Introduction



The PICU Survival GuideEverything you wanted to know but were afraid to ask…Table of Contents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc381781900 \h 2Airway5Breathing7CIrculation8Disability / Sedation9Electrolytes10Fluids11Gastro / feeding12Haematology13Infection14Lines151st edition - March 2018 ? St George’s PICUBy Mary Boullier, David Cohen & Nick Prince2nd Edition: May 2019, Sukesh Mohta, Jonathan RoundIntroductionWelcome to PICU! This is a quick-reference booklet full of practical, essential information for anyone new to PICU. It briefly covers some common clinical guidelines, and also a lot common practice in PICU that is not written down, but has become the way things are done.For the full and comprehensive guidelines for PICU go to: Paediatric Intensive Care Department at St George’s has 2 wards:1) Paediatric Intensive Care Unit (PICU) – 1st floor Lanesborough wing10 beds (2 cubicles / 4 semi cubicles / 4 open bay)Patients require either ICU or HDU support2) Paediatric Step Down Unit (PSDU) – 5th floor Lanesborough wing4 beds (4 open bay, 1 cubicle), non-ITU/HDU PSDU is not an admission unit, however, in some special circumstances a patient may be admitted directly to PSDU – this may include a patient who needs admission to hospital and is on home ventilation, however does not need ICU support. Patients in PSDU will be on a ‘stable’ or ‘improving’ trajectory.There is a side-room policy (useful to help decide who to give priority for side-room to) available on St George’s PICU guidelinesThe Permanent TeamBoard with staff photos is in the entrance to wardBoard with nurse’s names for the shift is next to Dr’s office (helpful for learning names)ConsultantsDr Caroline Davison – PICU Lead & Paediatric AnaesthetistDr Linda Murdoch – PICU & Paediatric AnaesthetistDr Jonathan Round – PICU, Reader in Clinical EducationDr Soumendu Manna – PICU & Clinical Fellowship Programme Lead, rota managerDr Anami Gour – PICU, Global Child HealthDr Buvana Dwarakanathan – PICUDr Nick Prince – PICU, College Tutor for PaediatricsDr Dilanee Sangaran – Locum Consultant, PICU Senior nursesAnita D’Souza – MatronGeorgina Wilcock – acting MatronRachel Upton – acting MatronUsha Chandran – Nurse Lecturer PractitionerJulie Geevarghese – Nurse Practice EducatorSistersSophie BreenSherly GeorgeHolly PriceJosephine RhodesMartin MakatoLouise MahonJacopo MarteroSian ButlerPharmacistEfe Bolton (bleep 7407)DieticianMichelle WebberPhysiotherapistsClaire-Louise ChadwickCaroline ShawMaria PinningtonStructure of the weekDaily timetable0830 – 0900Handover (in PICU seminar room during the week, coffee room on weekends)Patients allocated to medical staff (2-4 patients per doctor, one doctor will cover PSDU)0900 – 1100 Review patients allocated to you (notes/obs/results, examine, document, order tests)1100 – 1300 Sit down MDT Ward round (in PICU seminar room) 1300 – 1400 Lunch1400 – 1645Ward jobs/ meetings1645 – 1700Evening handover (short day team go home)2030 – 2100Handover to night team by long day team (coffee room)Specialty meetingsTuesday 1300Xray meeting – in St James’ Radiology dept seminar roomWednesday 0900DRUGGLE – Brief drug safety teaching by pharmacist Natasha. Discussion of any drug errors in past week + short teaching on any relevant drugsWednesday 1300ST 1-3 teaching (although all welcome). NICU seminar room.Wednesday 1430Paediatric Infectious Disease ward round (in paediatric seminar room)Thursday 0900Case base discussion: short teaching by a PICU consultantAdmission / discharge / handoverTransfer to Freddie Hewitt / Pinkney / NichollsPrior to the patient transferTransfer letter must be on iclip (a summary of admission and plan – save as a clinical note with title ‘PICU discharge summary’) Bleep paediatric registrar/SHO on 8152 and handover verbally (for all patients including specialties)If patient is under a specialty team; they should also be informed of the transferDocument on iclip who the verbal handover was given to and timeTransfer to another hospitalOn morning of planned transfer: call hospital and give medical handover to paediatric registrarComplete discharge summary on iclip – go to ‘depart’ and complete documentWhen patient leaves click on ‘discharge patient from ward’ and tick box at the bottom of screen ‘patient carer understands discharge plan’ReferralsThree sources of referralSTRS (South Thames Retrieval Service) / Children Acute Transport Service ( CATS) for North ThamesComplete referral form (found next to Stevie’s desk) for ALL referrals, even if not accepted.Discuss referral with consultant on call and nurse in charge prior to acceptingWard / EDSurgical elective admissions – surgeon / anaesthetist will request a bed and these cases will be discussed at morning handover and theatres will be updatedAll referrals must be discussed with a PICU consultant before acceptance / refusal Specialties in PICUIn general, the speciality manages the speciality matters, PICU manages and coordinates anything else. Eg surgical patient – the surgical team manages the operated organs, wound, drains. PICU manages pain, fluids, antibiotics, and other organs. Planning is done together and discussions with the family are coordinated and usually together.There are a large number of speciality focussed guidelines on the unit website. .uk.OncologySGH is both a primary treatment centre (PTC) and paediatric oncology shared care unit (POSCU). PICU at SGH provides the ICU support for patients of paediatric oncology at the Royal Marsden. Common reasons for admission to PICU includeNew diagnosis – tumour lysis syndrome / bleeding / infections / mass effect etcSolid tumour – admission mostly postoperativelySepsis with febrile neutropeniaRespiratory failure post bone marrow transplant / severe graft vs host disease If an oncology patient is in PICU the oncology team will come to WRTraumaSGH is a trauma centre with a helipad – receiving trauma admission from across SE England.Traumatic brain injury protocol is available on SGH PICU guidelines specialtiesPaediatric General Surgery NeurosurgeryENTMedical specialtiesRespiratory, Neurology, Endocrine, Gastro, Allergy, Paediatric Infectious Disease rightbottom TOP TIP! Paediatric Emergency Drugs App Drug doses and infusionsTube and line sizesGuidelinesProcedures (eg: how to tape ETT)Download here: 00 TOP TIP! Paediatric Emergency Drugs App Drug doses and infusionsTube and line sizesGuidelinesProcedures (eg: how to tape ETT)Download here: AirwayKey calculationsETT Tube size = Term infants: 3 cuffed / 3.5 uncuffed ETT. Age 6 -12 months: 3.5 cuffed / 4 uncuffed. Age 1- 2 yr: 4 – 4.5 cuffed / uncuffed. Child ≥ 2yr: (age/4) + 4mm (if airway swelling eg croup use 0.5-1mm smaller)For cuffed ETT use 0.5 mm smaller size ETT. Micro-cuffed ETT are preferred if available, these are high volume low pressure cuff ETT: which apply less pressure to sub-glottis hence reduced risk of airway trauma. Tube length = (age/2)+12cm (oral) (age/2)+15cm (nasal)Preference is for nasal ETT, however oral ETT may be used first to stabilise patient2 doctors should be present for intubation. LOCSIP: use LOCSIP document as safety check list and then fill it pleaseConfirm position with ETCO2Cuff should not be inflated in <10 yrs old unless difficult ventilationPosition on CXR – T2-3Laryngoscopy blade: for young infants, straight laryngoscopy blade: Miller blade / Robert Shaw / Stuart. Consider Stuart / Robert Shaw laryngoscopy blade (rather than Miller blade) when changing / doing nasal ETT for young infant as this gives a ‘wider’ view of oral cavity. Drugs for intubationAll patients should have STRS emergency drug calculator sheet at bedside, before start of induction.Induction agent. Discuss this with the attending consultant before its too late. IV Fentanyl 1-2mcg/kgIV Ketamine 1-2mg/kgIV Propofol 1-2mg/kg as a sole induction agent can be used in haemodynamically stable patient. Muscle paralysing agent: IV Rocuronium 1mg/kg ORIV Suxamethonium: Infant (up to 1yr): 2mg/kg. Child: 1mg/kg. Loose or wet tapes / reposition tubeThese need to be changed urgently to maintain secure airway – need at least 2 people for taskEnsure adequate sedation consider bolus of proprofol (1-2mg/kg) +/- muscle relaxant REMEMBER to switch to FULL ventilation BEFORE administering Propofol +/- muscle relaxant Check length tube is secured at and prepare tapes and duoderm1 person holds tube, 2nd person replaces tapesTo see how to apply tapes - ExtubationChecklistThe clinical condition