PICU Nursing Guide

PICU Fundamentals

Critical Reminder: Normal paediatric values differ markedly by age. Always interpret vitals in context — a HR of 150 is normal in a neonate but tachycardic in an adolescent.

📊 Age-Based Normal Vital Signs

Age Group	HR (bpm)	RR (breaths/min)	Systolic BP (mmHg)	SaO₂ (%)
Neonate (0–1 mo)	100–160	40–60	60–90	≥95
Infant (1–12 mo)	100–160	30–60	70–100	≥95
Toddler (1–3 yr)	90–150	24–40	80–110	≥95
Preschool (3–5 yr)	80–140	22–34	80–110	≥95
School (6–12 yr)	70–120	18–30	85–120	≥95
Adolescent (>12 yr)	60–100	12–20	90–130	≥95

Hypotension threshold: Systolic BP < 70 + (2 × age in years) for children 1–10 yr. Below this = hypotensive shock.

🚨 PEWS — Paediatric Early Warning Score

Scores 0–3 in each domain. Total ≥4 = escalate; ≥6 = consider PICU referral immediately.

Domain	0	1	2	3
Behaviour	Playing/Appropriate	Sleeping	Irritable	Lethargic/Confused
Cardiovascular	Pink, CRT <2s	Pale, CRT 3s	Grey, CRT 4s	Grey/mottled, CRT ≥5s
Respiratory	Normal rate, no recession	RR+10, mild recession	RR+20, moderate recession	5+ below normal or sternal recession
Nebuliser/O₂	None	—	4+ L/min O₂	≥50% O₂ or hourly neb
Vomiting post-op	None	1×	2×	≥3× / bilious

📈 PRISM-III Score Overview

Paediatric Risk of Mortality III — calculated in first 12 hours of PICU admission. Predicts risk of death.

Variables Assessed (17 total)

Systolic BP (age-specific ranges)
Temperature (>40°C or <33°C = high risk)
Mental status (GCS adaptation)
Heart rate (age-specific)
Pupillary reflexes (abnormal = 4–7 pts)
PT, PTT, total bilirubin
Potassium, calcium, glucose, bicarbonate
PCO₂, PaO₂/FiO₂ ratio
Creatinine (age-adjusted)

Score >20 = mortality risk significantly elevated. Used for benchmarking and ICU audit, not bedside treatment decisions alone.

👨‍👩‍👧 Family-Centred Care Principles in PICU

Dignity & Respect

Listen to family knowledge of the child
Honour cultural and religious values
Avoid terminology that diminishes family role
Individualise care to family preferences

Information Sharing

Daily family briefings from senior nurse or physician
Use interpreters when Arabic/English barrier exists
Written summaries of plan of care
Honest, timely communication at all stages

Participation

Invite family in ward rounds where appropriate
Encourage comfort touch, reading to child
Teach suctioning/NG care to willing parents
Family presence during procedures — supported

Paediatric Airway & Ventilation

WETFLAG: Memorise this mnemonic — it provides immediate weight-based dosing for all paediatric emergencies. Use the calculator tab for instant results.

🔤 WETFLAG — Emergency Drug Dosing Mnemonic

Letter	Parameter	Formula	Notes
W	Weight (kg)	(Age + 4) × 2 for 1–10 yr	Or use Broselow tape; neonates use actual weight
E	Energy (Joules)	4 J/kg	Biphasic defibrillation; max 200 J
T	Tube (ETT size, mm)	(Age/4) + 4 uncuffed; (Age/4) + 3.5 cuffed	Have size above and below available
F	Fluid (mL)	20 mL/kg bolus (sepsis); 10 mL/kg in shock with cardiac risk	Reassess after each bolus
L	Lorazepam (mg)	0.1 mg/kg IV	Max 4 mg; for seizures
A	Adrenaline (mL of 1:10,000)	0.1 mL/kg IV/IO	= 0.01 mg/kg; repeat every 3–5 min in arrest
G	Glucose (mL of 10%)	2 mL/kg of 10% glucose	For hypoglycaemia; recheck BG 15 min after

🫁 Cuffed vs Uncuffed ETT Selection

Uncuffed ETT (traditional guidance)

Preferred in children <8 years (narrow cricoid = natural seal)
Less risk of subglottic mucosal injury
Leak pressure should be 20–25 cmH₂O (if using uncuffed)

Cuffed ETT (current evidence-based)

Now safe and preferred in PICU even for infants
Allows better ventilation control, reduced contamination
Cuff pressure: maintain 20–25 cmH₂O (use manometer)
Formula: size = (Age/4) + 3.5; or 0.5 less than uncuffed

Lip-to-tip (ETT depth): 3 × ETT internal diameter (cm), or (Age/2) + 12 cm for oral ETT in children.

