Johns Hopkins University



Traumas Don’t forget to TAP IN when arriving to the Trauma Bay!ICPM Protocol: PAT092 Care of the Pediatric Trauma PatientAlcohol screening is required for all traumas ≥ 13y – consults, activations, admissions, and discharges. Use the CRAFFT screen in the Trauma H&P. Or if done later .crafft in epic can be doneConsult Social Work for all positive screens.Add to “Scut List” on GPS list.For admission orders, use JHH Pediatric Trauma Admission.KKI Head Injury Clinic referral is required for all admissions with skull fracture, bleeds, or concussions. Email patient information to appropriate case manager – she will make referral on Monday. Debbie10Sdwitten1@jhmi.eduLonna 10Nlbrady4@jhmi.edu Jane 9Njyorka@jhmi.edu Steph9Ssjacob@jhmi.eduPamPICUpbisker1@jhmi.eduInclude KKI Head injury Clinic contact information in the discharge instructions: “KKI will contact you within the next two weeks. If you do not hear from them, please call (443) 923-9400.”BurnsICPM Protocol: PAT095 Care of the Pediatric Burn PatientThe PED burn nurses perform the majority of burn debridement. However, GPS is expected to:Assist with debridement if procedure is expected to exceed 30m.Perform debridement when a burn nurse is unavailable.In these cases, you must:Write a procedure note. It cannot be a blurb in the burn consult note or H&plete a Lund & Browder diagram. Form is available in the PED.For burn admissions, use appropriate burn order sets:JHH PICU Burn AdmissionJHH Pediatric Burn Injury Admission Non-ICUFor INPATIENT BURN DRESSINGS, use .pedburndressing (Owner: C. Baldino)10S: 9am every day. You must go to assess the burn and write a procedure note. PICU: 9:30a burn rounds. Schedule dressing change with bedside nurse. You must go to assess the burn and write a procedure note. You must write a procedure note. It cannot be a blurb in the daily progress note. ERASLabel all ERAS patients on GPS list with one-liner, e.g., “ulcerative colitis s/p ileocecectomy with ileocolic anastomosis – ERAS”In addition to routine daily progress note, write a POD2 note using EPIC SmartPhrase: ERASPOD2 (owners: I. Leeds)BLOOMBERG CHILDREN’S CENTERTHE JOHNS HOPKINS HOSPITALPEDIATRIC SURGERY SERVICE MANUALFOR MEDICAL STUDENTS AND RESIDENTSEdited by: Seth Goldstein MDTABLE OF CONTENTSINTRODUCTION1RESIDENT RESPONSIBILITIES2Pediatric Surgery Fellows3Senior Residents and Moonlighters3Day Interns4Night Float Intern and Saturday Second Years5Pediatric Co-Follow5GPS Nurse Practitioners6GPS Clinical Pharmacologist6GPS Clinical Nutritionist6Medical Students6General Team Responsibilities7EPIC help_________________________________________________________ 9GENERAL ADMINISTRATIVE ISSUES 10Who Goes Where?10Pediatric Interventional Radiology Admissions10Clinics, Conferences And Rounds11PROBLEMS OF THE SURGICAL NEONATE 12NICU Survival Guide 12Recognition And Treatment Of Sepsis In Newborns14Tracheo-Esophageal Fistula And Esophageal Atresia.14Intestinal Obstruction16Intestinal Atresia16Hirschsprung's Disease17Meconium Ileus 17Malrotation19Omphalocele & Gastroschisis20Congenital Diaphragmatic Hernia 21Necrotizing Enterocolitis (NEC)23Postoperative Enteral Feeding24COMMON PEDIATRIC SURGICAL PROBLEMS26Seth Goldstein, M.D.Appendicitis26Pyloric Stenosis 27Intussusception 29Incarcerated Inguinal Hernia 30Reducible Inguinal Hernias in Infants31Foreign Bodies31Caustic Ingestions31Lower GI Bleeds35Biliary Atresia/Kasai____________________________________________ 35Chest Wall Deformities-Pectus Excavatum36Gastrostomy tubes37Empyema39Spontaneous Pnuemothorax____________________________________40PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD40Adesola Akinkuotu, M.D.Outpatient Surgery Guidelines40NPO Guidelines 41ERAS management______________________________________________ 41ERAS neonate management____________________________________ 41Fluid Management and electrolytes42Immunization Status 43Nutrition basics43Parenteral nutrition43Central Venous Lines 44Antibiotic Prophylaxis46Tracheostomy46Chest tubes47Nasogastric tubes47Apnea & Bradycardia Monitoring48Post-Op Antibiotics48Pediatric Pain____________________________________________________ 48PEDIATRIC TRAUMA49Lisa Puett, RN., Coordinator of Pediatric Trauma & Burn ProgramsPediatric Trauma at Johns Hopkins49Evaluation of the Pediatric Trauma Patient50Prearrival50Primary Survey50AMPLE History52Initial Data52Secondary Survey52Transfer52Head CT Algorithim53Tertiary Survey54Other Important Points54C-spine clearance55Spleen/Liver56Child Abuse56Head Trauma56PEDIATRIC BURNS57 Lisa Puett, RN., Coordinator of Pediatric Trauma & Burn ProgramsPolicy___________________________________________________________________Bravo/alpha burn criteria____________________________________________Documentation57Types of burns57Calculating TBSA%57Primary Survey58Secondary Survey59Initial Management59Burn Management in Peds ED59Inpatient management61Common Burn Dressings and treatments61Nutrition62EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)67General Information67Indications67Contraindications67Logistics of an ECMO Activation68Technique68ECMO Circuit69Management of a Patient on ECMO69Completion of an ECMO Run70APPENDICES72APPENDIX 1 Guidelines for the Mngnt of Appendicitis in Children72APPENDIX 2 Pediatric Glascow Coma Scale73APPENDIX 3 ETT Sizes74APPENDIX 4 Emergency Airway Management of Infant & Child 75APPENDIX 5 Gastrostomy Tubes 78APPENDIX 6 Pediatric Surgery Fellowship Conferences & Training79APPENDIX 7 Immunization Schedule 80APPENDIX 8 Emergency Drugs82APPENDIX 9 Guide to Surgical Procedures for Oncology83APPENDIX 10 Guidelines for Pediatric Preoperative Evaluation85APPENDIX 11 Intrapleural tPA for Empyema92APPENDIX 12 Guidelines for Catheter related BSIs95APPENDIX 13 Central line lock therapy guidelines97APPENDIX 14 Peri-OP antibiotic prophylaxis guidelines98APPENDIX 15 BURN DOCUMENTATION Requirements101APPENDIX 16 BURN WOUND CARE: ED PROCEDURE________________102APPENDIX 17 Non-operative management of liver & spleen injury_105IMPORTANT PHONE NUMBERS108NICU SEPSIS GUIDELINES112PICU ANTIBIOTIC GUIDELINES114REFERENCES116I. INTRODUCTIONThe purpose of this manual is to assist you in the management and care of the infants and children on the Johns Hopkins General Pediatric Surgery (GPS) service. Children are not simply small adults! Many of the basic guidelines of adult surgery still apply but if you are not sure about something, please say, "I don't know." Another team member or nurse probably does and avoiding mistakes is our highest priority. Please try to be understanding of the parents of our patients. By the time their child has come to the attention of a pediatric surgery service they are usually worried, anxious, and stressed. Treat them in a polite and supportive manner and they will eventually become great bedside allies during their child’s admission. If the parents ask a question for which you are not certain of the answer always say, “I don’t know. I will ask the team." This manual is not a textbook and is not intended to replace appropriate reading and case preparation. It is a working document that is intended to improve the functioning of the GPS service and will be revised frequently to account for changes on the GPS service. If you have a suggestion to make this manual more effective please bring it to the fellows’ attention. It will be incorporated into future editions.Printing of this handbook was generously funded by the Department of Pediatric Surgery through the Garrett Fund.II. RESIDENT RESPONSIBILITIESPediatric Surgery FellowsThere are two accredited fellows in the Johns Hopkins Pediatric Surgery Training Program: the senior fellow; and the junior fellow. In addition there is one non-accredited international fellow. The Accredited Fellows have independent operating privileges for life threatening emergencies only. In all other cases, patients must have an admitting attending, which is determined by the Fellows.The Senior Fellow is in the second year of fellowship training and is responsible for the care of all patients on the GPS service. His/her beeper is always on and he/she is always available for questions and help. He/she must be informed of all admissions and consults in a timely manner. The Junior Fellow spends the first month of fellowship rotating with the NICU and PICU teams, followed by one month on the GPS service and six months as the Chief Resident of the GPS service at the University of Maryland. In April of their first year, the Junior Fellow returns to the Hopkins GPS service in preparation for their Senior Fellow year. The International Fellow will counter rotate to Hopkins when the Junior Fellow is at Maryland and return to Maryland when the Junior Fellow returns to Hopkins.No invasive procedure or major change in the therapeutic management of a patient should be performed without conferring with the Senior or Junior Fellow.The Senior Fellow will make the call schedule for each month.The Fellows will provide back-up call from home for weekday nights and every other weekend.The Senior Fellow will assign cases for the next day on PM rounds.The Junior Fellow will take in-house call in the senior resident call pool and cover back-up call on alternating Senior Residents, Trauma Fellows and MoonlightersThe call schedule will be posted by the Senior Fellow prior to the start of the rotation. When on-call, the Senior Resident’s primary responsibilities are:New Emergency Department surgical consultationsNew in-house surgical consultationsCovering notes & calls on the NICU & PICU GPS patientsNotify on-call intern of all admissions **making sure complete and thorough exams are documented for all admissions.Emergency Room admissions. For all common pediatric surgical problems (covered in chapter VI) communicate directly with the on-call attending.Contact the back-up Fellow on call for:Complicated casesNew NICU admissionsNew PICU AdmissionsECMO activationsOperative TraumaMajor change in patient course (i.e. transfer to the PICU)Never turf an ER Consult to another service without first asking the Back-up Fellow or the Attending. The GPS Service does cover:Hematuria (possible Wilms’ tumor)GYN/ovarian pathology Aerodigestive foreign bodiesConsults may be prioritized based on acuity, but respond to pages immediately and tell the consulting service when to expect you.Do not give phone instructions to obtain advanced imaging or laboratory studies without first examining the patient.All females with abdominal/pelvic pain who may be sexually active must have a pelvic exam by a surgical resident or gynecologist and always with a female nurse present! Never be in a closedroom with a female patient without a chaperone. Parents are not chaperones. Patients will not have surgery based solely on a pediatric/medical evaluation Check urine b -HCG for all females older than 10 yearsTrauma Activations (Also see VIII. PEDIATRIC TRAUMA)The senior resident participates in the rapid management of all trauma patients. The resident will facilitate the work-up;Ordering a series of tests and then leaving is unacceptable.Activations occur in two types:Alpha – PICU - Resident Airway GPS Senior – All ElseBravo – GPS Senior runs entire traumaThe use of advanced imaging should be minimized as much as possible in children. (Ask the fellow/attdg with questions)Avoid Neck and Chest CT without strong indicationAll patients require Trauma evaluation note-pediatric for their H&PIn-house consults: Identify if the patient has been seen previouslyIf operated before, the pt goes to the previous attendingOtherwise, the on-call attending staffs new consultsThe surgical team has responsibility for the surgical patients in the NICU and PICUWork closely & collegially with the neonatologists and intensivists.Daily WorkThe team will meet at 05:30 on weekdays and 06:00 on weekends in the Garrett conference room.Overnight senior residents present PICU/NICU patients the night intern will present floor patients.A daily progress note is REQUIRED on each pt in the NICU and PICU.Senior residents are expected to ensure that each of their cases is appropriately pre-op’d. They are to notify a fellow if discrepancies are identified.During the day, one senior resident (typically the on-call senior) will have the consult pager at all times. They are responsible for coordinating the work up of all daily elective admissions and new consults. This is a shared responsibility - not only for the on-call residents. All team members may be asked by the senior with the pager to see new consults or admissions.Day InternsThe primary responsibilities of the day intern is the care of all floor patients on the GPS service as well as facilitation in the preoperative holding area.In addition to fielding floor calls on GPS patients, tasks include:Ensure all patients due for surgery within the future 48 hours have:Signed informed consent All appropriate labsBlood typed and crossed where indicatedAdequate bowel prepPICU Bed Assignment as requiredKeep the OR moving by pre-oping outpatient casesStart the daily text thread before the end of morning roundsComplete all discharge summaries Schedule follow-up appointments Write prescriptions for patients being discharged Day Interns will be assigned level-appropriate casesTrauma Activations (Also see VIII. Pediatric Trauma)Interns are expected to respond to all trauma