of the patient is resolved for which he / she was put on ventilator Optimised ventilation – low ventilator pressures, low FiO2, breathing spontaneously / reasonable cough and gag reflex present Spontaneous breathing trial successful.Suctioning / chest physio done if neededAirway trolley available at the bedside with equipment prepared if reintubation neededSet up CPAP / optiflow if likely to be neededCheck has been NBM 6 hrs prior to extubation and aspirate NGTDouble check / inform nurse incharge Deflate cuff and ask patient to cough (if older child)Remove ETTGive facemask O2 – or other NIV as appropriateFailed extubation If stridor post extubationGive adrenaline neb 1 in 1000 (1mg/ml): 400mcg/kg (can be repeated)Give IV dexamethasone 0.2mg/kgIf ongoing upper airways obstruction re-intubate and give 48 hours dexamethasone 0.2mg/kg TDS Use 0.5mm smaller / uncuffed ETT for reintubation with upper airway obstruction. TracheostomyIf correct diameter was chosen then length should be appropriateLong term traches are usually uncuffed but patient may require cuffed trache tube during acute illnessNew trache (1st 7 days) will have stay sutures securing trachea to skin – these will be tapped to child’s chestFor more information about paediatric tracheostomy settingsThere is a lot of different terminology and some terms mean the same thing We use Dragger Evita Ventilator. BIPAP ventilator mode is mostly a default mode on the unit to begin. CMV – Continuous mandatory ventilation: PIP, PEEP and set rate. Not synchronisedSIMV PS / BIPAP ASB – Combination of a set rate with all additional patient triggered breaths also supported. ASB – Assist Support Breath: PS above level of PEEP. SIMV – Synchronised intermittent mandatory ventilation: volume control + PS Breaths are syncrhonised with patient breaths. Patient can take extra breaths but these are unsupported. PS – Pressure support. PS is set abve PEEP and when patient triggers a breath the ventilator delivers the additional pressure support to assist. CPAP– Continuous positive airways pressure – can be via ETT or nasal cannula / face mask / hoodBIPAP – Bi-level Positive air way pressure - can be given non-invasively and may also be called SiPAPInitial settings suggestionPIPPEEPRateI TimeETCO2SatsStandard*16-305 15-200.7-14-7 kPA>90%AsthmaTo move chest512-2016-10 kPA>90%*PIP initially to get chest rise. Titrate to ET CO2 / paCO2, limit to prevent barotraumaSevere hypoxia in ARDS use recruitment manouveres, suction, increase PEEP Volume control mode of ventilator is used in patients’ with traumatic brain injury to achieve a tight control of EtCO2 and pCO2 of 4-5kPa Troubleshooting – alarming ventilator – DOPESDisplaced ETT. Check ETCO2. Check ETT length – has it movedObstruction – suction and check suction catheter can pass full length ETTPneumothorax – clinical examination +/- CXREquipment – Hand ventilate with bag – if problem resolves on bag then check ventilator settingsStomach – decompress by aspirating NGTALWAYS CHECK EtCO2 trace on the monitor NebulisersNebs can be used to loosen secretions – most beneficial when used prior to chest physio0.9% or 3% NaCL. 6% NaCl can be used with Chest Physio advice and consultant’s approval. DNase (Dornase alpha) may be used if problematic secretions with high ventilation requirement (peak airway pressures >28) Consider DNase neb with chest physiotherapy early in management of an Asthmatic Child CirculationReference values for normal heart rate and blood pressure targets in Paediatric age group: minimal target Systolic blood pressure for children: Age less than 1 month: ≥ 60mmHgAge 1month to 1 yr: ≥ 70 mmHgAge 1 - 10 yrs: (age X 2) + 70 mmHgAge > 10yrs old: min target systolic Blood pressure: > 90mmHgAdvisable minimal Mean blood pressure for children: Age (in yrs) X 1.5 + 40 mmHg For Premature Neonates: gestational age = mean Blood pressureREMEMBER LOW BLOOD PRESSURE IS A LATE SIGN OF SHOCK: treat aggressively. bolus: 0.9% NaCl fluid bolus in aliquots of 10-20ml/kg: reassess clinically after each fluid bolus – heart rate, capillary refill time, peripheral and central temperature, liver size, Blood Pressure, consciousness level and urine output.. Early use of blood products in patients of suspected