⚙️ Paediatric Ventilation Settings

Standard Initial Settings

Parameter	Target
Tidal Volume (Vt)	6–8 mL/kg IBW (lung protective)
PEEP	5–8 cmH₂O (start 5; increase for hypoxia)
FiO₂	Titrate to SaO₂ 94–98%
Rate	Age-appropriate (≈ normal RR)
Peak Pressure	<30 cmH₂O (avoid barotrauma)
I:E Ratio	1:2 standard; 1:3–4 in obstruction (asthma)
Target PaCO₂	35–45 mmHg (allow permissive hypercapnia in ARDS)

🌀 High-Frequency Oscillatory Ventilation (HFO)

Indications

Severe ARDS refractory to conventional ventilation
Oxygenation Index (OI) >20–40
Air leak syndromes (PIE, pneumothorax)
Persistent pulmonary hypertension of newborn (PPHN)

Key Parameters

MAP: Start 2–3 cmH₂O above conventional MAP
Frequency: 8–15 Hz (lower = more CO₂ clearance)
Amplitude (ΔP): Titrate to chest "wiggle" to umbilicus
FiO₂: Wean as oxygenation improves

OI Formula: OI = (MAP × FiO₂ × 100) ÷ PaO₂. OI >40 = consider ECMO consultation.

💨 High-Flow Nasal Cannula (HFNC) in Children

Indications

Bronchiolitis (first-line after standard O₂ fails)
Mild-moderate respiratory failure
Post-extubation support
Severe pneumonia — bridge to intubation decision

Flow Rates

Age	Starting Flow	Max Flow
Neonate	2–4 L/min	6 L/min
Infant	4–8 L/min	2 L/kg/min
Child	1 L/kg/min	40–50 L/min

Failure criteria: Persisting RR >70% above normal, SpO₂ <92% on FiO₂ 0.6, increasing work of breathing, exhaustion — escalate immediately.

PICU Drug Dosing

💉 Vasoactive Infusions

Drug	Dose Range	Notes
Dopamine	5–20 mcg/kg/min	5–10: inotropic; >10: vasopressor
Dobutamine	5–20 mcg/kg/min	Inotropic; no significant vasopressor effect
Noradrenaline	0.05–2 mcg/kg/min	Start 0.05–0.1; vasopressor of choice in warm shock
Adrenaline	0.05–1 mcg/kg/min	Cold shock / cardiac arrest; high doses → tachycardia
Milrinone	0.25–0.75 mcg/kg/min	Post-cardiac surgery; PDE-3 inhibitor; no loading in PICU
Vasopressin	0.0003–0.002 units/kg/min	Refractory septic shock; catecholamine-sparing

💊 Sedation & Analgesia

Drug	Bolus	Infusion
Midazolam	0.05–0.1 mg/kg IV	0.02–0.1 mg/kg/hr (max 0.4)
Morphine	0.05–0.1 mg/kg IV	10–40 mcg/kg/hr
Fentanyl	1–2 mcg/kg IV	1–4 mcg/kg/hr
Dexmedetomidine	Avoid loading in PICU	0.2–1.4 mcg/kg/hr (titrate)
Ketamine	1–2 mg/kg IV (procedural)	0.1–0.5 mg/kg/hr (analgesia)
Propofol	1–2 mg/kg IV (induction)	Avoid infusion >4 hrs in children (PRIS risk)
Chloral hydrate	25–50 mg/kg PO/PR	Procedural sedation; max 100 mg/kg

🧠 Paralytic Agents (Neuromuscular Blockade)

Drug	Type	Dose	Duration
Suxamethonium	Depolarising	1–2 mg/kg IV (infant: 2 mg/kg)	5–10 min
Rocuronium	Non-depol	0.6–1.2 mg/kg IV	30–60 min
Vecuronium	Non-depol	0.1 mg/kg IV bolus	25–40 min
Vecuronium infusion	Non-depol	0.05–0.1 mg/kg/hr	Continuous
Atracurium	Non-depol	0.5 mg/kg IV; 5–10 mcg/kg/min	20–35 min
Sugammadex	Reversal	2–4 mg/kg IV (routine reversal)	Immediate

Caution: Suxamethonium contraindicated in burns, crush injury, hyperkalaemia, myopathies, and malignant hyperthermia risk.