activationsTrauma responsibilities include:Complete trauma H&PAccompany pt for imagingFollow-up radiology readsFollow-up labs*Consent etiquette: In the majority of cases, obtaining signatures on a consent form should simply be formalizing a discussion that has already occurred between surgeon/fellow and patient/parents. Interns should be prepared to answer basic questions but not feel responsible for achieving informed consent. In other words, it is fine to get the signature even if there are further questions that you need to ask for help or backup with. Lastly, remember that the witness is simply certifying that the signatory is indeed the person indicated on the form, they are not a “double check” to make sure everyone understands the risks and benefits. DSS consent # is 410 361-2235 or 800 332-6347 Night Float Intern and Saturday Second YearsThe primary responsibility of the night intern is the care of all floor patients on the GPS service.By agreement, the night intern will also be covering floor patients on the adult thoracic service.A sign-out will occur between the day intern, the night intern, and the NP on weekdays at 17:00. Please attend promptly and arrange a meeting with the thoracic service either before or after.On weekends, sign-out will only occur at the 06:00 morning meeting In addition to fielding floor calls on GPS patients, tasks include:Ensure all patients due for surgery within the future 48 hours have:Signed informed consent (in-pt only)All appropriate labsBlood typed and crossed where indicatedAdequate bowel prepPICU Bed Assignment as requiredComplete discharge summaries for next-day dischargesWrite prescriptions for next-day discharges Assist with overnight admissionsFollow-up labs and convey resultsReview the add-on list in the O.R. to ensure no patient is overlooked.Postoperative check on all patients operated upon that day.Interns will be asked to scrub emergency cases where appropriate Pediatric Co-followThe GPS service has a pediatric co-follow who is a senior pediatrics resident. The Co-follow’s role is to ensure that normal pediatric care needs are met for each of our patients. They need to be notified of all patients admitted to the GPS service under two years of age. They will provide advice on immunizations, normal post-discharge pediatric follow-up and other issues related to the non-surgical care of children. Please be aware that a pediatric co-follow consult may be called on any other GPS patient in the hospital. This privilege is extended to the nursing staff. If the nursing staff feels a GPS patient would benefit from a hospitalists evaluation, the co-follow will be called for a consult. GPS Nurse PractitionersThe GPS pediatric nurse practitioners (NP) are an integral part of the team. In conjunction with the Day Intern, the inpatient NPs help care for the floor patients on a daily basis, prepare patients for discharge, coordinate consults etc. The NPs have extensive experience caring for infants and children and are available to all the surgical residents for consultation regarding feeding issues, rashes, ear checks, wound care, stoma care, G-tube problems, IV access, well-child care, common pediatric illnesses, and parental anxiety. Please do not hesitate to call upon them. THEY KNOW A LOT AND CAN BE VERY HELPFUL TO YOU IF YOU ASK. The nurse practitioners are also available to assist residents with their assigned patients when the resident is absent or in the OR.GPS Clinical PharmacologistThe GPS teams rounds daily with a clinical pharmacologist. The role of the pharmacologist is to prevent adverse drug interactions; ensure that patients receive the correct doses of medication; and define appropriate course lengths. Having a clinical pharmacologist on the service represents a significant asset to the GPS service. Any medication related questions should be referred to the clinical pharmacologist. GPS NutritionistThe GPS service has a clinical nutritionist available for help with enteral or TPN feeding plans. Plans can become quite complicated and typically require both a TPN and enteral component. The clinical nutritionist becomes an invaluable addition to the team when management of multi-modality nutrition becomes necessary. Please refer all nutrition questions to the clinical nutritionist.Medical StudentsEach month there are 1-2 medical students on service. These medical students are an integral part of the service and their participation is welcomed. Residents are responsible to provide the students with a wide exposure to many topics in pediatric surgery. Participation in the care of patients is proportionate to their level of experience and expertise. Nevertheless, medical students do not have the same obligations to the service as residents.Student should expect to scrub in cases daily. Discuss with the fellow or senior resident the night prior about the cases and read about the topics and patients prior to coming to the operating room. Introduce yourself to the patient and family in the pre-op area and perform exam with resident. Each student should spend at least 1 half day in clinic per week. General Team ResponsibilitiesFOR ANY PATIENT CARE PROBLEM THAT ARISES, ALWAYS FEEL FREE TO INVOLVE THE SENIOR RESIDENTS AND FELLOWS. All senior residents/fellows will welcome your call at any time.Check all ICU and other seriously ill patients again and again and again! Do not wait to be called! Find problems and fix them!The younger and smaller the patient, the faster they can clinically deteriorateCase Assignments:Case assignments are made by the Senior Fellow.Provide operating room coverage as assigned. Residents should be in Pre-op by 7:15 A.M. for first cases.All surgical patients must have consent and an H&P update. The GPS Service should not be the cause of OR delaysALL RESIDENTS should help complete Pre-Op paperwork during the dayThe resident covering a case must perform their own pre-op H&PNote: This does not have to be the H&P that admits the patient to the OR A resident should scrub on every index case. Pre-Op:Residents are expected to introduce themselves to patients and family, and identify the patient via name bracelet. After introduction: H&P is updatedSurgical site is verified and markedInformed consent is obtained. Patients cannot be brought back to the OR until all paperwork is completed.Consents:For a minor (under 18 years) parents or legal guardian must sign consent. Be aware that foster parents are not always legal guardians, and that social services may be involved. You will have to get consent from DSS caseworker (should be in social work notes or can get from foster family)Consents are signed by patients 18 years and over unless legal authority has been otherwise indicated.Consents must be specific to surgical site indicating left and/or right sides. (“Right” and “Left” must be written out. No abbreviations –“R/L”)Interpreters are available for all non-English speaking families. Weight:Infants under 1 year need daily weights dependent on disease state.Weight is documented in kilograms only. Do not estimate or round off patient weights.Use weight most recent today of surgery.Pagers:During cases, the intern and senior call pagers should be handed off to another resident outside of the OR.Resident Availability:Cases will not start without assigned resident in the OR. Residents must be present in the OR from the time the patient is induced until transfer to the PACU or ICU.Parent Present Induction:Parent-present induction is common for pediatric surgery.Please refrain from any unnecessary talking and noise during induction.Eyewear:Residents must wear appropriate protective eyewear (side protection too) before scrubbing for all cases.Hand Washing:Hand washing is the single most effective way to prevent the spread of infection and disease.Use hand gel before and after each patient encounterUse non-sterile gloves to avoid cross contamination.Skin Scrub/PreparationChlorprep is NOT approved for use on children under 2 months The pediatric patient population is more prone to Betadine burns. When prepping avoid dripping Betadine, especially near Bovie padAvoid pooling of betadine under the patient.Clean Betadine off of the patient at the end of the procedureAll Pectus Excavatum cases should be pre-scrubbed with chlorhexidine hand scrubPost-Op Orders: Post-op orders are to be completed immediate after case.If a post-op PCA will likely be needed, a pain consultation request can be submitted prior to induction.Post-op orders can be drafted prior to induction and finalized at the end of the case.Please review the need for foley and abx with either Fellow or the Attending. PACU Surgeon’s ReportWhen the patient is delivered to the PACU the resident or fellow will provide a report of the case to the receiving PACU nurse.Please include:AttendingProcedureComplicationsDestination (Floor vs. home)Confirmation of Post-op Order StatusEpic Help We have created a list of smart phrases that you can use to make your life on GPS easier (see below)by stealing them from Cathy Baldino or Michelle Felix. You have to use the .gpstraumaevaluation for all traumas and .pedburndressing for any dressing changes that you do. .GPS______ (head, babyhead, abdomen, lung, foreign body, ostomy, tef, esoph dilation, pectus, ACE, burn, central line, port, drowning, collar care, collar clearing, gcfistula, GJT, liverspleen, NOS, progress note, transfer, woundvac) IV. GENERAL ADMINSTRATIVE ISSUESWho Goes Where?Where do children get admitted?Preterm Neonates NICU 8th floor BCC0-1yr Newborns 9 South Floor BCC1yr to 3yrs Infants & Toddlers 9 North Floor BCC4yrs to 11 yrsSchool age Children10 South BCC>12yrsAdolescents10 North BCCWho goes to the PICU?Critically ill childrenVentilatorsRisk for rapid decompensationNeurovascular checks more frequent than q2hPost-op cardiac neonatesAll ECMO activationsUse the “IMC” designation on the appropriate floor for pts who need continuous monitoring but do not meet the above criteria i.e. continuous pulse ox monitoring.Pediatric Interventional Radiology AdmissionsPediatric Interventional Radiology admissions are under the IR Service.Pediatric Surgery (GPS – General Pediatric Surgery) co-follows with IR from 5:30pm to 7am.Pediatric hospitalists and GPS co-follow resident follow along with all children < 2 years old.If IR wishes for pediatric hospitalist to co-follow on an older patient for a certain reason, they need to call the on call hospitalist at #4-HOSP (#4-4677) to discuss. This should rarely be necessary. The pediatric hospitalist may or may not involve the pediatric house staff in the patient care, at their discretion.The IR fellow will be responsible for all pages on patients on IR service at 3-CVDL. This pager needs to be answered expediently (for example, by the scrub nurse when fellows are scrubbed). On weekends, the IR fellow on call is responsible for pages on IR service pediatric patients at 3-CVDLOn weekdays and weekends, every day at 5:30pm, the IR fellow signs out to Senior GPS resident/fellow on pager 3-3981 for pediatric IR patients in the hospital.Nurses may reach the on call IR fellow for routine overnight calls. GPS is co-following and can be called but are available for emergency response since they are in house overnight.Clinics, Conferences And RoundsGeneralMorning Rounds begin in the 7th floor Garrett Conference Room at 5:30 AM weekdays and 6:00AM on weekends and holidays. Evening rounds will be held in the Garrett Conference room at 5pm or when the cases of the day are finished.Conferences (ATTENDANCE IS MANDATORY) **see appendix 6 for times Surgery Clinic:Meets daily 8am M, W, F and 2 pm T . No scrubs.1 half day per week required by all residentsPostoperative checks and long-term follow-up are also provided. Residents should attempt to see patients that they 1) operated on, 2) cared for in the hospital, or 3) have previously seen in the clinic.V. PROBLEMS OF THE SURGICAL NEONATENICU Survival GuideRespiratory Norms:RR 40-60O2 Sat >94% in term infant88-95% in chronic preemiesABG NormspH 7.35 – 7.45pCO2 35 – 45For every 10 of change in pCO2, pH changes 0.08VBG or Cap Norms:pH 7.30 – 7.40, 40- 50Pressure-Control Ventilation: PIP -peak inspiratory pressurePEEP -positive end-inspiratory pressureMAP -mean airway pressureManeuvers to Increase pO2 :Increase FiO2 Increase PIP Increase PEEP Increase inspiratory timeTo decrease pCO 2Increase rateIncrease PIPDecrease PEEPOscillatorMAP: mean airway pressuredelta P: amplitudeincrease MAP to increase pO2increase delta P to decrease pCO2Apnea / Bradycardia of PrematurityTypical for <35 weeks GAUsually outgrown by termTreatment options:Watch & wait especially if olderCaffeine Citrate Load bolus - 20mg/kg; max 40mg/kgMaintenance 5-10mg/kg/d; max 20mg/kg/dAminophylline Load Bolus 5-8 mg/kgMaintenance 2-6 mg/kg/dose PO/IV q8-12hCardiovascular ConsiderationsNorms: Hr 120-160HR of 80 can be normal for term infantsMAP: approx 3 –5 above GA (35 weeks = MAP 40mmHg)Patent Ductus ArteriosusMurmurIncreased pulse pressureBounding pulsesPalmar pulsesWorsening respiratory parameters Treatment Post Natal Age < 48 hoursIndocin 0.1 mg/kg/dose IV q12-24h x 3Post Natal Age 2-7 daysIndocin 0.2 mg/kg/dose IV q12-24h x 3Post Natal Age >7 daysIndocin 0.25 mg/kg/dose IV q12-24h x 3Contraindicated in renal failure, NEC, bleedingCommon Pressor medications: (initial; titrate to