meningococcal sepsis (FFP / Octaplas / platelets) and in trauma patients (PRBC): Ensure group and cross matched samples are available. Minimum two secured intravenous access MUST be achieved.Broad spectrum IV antibiotics cover ASAP, MUST be within 1st hr of contact if sepsis is suspected. IO access: if none CVL access present and patient is in Fluid Refractory shock. Start Inotropes: if 40-60ml/kg fluid resus has been given (Fluid Refractory shock). Common default initial inotropes in children: IV Dopamine @ 10 – 15 mcg/kg/minIV Dopamine can be started through a secured peripheral venous access. Consider an early start of inotropes and intubation in patients of septic shock.Start Inotropes before induction for intubation in patients of sepsis. Be prepared for decompensation during induction and intubation. Continue on-going fluid resus with inotropes on board. Achieve a secured central venous access: preferably US guided at earliest possible if patient is in fluid refractory shock. Should have had an IO inserted by this stage if not done so. Intubation takes precedence over CVL access. Once CVL is achieved:Warm vasodilatory shock: on going fluid resus + Noradrenaline infusion a common scenario in febrile neutropenic oncology patientFebrile patients with indwelling devices: infected VP shunt / infected CVLCold shock: cautious fluid resus + adrenaline infusion Cold shock is much more common in Paediatric age group than adults: Its usual presentation of sepsis in young childrenAdvisable to have invasive arterial blood pressure monitoring if Shock is an active issue. Fluid refractory + Inotropes Refractory shock (patient is on two inotropes)Ensure drug infusions delivery Replace and replenish losses IV Hydrocortisone: 2mg/kg, max 50mg, 6 hrly Consider Echocardiogram: to rule out cardiogenic shockRule out obstructive reasons of shock: i.e. large pleural effusion Rule out intra-abdominal hypertension Appropriate source control of sepsisEscalate care appropriately: consider referral to ECMO / SedationSedationIn invasively ventilated patients, usually start with IV morphine and IV midazolam infusion – then add in clonidine and wean off midazolamStep 1 – Morphine 50 -100mcg/kg bolus (max x2) then infusion 10-60mcg/kg/hr (inc by 10)Step 2 – Midazolam 50 - 100mcg/kg bolus (max x2) then infusion 60 -240mcg/kg/hr (inc by 60)Step 3 – Clonidine 1-5mcg/kg 8hrly PO, Need to give initial test dose of 1 mcg/kg; usual dose used is 3mcg/kg/dose every 8 hrs. Or clonidine infusion: start at 1mcg/kg/hr – increase by 0.5mcg/kg/hr – up to max 2mcg/kg/hr if cardiovascularly stable. High infusion rate of Midazolam and clonidine can be used in patient with Dystonia. Patient with Status Epilepticus may need high doses of midazolam infusion to gain control.Prolonged sedation Midazolam should be weaned and stopped by day 5Clonidine should be optimisedAdd chloral hydrate 15-50mg/kg 3 -6 hrly (Max 200mg/kg/day) +/- Alimemazine 1-2mg/kg 8 hrly POSee guideline for futher advice blockerA small proportion of children will require continuous infusion of a neuromuscular (NM) blocker when fully invasively ventilated. Ensure patients are optimally sedated before commencing NM blocker agent. IV rocuronium infusion is usual practice (300-600mcg/kg/hr). Need for NM blocker should be reviewed regularly and should be discontinued as soon as possible. SeizuresPatients may be on PICU for refractory seizure on midazolam infusionEEG request form found on intranet – search EEG on intranet home page for form. Fax to 0208 725 4637. Call ext 5290 to confirm receipt. rightbottom TOP TIP! Always prescribe drugs as per the nurses’ drugs prep guide on the intranetThis ALWAYS takes precedence over the BNFC00 TOP TIP! Always prescribe drugs as per the nurses’ drugs prep guide on the intranetThis ALWAYS takes precedence over the BNFCElectrolytesPotassiumNormal serum value: 3.5 to 4.5mmol/LUsual daily maintenance 2-3mmol/kg/day – may need more if on diureticsHYPOKALAEMIA (K+ <3.0) If enteral route available: Give 1mmol/kg, check serum potassium after 1-2 hr. Enteral route is preferable to Intra-venous route.If enteral route not available: IV Potassium chloride 0.4 – 1mmol/kg can be given. Infusion over 1-2 hrs thru central venous line. Max dose 