⚡ Emergency Drugs

Drug	Dose	Indication
Adrenaline 1:10,000	0.1 mL/kg IV/IO	Cardiac arrest; anaphylaxis 0.01 mg/kg IM
Atropine	0.02 mg/kg IV (min 0.1 mg)	Bradycardia; pre-intubation in infants
Adenosine	0.1 mg/kg rapid IV (max 6 mg first dose)	SVT; escalate to 0.2 then 0.3 mg/kg
Amiodarone	5 mg/kg IV over 20 min (VT/VF: 5 mg/kg rapid)	Pulseless VT/VF, SVT
Sodium bicarbonate	1 mmol/kg slow IV (8.4% = 1 mL/kg; dilute 1:1)	Severe metabolic acidosis, hyperkalaemia
Calcium gluconate 10%	0.5–1 mL/kg IV slowly	Hypocalcaemia, hyperkalaemia, CCB toxicity
Naloxone	0.01 mg/kg IV (titrate to effect)	Opioid reversal
Flumazenil	0.01 mg/kg IV (max 0.2 mg)	Benzo reversal — use cautiously

🧬 Anticonvulsant Ladder

Step	Drug	Dose	Route	Timing
1st	Diazepam	0.2–0.5 mg/kg (max 10 mg)	IV / PR	0–5 min; may repeat once
1st	Lorazepam	0.1 mg/kg IV (max 4 mg)	IV / IN	Preferred if IV access
1st	Midazolam	0.2 mg/kg buccal; 0.1 mg/kg IV	Buccal / IV / IM	Prehospital first-line
2nd	Levetiracetam	40–60 mg/kg IV (max 3 g)	IV over 5–15 min	5–20 min post-benzo
2nd	Phenytoin / Fosphenytoin	20 mg/kg IV (max 1 g)	IV over 20 min (monitor ECG)	Alternative 2nd line
2nd	Phenobarbitone	20 mg/kg IV (max 1 g)	IV over 20–30 min	Neonates — 1st choice 2nd agent
3rd	Thiopental sodium	2–5 mg/kg IV; infusion 1–5 mg/kg/hr	IV — needs intubation	Refractory status
3rd	Midazolam infusion	0.05–0.4 mg/kg/hr	IV continuous	Refractory status

Common PICU Conditions

🦠 Paediatric Septic Shock (PALS Algorithm)

Recognition (within 1 hour)

Fever/hypothermia + altered mental status
Warm shock: flash CRT, bounding pulse, wide pulse pressure
Cold shock: prolonged CRT (>3s), weak pulse, mottled
Lactate >2 mmol/L or >4 mmol/L = severe

Management Bundle

Fluid: 10–20 mL/kg isotonic boluses; reassess after each. Caution if signs of fluid overload (rales, hepatomegaly). Up to 40–60 mL/kg in 1st hour without cardiac disease
Antibiotics: Within 1 hour of recognition — broad spectrum empirical
Vasopressor: Cold shock → Adrenaline (start 0.05 mcg/kg/min); Warm shock → Noradrenaline (start 0.05 mcg/kg/min)
Corticosteroids: Hydrocortisone 1–2 mg/kg Q6H if catecholamine-resistant shock
Target: MAP ≥ (age × 1.5 + 40); ScvO₂ ≥70%; lactate normalisation

GCC Note: High prevalence of gram-negative sepsis (Klebsiella, Pseudomonas) in NICU graduates. Consider antifungals (fluconazole/caspofungin) in immunocompromised.