effect)Dopamine: 2.5 –20 mcg/kg/minDobutamine: 5 – 20 mcg/kg/minEpinephrine: 0.05 – 1 mcg/kg/minHydralazine: 0.1 – 0.2 mg/kg/dose IV q 4-6h, or 0.25 –1 mg/kg/dose PO q6-8hFluids, Electrolytes and NutritionRequirements increase with:Decreasing gestational ageIncreasing DOLNPO Neonates Require D10 IVF if not on TPNNeonate Fluid ratesTerm: start at 80 – 100 cc/kg/d advance by 20 cc/kg/d to 120 cc/kg/d1000-1500gmsstart at 80 – 100 cc/kg/dadvance by 20 cc/kg/d to 150 cc/kg/d<1000 gmsstart at 100-150 cc/kg/d, use serum sodium (q6 –12h) to guidemay raise to 170 –300 cc/kg/dMaintenance electrolytesNa: 2-4 mEq/kg/dK: 2 mEq/kg/dCa Glu: 200 – 800 mg/kg/d divided q6hTPN:<1500gm: AA/IL start at 3g/kg/d Advance to 4g/kg/d>1500gm: AA/IL start at 3Advance to 3.5Enteral feeds:Enfamil 20 for > 2 kg Premature Enfamil 20 for < 2 kgD10 = 100g/L = 100mg/ccD25 = 250g/L = 250 mg/ccBili > 5% of body weight needs phototherapyBili > 10% of body weight need exchange transfusionIncrease daily fluids by 10 cc/kg/d with lights.Infectious Disease Considerations:Neonate Sepsis caused by:Group B StrepE coliListeriaEmpiric Treatment Considerations:Routine Head US:<30 weeks DOL 1-2DOL7-1030-34 weeks DOL 7-10, or if clinical suspicion 30 days to look for PVLEye exams should be obtained for: any baby <32 weeks32 –34 weeks on O2other suspicionsfor retinopathy of prematurityAt corrected 35 weeks GA4-5 weeks post-natallyRecognition and Treatment of Sepsis in Newborns:Signs: (Often reported by bedside nurses)HypothermiaLeukopeniaThrombocytopeniaMottlingLethargyApnea, cyanosis, desatsPoor feedingIrritabilityWorkup:Blood culturesUrine cultures (bagged specimens are useless)Sputum culturesLPCXRPT, PTT, platelets, CBC and differentialTreatment:Empiric antibiotics after workup is initiated (See sect 1.g)Volume SupportPressors if necessaryAdministration of FFP if DIC is present.Mechanical VentilationTracheo-Esophageal Fistula And Esophageal Atresia:These anomalies are frequently not identified prenatally. The only prenatal hint is usually polyhydramnios.There are 5 variants of the TEF/EA anomalyEA with distal Fistula (85%)Pure EA(7%)EA with Proximal Fistula(3%)EA with Proximal and Distal Fistula (<1%)TEF without atresia(4%)Inability to pass an NGT into the stomach strongly suggests EA especially when the tip fails to pass the carina. Frequently, the child will be blowing bubbles of saliva during respiration.Keep the infant’s head at 45 degrees and connect the NGT to continuous low suction to keep the upper esophageal pouch empty.Presence of gas in the stomach suggests a distal fistula.Ventilation using mask and bag should be avoided if there is a distal TEF to prevent gastric distention with further respiratory impairment or gastric perforation.If a patient with a distal fistula has a distended abdomen it is a surgical emergency. Gastric distention can causeCardiac arrest due to pericardial compressionGastric reflux into the trachea with acute pneumonitisGastric RuptureEA/TEF is frequently associated with VACTERL anomalies. Asses the patient for:Vertebral Anomalies(6-21%)Anorectal Anomalies(10-16%)Cardiac anomalies (13-34%)Renal anomalies (5-14%)Limb Anomalies(5-19%)An echocardiogram is required STAT in all TEF/EA patients to determine whether the child has congenital cardiac anomalies and to ascertain if there is a right or left aortic arch. This helps determine which side a thoracotomy is to be performed. Always remind the cardiology fellow that pressing firmly on the stomach with the echo probe can lead to death by aspiration thru the patent TEF.Intestinal Obstruction:Common causes for intestinal obstruction in infants:Intestinal atresiasHirschsprung's DiseaseMeconium ileusMalrotationBILIOUS EMESIS IN AN INFANT IS A SURGICAL EMERGENCY.BILIOUS EMESIS IN AN INFANT DENOTES DUODENAL OSBSTRUCTION AND ISCHEMIC BOWEL FROM A MIDGUT VOLVULUS UNTIL PROVEN OTHERWISE. Obtain an IV and initiate NGT decompression when intestinal obstruction is suspected.Haustral markings are not typically present on newborn plain films. Therefore, the colon cannot be distinguished from small bowel. Contrast studies are required to make the diagnosis.Gastrograffin is very hyperosmolar and can cause rapid loss of fluid into the gastrointestinal tract, leading to dehydration and shock. Therefore, infants should always have an IV placed prior to a gastrografin study.Intestinal Atresia:Occurs in the following order of frequency:Jejunoileal(50%)Duodenum(44%)Colon(6%)Pylorus(<1%)Atresias are commonly associated with a prenatal history of polyhydramnios. Prenatal ultrasound diagnosis of dilated stomach and/or duodenum may be indicative of duodenal atresia.Vomiting usually occurs within the first 48 hours of life. Emesis is bilious except in pyloric atresia and very proximal duodenal atresia.Plain films of the abdomen should be obtained in all cases of prenatal polyhydramnios. The more proximal an atresia the less severe the subsequent abdominal distention.Double bubble of duodenal atresia is pathognomonic and no contrast study is indicated. If no double bubble seen, inject air into NGT and repeat AXRWhen multiple loops of dilated bowel are seen, suggesting a distal atresia; a UGI is mandatory.A contrast enema is required to identify a microcolon which is a highly reliable finding for small bowel obstruction and to ensure patency of the colon.30% of children with duodenal atresia have trisomy 21. These children may have complex cardiac anomalies. All infants with duodenal atresia require an urgent cardiology evaluation and echocardiogram prior to operation.Hirschsprung's Disease:Hirschsprung's Disease is characterized by an absence of ganglion cells leading to ineffective conduction of peristalsis and functional obstruction. The aganglionic segment may be limited to the rectosigmoid or extend more proximally to involve the entire colon.Symptoms are non-specific and include episodic abdominal distension, constipation, obstipation or diarrhea. Any newborn that fails to pass meconium in the first 48h after birth should be evaluated for Hirschsprung’s Disease.A contrast enema is the initial study and should be obtained in all cases. A positive study will show a transition zone at the narrowed rectum with a dilated colon proximally. However, this finding is often absent in infants. (Specificity 60%)Suction rectal biopsy is used to confirm the diagnosis in neonates. A biopsy showing an absence of ganglion cells and hypertrophied nerves in the myenteric plexus of the muscularis layer is confirmatory. The presence of ganglion cells rules out Hirschsprung’s disease.For neonates, a pull-through procedure is commonly performed either in the first 1-3 weeks of life as a primary procedure or when the baby is thriving following a divided colostomy (ie. 6 months of age).Hirschsprung's may be managed with rectal irrigations in select patients with distal transition zones. Patients identified later in life typically undergo a temporary, or “leveling” colostomy above the level of the aganglionic segment. Meconium Ileus:33% of all neonatal small intestinal obstructions are due to meconium ileus secondary to cystic fibrosis.Meconium Ileus is typically the first finding of cystic fibrosis although only about 15% of infants with cystic fibrosis will develop meconium ileus. The incidence of cystic fibrosis in the Caucasian community ranges up to 1 in 1150 live births. There is a known mutation prevalent in the Hispanic population, but otherwise it is extremely rare in non-caucasian communities. Males and females are equally affected.These patients will typically present similar to other neonatal obstruction patients:bilious vomitinggeneralized abdominal distentionfailure to pass meconium in the first 24 to 48 hoursThe meconium may be palpable as a doughy substance in the dilated loops of distended bowel. Plain film of the abdomen demonstrates bowel loops of variable size with a soap bubble appearance of the bowel contents. Microcolon is a highly reliable finding for distal bowel obstruction that may be intraluminal from inspissated meconium or atresia due to intrauterine volvulus. Calcifications on the abdominal film usually indicate meconium peritonitis resulting from an intrauterine intestinal perforation. A contrast enema is contraindicated if the plain film shows calcifications.The initial treatment is typically nonoperative in an otherwise well-appearing child. Treatment consists of gastrografin enemas under fluoroscopic visualization. Commonly, a 50% solution of gastrografin and water is infused into the rectum and colon through a catheter.Gastrograffin enemas typically result in a rapid passage of semi-liquid meconium for 24 to 48 hours. Serial radiographs are taken at 12 and 24 hours to evaluate progress. Subsequent enemas may be required.Operative indications in meconium ileus:Gastrografin enema failureCalcifications in the abdominal cavityIll-apperaing infantsIf the diagnosis of meconium ileus is in doubt.N-acetylcysteine (mucomyst) or saline enemas can be given to complete the evacuation. Mucomyst can be given through NG tube as wellOnce the meconium ileus is relieved all these patients need a confirmatory test for CF. Options include;A sweat test (100% accuracy)-This test is usually not practical prior to operation since the child has to be at least 2kg or > 72 hours in age. A buccal smear-only 80-90% sensitive because it looks for only common genetic mutations.All CF infants require vigorous pulmonary therapy. When enteral feedings are initiated, a pancreatic enzyme preparation is given with each feeding. Typically, one pancrease pearl per 10cc of formulaMalrotation:Presentation of patients with malrotation range across a spectrum from normal well-appearing children to hemodynamically unstable. Any patient with the following must be evaluated for malrotation:Bilious Emesis (95%)Abdominal DistentionAbdominal PainInconsolabilityBloody Emesis (due to gastritis)Bloody Stools (due to necrosis)Time of presentation:30% in first week. 75% in First month90% in the first yearFindings on plain AXR:Gasless abdomenDilated intestine like SBODuodenal obstruction with a double bubbleIf the child is not acutely ill, obtain an UGI to look for position of the ligament of Treitz.Classic Malrotation on UGI:Absent duodenal sweep Duodenum stays to the right of midline and corkscrews downDuodenum is anterior and/or lateral to the SMACecum may be midlineMalrotation Anatomy predisposes the bowel to volvulus following normal peristalsis and consists of:Ladd’s bands - fibrous attachments from the retroperitoneum to the cecum which may obstruct the duodenumAbsence of a ligament of Treitz Midline cecum Narrow vascular pedicleMidgut volvulus is the most serious consequence of malrotation and is a SURGICAL EMERGENCY. Delay in diagnosis can result in loss of the entire midgut, which is uniformly fatal.Principal Sign: Sudden onset of bilious emesis An upper GI is the preferred study and should be done in almost all cases. This study may be omitted in the work-up if shock or a clear indication for exploration are present.UGI should be done emergently. Hours may be the difference between a reversible condition and loss of the entire midgut. Contact the Senior Fellow immediately upon consultation for bilious emesis, so operative intervention (if needed) may be expedited.After diagnosis complete these Pre-op Maneuvers: NGTIV HydrationORNO DELAYS! Treatment for Malrotation is the Ladd’s Procedure: Supraumbilical transverse incision. To decompress the volvulus, rotate the small bowel COUNTERCLOCKWISE. Lyse the Ladd’s BandsPlace small bowel on the right side Place large bowel on the left (Cecum will lie in the LLQ)Perform an appendectomyIf bowel is dead treat as follows:Short segment -resect with primary anastomosis.Short segment w/ questionable viability-resect dead and bring out stomas. If stomas necrose in 24-48h, re-explore.Large segment (or multiple questionable segments) - Close and do second look in 24-48h. Malrotation after the 1st year of life: Symptoms may occur in childhood to adultsTypically vague chronic symptoms10-14% may have acute volvulus. 