In the first article on this subject I looked at which intensive care is which; what you can expect when you and your child first arrive on one of the units and I briefly introduced to you the main people you will come across during your first hour on the ward. In this article I intend to describe the equipment that you are likely to find around your child’s bed.
Again this article is not referenced as is my usual practise, but written from experience. However, this does not mean that I don’t love learning. I love receiving comments, so feel free to share you experiences with me either publicly or personally.
What equipment will I find around the bedside?
There are certain things that your child will be attached to, firstly because they need it, and secondly because if they don’t then they will not be in need of an intensive care bed and will be in the process of being transferred to the ward; where they can be looked after in a more ‘play’ friendly environment.
As a parent you will not be able to stay at the bedside of your child when they are in intensive care. This will mean that you will have to stay at home, at one of the parents rooms at the hospital (these may be limited or non-existent, and you may have to meet certain criteria to be allocated one: such as living a certain amount of miles away), or in one of the charity run houses. I can not give you much information on these, but on arrival at the hospital the ward clerk will introduce themselves to you and be available to advice you on somewhere to stay.
Once your child has been discharged from the intensive care, unless you have found a charity run family room, you will usually lose any residential place you have found as there is space for one parent to stay at the bedside. This means that you can stay with your child whether they be a baby or sixteen years old. Parents often chose to take it in turns to do this when it doesn’t fall to the mother.
So, if there is no fold out bed at the bedside what is there?
This looks like a television. It might be flat screen, or seem more old-fashioned, and it might have different coloured lines on it each day, but it is always doing the same thing. Like any computer screen the nurse on duty that day can change the size of the lines and numbers and their colours to their personal preference.
After-all, as alluring as it is for parents to stare at, it is the nurses that have to read off it continuously and record information from it at least hourly. They should be happy enough to explain the readings to you, but some nurses do avoid doing this as they feel that it helps parents not to become anxious focusing on numbers and forgetting to look at the colour of their child. Personally, I probably give out too much information sometimes, knowing that I would want to know.
If you feel you are not getting the answers you want then politely ask someone else. Between the bedside nurse, the nurse covering her breaks, the nurse in charge, the named registrar that day, the physio (who probably will come twice a day) and the overseeing consultant I assure you it wont take long to find out what is beeping on the monitor if you want to!
What is it reading?
Firstly there are three, or five, possibly different colored, wires stuck via gel stickers to your childs chest and abdomen (and possibly a limb). These are measuring their heart rate and rhythm (shown at the top in the picture of the monitor above), and recording this is the usual practise for every child. It is not because there is necessarily a problem with your child’s heart, but because this is a more accurate way to measure heart rate than by saturation probe alone and a change of heart rate is a good indicator of pain, temperature, stress, or even just being too sleepy!
Although this monitoring is known as an ECG, if the doctors request an ECG or electrocardiogram then they require a 12 lead ECG, This is actually taken using 10 wires attached to electrodes (gel stickers to chest and limbs), but records the hearts activity from 12 different leads (the voltage difference between two of the electrodes). Any form of ECG monitoring is completely painless. It is recommended though that the gel electrodes/ stickers be changed everyday to avoid the skin underneath them drying out.
If the ECG line disappears then it is due to one of the wires coming unattached. If the monitor beebs then it is alerting the nurse to a change in heart rate which they can then chose to do something about. The monitor will beep a lot and the nurse will start to look concerned long before there is anything to worry about.
Oxygen saturation is monitored (bottom of the monitor picture) by a lead attached to a light and a plaster on your child’s finger, toe or ear lobe. This is looking at the percentage of oxygen in the body. It is not always accurate due to your child moving or being cold. It is important to assess it while looking at the trace next to it which should be the outline of uniform craggy mountains, but large hills are also OK too. This will cause the monitor to beeb a lot due to a loss of signal.
It’s measurement is completely painless, but after the probe has been in the same place for too long it can cause the finger or toe to feel like it’s pulsing, in my experience. The light can cause also redness to the skin too, so the nurses would usually move it every 4 hours. Young children can try to take it off merely because it feels weird having something wrapped wound their finger or toe as it is slightly heavy with the lead on it. Once they are no longer disoriented though it usually stops bothering them.