⚡ Status Epilepticus

Definition: seizure >5 minutes or recurrent without recovery
Refractory: persisting >30 min despite 2 agents

Immediate Actions

Airway, O₂ — suction, nasal airway if needed
BGL — if low give 10% glucose 2 mL/kg
ECG, temperature, Na, Ca, Mg levels
EEG monitoring once stabilised

Follow anticonvulsant ladder (see Drug tab)

EEG Monitoring Targets

Burst suppression ratio 50–90% in refractory SE
Continuous cEEG if paralysed (detect subclinical seizures)
Wean sedation/AEDs gradually when seizure-free 24–48 hrs

GCC Context: Metabolic causes (organic acidaemias, urea cycle disorders) more prevalent due to high consanguinity — check amino acids, ammonia early in neonates/infants.

🍬 Paediatric DKA Management

Criteria

BGL >11 mmol/L + ketones >3 mmol/L or ketonuria
pH <7.3 or bicarbonate <15 mmol/L
Severity: Mild (pH 7.2–7.3), Moderate (7.1–7.2), Severe (<7.1)

Fluid Management (ISPAD 2022)

Restoration only if shocked: 10 mL/kg 0.9% NaCl over 30 min
Replace deficit + maintenance over 48 hours using 0.9% NaCl
Add 40 mmol/L KCl once urine output confirmed
Switch to 0.45% NaCl + glucose 5% when BGL <14 mmol/L

Insulin

Start 0.05–0.1 units/kg/hr after 1–2 hrs of fluid
No insulin bolus in children
Target BGL reduction: 2–5 mmol/L/hr

DO NOT give bicarbonate in paediatric DKA — increases risk of cerebral oedema. Only consider if pH <6.9 with haemodynamic compromise under senior supervision.

Cerebral oedema: Headache, bradycardia, Cushing's triad, pupil change → mannitol 0.5–1 g/kg immediately; consider hypertonic saline 3% 3–5 mL/kg.

🫁 Bronchiolitis (RSV)

Diagnosis

Age <12 months, first episode wheeze
RSV most common (Oct–Mar in GCC); also Rhinovirus, hMPV
Signs: tachypnoea, subcostal/intercostal recession, fine crackles, wheeze

Supportive Care (EVIDENCE-BASED)

Nasal suctioning — frequent, especially before feeds
O₂ to maintain SpO₂ ≥90–92%
NG feeds if >30–40% increased work of breathing
HFNC: first escalation for moderate-severe (2 L/kg/min)
CPAP/BiPAP: if HFNC fails or severe apnoea
Intubation: respiratory failure, recurrent apnoea

NOT recommended: Salbutamol, adrenaline nebulisers, steroids, antibiotics, ribavirin — not routinely evidence-based in bronchiolitis.

🧠 Bacterial Meningitis

Empirical Antibiotics (age-based)

Age	Antibiotic	Dose
<3 months	Ampicillin + Cefotaxime	200 mg/kg/day ÷ 6H
3 mo – 18 yr	Ceftriaxone	100 mg/kg/day ÷ 12H (max 4g/day)
Any age (MRSA risk)	+ Vancomycin	15 mg/kg Q6H

Dexamethasone

0.15 mg/kg Q6H × 4 days
Give 10–20 min BEFORE or with first antibiotic dose
Greatest benefit: H. influenzae and pneumococcal meningitis
Reduces hearing loss; less clear benefit for other organisms

LP Timing — Contraindications to Immediate LP

GCS <9 or deteriorating conscious level
Papilloedema / focal neurological signs
Haemodynamic instability
Coagulopathy (platelets <50, INR >1.5)
Skin infection over LP site

Important: Start antibiotics immediately — do NOT delay for CT or LP if contraindications present. LP can be performed after 48 hours if clinically stable.

CSF Interpretation

	WCC	Protein	Glucose
Bacterial	>1000 PMN	↑↑	↓ (<50% serum)
Viral	10–500 lymph	Normal/↑	Normal
TB	100–500 lymph	↑↑↑	↓↓

PICU Procedures & Monitoring

🦴 Intraosseous (IO) Access — EZ-IO

Sites (preferred order)

Proximal tibia: 2 cm below tibial tuberosity, medial flat surface (most common in children)
Distal tibia: Proximal to medial malleolus (alternative)
Proximal humerus: Greater tubercle — preferred in adults; used in older children
Distal femur: Neonates/infants if tibia inaccessible

Needle Sizes (EZ-IO)

Pink (15 mm): 3–39 kg
Blue (25 mm): ≥40 kg or obese smaller patient
Yellow (45 mm): excessive tissue depth

Contraindications

Fracture ipsilateral to insertion site
Previous IO in same bone within 24 hrs
Overlying infection or burn
Osteogenesis imperfecta
Prosthetic limb

All IV drugs/fluids/blood products can be given IO. Flush each drug with 5–10 mL NS. Use pressure bag or rapid infuser for fluids.