30% may have intermittent vomiting (bilious), and colicky abdominal or recurrent partial SBO. Some have malabsorption and FTT.Omphalocele & Gastroschisis:Omphalocele – a central abdominal wall defect at the site of the umbilical ring. The abdominal contents are covered by a sac composed of peritoneum, Wharton’s jelly and amnion. Gastroschisis - a smooth-edged abdominal wall defect adjacent to a normal umbilical cord, typically on the right. The abdominal contents are eviscerated and uncovered.The bowel must be covered promptly to prevent hypothermia. Options include:Warm saline soaked sponges Plastic Bowel bagNote: Gauze bandages tend to stick to the bowels – Do not use themThese anomalies require lateral support to prevent the mesenteric vessels from becoming kinked. Support them initially as follows: Gastroschsis: place the child in the decubitus position with the defect down (typically right lateral decub)The bowel should be supported by towelsOmphalocele:Cover the defect with Xerofrom GauzePlace an unwrapped Kerlex roll bilateral to the defectWrap the entire child with an additional Kerlex ventral to dorsalPlace child in supine positionTreatment maneuvers:GI decompression with an NG tubeRectal exam to evacuate and decompress colonFoley catheter placement to monitor urine outputEmpiric intravenous antibioticsIV Fluid supportThese patients typically require NS boluses to initiate urine Rule out associated anomalies, Omphalocele:Cardiac Renal Chromosomal (trisomy 13, 18, 21)Beckwith-Wiedemann (large tongue, gigantism, hypoglycemia)Imperforate anusGastroschisis Intestinal Atresia.For gastroschisis, a silo is often used to protect the viscera prior to definitive repair. The silo must be supported to prevent it from falling to the side of the baby, which would kink the blood supply to the intestine.Nutrition-when ready start feeds low calorie and slowly, daily wgts, strict I/O, any vomiting and # of stools/day.Treatment Protocol For Congenital Diaphragmatic Hernia (CDH):Modern treatment protocol for CDH:Delayed surgical repair until resolution of fetal circulationMinimize iatrogenic barotrauma from excessive ventilation. ECMO if mechanical ventilation is insufficientNote: Timing of surgical repair is dictated by clinical course. Do not make treatment changes without discussion with the Senior Fellow or the attending.Initial NICU Management:NeurologicalHead ultrasoundMinimize SedationRespiratory: Order of Advancing Ventilator Support:Supplemental OxygenSIMV (neonatal pressure support) High frequency ventilation (oscillator)ECMOVent SettingsMaintain spontaneous respirationsPeak inspiratory pressure <25 cm H2O (if possible)Rate: Initial settings of 25-35 breaths per minuteFiO2=1.0Goals:Mean airway pressure: <12-13 cm H2O Barotrauma kills CDH babiesPreductal oxygenation: Cerebral PerfusionpO2>60O2 Sat >90%. Postductal Oxygenation: Distal PerfusionpO2/O2 Sat's will often be <60 /90%Do not use these postductal values to adjust ventilator settings.Permissive hypercapnia:Maintain pH > 7.25Maintain pCO2 <60 Note: Allow pCO2 to rise >60 and use small amounts of NaHCO3 to maintain pH >7.25. Increasing ventilator settings will elevate mean airway pressures and cause barotrauma. Cardiovascular:Cardiology consult Echocardiogram on admissionConserve IJ and EJ for possible ECMO CannulationRight radial (preductal)UA, PT, or DP (postductal) Drugs: Fentanyl 1-2 mcg/kg PRN for agitationEmpiric systemic antibioticsZosynAmp/GentPressorsDopamineDobutamine Lab studies:Pre- and postductal ABG's q 1 hourHematocrit, lytes, ionized Ca q 6 hours PT, PTT q AMCBC, Chem 20 q AMType and Screen Necrotizing Enterocolitis (NEC):NEC is a disease of low birth weight newborn infants characterized by ischemic necrosis of the gastrointestinal tract secondary to stress, followed by bacterial invasion of damaged tissue. Typically seen between the second and fifth day of life and usually after the initiation of monly seen associated with: RDSApneic spellsLow ApgarsPremature rupture of the membranesBreech deliveryExchange transfusionsCesarean sectionUmbilical artery catheter.Clinical findings: Bloody diarrheaAbdominal distention Poor feedingIncreased apneic spellsLethargyProlonged gastric emptying (read as: Increased aspirates)Bilious emesisNEC is frequently evaluated with serial radiographs. The main findings are: Dilated bowel –earliest signIntramural gas (pneumatosis)Not indicative of severityMay disappear without actual improvementPortal venous gasUsually indicates increased severityMay disappear without actual improvementPneumoperitoneum.Tissue damage is typically focused on the ileum, cecum, and right colon. Findings of increasing severity include:Mucosal ulcerationSubmucosal hemorrhage Necrosis of the entire bowel wall. Pneumatosis is found in the submucosa and subserosa. Treatment: NPONG suctionBroad-spectrum antibiotics for 7-10 days empirically.Serial RadiographsSerial CBC, platelet count, blood pH, electrolytes.Contact precautionsSlowly increase feeds then increase calories Surgical Indications:AbsolutePneumoperitoneum - most sensitive film is lateral decubitusRelativeAbdominal wall cellulitis Palpable mass on abdominal examPersisting isolated dilated loop of bowelFailure to respond to medical therapyThrombocytopeniaAcidosisSevere hemodynamic instabilityPre-Op Preparation:Check CBC, PT/PTT, Electrolytes, and ionized CalciumIf platelets < 100K, order 2 units of platelets.Move promptly to ORPostoperative Enteral Feeding:Initiation of feedsTerm newborns:150 cc/kg/day of 20-kcal/30cc formula q3-4h Goal: Weight gain of 20-30 grams/dayPremature infantsHigher volume because of evaporative lossesMore frequent feedingGavage may be necessary Continuous feeds may be easiestPostoperativelyAfter passage of flatus and stool Begin with D5W or Pedialyte.Examine frequently for abdominal distention Gastroesophageal RefluxCommon in infants and is temporary.Medical management Feeding upright in a chair Leaving infant in chair at least one hour after feedingThickening feeds with cereal.Medications Ranitidine PO 2-4mg/kg/day Q12Lansoprazole <10 wks old: 0.2-0.3 mg/kg/day>10 wks old: 0.5-1 mg/kg/dayGastric Residuals:For bolus feedsHold for residual >1/2 of previous feedFor continuous feedsCheck residuals every 4 hoursHold feeds if residual exceeds half the amount infused in 4 hours.Infants usually tolerate increasing volume more readily than increasing concentration of feedings. Increasing osmolarity leads to diarrheaIncreasing volumes leads to gastric residual and/or vomiting.Infant formulas:Term InfantFirst Year of LifeBreast milk Ideal for infantsWell toleratedEasily digestedFormulaStandard - Similac/Enfamil/SMALactose is carbohydrateCasein/Whey is proteinAfter Year OneCow's milk Training FoodsSpecial CasesLactose Intolerance and AllergySoy Formulas - Isomil/Prosobee Sucrose & starches are CarbohydrateSoy is the protein sourceMalabsorption, short bowel, gastroschisis, CFHydrolyzed Formulas -Nutramigen, Pregestimil,, Neocate Sucrose & starches are Carbohydrate Pre-digested proteins (hydrolyzed casein)Free-Amino Acid Based FormulasElecare; Neocate (Infant & Jr)Corn Syrup are solids Protein is free amino acidsVI. COMMON PEDIATRIC SURGICAL PROBLEMSAppendicitisBasicsThe most frequent surgical consultation in the emergency department The most common abdominal surgical problem in childhood. Early appendectomy for non-perforated appendicitis typically results in hospital discharge within two days.Children less than 2 years of age typically present with a perforated appendixDo NOT start antibiotics for “appy rule out” overnight admissions when presentation is equivocalPresentation:Abdominal pain begins as periumbilical visceral pain Typically migrates to the right lower quadrant – focal peritonitisPerforation typically occurs at around 36 hours (± 10 hours) after pain beginsAbdominal pain usually precedes vomiting.Associated symptoms:AnorexiaNauseaVomitingExaminationFever and leukocytosis tend to be minimal in early appendicitis Consistent, localized point tenderness is the cardinal signPsoas and Rovsing signs are variableRectal examination may revealRetrocecal appendicitisPelvic massPhlegmonAbscessUse a pelvic exam to rule out GYN pathology in sexually-active young womenLabsBMP and CBCPregnancy test if >10 years oldImagingNo imaging is needed if the history and physical examination strongly suggest appendicitis.A calcified fecalith on KUB is strong evidence for appendicitisFound in only 10-15% of casesUltrasound is the most common imaging strategy used in childrenTypically used for all femalesUsed in males for non-classic presentationCT’s are rarely obtained in childrenMRI A/P appendicitis protocol if further imaging neededAntibiotics -The Johns Hopkins Guidelines for the Management of Appendicitis in Children is found in APPENDIX 1Perforated Appendicitis:Patients with prolonged symptoms (>5 days) prior to presentation may have perforated appendicitis with phlegmon or abscess seen on imagingNon-operative management may be appropriateIR consultation for drainage/aspiration of abscessesBroad spectrum antibiotics, IVFsConsider Interval appendectomy in 6-8 weeks esp if + fecalithPyloric StenosisBasicsTypically occurs in the first 3-6 weeks of lifeExtremely rare prior to week of life 3Male predominance 4:1PresentationClassic: worsening vomiting over several days leading to projectile NON-BILIOUS vomiting after EVERY feed. Lack of vomiting after every feed should prompt a search for other causesIf vomiting has lasted several days the pt may appear toxicExamination:Classic: a palpable ”olive” in the RUQIf present no further diagnostic tests are necessaryTo palpate:Give the infant a pacifier Elevate the baby's feet Palpate over the spine at the midline Palpated by rocking superiorly and inferiorlyImagingUltrasound is imaging study of choicePositive US findingsWall thickness > 3mm ANDChannel Length >16mmUGI if diagnosis is in questionPre-operative maneuversNote: pyloric stenosis is NOT a surgical emergencyElectrolytes must be corrected prior to induction of anesthesiaLong-term vomiting leads to hypokalemic hypochloremic metabolic alkalosis This MUST be corrected like so:Make sure the vomiting is NOT biliousIf it is get an UGI ordered and contact the Senior FellowIf vomiting is non- bilious, check UOP if low then “3.”Use NS blouses of 20 cc/kg to induce UOPIf no urine in 1 hr; repeat NS BolusObtain labs or review OSH labsIf electrolytes come back with HCO3 > 30 give D5 1/2NS at 1.5 x maintAdd 20 mEq of KCl/L to fluids after good UOP has been established.Check labs every 6 hours.Pre-op Goals: (Anesthesia will not put the pt to sleep otherwise)Cl> 90 ANDHCO3 < 30 AND Normal KNo need to repeat labs once:D5 1/2 NS w/ 20MEq of KCl/l is running Goal lytes are obtainedUOP is goodPostoperative management:Note: Warn parents that post-op pyloric pts frequently vomitFeeding may resume 6 hrs post-op and are spaced out Q3hrsThe first feed is 15 ml of PedialyteIf tolerated the next feed is 30 ml PedialyteIf tolerated switch feeds to 30 ml of formulaIf tolerated advance to goal volume formula feedPt may d/c home once tolerating two consecutive ad lib goal feedsIf a pt vomits, repeat the vomited feed/volume at the next feeding time until tolerated then continue to advance feeds as indicated.If the bowel lumen is injured intra-opNGT suction x 2 daysIV ABXIntussusceptionBasicsAn invagination of a portion of the intestine into the lumen of an immediately adjoining part.Typical age range: 4 months to 2 years Peak incidence at age 8 monthsOutside this age range consider a lead point for the intussusception:Meckel's diverticulumIntestinal polypTypical location - ileocecal valvePresentation and ExaminationClassic triad: (rarely are all found)Intermittent colicky abdominal painAbdominal "sausage-like" massCurrant jelly stools.ImagingUltrasound is the diagnostic test of choicePositive tests yield a target signIf found a therapeutic air contrast enema is needed.TreatmentAir contrast enema Should not be performed if the child has peritoneal signsBoth confirmatory and therapeuticIf successful, enemas can be repeated 2 more times if the pain returnsSurgery is not needed if reduction is complete.General principlesA functioning IV must be in place Give prophylactic ABX (cefoxitin) x 1 for concern of translocationReduction is successful when there is free reflux of air or contrast into the ileumRepeat attempts can be made if the baby's condition will permit.Surgery Required for all children with peritoneal signsMandatory if reduction cannot be accomplishedA sick child should go to the OR afterIVFIV ABXNGT placementResection may be requiredPost Reduction CareAdmitted GPS for 24 hours observation even after non-operative reductionNPO for the first 6 hours; then gradually advance the dietHigh temperatures typically follow reductionIf symptoms recur, enema reduction should be repeated againThe recurrence rate after enema or surgical reduction is ~ 5%.Incarcerated Inguinal HerniaBasicsTypically found in infants during the first year of life (F>M)Girls typically have sliding hernia w ovary/tube in canalMost can be reduced manually which obviates the need for emergency surgeryReduction techniques:Infant needs to be calm- sweety dipped pacifierED can provide conscious sedation. Very steep Trendelenburg position assists in reducing the hernia.Have an assistant hold the infant above the knees in a frog leg position to relax the abdominal wall.Technique: Use one hand to put traction on external ring, apply steady even pressure to hernia into the canalA considerable length of steady pressure (5 minutes) may be required to produce the desired reductionShould feel the hernia “pop” into the abdomen on reductionTry to milk the bowel contents out of the incarceration, until it is less edematous and can be put back into the abdomen.Some hernias reduce easily; others require several attempts.If successful, the patient is always admittedRepair is performed electively within the next 24-48 hours after the edema has resolvedThe infant should have serial examinations to rule out re-incarcerationEmergency surgical intervention is required if the hernia cannot be reduced, or if there is post reduction evidence of intestinal obstruction, or nonviable bowelHydroceleIt is imperative to differentiate an incarcerated hernia from a hydrocoele of the cordHydrocoele of the cord is often tenseHydrocoele in the first year rarely requires operative intervention.Clues to distinguish a hydrocoele from a hernia:Transillumination - hydroceles are filled with clear fluidNon-tenderSwelling discontinuous with inguinal ringThese infants can be