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The degree to which the surgical services manage the medical issues of their patients will depend on the service and the patient. Orthopedic patients from Shriners are admitted to the service of the Pediatric Intensivist if the orthopedic surgeon does not have privileges. The pediatric residents write admitting orders for most of these patients. BBBD/IAC patients. The BBBD service is the primary service and writes all orders on the patients. They should be called for anything that is needed short of immediate resuscitation. Routine Procedures There are pre-printed orders for general PICU admits, CV surgery admits (track A and general), and ECMO admits. If you use a pre-printed order and want to write more things, use regular order paper. There are also pre-printed orders for sedation drips, muscle relaxant drips, cardiac patient ventilator weaning. Others are being added on an ongoing basis. Admitting orders to the PICU should include the following categories: Diagnosis Attending physician Condition Vital sign frequency (routine is q2). If you want things documented more frequently, be specific. (Hourly is reasonable for sick patients) Allergies Nursing—specific nursing requirements Dressing changes Chest tube orders CVP/A-line orders NG Foley Diet/NPO IVF (type/rate) Meds Drips written in amount/kg/minute (vasoactive) or amount/kg/hour (sedation/narcotic); consult with PICU MD or nursing staff about concentration to order. Labs—labs wanted on admission as well as lab schedule if needed. Ventilator settings along with weaning parameters (i.e., wean oxygen for O2 sat>???) Call HO orders. It is best to write these and also to speak with the RN caring for the patient about specific issues you are worried about, to ensure accurate communication. There are special order sheets for muscle relaxants, sedation, and PCA. If you are unfamiliar with them, ask the intensivist or the nurse to assist in using them. Post operative cardiac patients and ECMO patients have pre-printed orders. These will be completed by the intensivist or the pediatric resident with attending supervision. Verbal Orders Verbal orders may be taken only when necessary. These must be written and signed as soon as possible after having been executed. Emergency Procedures In the absence of a physician, if a child's condition changes while waiting for the physician caring for the child, the nurse may do the following where appropriate: 1. Draw blood gases, electrolytes and hematocrit, and send these to the lab for stat results. 2. Call for chest x-ray or other appropriate x-ray. 3. Administer oxygen. 4. Institute cardio-pulmonary resuscitation with Ambu bag and external cardiac massage. 5. The PICU attending should be called immediately for any sudden, unexplained change in a patient’s condition. In the event of a cardio-respiratory or respiratory arrest where the PICU attending is not immediately available, the Pediatric Code 99 team may be called. 6. If an anesthesiologist is needed emergently, the pediatric on call anesthesiology number should be paged.
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