🩸 Arterial Line in Small Patients

Sites

Radial artery: First choice; Allen's test first (or pulse ox on thumb)
Femoral artery: Emergency, large vessel; monitor for ischaemia
Dorsalis pedis / posterior tibial: Alternative in infants
Umbilical artery: Neonates only; UAC

Catheter Size

Neonates: 24G
Infants/toddlers: 22G
Children: 20–22G

Maintenance

Heparinised flush (1–2 units/mL NS), continuous at 1–3 mL/hr
Zero transducer at mid-axillary line (4th ICS)
Check limb perfusion hourly — colour, CRT, temperature
Site change every 5–7 days or at first sign of concern

💙 PICC Line Care

Insertion Considerations

Confirm tip position at cavoatrial junction on X-ray
Measure arm circumference before insertion (oedema monitoring)
Single-lumen preferred in children unless dual access critical

Daily Care Bundle (CLABSI prevention)

Hand hygiene (5 moments)
Assess line necessity every shift — remove if not needed
CHG 2% dressing change every 7 days (or if wet/soiled)
Scrub the hub × 15 sec before each access
Closed needleless system; blood cultures before starting antibiotics
Maintain dressing integrity; document in care plan

CLABSI bundle compliance reduces infection rates by 65–70% in PICU. Document all bundles on daily safety checklist.

📊 Pain & Sedation Assessment

FLACC Scale (0–10) — Non-Verbal / Intubated

Domain	0	1	2
Face	No expression	Occasional grimace	Frequent frown/clenched jaw
Legs	Normal/relaxed	Uneasy/restless	Kicking/drawn up
Activity	Lying quietly	Squirming/tense	Arched/rigid/jerking
Cry	No cry	Moans/whimpers	Crying steadily
Consolability	Content/relaxed	Reassurable	Inconsolable

COMFORT-B Sedation Scale

Scores 6 domains (alertness, calmness, respiratory, crying, movement, muscle tone). Score 6–10 = over-sedated; 11–22 = optimal; 23–30 = under-sedated. Reassess Q4H.

NRS Scale

Numeric Rating Scale (0–10) for children ≥6 years who can self-report. Use Wong-Baker FACES for age 3–6.

🧠 Continuous EEG (cEEG) Monitoring in PICU

Indications

Refractory status epilepticus
Post-cardiac arrest (therapeutic hypothermia)
Hypoxic-ischaemic encephalopathy (HIE)
Encephalitis / meningitis with altered consciousness
Post-neurosurgery with seizure risk
Unexplained altered consciousness
Metabolic encephalopathy (hyperammonaemia)

Nursing Responsibilities

Apply electrodes according to 10-20 system (or 10-10 in neonates)
Document clinical events with EEG annotations
Minimise movement artefact — note suction, procedures
Notify neurologist of electrographic seizures
Monitor electrode integrity every 4 hours
Integrate EEG findings with clinical status in handover

GCC Context

🏥 Major Paediatric Hospitals in GCC

Hospital	Location	Notes
Batterjee Children's Hospital (BCH)	Riyadh, KSA	Tertiary paediatric centre; large PICU; cardiac surgery
National Guard Health Affairs – Paeds	Riyadh, KSA	Integrated paediatric services; PICU & NICU
Sheikh Khalifa Medical City (SKMC)	Abu Dhabi, UAE	Tertiary PICU; ECMO program; cardiac PICU
Al Jalila Children's Specialty Hospital	Dubai, UAE	Dubai's first dedicated children's hospital; Level III PICU
Al Wasl Hospital – Paediatrics	Dubai, UAE	General paediatrics; lower-acuity admissions; step-down
Hamad Medical Corp – Women's & Neonatal	Doha, Qatar	Largest NICU in Qatar; paediatric emergency
Salmaniya Medical Complex	Manama, Bahrain	National referral centre for paediatrics
Khoula Hospital	Muscat, Oman	Tertiary surgical centre; paediatric trauma PICU