sent home & booked for elective surgeryComplicationsInfarction of the testicleReduction will usually reinstitute blood flow to the testis.Incarcerated inguinal hernias in girls invariably are sliding hernias containing ovary and tubeIf asymptomatic, these can be repaired on a semi-elective basisThe blood supply to the ovary is usually not impaired, and the vessels are small in comparison.Reducible hernias in premature and complicated full-term infants:If consulted on an inpatient preemie with multiple problems either:Repair within 4 days prior to discharge homeBabies < 52 weeks post-conceptual age or with a history of prematurity (gestational age < 38 wks at birth) must be admitted overnight after hernia repair for cardio-respiratory monitoringForeign BodiesBasics:Requires a high index of suspicion and a low threshold for endoscopic examination if there is any question of aspiration of a foreign bodyExcessive morbidity and mortality results from unaddressed foreign body aspirationsMost common in the toddler age groupFirst get AP & lateral CXR to determine the location of the objectRadiopaque will show locationRadiolucent FBs (wood, plastic, food) will not be seen on CXREsophageal: Obtain esophagram if high index of suspicion Airway: often presents as hyperinflation on CXR of affected side- Ball valve effect in bronchusInspiration/expiration CXRLateral decubitus CXR Affected (down) side will have absence of mediastinal shift from gravityLaryngeal foreign bodiesA foreign body lodged in the oropharynx or glottis may warrant immediate attention to clear the airway:Heimlich maneuverDirect laryngoscopyBronchoscopyIf possible, a mask airway should be maintained and more controlled laryngoscopy performed in the operating room.If the patient is ventilating adequately when seen, no maneuvers should be performed until the patient is in the O.R. where conditions and equipment are idealTracheobronchial foreign bodiesLess than 10% of foreign bodies are located above the carinaMajority located in the right main stem bronchusHistory alone may be sufficient to warrant admission and endoscopy, even in the absence of physical and X-ray findingsPlain chest X-ray will reveal the foreign body if it is radio-opaque. However, most foreign bodies such as wood, plastic objects, or peanuts are not radio-opaque and may only manifest as hyper- or hypo-inflation. Obtain Insp/Exp films or lateral decub CXRManagementThe Storz rigid bronchoscope or optical forceps greatly facilitate foreign body removal from the tracheobronchial treeA fine Fogarty arterial embolectomy balloon passed beyond the object can aid in its removal, particularly if the object is fragile (e.g., peanuts), and will not withstand the pressure of forcepsThe consequences of the neglected foreign body are quite serious and include:AtelectasisRecurrent pneumoniaEventual destruction of the segment or lobeSince there is minimal morbidity using the miniaturized bronchoscope, an aggressive approach is warrantedAll patients should have a postoperative CXREsophageal foreign bodiesAn esophageal foreign body can cause respiratory distress in small childrenObjects tend to lodge just below the cricopharyngeus muscle, usually behind the larynx or cervical trachea, thereby obstructing the airway. Other locations include aortic arch, left main bronchus, diaphragmDiagnostic testsCXR will locate the object if it is radio-opaquePA and lateral to determine position and possibility of 2 objectsDisk batteries have step off on lateral projectionsAbdominal film will determine if the object has slipped through to the stomachEsophagram is occasionally requiredManagement:Endoscopic (rigid or flexible) under general anesthesia typically during business hoursOvernight presentations should be admitted to floor NPO Sometimes a long laryngoscope will be sufficient to allow removal with either foreign body forceps or a Fogarty catheterPassage of the scope beyond the site of impaction is generally not necessary and can increase the risk of esophageal perforationConsider a postoperative CXR to check for pneumomediastinum if multiple passes of the scopeDisk batteries require emergent endoscopic retrieval Can cause caustic injury and full thickness lesionRequire level 1 to ORGastrointestinal foreign bodiesOnce in the stomach, most ingested foreign bodies will safely traverse the GI tract, usually within 4-5 daysOne exception is magnets - Multiple magnets should be removed aggressivelyThe problem sites are:PylorusLigament of TreitzIleocecal valveIf the object is radio-opaque, it can be followed with serial X-ray filmsThe child should be followed for abdominal pain, vomiting, or blood in the stool . Once the object has passed the ileocecal valve the patient can typically be discharged with appropriate follow-upIf after 4-6 weeks the object is still in the stomach, it can be retrieved by EGDCaustic IngestionsBasicsAll patients with suspected caustic ingestion are admitted for esophagoscopy under general anesthesia in 12-18 hr from injuryAlthough most patients with esophageal injury show burns of the oropharynx as well, this is not a completely reliable guidelineUpper airway injury as well as face and hands should be assessedPharyngeal burns may be so severe as to require tracheostomySymptoms can occur between 1-5h after ingestionTypesAcids: Toilet bowl cleaners, rust removers (HF1). These cause coagulation necrosis.Tend to injure the stomach.Bases (alkali): NaOH, KOH, ammonia, electric dishwasher soaps, some denture cleaners, non-phosphate detergents, hair strengtheners. These cause liquefaction necrosis.May involve full thickness injury.Tend to injure the esophagus.Caustic flakes or powder tend to stick and cause localized oropharyngeal and upper esophageal injury. Lead to segmental strictures.Bleaches: Clorox (Na Hypochlorite).Experimentally causes superficial burns and ulceration, no strictures.Disk batteries: Experimental model – 1 hour = mucosal injury, 2-4 hours = muscularis injury, 8-12 hours = perforation.Pills: Can get stuck and adhere to mucosa.NSAIDS – hemorrhage and stricture. Potassium Chloride – strictures, hemorrhage, death. Quinidine – strictures. Always think about battered child syndrome, Munchausen’s by proxy (8%). 78% of poisonings occur with patient near parent. Get social services involved if story is incongruous with injuries.Management – Acute:DO NOT INDUCE VOMITING, DO NOT LAVAGENPO and IVF.Wash skin and eyes; wash out mouth with water or milk. CXR and KUB for sx of respiratory distress, odynophagia, drooling, abdominal pain.Esophagoscopy 24-48 hours post injury. Do not evaluate distal to lesion.Avoid in patients with severe oropharygneal burns or laryngeal edemaRepeat evaluation in ~2weeksBarium swallow in 2-3 weeks.In patient:Moderate burns – Inpatient 2 weeks, abx and steroidsSevere or full thickness – as above, omit steroid administration. Consider esophageal silastic stent with distal penrose to prevent GER or NGT for 6 weeks as sole treatment. If full thickness stomach injury gastrectomy/esophagectomy. Esophageal stricture: develops in 7-15%. Long term risk of cancer. Lower GI Bleed:NEONATES: Condition - WorkupSwallowed maternal blood - Apt testHemorrhagic disease of the newborn – Coags, Vit K deficiency NGT, Thrombocytopenia from multiple causes, UGIAnal fissure - Anal examNEC - KUB, cross table lateralMalrotation and volvulus – UGIAllergic colitis from formula – EosinophiliaINFANTS 3-18mo: Condition – Workup Anal fissure - Anal examIntussusception - Colon study-air or contrastIntestinal volvulus - KUB, Small Bowel Follow ThroughEctopic gastric mucosa - Meckel's scan for ectopic gastric mucosaGastroenteritis – Coags, NGTTODDLERS and PRESCHOOL: Condition – WorkupAnal fissure – Anal Exam, Coags, NGTRectal prolapse - Anorectal examGastroenteritis – KUBMeckel`s diverticulum - Meckel`s scanJuvenile polyp - Upper and lower endoscopyTrauma - RBC scanOLDER CHILDREN and TEENS 6-18y: Condition – WorkupPolypoid diseases - Coags, KUB, NGTUlcerative colitis - Upper and lower endoscopyHemorrhoids - Anorectal examMeckel`s - Meckel`s scanBiliary AtresiaBackground– rare 1:18 K infants, non-hereditary, leading cause of liver transplants in infants/toddlersCause- unknownSymptoms-persistent hyperbilirubinemia > 2 wks of age????? ?????????????????????????Acholic stools??????????????????????????? ???Poor weight gain???????????????????????????? ??Poor feeding???????????????????????????? ??Sleepy???????????????????????????? ??Dark urineDifferential Diagnosis- Hereditary disorders (Alagilles, Wilsons, Primary Sclerosing cholangitis)?????????????????????????????? Viral hepatitis?????????????????????????????? Autoimmune hepatitis?????????????????????????????? Toxicity d/t exposure ie: acetaminophen ODWork up--?? Blood test screening for genetic disorders????????????????????????????? Hepatic duplex????????????????????????????? HIDA scan- NPO & no narcotics x 4 hrs prior????????????????????????????? Liver biopsy Intraoperative cholangiogramTreatment - KasaiPost-op Kasai Management: MedicationsActigall: Oral - 10mg/kg/dose – BID (helps absorb bile acids decrease pruritis)Bactrim: Oral - 5mg/kg - Daily (cholangitis prophylaxis)ADEK: Oral - 2mL - Daily Ranitidine: Oral - 2mg/kg – BID Tylenol: Oral - 12.5mg/kg/dose - q 12 hours PRN Additional Medications: depending on clinical picture/lab valuesK : oral 2.5mg MWF (only with abnormal coags)In INRis hight (>1.2) then they will start it here and stay on until GI f/u aptSpironolactone: start 1mg/kg BID to 2mg/kg/BIDCan be TID based on clinical exam, may increase frequency if clinically neededInitiate after POD4 if pt is edematous and having increase abdominal girth post op Strict I/O-monitor for ascites, edema, color of urine, strict I&Osmonitor stools for color, hematocheziaMonitor BP/persistent portal hypertension, varaciesacetaminophen Q 12 hrs, narcotics & other meds given at longer intervals ie:Q6+ hrs d/t poor clearance r/t liver failureEnteral feeds after bowel function returns:Breast milk , BM with MTC oil (per nutrition)/ Pregestimil (short chain fatty acid formula- best tolerated and absorbed)Things to be aware of while on floor: Abdominal distentionNauseaVomiting Clay/gray color stools Bilious emesisTea color urine Itchy/yellow skin Chest Wall Deformities-Pectus ExcavatumBackgroundCaused by overgrowth of costal cartilages causing sternum to angle posteriorly toward spineMale to female ratio 3:1.Etiology unknown but ~ 30% incidence in relativesOften apparent at birth but may increase in severity with growthAssociated Anomalies:Marfan’s SyndromeScoliosisIndications for RepairSeverity and symptomsPsychosocial issuesManagementPreop: may have any of following: CT with Haller indexPFT’sEchocardiogramIntraop: Nuss ProcedurePrep with chlorhexidine hand scrubSmall bilateral intercostal incisionsLarge clamp passed across mediastinum from left to rightStainless steel bar custom shaped to desired contour passed across mediastinum concave side upBar then flipped to elevate chest wallBar secured with stabilizers & wire to remain in 3 yearsPostop: Nuss ProcedureCXR (AP, possible lateral) in PACU to check bar positionPCA for 2-3 days managed by the Pediatric Pain TeamConvert to oral pain meds on 2nd or 3rd PODWill need narcotic Rx for home pain managementPost-op clears, then advance diet as toleratedOOB and early ambulation, incentive spirometerIf urinary retention, place foley for 24 hoursBar removalTypically 3 years after placementOutpatient procedureMinimal pain meds (No narcs typically)NO POST-OP CXR unless symptomaticDesatsMajor Chest painGastrostomy tubeIndications Nutritional supplementation: Failure to thriveOral AversionOromotor Dysfunction & DysphagiaMedication administrationWork-UpMany of these children require a concomitant NissenWork up must determineNormal RotationGastric Feeding tolerance by NGTBolus NGT feeding ToleranceUGI – REQUIRED to rule out Malrotation (not to determine reflux)pH probe to prove reflux in symptomatic child w/ bolus toleranceMalro get’s a Ladd’sReflux or Bolus intolerance gets a NissenPlacement methodsOpen – Cardiac InfantsPercutaneous (PEG) - > 1y/oLaparoscopic – Neonates and InfantsTypes of gastrostomy tubesMalencot or Pezzar: used if decompression is necessaryBalloon gastrostomy tube (MIC)Balloon gastrostomy button (MIC-Key) Post Operative ManagementNPO following the placement of the G-tubeAsk attending if toradol OKFeeds may initiate at midnight on POD#0 or POD#1amFor smaller childrenPedialyte @ 5ml/hr x 4 hours then; Switch to pre-op formula at 10ml/hr;Increase feeds by 5ml q4hrs until at goalFor older children (>1 year)Start with Pedialyte @ 10ml/hr x 4 hours then; Switch to pre-op formula at 20ml/hrIncrease feeds by 10ml q4hrs until at goalGtube must be a continuous rate for 24 hours before changing to bolus feeds and Nissen/Gtube must be on continuous feeds for 3 days then can change to bolus feeds. Stitches can be removed day 3-5 based on the attendingTubes are changed electively in clinic at 12weeks (earliest 6-8weeks)ComplicationsLeak: Refer to Wound and Ostomy nurses Accidental dislodgingEarly inadvertent removal- notify Fellow or Attending before attempting replacement Within 2 weeks of insertion:Re-insert tube or foley immediately Obtain a g-tube study with contrastDo not force the tube inIf a foley was used and the contrast study shows access to the stomach, re-insert a