University Hospital of Wales Paediatric Intensive Care Unit Guideline Printed on Wed 23-jul-08
Search Site

Last updated March 7, 2019 8:21 AM

0300 0300 789

02920 744622

External links


029 2184 7322


Noah's Ark Childrens Hospital for Wales
Heath Park
CF14 4XW
02920 747747

Guidlines for clinical scenarios

The following guidelines have been prepared by Dr Ollie Masters, Consultant Anaethsetist at the Royal Gwent Hospital to help provide quick practical guidance to anaesthetic staff in a DGH setting who are managing a critically il child. The guidelines have been reviewed and agreed by the consultant team on PICU.

The emphasis is on these being guidelines, and it is not mandatory to follow them. They do, however, make suggestions on the combined experience of the team here.


Acute Asthma

Congenital Heart Disease


Other Information for anaesthetists

The majority of children being transferred to the paediatric intensive care unit will be intubated, and outside of the neonatal period, most paediatricians will ask that induction and intubation be done by an anaesthetist. Listed below are some frequently asked questions relating to anaesthesia:


What agents should I use for induction?

The choice of induction agents and the most suitable site for induction and maintenance of anaethesia is the choice of the anaesthetist who has been asked to assist. Generally, the best method to use is the one which you are most comfortable with. If you have specific questions relating to a particular clinical circumstance, we will be happy to give advice. We generally avoid using gas induction for anything other than acute upper airway obstruction, and particularly would seek to avoid this method in patients with septic shock. Evidence for the benefit of rapid sequence induction in children is even more uncertain in children than it is in adults. In smaller children, unless you have a team present who are familiar with rapid sequence induction and with the size of patient you are dealing with, we would recommend using another technique. The drug calculator can be used for dosages of commonly used induction and maintenance agents.

Tube sizes and lengths?

Below is the expected size and length of endotracheal tubes according to patient's age and size:

Weight (kg)

Diameter (mm)

Length oral (cm)

Length nasal (cm)

< 1




1 - 3.5




3.5 - 7




8 - 10




11 - 14




15 - 18




19 - 22




23 - 28





A CXR is essential to check tube position prior to transporting the patient.

Should the endotracheal tube be cut?

No please do not cut the tube.

We only occasionally cut the endotracheal tube to a manageable length once the tube has been secured and a chest x-ray has confirmed that it is in the optimum position. Our previous experiences have taught us that tubes are often cut quite short, and a subsequent chest x-ray may demonstrate that the tube is in a very high position and because the tube has been cut short, we have to replace it with another tube, rather than the easier method of simply advancing the existing tube.

Is it advisable to use cuffed tubes?

Yes - please use cuffed tubes.

Paediatric endotrachelal tubes with micro-cuffs are now widely available.

Data describing problems in children relating to cuffed tubes, apply to old style low volume high pressure cuffs and not to the cuffs in modern use. In children for whom high ventilation pressures maybe required (ARDS, sepsis, aspiration pneumonia), a cuffed tube is particularly useful. Experience has taught us that when an uncuffed tube has been used, a significant leak develops at high pressures and impairs ventilation and the tube needs to be replaced with a larger one - this is clearly not ideal in a patient for whom ventilation is starting to become difficult. Much better is to have a cuffed tube in place, and for the cuff to be inflated if ventilation problems secondary to a leak develop.

Oral or nasal intubation?

The most important thing is to have a secure airway and we do not have a strong preference of one over the other. If the patient has been an easy intubation and tolerated it well, a nasal tube is probably more stable during retrieval, and is better tolerated than an oral tube, often requiring less sedation. This is particularly useful in the group of children who have croup or some other upper airway obstruction but are otherwise well. With nasal tubes in, we can often stop sedation at an early stage even with the endotracheal tube in situ and this prevents problems with sedation withdrawal later on in the clinical cause.

Can propofol be used in children?

Propofol is the drug we most commonly use for induction of anaesthesia. The Committee for Safety of Medicines contra-indicates the use of Propofol by continuous intravenous infusion for sedation in intensive care. It does not preclude its use for maintenance of anaesthesia. Its use as an infusion to facilitate CT scanning and inter hospital transfer of patients could be considered maintenance of anaesthesia.

Where can I brush up on my paediatric anaesthetic skills?

Many consultant anaesthetists in District General Hospitals feel that their ongoing exposure to paediatric work is limited, making it more difficult to manage children in the inevitable acute emergencies that they will be asked to deal with. We can offer one week secondments to the University Hospital of Wales, of which the majority of time is spent in theatre with paediatric anaesthetists and sometime with paediatric intensivists on PICU and this includes the opportunity to accompany the PICU team on retrievals.



This page edited December 8, 2016 11:32 AM by Allan Wardhaugh