🧬 Genetic Conditions Prevalent in GCC

Consanguinity rates 20–60% in GCC → markedly elevated autosomal recessive disease prevalence

Inborn Errors of Metabolism (IEM)

Phenylketonuria (PKU) — screened neonatally in all GCC states
Maple Syrup Urine Disease (MSUD) — encephalopathy, sweet urine odour
Urea Cycle Disorders (OTC deficiency) — hyperammonaemia, coma
Organic Acidaemias (MMA, PA, IVA) — metabolic acidosis, ketonuria
Fatty Acid Oxidation Disorders (MCAD) — hypoketotic hypoglycaemia
Glycogen Storage Diseases — hepatomegaly, hypoglycaemia

Congenital Heart Disease

Higher prevalence than global average in Arabian Peninsula
VSD, ToF, TGA, HLHS common in PICU referrals
Post-cardiac surgery patients: monitor SVC, PA pressures; pulmonary hypertensive crisis risk

Haematological

Sickle Cell Disease — SCA crisis, acute chest syndrome, stroke
Beta-Thalassaemia major — chronic transfusion, iron overload
G6PD deficiency — haemolysis with oxidant exposure

👩‍⚕️ PICU Staffing Ratios — GCC Standards

Country	Nurse:Patient Ratio	Physician Cover
Saudi Arabia (MOH)	1:1 (ventilated); 1:2 (stable)	Resident 24/7; Intensivist consultant cover
UAE (DOH/DHA)	1:1–2 per acuity	Fellow 24/7; Attending consultant on-call
Qatar (HMC)	1:1 (ventilated)	Board-certified intensivist 24/7 in-house
Kuwait (MOH)	1:2 standard	Senior resident + consultant cover
Bahrain	1:2 (varies)	Consultant on-call 24/7
Oman	1:1–2	Resident in-house; consultant reachable

GCC Trend: All major PICU centres moving toward 24/7 in-house attending intensivist model aligned with SCCM/ESICM standards.

🚁 PICU Transport to Tertiary Centre

Stabilise Before Transport ("STABLE" Mnemonic)

S — Sugar (BGL 4–8 mmol/L)
T — Temperature (36.5–37.5°C)
A — Airway (secure ETT; confirm position; CXR)
B — Blood pressure (stable; vasopressors drawn up)
L — Lab work (sent and reviewed)
E — Emotional support (family briefed; consent taken)

Transport Team Minimum

Paediatric transport nurse (PICU-trained)
Physician (paediatric registrar minimum)
Transport equipment: portable ventilator, defibrillator, infusion pumps, drug kit
Pre-alert receiving PICU ≥30 min before arrival

🕌 Family Visiting in PICU — Cultural Expectations (GCC)

Visiting Practices

Extended family involvement is normative — expect multiple family members
Family spokesperson (usually father/elder male) for major decisions
Mothers often wish to stay 24/7 — accommodate where safe
Prayer times (5×/day) — schedule procedures around if possible
Quran recitation at bedside — welcome and normalise

Communication Considerations

Use certified medical interpreters for Arabic-speaking families
Avoid delivering bad news in busy corridors
Privacy for family discussions — dedicated family room
Allow family to seek second opinions — facilitate this
Discuss prognosis sensitively; avoid blunt prognostic statements

End-of-Life Care

Withdrawal of care: sensitive; involves religious guidance (imam)
Brain death: must be certified by two senior physicians; family may request time
Post-mortem: often declined for religious reasons; respect this
Ensure same-gender nurse where possible for personal care
Facilitate family time and privacy at end of life

Interactive Calculators

WETFLAG Emergency Calculator

Enter patient weight to auto-calculate all WETFLAG parameters. If weight unknown, estimate using (Age+4)×2 for 1–10 years.