g-tubeIf the tube cannot be inserted without difficulty, dilate the tract serially with 8Fr, 10Fr and 12Fr Cook dilators and then attempt to reinsert. This often requires sedation and possibly ORRadiologic confirmation is not necessary for accident dislodgement in a tube that has a matured tractPrompt response to calls about dislodged GTs are critical as tract may close within hoursExcessive granulation tissue or redundant gastric mucosaCan be cauterized w silver nitrate sticksEmpyemaCausesPneumonia- most commonExtension of mediastinal, retropharyngeal, paravertebral infectionsThoracic surgery or traumaStagesStageTime after onsetFluid characteristicsTreatmentExudative24-72hrsThin fluid, few cellsDrainage (CT or needle)Fibrino-purulent5-10 daysFibrinous debris, many PMNs, loculated septationsFibrinolysis +/- thoracoscopyOrganizing2-4 weeksThickened pleuraPleurectomyOrganismsStaph aureus – most commonStrep pneumoniaeHaemophilus influenzaPseudomonas aeruginosaPresentationHx of URI w fever and coughPleuritic chest pain and resp distressLethargy, tachycardiaDiminished breath sounds and dullness to percussion on examWork upCXRUS Usually adequate for diagnosisID locuated fluid collectionsCT Chest for special circumstancesThoracentesisComplicated pleural effusionpH <7.2glucose < 60mg/dLLDH >1000 un/LTreatmentIV ABX, may require PICC for homeEarly- chest tube drainage aloneAdvanced (loculations)- Chest tube drainage and fibrinolysis w tPAVATS w drainage and decorticationDr Lukish uses tPA post opSee appendix for tPA procedure guidelines Spontaneous PneumothoraxMost common in tall, lean adolescent males, Family history????? Recurrence rate 50% after one, 62% w/second, 83% if third incident????? No history of trauma or recent illnessCausesBlebsUnknownInfectiousCPAMSymptomsIpsilateral chest painDyspneaDiminished breath soundsTracheal shiftDiagnosisCXRManagement< 20% ?lung volume and asymptomatic??????????? ?100% O2 & observe > 20% or symptomatic small pneumo- Place chest tube or pigtail catheter and wall suction- Place to suction for 48 hours if no air leak, then place to water seal prior to removal -If persistent air leak, troubleshoot system and then consider CTRecurrent spontaneous pneumo???????????? Place chest tube/Pigtail and obtain CTVATS for blebectomy and pleurodesis if CT + blebs on ipsilateral side, blebs on contralateral size just observe???????????VII. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILDMany pediatric surgery patients do not require preoperative lab work. As a rule same day surgery patients do not require lab work or diagnostic studies unless there is an underlying diagnosis that places the child at increased risk related to surgery or anesthesia. Pre-op labs are not routinely ordered on pediatric surgery patients. Outpatient Surgery GuidelinesPlease refer to Appendix 10 for broad coverage of outpatient surgery guidelinesNPO GuidelinesPatients should be awakened and offered fluids the night prior to surgery<2 Years Old:NPO for solids at midnightNPO for milk/formula 4 hours prior to surgeryNPO for clear liquids 2 hours prior to surgery>2 years old and olderNPO for solids and milk at 8 hoursMay have clear liquids up to 2 hours prior to surgeryClear liquids include breast milk unless a bowel prep is requiredPatients should be sent home on pain medications:Tylenol only for child < 6 months of ageOxycodone for older children when extent of operation warrantsFollow-up: Return to clinic in 2 weeks unless it is a line removalIn-Patient guidelines ERAS ProtocolStart IVF D5 ? c 20kClear liquid diet until 4am then NPONeomycin 23mg/kg/dose (max dose 1gram)x 2 given PO at 1hr & 4 hrs after admissionNeomycin 500mg/ml in syringe to be sent to OR w/pt day of surgeryErythromycin 30mg/kg/dose(max dose 1gram)x 2 given at 1 & 4 hrs after admissionBisacodyl 30 mg x 1 dose given at 3 hrs after admission (for pts 12yr >)Miralax 238 gms given with 32 oz of Gatorade on admission, (pts 10 yr+) To be finished within one hour Miralax 3mg/kg (max 238 gms ) given with 8 -24 oz of pedialyte or Gatorade on admission for pts (0-9 yr) to be finished within one hour.Gabapentin 5mg/kg (max dose 300mg) QHS x1 for patients 2yrs and upWash pt with chlorhexidine wipes the night before and morning of surgeryERAS protocol for Neonates (pre-term to 37)IVF to run at 60cc/kgPedialyte started at 90cc/kgCheck glucose every 4 hoursNeomycin 23mg/kg/dose (max dose 1gram) x 2 given PO at 6pm & 11pm the night before surgeryNeomycin 500mg/ml in syringe to be sent to OR w/pt day of surgeryFlagyl 7.5mg/kg/dose (max dose 500mg) x 2 given PO at 6pm & 11pm the night before surgeryWash patient with Sage CHG 2% cloths applied to the abdomen the night before and the morning of surgeryNPO GuidelinesMedications: Can be given with a sip of water except for the following which should not be given within 8 hours of surgery:White liquid antacids (Mylanta, Maalox)Stool softeners (carafate, senna, miralax)ACE inhibitors (captopril, lisinopril, enalapril)ARBs (losartan, valsartan, irbesartan)Solid foods, milk, meat-8 hours (or after midnight) before arrival at the hospitalInfant formula - 6 hours prior to arrival at the hospital/ first case startBreast milk - 4 hours prior to arrival at the hospital/ first case startClear liquids - 2 hours prior to arrival at the hospital/ first case start2Fluid ManagementIndications for pre-operative IV fluidsVomiting, diarrhea, fever or preoperative bowel preparationDelay of surgery more than 6 hours in infants or 8 hours in childrenMaintenance IV fluidsNewbornDay of Life #1: 80ml/kg/d of D10WDay #2: 100ml/kg/d of D10 1/4NSGlucose infusion rate (GIR) 4-6mg/kg/min (term) or 5-8 mg/kg/min (preterm) = [IVF rate (ml/hr) x dextrose conc (g/dL) x 0.167]/wt (kg)Older children100ml/kg/day or 4 ml/kg/hr for first 10kg50ml/kg/day or 2 ml/kg/hr for second 10kg20ml/kg/day or 1 ml/kg/hr for every kg over 20Remember “4-2-1” Rule (When wt> 20 kg add 40 to wt in kg for maint rate)Standard maintenance IV fluid: D5 1/2NS with 20mEq/L KClElectrolytesDaily sodium: 2-5mEq/kg/dayDaily potassium: 1-2.5mEq/kg/dayBlood productsEstimated blood volumeNewborn 90cc/kgChild 80cc/kgAdult 70cc/kgPRBCs10cc/kg will raise Hct by 3-4%Platelets 1 unit/10 kg will raise count by 25,000FFP10-15 ml/kg for coagulopathyCRYO1 unit/5kg to replace FibrinogenGI losses: Over 30cc/kg/day Replace all with cc per cc.Gastric: Infants: D5 1/2NS with 20mEq/L KCl or if on formula or TPN can use normal saline Older: NS w 20mEq/L KClDistal GI losses: D5LRImmunization status -See Appendix 7 for immunization schedule1Nutritional basicsGrowth parametersMeasure weight dailyMeasure length weekly (in NICU)Follow growth parameters closely in making decisions on nutritionAverage weight gainPremie <2kg: 15-20 g/dayPremie >2 kg: 20-30 g/day0-3 months: 25-35 g/day3-6 months: 20 g/day6-12 months: 12 g/day12-18 months: 8 g/dayCaloriesTerm neonate 100-120 kcal/kg/dayPreterm 120-130 kcal/kg/dayVery low birth weight (<1kg)>150kcal/kg/dayParenteral NutritionIndications:Prolonged period of fasting (> 5 days)MalnutritionCan be initiated using peripheral or central venous accessIf peripheral access is used, the PN solution must be diluted to avoid phlebitis and sclerosis –osmolality <1000If PN is to provide for >3days; recommend central access to optimize nutritional provision without osmolality limitsFull CPN requires that central line be at the junction of the SVC and right atriumDaily fluid requirements for pediatric population0-10kg 100ml/kg10-20kg1000ml + 50ml/kg >10kg20+kg1500ml + 20ml/kg > 20kgMain componentsLipidsInitiated at 1g/kg/day slowly increased with maximum dose of 3g/kg/dayCheck weekly triglycerides and adjust lipids PRNDextrosePreterm infants started at a rate of 5mg/kg/min; advance by 1-2 mg/kg/min pending blood glucose< 110 to max of D12.5 in peripheral lines; D20-25% in central lines; or GIR of 18mg/kg/minTerm infants start at 2.5% higher than their normal fluids. If BS<110advance to a max of 12.5% in peripheral lines and D20-25% in central linesProtein<1kg – start at 1.5 g/kg advance by 1g/kg to goal of 3.5-4 g/kg1-2kg start at 2 g/kg/day advance by 1g/kg to goal of 3-3.5 g/kg>2 kg and term infants start at 2g/kg and go up 2-3 g/kg to goal of 2.5-3.5 g/kgAdolescents start at goal of 0.8-2.5 g/kgCPN should also contain water and fat-soluble vitamins as well as trace elementsAll patients on TPN should get daily electrolytes in the initiation phase 6All TPN orders must be entered into POE and on Hopkins Pediatric CPN portalCompleted forms are faxed to the pharmacy daily at 5-0283Guidelines for advancement and calorie, fluid, and protein recommendations for parenteral nutrition can be found in Nutrition Assessment note in POECentral Venous LinesAccess points usually include:internal jugularsubclavianfemoral If access is obtained from an upper vein, the goal is to ensure that the line is at the cavoatrial junction on chest x-rayNon-tunneled central lines:Used for short or medium-term accessInclude Arrow and CookTunneled central lines:Usually placed in the operating room under fluoroscopyBrands: Cook, Broviac, HickmanInstill heparin flush to fill catheter if not in useTotally implanted central venous lines (Ports)Used for long-term, intermittent access such as for patients with malignancies, hematologic illnesses or renal failureThese are accessed with special non-coring (Huber) needles. 3Per Hopkins policy, nurses are not allowed to access until POD#5 after placementBe sure to ask team if they will need it accessed in the operating roomInstill heparin flush (final flush dosing) to fill tube if not in being used GPS requires ANC >= 500 to place a portComplicationsLine break: Call the GPS senior or fellow to discuss – Repair kits existContact fellow prior to repairing lineThis is considered an urgent procedure and repair should be performed expeditiously before the line is lostRepairing and salvaging lines is especially important for patients on long term TPN (ie short gut) and have had multiple repeated line placementsRepair kits are located in Peds ED or Interventional radiology Know the size and type of catheter in patient, repair kit must match sizeTechniqueClamp the line proximal to the break, Prime the repair segment with saline flush. Squeeze the silicone glue into the barrel of a 3cc syringe and apply the blunt tip. Do not squeeze the glue into the needle until ready to use. Prep the line sterilely and lay on a sterile towel.Cut with disposable scissors. Partially insert the metal piece of the repair segment into proximal stump and apply glue to metal segment circumferentially before fully inserting. Apply more glue around connection and slide clear plastic sleeve over the repair site. Inject as much glue as possible inside the sleeve. Gently try to flush the line with saline. If it flushes then follow with heparin flush. If resistant, stop. No further flushes should be attempted for 12-24 hours. At that time tpa may be instilled if the line still cannot be flushed. After repair, lines should not be used for a minimum of 12 hours, preferably 24 hours. Stenting the repair with a tongue depressor may be helpful. Administer fluids via peripheral IV until cvl is safe to use again.Line occlusion: Make sure that the line is unclampedTest the line yourselfCall VAT to declot with tPATPA should be applied for 2-4 hours, at least 2 attempts, if still not resolved, consider leaving TPA in overnightCatheter site infectionErythema or drainage from the insertion siteSend peripheral and central blood culturesTreat with local wound care and empiric antibiotics until cultures result then de-escalateRemove if: Continued local infection despite 48-72hr abxDeveloping systemic infectionFungal infectionOngoing sepsisPersistent + cultures on appropriate ABXCentral line associated blood stream infection (CLABSI)See guidelines in Appendix 12 and 13Obtain peripheral and central line blood culturesTreat with empiric antibioticsTunneled catheters are treated with intent to sterilizeCultures are drawn dailyAntibiotic locksHydrochloric Acid may be required by protocol to clear lineAntibiotic prophylaxisMost important method of preventing surgical site infections is proper hand scrubbingClipping, if necessary, should be done just prior to surgerySystemic prophylaxis should be given only when risk of wound infection and benefits of prophylaxis outweigh risks of adverse drug reactionsClean cases: Respiratory, GI, or GU tract or oropharygeal cavity is not enteredRisk of infection is low at 1-2% therefore prophylaxis is NOT neededExceptions include implantation of prosthesis, open-heart surgery, exploration of body cavity in neonates or neurosurgical casesClean-contaminated: Respiratory, GI or GU tract is entered in a controlled setting.Risk of infection is approximately 3-15%Contaminated: Include open wounds, cases in which there has been a break in sterile technique, exposed viscera at birth, congenital anomaliesRisk of infection is approximately 15%Dirty: Included penetrating trauma >4hrs, devitalized tissue, wound with infection/ perforated viscus. 