Blood pressure is monitored by a cuff on the leg or arm in the same way as you would have had yours measured at the GP. However, the cuff usually doesn’t tighten as much as it is usual to expect a child’s blood pressure to be lower than an adult as they are smaller and the blood has less resistance and distance to go to get round the body. In intensive care it is common to measure the pressure in the vein and the arteries (the latter is shown as a red line in the picture) separately and this is done using a plastic tube like a cannula that goes directly into a large central vein or an artery. This has the benefit that once in it is no more annoying than a cannula (discussed in article one) and it gives continual monitoring that is accurate and there is no need to keep doing cuff blood pressures which are more stressful for the child.
These lines can also be used to take blood which is of course a benefit as it means your child only has one entry point into their vein, or one into their artery and doesn’t need to be the constant victim of needles. It is painless to remove blood from these lines. Blood needs to be taken regularly in intensive care to keep your child stable. Perhaps every day, but also perhaps every twenty minutes! Don’t be fooled by the length of the thin syringe. These mean a very small amount is taken with the usual being half a millimetre. The fatter syringe is about five millimeters and same amount of liquid as you’ll find on a teaspoon and the team doesn’t like to take this much very regularly.
Your child’s temperature can also be continuously monitored (not shown in the picture) by a probe stuck on their foot, or lower leg for a peripheral temperature and through a line going into their nose and down the back of their throat to measure their core temperature. They will only have this second form of measurement if they are asleep and sedated so there is no fear of it being painful.
Apart from the respiratory rate (shown in white in the picture) the last main form of measurement you may see on the monitor (although again not in this picture) is something called an end tidal. This is connected to the breathing tube and it measures the amount of carbon dioxide being released. It is a good tool to avoid too many blood tests and helps to ensure your child is being ventilated properly. It can also help with removing the breathing tube altogether. In my experience, almost every day this will stop recording for one reason or another and this is never due to your child’s condition worsening.
The monitor itself is usually in the air above your child’s head and it can be rotated to different angles. At the head of the bed there will be a ventilator. This will usually remain in this position whether it is being used or not. If a child is in intensive care then at some point they will need the ventilator as this is usually the reason why they are not being cared for on the ward or high dependency unit.
The point of intensive care is to support your child’s normal bodily functions so that they can concentrate all their energies on getting better themselves through using their calories to repair their tissues or fight infection. The ventilator is no different. It takes over the job of the lungs when your child is too tired themselves, needs to conserve their energy or has been sedated and this medicine will affect their ability to breathe. There is usually nothing wrong with their lungs and with the correct balance, as a ventilator is not as efficient as our lungs in the long-term, your child will be left with no negative effects on their lungs from being ventilated.
The ventilator shown in the above picture is similar to what you would see, but quite a bit more clumsy looking as they have been updated since this was taken. It is connected to the breathing tube or ETT, and I discussed how this was inserted in article one. The breathing tube goes between the vocal chords so even when waking up your child probably wont be able to make any sound to talk or cry. The ability to make noise will return as soon as the tube is removed unless you have already been advised otherwise. Whenever a breathing tube is in, and it is not attached to a ventilator, it is like trying to breathe through a straw, so to help them your child will have to have it attached to a green bag that the team use to manually breathe for them, or hold to support your child with their breathing.
When thinking of ventilation, through an ETT, it works in the opposite way to how we breathe by pushing air into the lungs; instead of allowing it to flow in naturally due to the negative pressure created by the dropping of the rib cage and the expanding of the ribs. In thinking on how it works I like to think of our lungs as a party balloon. When it is new it is nearly impossible to blow up without stretching it, or someone with a lot of puff even starting it off for you!