Weight (kg)

W — Weight

—

kg (confirmed)

E — Energy

—

Joules (4 J/kg; max 200 J)

T — Tube (uncuffed)

—

mm ID

T — Tube (cuffed)

—

mm ID

F — Fluid Bolus

—

mL (20 mL/kg)

L — Lorazepam

—

mg IV (0.1 mg/kg; max 4 mg)

A — Adrenaline 1:10,000

—

mL IV (0.1 mL/kg)

G — Glucose 10%

—

mL (2 mL/kg)

Paediatric Drug Dose Calculator

Select a drug and enter weight to calculate recommended dose, max dose, and administration notes.

Drug

Weight (kg)

Drug Name

Patient Weight—

Calculated Dose—

Maximum Dose—

Route—

Administration Notes—

Disclaimer: Always verify doses against your institution's formulary and with a pharmacist. This calculator is a reference aid only.

MCQ Practice — PICU Nursing (10 Questions)

1. A 2-year-old child weighs 12 kg. Using the WETFLAG mnemonic, what is the correct energy dose for defibrillation?

Energy dose = 4 J/kg. For 12 kg: 4 × 12 = 48 J. Maximum dose is 200 J regardless of weight.

2. Which paediatric pain scale is most appropriate for a 4-year-old intubated child who cannot self-report pain?

FLACC (Face, Legs, Activity, Cry, Consolability) is validated for non-verbal/intubated children. Wong-Baker FACES requires self-report (age 3–6 who can communicate). NRS and VAS require verbal self-report.

3. A 5-year-old child in septic shock presents with warm extremities, flash capillary refill, and bounding pulses. Which vasopressor is the preferred first-line agent?

Warm shock (vasodilatory) is characterised by low SVR. Noradrenaline (norepinephrine) is the preferred vasopressor for warm/distributive shock. Adrenaline is preferred for cold shock (low cardiac output). Dopamine is less favoured due to side effects.

4. You are caring for a 3-year-old with DKA (pH 7.15). The family is concerned and asking about giving bicarbonate. What is the correct response?

ISPAD guidelines clearly state bicarbonate should NOT be given in paediatric DKA as it increases the risk of paradoxical CSF acidosis and cerebral oedema. Insulin and fluid therapy will correct the acidosis. Exception under senior supervision: pH <6.9 with haemodynamic compromise only.

5. When performing intraosseous access with EZ-IO in a 10 kg infant, which needle size should you select?

The Pink 15mm EZ-IO needle is designed for patients 3–39 kg. The Blue 25mm is for ≥40 kg or obese smaller patients. Yellow 45mm is for excessive soft tissue depth. At 10 kg, the Pink needle is correct.

6. A 6-month-old with bronchiolitis has a SpO₂ of 88% despite standard O₂ via nasal cannula at 2 L/min. What is the appropriate next escalation step?

HFNC is the recommended first escalation in bronchiolitis when standard O₂ fails (SpO₂ <90–92%). Salbutamol and steroids are NOT recommended in bronchiolitis (no evidence). Intubation is reserved for respiratory failure or recurrent apnoea — not as the next step here.

7. What is the correct first-line dose of adenosine for SVT in a 20 kg child?

Adenosine first dose = 0.1 mg/kg (max 6 mg), rapid IV push followed immediately by flush. For 20 kg: 0.1 × 20 = 2 mg. Second dose: 0.2 mg/kg (max 12 mg). Must be given as rapid bolus close to heart (antecubital or central).

8. In the GCC context, which of the following explains the higher prevalence of inborn errors of metabolism compared to global averages?

Consanguinity (marriage between relatives) rates in GCC countries range from 20–60%, significantly increasing the chance of autosomal recessive conditions including inborn errors of metabolism (PKU, MSUD, organic acidaemias), haemoglobinopathies, and congenital heart disease. All GCC states have expanded neonatal screening programs.

9. A PEWS score of 6 is calculated for a ward patient. What is the appropriate action?

PEWS ≥4 requires escalation; PEWS ≥6 mandates urgent medical review and consideration of PICU referral immediately. PEWS is designed as an early warning — the purpose is to act before full deterioration. Never delay escalation while administering treatments alone.

10. What is the maximum cuff pressure that should be maintained for a cuffed ETT in a PICU patient?

ETT cuff pressure should be maintained at 20–25 cmH₂O using a manometer. Pressures below 20 cmH₂O risk aspiration and inadequate seal. Pressures above 25–30 cmH₂O compromise tracheal mucosal blood flow and risk tracheal stenosis. Check Q4–8H and document.