4Antibiotic should be administered within 60 minutes of incisionAntibiotic should be re-dosed ifcase >4hrs>30% blood volume loss>1500ml if >50kg and normal renal functionSee Appendix 14 for specific prophylaxis guidlines5TracheostomyUsually performed in the operating room as an elective case on a child who is already intubatedThe operationTransverse incision in the lower neck and dissecting down to the tracheaThe trachea is incisedjust below the isthmus of the thyroid no higher than the second tracheal ringA stay suture on each side of the tracheostomy with polypropylene sutures and labels for “right” and “left”5The ETT is withdrawn under direct visionUse a cuffless tubeFirst trachea change to be done by GPS senior at 7 days Respiratory distress in a patient with new tracheostomySuction first but only for a moment Pull up on the stay sutures and remove the trach tubeRe-insert endotracheal tube and replace tracheostomy when airway is well-establishedChest tubesIndications: PneumothoraxHemothoraxPleural effusionInsertion site:Pneumothorax: place on the anterolateral aspect of the chest wallHemothorax/ pleural effusion: Place posterolaterallyInsertion TechniquePrep and drape the skin and anesthetize with local anesthetic Make a small incision in the mid-axillary line at the level of the nippleUse a curved hemostat to tunnel superiorly and above the higher rib into the pleural cavityOnce in the pleural cavity spread the hemostat to create a tractInsert the chest tube into the pleural cavity and ensure that all holes are intrathoracicObtain a post-insertion chest x-ray to confirm the positionChest tube removalChest tubes should be removed after: being placed on water seal CXR evidence of post-seal resolution of hemo/ pneumothoraxNOTE: Lukish wants ALL his Chest tubes removed ON SuctionTake off water seal two hours prior to pullHe only wants symptomatic post-pull CXRChest tubes should be removed at the end of inspiration or with a vasalva maneuverIf the patient, is cooperative, you can ask them to blow like they are blowing on a birthday cakeOnce the tube is removed, cover with xeroform and an occlusive dressing such as a TegadermObtain a post-pull CXR an hour afterwardsNasogastric tubesUsed for gastric decompression and enteral feedsUse sump tubes for decompressionConfirm the position of the tube by instilling a small amount of air while auscultating over the stomachIf the NG tube output is high, get an abdominal xray to confirm its placementGavage feeds in neonates and infants for:lack of gagweaknessrapid respiratory rateRequires 1:1 replacement when volumes are highApnea and Bradycardia monitoringEx-preemie infants (<37 wks) up to 52 wks post-conceptual age require overnight apnea and bradycardia monitoring for recovery from anesthesia with narcoticsPost-operative antibioticsIndicated in the setting of post-operative surgical site infection or abscess.Wound infection: signs include erthyema, leukocytosisTreat with oral or IV antibiotics depending on severityAbscessDefinitive treatment is incision and drainageOnce the wound is opened, pack with aquacel or wet-to-dry saline solution and let it heal with secondary intention4Pediatric Pain TipsPCA’s can only be ordered by the Pediatric Pain TeamYou cannot order a narcotic and sedative together as it is considered conscious sedation (ie oxy and valium)If the Pain team is involved, no other narcotics, sedatives, analgesics can be ordered by our service.Place order for pain team consult with transfer orders from OR to PACU, for patients except lap appy, lap chole, umbo/inguin hernia, GC fistula repair, lap nissen/GTubeOrder ketorolac ATC for lap chole/appy, hernia, GC fistulas. May also order morphine prn and acetaminophen for breakthrough painNSAIDs not ordered for onc , hemophiliac, chronic renal disease, ICH, liver/spleen/kidney lacs.No acetaminophen for liver failure patientsProcedures-Bedside procedures- removal of chest tubes/drains/TPA instillation/wound VACs/wound explorationDiscuss time of procedure with patient and nurse. If patient has PCA instruct pt/nurse to give bolus doses as allowed starting 30 min prior to procedureIf PO meds instruct nurse to give oral pain meds/anxiolytics one hour prior to procedureCentral lines cannot be removed at the bedsideVII. PEDIATRIC TRAUMAI. Pediatric Trauma at Johns HopkinsPolicy: Care of the Pediatric Trauma Patient PAT092.“Pediatric” is defined as patients aged < 15y arriving directly from the scene of injury; patients > 15y are adult patients. Patients < 17y may be transferred in from OSHs.Three categories of pediatric trauma activation:Alpha trauma: highest priority; unstable patients or injuries that may quickly result in instability.Bravo trauma: high priority; stable patients with a significant mechanism of injury or specific types of injuries. Critical trauma transfers: high priority; essentially a stabilized Alpha trauma arriving to the trauma bay for primary & secondary survey; then, expeditious admission to the PICU.PED Trauma Activation CriteriaMechanisms not meeting above criteria GPS Consult CriteriaNAT work upPED trauma requiring chest or abdominal CTTeam members who respond to pediatric trauma activations include:GPS attending (required for Alpha traumas only)GPS fellow/senior resident-team leaderGPS intern/NPPICU fellow and attending for airway management (Alpha traumas only)ED attendings:on odd days- pediatric emergency medicine attendingon even days- adult emergency medicine attendingPED resident and AED residentPED NursingPICU Nursing (Alpha traumas only) Respiratory Therapy (Alpha traumas only) Pharmacy (not available 24/ 7) ); If needed during off shifts can activate an RRTRadiologyAdditional ancillary services, i.e., Social Work, Chaplain, Security.All team members require yellow gown and role name tag upon entering room.Establish roles early prior to patient arrival.Pediatric/ adult ED resident enters orders (labs, imaging) while the patient is in the ED; paper requisitions for imaging are also acceptable and can be filled out by the GPS team, if plete the trauma-specific H&P note in the patient’s electronic medical record (eMR) for all Alphas, Bravos, critical & non-critical trauma transfers & trauma consults. Fill in all information and be accurate: it becomes part of the patient record, and data is submitted to the National Trauma Data Bank.Use the pediatric trauma-specific order sets for all trauma admissions.Consult other services as needed through PING.Procedures, e.g., central lines, chest tubes, etc.: document a procedure note in eMR.All patients admitted following a pediatric trauma activation are admitted to the GPS service for at least 24 hours; transfer to another service can be considered later if the patient has only single-system injuries. Exceptions include isolated injuries taken to OR by specialty service with remainder of trauma work up completed and negative. II. Evaluation of the Pediatric Trauma PatientPre-arrival: obtain as much information as possible regarding the mechanism of injury and potential injuries, prepare a game plan based on this information, and obtain equipment that may be required for emergent procedures.Primary SurveyEMS provides their report as the patient is moved to the ED stretcher. Do NOT delay initiation of the patient evaluation to hear details from EMS that can be provided after the patient is stabilized. , (30 second time out). The ED attending or fellow (or GPS attending or fellow, if present) serves as team leader, looking at the “big picture” of the resuscitation. The primary survey is performed by the GPS intern/NP/ fellow/ senior resident. The GPS senior/intern/NP documents the trauma history and physical and assists with procedures, as neededPerform ABCDE evaluation per ATLS protocol.AirwayIndications for rapid-sequence intubation: GCS8Significant facial trauma with poor airway controlAirway obstructionShock unresponsive to fluid resuscitation Failure to adequately oxygenateParalysis secondary to high spinal cord injuryBlunt chest trauma compromising ventilationEndotracheal tube size can be estimated by:The size of the child's little finger or naresAccording to the following formula for children 1-10 years old: (Age in years/4) + 4.A surgical airway is indicated when orotracheal intubation is unsuccessful or contraindicated.Surgical cricothyroidotomy is rarely indicated in children.A needle cricothyroidotomy is instead preferred.Can support patients for 30-45 minutes with transtracheal jet ventilation.With patient supine and the neck prepped:Palpate the cricothyroid membrane.Assemble a 12- or 14-gauge catheter over a needle.Connect it to a small syringe.Puncture the skin midline over the cricothyroid membrane.Direct the needle at 45 degree angles caudally.Insert the needle through the lower half of the membrane while aspirating.After aspiration of air, advance the catheter inferiorly while withdrawing the stylet/ needle.Attach the catheter to oxygen tubing and secure it to the neck.BreathingListen for bilateral breath sounds.Emergent needle decompression of tension pneumothorax & chest tube placement, as neededOperative indications:Initial chest tube output > approximately 15-20 mL/kg Ongoing output of > approximately 5 mL/kg CirculationConfirm the presence of a pulse and begin compressions if not present.Obtain non-invasive blood pressure.Obtain two large-bore IVs.Use intraosseous access or place a central line if adequate peripheral IV access cannot be obtained quickly (within 2-3 attempts).Control any external hemorrhage.Give 2 boluses of 20 mL/kg of isotonic crystalloid (NS or LR) for hypotension, followed by 10 mL/kg of PRBC if still hypotensive and there is concern for ongoing hemorrhage. Discuss activation of the pediatric massive transfusion protocol (MTP), if needed.Children can maintain nearly normal vital signs even with severe hemorrhage.The primary response to hypovolemia in children is tachycardia.Hypotension is a LATE sign of shock in children (may not occur until after 40% of blood volume is lost).Indications for an ED thoracotomy: Penetrating injury with loss of vital signs en route/ within 5 minutes of arrival to ED.Blunt or penetrating injury with loss of vital signs in the ED.Deformity & Disability: Perform a brief neurologic exam, e.g., GCS, pupils, etc.Check pelvis stability and look for long bone fractures.Exposure: Remove all clothing.Try to keep patient warm thereafter, e.g., warm blankets, warmed IV fluids, level one warmer, bear-hugger, etc.Ensure there are no chemicals on the patient.Obtain an AMPLE HistoryAllergiesMedicationsPast medical historyLast mealEvents leading to injury and environment of injuryInitial Data CollectionTrauma Lab PanelCXR (if mechanism warrants)Advanced tip: place a CXR plate on stretcher prior to patient arrivalPelvic XRFAST Secondary SurveyPerform a complete head-to-toe examination.Log-roll the patient with the C-spine stabilized to examine.The back for spinal tenderness/deformity. Perform a rectal examination.Remove the hard board before rolling the patient back. Leaving patients on the hard board can quickly lead to skin breakdown.Additional procedures (NG/OG, Foley catheter, change to padded rigid cervical collar (Aspen of Miami J/ Jr.), additional IV access, etc.) are performed as neededDo not place an NG if there is concern for naso/oropharyngeal trauma or skull fracture.do not place a Foley catheter if urethral injury is suspectedTransport/Additional StudiesHead CT should be used selectively to avoid the long-term risks of cancer associated with radiation.Add CT of the face if facial fractures are suspected based on the physical exam.Utilize the PECARN algorithm to identify which pediatric trauma patients should undergo head CT.The PECARN AlgorithmSuggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores of 14–15 after head trauma*GCS=Glasgow Coma Scale. ciTBI = clinically-important traumatic brain injury. LOC=loss of consciousness. *Data are from the combined derivation and validation populations. ?Other signs of altered mental status: agitation, somnolence, repetitive questioning, or slow response to verbal communication. ?Severe mechanism of injury: motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 0.9 m (3 feet) (or more than 1.5 m [5 feet] for panel B); or head struck by a high-impact object. §Patients with certain isolated findings (i.e., with no other findings suggestive of traumatic brain injury), such as isolated LOC, isolated headache, isolated vomiting, and certain types of isolated scalp hematomas in infants older than 3 months have a risk of ciTBI substantially lower than 1%. ?Risk of ciTBI exceedingly low, generally lower than risk of CT-induced malignancies. Therefore, CT scans are not indicated for most patients in this group.From: Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3; 374(9696):1160-70.Obtain plain films of the cervical spine rather than CT to avoid thyroid radiation, even if CT is performed of the head or chest.Get CT of the abdomen/pelvis as needed based on physical exam findings and mechanism.Get plain films for any significant findings on examination of the extremities:One joint above.One joint below.FAST exam can be considered but should never delay care. Although appealing to minimize radiation, FAST is relatively insensitive in children because of the frequency of solid-organ injury that is seen without associated hemoperitoneum.LabsConsider CMP/amylase/lipase/urinalysis to screen for abdominal injury.Get CBC, coagulation profile, and type and screen if any concern for bleeding.Transport the patient directly to the PICU or OR as necessary or to the pediatric ED for observation until discharge