Ventilation, namely CPAP, ensures there is a constant amount of pressure in the lungs. It is that little bit of air left in a balloon, that has already been blown up, and it makes it easier for you to blow the balloon up next time. Naturally if we didn’t maintain this constant pressure, as we do, in our lungs ourselves then our alveoli could stick together flat and become the hard to blow up balloon. As a machine the ventilator needs to be set to give this CPAP and it is set at a slightly higher level than we would naturally have for extra support. In fact on coming off ventilators young children, and babies in particular, often need to switch to the CPAP machine. Cpap alone can usually be administered through a face, or nose mask, and this gives them a little more support in breathing than oxygen alone which does nothing to keep the alveoli open, but only helps in dilating vessels slightly, or keeping the oxygen levels up.
On the ventilator as well as CPAP it is probably set to administer so may breaths per minute. This is to ensure that your child has the same breathing rate they would perhaps normally have. The ventilator is even programmed to wait a set period of time to see if you child is going to trigger to breathe at a certain time. The aim is to breathe for your child when your child wants to breathe, but if a breath isn’t triggered then it will give them one at the end of the few second time period. Lastly the ventilator also ensures that your child’s lungs expand to a certain size to ensure the ultimate efficiency. All these settings are decided by the medical and nursing team and the are tweaked according to the blood tests taken and the settings on the monitor to ensure your child remains in optimum health.
With a tube down the back of their throat to the top of their lungs they will be unable to swallow. The usual secretions we all have will be sucked out using a suction machine. Deep suctioning will only be done when your child is asleep and sedated as it is painful.
The nasogastric feeding machine
This breathing tube will also mean they can’t eat. They will still need their calories and the aim would be to give these into the stomach. They are fed a special age appropriate milk through a tube in their nose called a nasogastric tube (or sometimes mouth: orogastric tube) that travels into their stomach.
Having had one of these I can tell you it is a little eye watering when it is passed and you can feel the liquid running through it down your throat. It also felt painful in my throat a bit when it was not secured properly as it shifted in position from side to side, but most people find it no more than slightly annoying whereas others can’t feel it at all. It rarely seems to bother young babies. The aim would be to remove it as soon as possible and usually soon after your child wakes up.
If there is a reason why your child can’t be fed as their tummy needs to rest too then rest assured they are receiving the necessary calories through their blood stream. Obviously you would rather they get food, but rest assured so would the medical team. However, if a gut is fed that doesn’t want to be it wont take long to be irreparably damaged and this will mean surgery and lifelong problems for your child. The digestive system is very delicate and often the first thing to ‘start sulking’ when your body is anyway stressed.
The last, main thing by your child’s bed are infusion pumps and these come in different shapes and can be very overwhelming. The amount of pumps your child has does not equal the amount of lines they have in their body. One central venous line can have one puncture mark to the skin that leads to three lumens and it is not uncommon to have three infusions running to each lumen. To save your maths brain that is nine infusions accounted for already!
These infusions are not all medicine either. One is probably sugar-water with salt which may have other electrolytes in it. This keeps your child hydrated. Then two more syringes of salt water are probably running through lines to keep them open and reading blood pressure.
The usual medicines your child will be getting are sedation (this could be two syringes working in partnership) and perhaps a third medicine to keep their muscles relaxed to really rest the body. There are then usually a couple of medicines to support the heart with keeping your child warm and the blood pressure stable. This is not usually because there is anything wrong with your child’s heart.. but just temporary support.
Remember the bedside nurse is there to support you too, so feel free to share any concerns.
I hope you have found this article interesting. I hope that any stay your child has in intensive care is short and finishes with a positive outcome and I hope you feel able to share your experiences in the comment boxes below; for in turn then you will be supporting someone yourself.
- What to expect from intensive care (paediatric, neonatal, cardiac) (niccilouise.wordpress.com)
- Matthews room: a blog following matthew’s struggle with leukemia http://www.matthew.mask.net.au/photo5a.htm
- Neonatal Song Lowers Heart Rate, Improves Suckling (medicaldaily.com)
- Why Do Babies Calm Down When They Are Carried? (asianscientist.com)
- Neonatal Nursing within the Air Force (nicunursing.wordpress.com)
- From mice to humans, comfort is being carried by mom (esciencenews.com)