physical restraint in picu

  1. hello everyone.
    on my picu in st. gallen, switzerland, we are attempting to develop a standard guideline for the use of physical restraint in ped. icu. we have based it on the american society for critical care medicine guidelines from 2003, and are trying out the richmond sedation agitation scale as an asessment instrument. do any of your units have a guideline in use. i havent found any pediatric specific literature. it would be great if anyone had some tips to give us
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    About swiss brian

    Joined: Jan '08; Posts: 5; Likes: 5
    staff nurse
    Specialty: 18 year(s) of experience in er/micu/picu/nicu


  3. by   Qwiigley
    When I began PICU care apprx 15 yrs ago, all the kids on a vent were paralyzed with norcuron (vecuronium). Then we evolved to 2 pt soft restraints, then no restraints if a family member signed a form to watch over them. Nowadays, no restraints unless the kid has proven that he will pull his tube. That's when I left and went back to school!!!
    We don't use a tool at all. No other criteria. Sad, but true. (25 bed PICU) Separate Cardio-thoracic ICU (20 beds) and separate NICU another 35 beds.
  4. by   pcicurn7
    We do 2 pt soft wrist restraints whenever the kids have anything they can remove...ET tubes, RAs, chest tubes, etc. They require lots of documentation and a 2 RN check. We usually do not use vec drips for this purpose (though it depends on the patient).
  5. by   MaleICURN
    So far I found one kiddo (!) - 15 yo, ETOH on board on 4 pt's restrains. In addition our Hospital Police Officers were involved in this case. Otherwise, if we have a pt. e.g. on extubation trial, this is usually 1:1 and required LITERALLY sit at the bedside. If you have to go to the restroom, you call someone to STAY at the bedside. Only kind of restrains are "no-no's", which blocks kids elbows.
    Sedation - mosty Versed/Morphine, or, more often Versed/Fentanyl (and occasionaly paralysis - vecuronium) take off need for restrain.
    We have a good policy, that parents can stay with their children 24/7. Most parents are OK with no-no's, however, I don't know, hew they would react for REAL restrains.
  6. by   NotReady4PrimeTime
    We use soft restraints times two on virtually all of our patients. We only very rarely use paralytics on our patients unless actively cooling them. Our sedation regime used to be almost exclusively morphine and midazolam infusions, but we have a new intensivist who doesn't like either of those so we're moving to hydromorphone or fentanyl and ketamine infusions. I'm not sure this is necessarily a wise choice but I'm only a nurse and my opinions matter very little. We have also started using clonidine (another questionable choice in a unit that is primarily cardiac) for sedation at the behest of one of our fellows, who is also doing an anaesthesia fellowship. And we use a LOT of chloral hydrate. We have no formal sedation assessment in place. We also are not exclusively 1:1 for patients with inntracardiac or other invasive lines, ETTs, pacemaker dependence, chest tubes and the like so have to resort to both physical and high-dose chemical restraints to minimize the risk of unplanned extubation/line removal etc. Our incidence of withdrawal is high and we use a ton of methadone both in the PICU and on the wards after transfer.
  7. by   kessadawn
    [font="franklin gothic medium"]we use soft wrist restraints in my picu, sometimes elbow splints instead depending on line access. our kids are well sedated, but rarely paralyzed. babies are swaddled if possible, so no need to restrain them sometimes. we are a very well-staffed unit, however, and all intubated kids are 1:1. never in my life would i trust a parent to sign a contract to be responsible for the intubated kid...many of our parents usually don't listen to rules anyway and must be constantly reminded. we don't use any type of sedation or agitation scales here. we have occasionally had to use 4 point leather restraints on large hallucinating teens, but it's pretty rare. usually when they come in high, they're pretty happy...
    Last edit by kessadawn on Jan 8, '09 : Reason: cannot spell or punctuate correctly
  8. by   NotReady4PrimeTime
    Quote from kessadawn
    [font=franklin gothic medium]we are a very well-staffed unit, however, and all intubated kids are 1:1.
    i'm coming to work with you!!
  9. by   TexasPediRN
    Quote from kessadawn
    [font=franklin gothic medium]
    we are a very well-staffed unit, however, and all intubated kids are 1:1. .
    Quote from janfrn
    i'm coming to work with you!!

    omg me too.

    where do we need to move??

    i hate working our picu b/c of having 2 intubated kids - but 1:1 and i can stay in the room with my pt all day and give proper care??

    sign me up!!
  10. by   kessadawn
    [font="franklin gothic medium"]ohio is waiting for you, girls, and i'd welcome you both!
  11. by   NotReady4PrimeTime
    Can I bring my snow?
  12. by   PICNICRN
    Looks like I'm takin the bus to Ohio too!!

    We, unfortunately, are not always 1:1 on intubated pts. We use soft wrist restraints/no nos/swaddling whatever works safely for the pt. Never do we rely on a parent! We use fentanyl and versed drips on all intubated kiddos- then go to Propofol the day before extubation. We do use alot of Vec/Nimbex also. And I have become a big fan of Chloral! All in all, I think we do a pretty good job at keeping our kids comfy and safe.
    We use a sedation/vent comfort scale although I could not tell you what it is called. And really, it seems to be something we just fill out- I can't say that I have ever said "oh the kid scored suchand such so let me adjust my sedation". Really, I don't even think most people fill it out.
  13. by   kessadawn
    Quote from janfrn
    can i bring my snow?
    [font="franklin gothic medium"][font="franklin gothic medium"]good grief, no way! we've got 5-10 more inches of our own crap coming tonight, just in time for my weekend commute!

    i am so tired of snow!
  14. by   NotReady4PrimeTime
    I hear ya sister! Today is the first day it DIDN'T snow since I can't remember when. But there's more in the forecast, including some freezing rain. That ought to make the commute to work a real treat, since I haven't even seen a plough yet this winter.

    But back to restraints in the PICU. It would be very nice if anaesthesia brought the kids back in a state that would allow us to get them completely admitted before they tried to sit up.