20mmol IV.Rate of administration: 0.2mmol/kg/hr. NOT more than 0.5mmol/kg/hour.RECHECK serum potassium in one hour after starting IV correction. Target serum potassium levels of 4-5mmol/L in patients of cardiogenic shock /arrhythmia and paralytic ileus.If on TPN discuss with pharmacistHYPERKALEMIA: (K+ ≥ 5mmol/L). Excessively squeezed capillary sample can have falsely high potassium values. If true hyperkalemia or patient at high risk of hyperkalemia / developing renal failure: STOP all potassium containing fluids, including TPN and drugs which can increase serum potassium like Spironolactone (potassium sparing diuretics) and Captopril (any ACE inhibitor)Recheck / Send blood sample to labs for electrolytes, bone profile, urea and creatinine. Make sure blood sample was not contaminated with potassium containing fluid. Salbutamol nebulisation: 2.5 – 5mg nebulisation – B1 adrenergic receptor stimulation by salbutamol shifts intravascular potassium to intra-cellular and reduce serum potassium concentration. IV Sodium Bicarbonate: 0.5 – 1mmol/kg. (preferably by CVL) SERUM POTASSIUM ≥ 6mmol/L IS A MEDICAL EMERGENCY: treat aggressively and seek advice. IV Calcium gluconate 0.5 ml / kg slow IV (preferably by CVL – remember Bicarb and Calcium are incompatible and can cause precipitation: flush generously with IV 0.9% NaCl in between). IV Calcium does not lower serum potassium but antagonises effects of high potassium on myocardium (reduces cardio-toxicity of hyperkalaemia). IV Salbutamol 5mcg / kg. Repeat IV Sodium bicarbonate and hyperventilate: try to get blood pH > 7.35Consider IV Glucose + IV Insulin infusion, if serum potassium is persistent > 5.5mmol/L after above measures.Actively look for causes of persistent hyperkalemia like tumour lysis / haemolysis / AKI CRRT MagnesiumAim 0.8-1.0mmol/L. If low prescribe IV replacement – see nurses prep guide for doses. Aim for high Mg level (≥ 1mmol/L) in patients with bronchial asthma, pulmonary hypertension, arrhythmia and status epilepticus. Persistent low magnesium levels will cause refractory low potassium and low calcium levels. Calcium: Look for and target normal ionized calcium levels (1.2 – 1.4mmol/L), specifically in patients of arrhythmia / shock / trauma / actively bleeding / massive transfusions. Correct with IV Calcium through CVL: check for dose as per nurses guide / iClip. SodiumUsual maintenance = 2-4mmol/kg/dayIf Na abnormality – assess fluid statusHyponatraemia – follow PICU guidelinesFluidsFor full guideline see St George’s PICU guidleines: calculationIV fluids should only be used if it is not possible to give feeds enterally. In PICU 80% maintenance fluids should be given unless otherwise specified.Use this method to calculate 100% maintenance – then give 80% of this volume over 24 hoursExample 22kg child1st 10kg = 100ml/kg/day= 1000ml2nd 10kg = 50ml/kg/day= 500mlSubsequent kg = 20ml/kg/day= 40ml100% maintenance = 1540ml/day = 64ml/hr80% maintenance = 51ml/hrUp to max of 2500ml/day for young adult male and 2000ml/day for female as 100% allowance. Types of fluid0.9% NaCl + 5 % Dextrose (+/- KCl 10mmol/500 ml bag) is a common fluid of choiceFor neonatal age group: 0.45% NaCl + 10% Dextrose (+/- KCl – 10mmol/500ml bag) Bolus – for hypovolaemiaIf a bolus is required give 10-20ml/kg aliquots of 0.9% NaClConsider Ringer’s Lactate if hyperchloraemia (don’t use if metabolic condition)Consider PRC if blood loss (trauma / post op)DehydrationReplace over 24 hours (48 hours if DKA – follow DKA fluid protocol)Fluid deficit (ml) = weight (kg) x % dehydration x 10Gastro – feedsMichelle Webber (dietician) has put together a very thorough protocol regarding feeds choice AgeWeightFeed0-1 yrs<10kgExpressed Breast MilkSMA first / Cow & Gate 1, Aptamil first1-6 yrs10-20kgNutrini7-12 yrs20-45kgTentrini7+ yrs>45kgNutrisonIf already on a milk feed at home try to use the same feed in hospitalIf the feed is not available – refer to feed protocol to find suitable alternative that is stockedGastric protectionIf not receiving enteral feeds prescribe ranitidine for gastric protection Prescribe gastric protection if patient is on systemic steroidsBowel managementPatients on PICU are at risk of constipation: note to review bowel motion in patients’ PICU day