is to make sure everyone on the medical team knows the plan for the evening. They are usually shorter and with a smaller team than morning rounds. 

You may notice different team members over the course of the day. Many members of the team work in shifts – day shift and night shift. The day team and night team will switch at about the same time every day. In most hospitals, the shifts usually switch around 7:00 AM and 7:00 PM for the nurses. The doctors, nurse practitioners, and physician assistants may have a different time for shift change in the evening depending on the hospital. The medical team will “sign out” or share the details of your child’s care with each other before they switch.

Commonly used ICU medicines

Your child may need many different medicines in the ICU. Which medicines and how much of those medicines will depend on what your child needs. Most medicines will be given through an IV or central line, but some may be given through the feeding tube. Some of the most common medicine categories are:

• Vasopressors: These are medicines that raise blood pressure if it is too low or support the heart function if your child has heart failure. Some examples of vasopressors are epinephrine, norepinephrine, and vasopressin. 
• Analgesics and sedatives: These medicines help with pain control (analgesics) and will make your child sleepy (sedatives) and comfortable. These medicines may be used to put your child’s body into “rest” mode. By lowering the brain’s activity, the brain and the body will also need less energy. This helps to protect uninjured areas of the brain after a cardiac arrest. Additionally, there are many reasons why your child might be uncomfortable in the ICU. The breathing tube, intravenous lines, or other medical devices might cause discomfort or anxiety. These medicines can be given in the form of a drip (continuous medicine given through an IV), scheduled daily dosing, or only when necessary (“PRN”). A few examples of analgesics include acetaminophen (Tylenol), ibuprofen (Advil or Motrin), morphine, hydromorphone (Dilaudid), and Fentanyl. Sedatives commonly used are propofol, dexmedetomidine (Precedex), and midazolam. 
• Neuromuscular Blockade: Medicines to temporarily chemically paralyze the muscles may be used. These medicines can help stop shivering and help the ventilator work better. If your child receives these medicines, they will also receive sedating medicines to prevent anxiety. 
• Anti-Seizure Medicines: Some children can have seizures after a cardiac arrest. Your child may receive medicine to prevent or stop seizures. Some common seizure medicines include levetiracetam (Keppra), fosphenytoin, and phenobarbital. 
• Stomach acid-reducing medicines: The stomach lining can become irritated when the body is under stress. The medical team can use medicines to reduce stomach acid and prevent ulcers that can cause bleeding. Examples of these medicines are omeprazole (Prilosec), famotidine (Pepcid), and pantoprazole (Protonix). 
• Bowel regimen: It is very common for children to get constipated in the ICU. The medical team will start medicines to help maintain regular bowel movements. Some examples are Docusate, Senna, and Miralax. 
• Insulin: Insulin is given to help control high blood sugar. 
• Fluids: IV fluids, usually with sugar and electrolytes, are given to keep the body hydrated.
• Delirium medicines: Your child may become confused during the ICU stay. Your child can also become agitated and have disrupted sleep patterns. This is common for all children in the ICU, but especially common in children with brain injuries.  The medical team may start medicines such as melatonin, quetiapine (Seroquel), or olanzapine (Zyprexa) to keep your child calm.

Sources

ICUsteps. (n.d.). Your time in the intensive care unit (ICU). https://icusteps.org/information/guide-to-intensive-care/your-time-in-the-icu

Nemours KidsHealth. (2021, September). When your child is in the pediatric intensive care unit. https://kidshealth.org/en/parents/picu.html

Understanding Your ICU Stay: https://www.sccm.org/getattachment/MyICUCare/During-the-ICU/UNDERSTAND_Download.pdf?lang=en-US

Thank you to our contributors

Annie Gula & Samantha Fernandez