Pediatric ICU (PICU, Pediatric Intensive Care Unit)

In one children's intensive care unit, deaths fell from 11 percent to 4.8 percent in a generation. More than 95 in 100 children admitted now leave the unit alive.

A pediatric intensive care unit, or PICU, treats infants, children and teenagers whose breathing, circulation or brain needs support that a ward cannot give. Newborns in their first month belong to a separate neonatal unit. The figures above come from the Royal Children's Hospital in Melbourne, which compared 4,010 children admitted in 1982, 1995 and 2005 to 2006 and found that illness was just as severe in the later years while far fewer children died (Namachivayam and colleagues, Pediatric Critical Care Medicine, 2010). This page explains what the Pediatric ICU at Biruni Hospital in Istanbul does, what parents can expect in the first hour and the days after it, and how a family abroad can have a child's file reviewed.

The first hour

Arrival looks chaotic to a parent. It follows a fixed order.

Within the hour a senior doctor sits down with the family and says what is wrong, what has been started and what the next six hours should show.

What parents ask

Children are not small adults

A healthy child hides serious illness well, then worsens fast. That is why pediatric units watch trends and not single readings.

Normal values change with age. A heart rate of 150 is ordinary in a baby and alarming in a twelve year old. A breathing tube for an infant is about as wide as a drinking straw, so a little swelling or mucus that an adult would never notice can block it. Small bodies lose heat and sugar quickly, and they hold so little blood that the volume drawn for tests has to be counted. Drug doses are worked out per kilogram and checked by two people, because a decimal point in the wrong place is a tenfold error. Children also compensate. Their blood vessels tighten and the heart speeds up to hold blood pressure steady until very late in an illness, which means a normal blood pressure reassures nobody in a PICU, and the staff look at skin color, the warmth of hands and feet, the time a pressed fingertip takes to turn pink again, and how much the child is interacting.

All of this shapes the unit. Equipment comes in every size from infant to adult, and the nurses and doctors work only with children.

Why children are admitted

1. Breathing trouble. Bronchiolitis in infants, pneumonia, severe asthma and croup lead the list in every season.
2. Severe infection. Sepsis, meningitis and infections in children whose immunity is low.
3. The brain. Long seizures, head injury, and coma from any cause.
4. After surgery. Heart, brain, spine and major abdominal operations, for planned monitoring.
5. Metabolic emergencies. Diabetic ketoacidosis, severe dehydration and poisoning.

Breathing support has become gentler. In a trial of 1,472 infants with bronchiolitis in the emergency departments and wards of hospitals in Australia and New Zealand, warmed high-flow oxygen through soft nasal prongs was compared with standard oxygen, and 12 percent of the high-flow group needed their care stepped up against 23 percent of the others (Franklin and colleagues, New England Journal of Medicine, 2018). Of the infants who failed on standard oxygen, 61 percent then settled on high flow. Many babies now get through the illness on nasal prongs, awake, feeding, and in a parent's arms.

Sepsis is the opposite case. It demands speed. A survey on five days across 128 pediatric units in 26 countries found severe sepsis in 8.2 percent of the 6,925 children screened, with the chest the source in 40 percent. Three in four needed a ventilator and one in four died, a figure that did not differ between wealthy and poorer countries (Weiss and colleagues, American Journal of Respiratory and Critical Care Medicine, 2015).

What the numbers say

Two findings belong side by side. Start with the encouraging one. Across 44 children's hospitals in the United States, deaths among children coded with severe sepsis or septic shock fell by 10.9 percentage points between 2004 and 2012, even as more cases were recognized (Balamuth and colleagues, Pediatric Critical Care Medicine, 2014). Now the sobering one. In the Melbourne comparison quoted at the top of this page, the share of survivors living with a moderate or severe disability rose from 8.4 percent in 1982 to 17.9 percent in 2005 to 2006, partly because children with very complex conditions who would once have died now survive. The international sepsis survey found at least moderate new disability in 17 percent of survivors. Families should hear both halves. A good unit plans for rehabilitation, schooling and follow-up from the first week, and does not treat discharge from intensive care as the end of its job.

Parents at the bedside

You know your child better than anyone in the building. Use that.

• Tell the nurse what is normal for your child, including words, comfort habits and how pain usually shows.
• Bring a favorite blanket, toy or recorded song from home.
• Touch, hold hands and talk, even when your child is sedated.
• Join the morning round and ask for anything unclear to be said again in plain words.
• Sleep and eat. A long stay needs parents who are still standing in week two.

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Brothers and sisters worry too. The nurse will explain how and when they can visit, and a short, prepared visit usually frightens a brother or sister far less than the pictures they have been building in their own heads at home.

After the PICU

Going to the ward feels like the finish line. Parents often find it the hardest week. The nurse who sat at the bed all night now looks after several children, the monitors are fewer, and a child who was calm under sedation turns weak, clingy, angry or unable to sleep as the medicines wear off. None of this means something has gone wrong. Muscles waste quickly in a sick child and return with play and physiotherapy, sedative drugs given for more than a few days are reduced step by step to avoid withdrawal, and nightmares or fear of hospital staff fade in most children over weeks, faster when parents talk about the stay openly and keep routines familiar. Parents carry their own share. Poor sleep and intrusive memories are common in mothers and fathers after a PICU stay, and they deserve the same attention, which starts with telling your own doctor what the family has been through.

Before you leave the hospital, ask for three things in writing, namely the medicines with their stop dates, the follow-up appointments, and the warning signs that should bring you back.

Families from abroad

The international patients office assigns one coordinator with the first message, and that person stays with the family through discharge and answers the same WhatsApp number once you are back home. English, Arabic, French, Russian, Serbian, Romanian and Spanish are spoken in the office, and interpreters are arranged for other languages so that parents hear every explanation and every consent in words they fully understand. The same desk books accommodation near the hospital, airport transfers and daily transport, and it issues the invitation letter that consulates ask for with a visa application. Halal, vegetarian and diabetic meals come from the hospital kitchen, the building has a prayer room, and a request for a female physician is passed to the department and met wherever the rota allows. When the child moves from intensive care to a ward room, a companion bed lets a parent stay the night. Nothing in this list costs extra effort from the family.

To start, send the current medical summary, recent blood tests, imaging reports, the list of medicines and machines in use, and your child's age and weight. A pediatric intensive care doctor reads the file free of charge and replies in writing.

Cost

Days in the unit drive the total. Ventilation, dialysis, blood products, operations and costly anti-infective drugs add to it, and the air ambulance is quoted by the flight company as a separate matter.

In this market a children's intensive care stay is quoted per day with a written list of what the day rate covers. Two questions belong in writing, namely who revises the estimate as the stay lengthens and whether your insurer will be billed directly. Figures given before the doctors have read the file mean little.