review. Regular movicol could be considered to prevent this, or suppositories such as glycerine.HaematologyBlood productsPatient needs to have 2 blood group samples sent (labelled with different sampling times, 30 minutes apart, preferably by 2 different health care professionals) before any blood product can be issued.Usually samples should be 2-4mls in adult pink bottleFor small babies the lab will accept lilac (paediatric FBC) bottle – with handwritten label (on a sticker)Blood can be requested by phone and should be prescribed on iclip. PICU usually follow conservative blood product transfusion policy. For oncology patients Hb and Platelets targets are usually agreed beforehand. DISCUSS with Consultant PICU before transfusions. Hb: Patients are usually not given packed red cells transfusion (PRBC) for Hb as low as 70gm/L on PICU, if are stable / improving. PRBC 10-15ml/kg over 2-4 hrs: can raise patients’ Hb by 10 – 30 gm/L. FFP: Fresh Frozen Plasma / Octaplas: 10 – 20ml/kg over 1-2 hrs.Platelets: 5-10ml/kg over 15-30 minutes. Transfuse platelets as soon they are received from blood bank. Platelets denature rapidly when kept outside un-agitated. Cryoprecipitate: it is used to replenish blood fibrinogen level; target plasma fibrinogen level > 1-1.5gm/L. Dose of cryoprecipitate: 5ml/kg, given over 15-30min. Infection SamplesBAL should be sent for all intubated patients with LRTIAnaesthetic trainees or physiotherapists will be happy to teach you how to take a BAL (needs to be done by a Dr)AntibioticsConsider using max dose of antibiotics for the age and weight of a patient admitted to PICUCeftriaxone is NEVER used in PICU (due to possible incompatibilities with other infusions). Any patient who has been started on ceftriaxone should be changed to cefotaxime – they can receive the first dose 12 hours after the initial dose of ceftriaxone.Follow the microguide for antibiotic choiceLRTI admitted to PICU requiring intubation and ventilation: usually receive IV Co-Amoxyclave. Difficult cases can be discussed with PID – ward round is on Wed afternoons.IV aminoglycosides needs regular follow up of levels. Vancomycin – take level pre 4th dose (0-30mins prior to dose). Dose should be given – do not delay pending result.For Vancomycin dosing guidance see TOP TIP! Download MicroGuide app for St George’s Paediatric micro guidelines00 TOP TIP! Download MicroGuide app for St George’s Paediatric micro guidelinesLinesInvasive arterial lines: US guided, radial artery cannulation is most preferred option. Advisable to have invasive arterial line on any critically sick patient like with shock / traumatic brain injury / high ventilator settings / ARDS etc.. Infants: 24 Gauze, IV cannula (Jelco)Young children: 22G, IV cannula (Jelco) or 22G, arrow, 4cm arterial lineOlder children / Adolescents: 20G / 3 Fr, leadercath arterial line Femoral arterial line: 20G leadercath cm arterial line. In neonates 22G 8cm line can be used. Vascular team: for children > 6-7kgs: a paediatric ward based specialist nurse service can help to put a mid-line ( 22G, 8cm, arrow, single lumen venous access) on PICU patient. They can be contacted on bleep: Central venous access: US guided femoral central venous access is preferred approach in children on PICU. There is none evidence to show in children that femoral venous access has more chance of infection in comparison to internal jugular venous access. Femoral CVL access: Infants: 4.5 Fr, triple lumen, 6 / 8cm lines Young children: 5 Fr tipple lumen, 8 – 12 cm. 15cm length can be used in older children. Older children (> 40 kgs) and adolescents: 7 fr, triple lumen, 15 cm line.Internal Jugular venous access: Infants: 5 Fr, triple lumen, 6cm / 5 Fr, triple lumen, 5 cm.Young children: 4.5 Fr, triple lumen 6 cm / 5 Fr, triple lumen, 5-8 cm.Older children: 5 Fr, triple lumen: 8-12cm.Young Adolescents: 7 Fr, triple lumen: 12 cm Young adults: 7 Fr, quadruple lumen: 15cm / 8.5 Fr, quadruple lumen. Chest X-ray and document position of internal jugular CVL before being used. For TPN and inotropes purposes ideal tip position is at right atrium and SVC junction. (at the level of tracheal carina/ 5-6 vertebral body). ................
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