or admission to a general care unit.Tertiary SurveyTo be completed when the patient is alert and no distracting injuries remain.C-spine can be “cleared” during this examination.C-spine clearance consists of both a negative clinical examination (no mid-line spinal tenderness and no pain with flexion, extension, lateral flexion, or rotation) and negative radiographic examination (plain films or CT).If there are no fractures on CT or plain films but tenderness or pain with movement remains, continue spinal precautions and obtain an MRI of the spine.III. C-spine clearance- please write a procedure note if you clear the collarOther Important PointsSpleen/LiverSEE APPENDIX 17 for management monly injured in blunt trauma.Most isolated spleen/liver injuries in children can be treated NON-operatively.Operative management of spleen/liver injuries is indicated for ongoing hemorrhage and/or refractory hemodynamic instability.Grading for splenic injuryGrade I: subcapsular hematoma 10% of surface area, capsular laceration 1 cm depth.Grade II: subcapsular hematoma 10–50% of surface area, intraparenchymal hematoma 5 cm in diameter, laceration 1-3 cm depth not involving trabecular vessels.Grade III: subcapsular hematoma > 50% of surface area or expanding, intraparenchymal hematoma > 5 cm or expanding, laceration > 3 cm in depth or involving trabecular vessels, ruptured subcapsular or parenchymal hematoma.Grade IV: laceration involving segmental or hilar vessels with major devascularization (> 25% of spleen)Grade V: shattered spleen, hilar vascular injury with devascularized spleenGrading for liver injuryGrade I: subcapsular hematoma 10% of surface area, capsular laceration 1 cm depth.Grade II: subcapsular hematoma 10-50% of surface area, laceration 1-3 cm in depth.Grade III: subcapsular hematoma > 50% of surface area or expanding or ruptured, laceration > 3 cm in depth.Grade IV: parenchymal disruption of 25-75% of hepatic lobe, 1-3 cm laceration of Couinaud’s segments in a single lobe.Grade V: parenchymal disruption of > 75% of hepatic lobe, > 3 cm laceration of Couinaud’s segment in a single lobe, juxtahepatic venous injuries.Grade VI: hepatic avulsion.Child AbusePay attention for suspicious injuries, signs on physical examination, and conflicting stories or inconsistencies in the history that raise concern for child abuse.Document all noted injuries in detail.Work-up for abuse generally consists of a skeletal survey with addition of head CT, brain MRI, and/or abdominal CT, as indicated.If the patient has a significant finding on neuroimaging, consider an ophthalmologic evaluation with a dilated fundoscopic exam to look for retinal hemorrhages. If the patient has negative neuroimaging, there is a low probability for retinal hemorrhages! Therefore, an ophthalmic exam is not necessary.Social work/CPT consult. Any concern for child abuse MUST be reported to CPS for investigation.Head TraumaSurgical decompression is indicated in the presence of a rapidly expanding epidural or subdural hematoma that causes an increase in ICP and/or focal compression: done immediately if signs of increased ICP, altered mentation, focal neurologic signs, pupillary changes, or midline shift are present.Conservative management with close monitoring in the PICU is acceptable if no focal neurologic signs, altered mentation, or midline shift are present and the hematoma is relatively small (<2 cm).ICP monitor may be required with loss of neurologic exam in setting of head trauma.Skull fracturesCategorized as: Open or closed, based upon the presence or absence of an overlying scalp laceration in continuity with the fracture site.Depressed or non-depressed, based upon the relationship of the bone fragments to each other.Depressed skull fractures often cause injury to the underlying brain and are often open.Depressed skull fractures are treated surgically with debridement and elevation when any of the following indications are present: The depression is greater than the thickness of the skull (approximately 8-10 mm).A focal neurologic deficit results from compression of the brain parenchyma.A significant underlying intracranial hematoma is present.Pneumocephalus is seen.The frontal sinus is involved.Gross cosmetic deformity exists.Gross wound contamination is present. Intraparenchymal bone fragments are seen, indicating laceration of the dura mater and an increased risk of infection.Non-operative management is appropriate for patients with depressed skull fractures (even if open) that possess none of the above findings.A "ping-pong fracture” is a type of greenstick fracture typically seen in newborns (because of the plasticity of their skull) that appears as a local concavity of the skill without sharp edges: unless the depression is deeper than the thickness of the skull (or another indication for surgery is present), these fractures usually do not require surgical intervention because the skill will remodel and smooth out the defect during growth.IX. PEDIATRIC BURNSPolicy: Care of the Pediatric Burn Patient PAT095.All burns > 20% TBSA are activated as Alpha traumas and should have an expeditious admission to the PICU or OR. See Appendix 12 for documentation requirements for pediatric burn patients.Types of burnsSuperficial [1st degree]Damage limit: epidermisAppearance: red and drySensation: pain or tingling at siteTypical Causes:SunburnHot liquid splashes Flash burns.Natural healing time: 5-7 daysTreatment: oral analgesics and topical moisturizersSuperficial & Deep Partial Thickness [2nd degree] Damage Limit: Dermis; Portion of hair follicle remainsAppearance: red, white or tan, possibly mottled with blistersSensation: Extreme pain; sensitive to cold airTypical Causes:ContactSevere heat flashes ImmersionNatural healing time: Superficial partial thickness: 1-2 weeksDeep partial thickness: 2-3 weeks Treatment: debridement & dressing; possible grafting for deep partial thickness. Full thickness [3rd degree]Damage Limit: Sub-dermal tissue; No hair follicle remainsAppearance: Skin white, brown, deep red; dry and leatherySensation: Little to no pain at siteTypical Causes:FlameGrease Chemical Electrical – usually associated with internal burnsNatural healing time: never Treatment: Excision and graftingCalculating burn % TBSA:Only second and third degree burns are included in % TBSA: Palm methodEntire palmar surface and fingers of CHILD’s hand = 1%Fast but crude estimationLund and Browder chart*Lund and Browder Chart?Age (years)Superficial Partial ThicknessDeep/ Full ThicknessArea (%)0-11-45-910-15 >15Head191713107Neck22222Trunk Ant.1317131313Trunk Post.1313131313Right Buttocks2.52.52.52.52.5Left Buttocks2.52.52.52.52.5Genitalia 11111Upper Right arm44444Lower Right arm44444Upper Left arm33333Lower Left arm33333Right hand2.52.52.52.52.5Left hand2.52.52.52.52.5Right thigh5.56.58.58.59.5Left thigh5.56.58.58.59.5Right leg555.567Left leg555.567Right foot3.53.53.53.53.5Left foot3.53.53.53.53.5TOTAL:Primary Survey:History:Mechanism and source of injuryTime of injuryAirway and breathingAirway patencyRespiratory rateRespiratory effortSinged nasal/ facial hairCarbonaceous sputum Monitor pulse oximetryAdminister oxygen if necessaryHave a LOW THRESHOLD FOR INTUBATIONCirculation and cardiac statusInspect heart rate and blood pressure for hypovolemic shockMonitor for dysrhythmias Check pulses in all extremitiesMonitor urine output with Foley catheterSTOP THE BURNING PROCESSExamine body surfaceRemove clothing.Calculate body surface area percentage and determine depth.Cover and dress wounds properly. See APPENDIX 16: BURN WOUND CARE: ED PROCEDURE.Elevate burned extremities and check hourly, especially for circumferential burns.Assess for compartment syndrome.Secondary SurveyNeurologic evaluationCheck for concurrent injuryPain managementObtain labsCBCCMPArterial blood gasObtain a CXR and c-spine and pelvic films, if applicable.Fluid ResuscitationFluid resuscitation is required for all burns > 20% TBSA.Avoid boluses if possible.The goal is to initiate fluid resuscitation upon admission to the PICU. See also, Fluid Resuscitation for the PICU Burn Patient MDU042. If transport from the PED trauma bay to PICU is expected to be < 60 minutes,For patients < 40kg and hemodynamically stable, initiate D5LR at maintenance rate in the PED trauma bay and initiate fluid resuscitation upon admission to the PICU.For patients > 40kg and hemodynamically stable, defer fluid resuscitation in the PED trauma bay and initiate fluid resuscitation upon admission to the PICU.If transport from the PED trauma bay to PICU is expected to be > 60 minutes, or the patient is hemodynamically unstable, fluid resuscitation shall be initiated in the PED trauma bay and managed by the PICU nurse.PICU nurse manages the hourly fluid titrations based on urine output.Burn Management in the Peds EDAn Alpha trauma will be activated for:Burns with signs of inhalation injury.Burn injuries > 20% TBSA.Criteria for GPS consult/Burn center referral:Partial thickness (2nd?) burns ≥ 10% TBSAPartial thickness burns that involve face (>1%), hands or feet (when a joint is crossed), genitalia, perineum or major jointsFull thickness burns of any sizeElectrical burns including lightening injuryObtain EKG & CK levelChemical burnsContact Poison Control 1-800-222-1222 for recommendations (alkali vs. acidic)Circumferential partial – full thickness injuryBurn injury of any size in patients with pre-existing medical conditions that could complicate management, prolong recovery or effect mortalitySW concerns cannot be resolved or there is a concern for non-accidental trauma (NAT)Home caregiver is unable to demonstrate ability to provide effective wound careOther injuries at the discretion of the PED provider.ED policies for burn debridementAsk for the PED Burn Nurse when you arrive for consultation.Administer tetanus prophylaxis, if necessary.Most burns can be debrided in ED except:Burns requiring > 30 minutes of sedation with 2 providers (i.e., GPS and PED burn nurse) debriding.Unstable or intubated patients requiring PICU.Patients requiring escarotomies.ED attending does not feel can provide adequate sedation, e.g., patients ≤ 3mon of age or cardiac comorbidities.PED burn nurse programTrained RNs perform debridement & dressings.Will help facilitate procedural sedation.Will complete L&B for burns they debride.Require assistance from GPS for debridement/ dressings taking > 30min with one provider.Bedside RN will complete wound photography. Photos are available under the MEDIA tab in EPIC.debridement & DressingsSee APPENDIX 16: BURN WOUND CARE: ED PROCEDUREInpatient managementPED, PICU, OR: Non-debrided burns SHOULD NOT be admitted to 10S unless a plan is discussed & agreed on by PED, GPS & 10S. This is a RARE occurrence (i.e., PED Purple Alert). If this occurs, GPS has agreed to take the patient to the OR for initial debridement.Burn Management on 10 SouthDressing changesPre-medication for dressing changes begins at 08:00.Dressing changes begin at 09:00 in the treatment room. If there is a preference for dressing change order, please call the 10 South Charge RN BEFORE 08:00 with preferred patient order.Burn Management in the PICUMultidisciplinary burn rounds occur at 09:30.Dressing changesThere is not a set time for dressing changes. Time should be coordinated with AM bedside nurse ASAP.Occur in the patient’s room or OR.PainPediatric Pain Team should be consulted on all burns.Work collaboratively with the Pain Team and PICU to develop the best plan for the patient. Patient needs to tolerate dressing change without sedation to be transferred to floor.Fluid resuscitationSee Section IX.8.Avoid boluses if possible. NutritionEnteral/ oral feeds should be started within 24h of injury, when possible.Patients with ND tubes DO NOT need to be NPO for procedures; however, this is at the discretion of the Anesthesiologist.If patient is on vasopressors, enteral feeds may not be an option. Define acceptable vasopressor levels for feeding with the PICU team.Pharmacology >30% burnOxandrolone 0.1mg/kg/dose BID (max dose of 10mg) to be started 24-48 post resuscitation Propranolol 2mg/kg/day Q4-6 hours initially and may increase to 4mg/kg/day as a goal of reducing tachycardia by 20%Common burn dressings and treatmentsSilvadene (silver sulfadiazine): white cream, painless administration, antibacterial, poor penetration of eschar, widely used for burns, not on face or genital area. Can turn a yellow color. Side effects: methhemoglobinemia, leucopenia.Sulfamylon (mafenide): white cream, Painful Administration, bacteriostatic, good penetration of eschar. Used commonly on ear burns. Side effects: metabolic acidosis due to carbonic anhydrase inhibitionBacitracin- clear ointment, painless administration, poor penetration of eschar. Commonly used on face. Often used with overlying Adaptic or Xeroform. Side effects: RashSilver Nitrate- often used as a sheet or as a solution (0.5%), painless administration antibacterial and antifungal. Good penetration of eschar. Note: stains everything it comes into contact with brown. Side effects: leeching of electrolytes (Na, Cl)Mepilex AG – Silver impregnated dressing, self-adhesive silver containing foam dressing.Adaptic – Petrolatum covered synthetic mesh.Biobrane- synthetic mesh with silicone (transcyte without fibroblasts on the one side)Scarlet red- fine mesh, semi-occlusive gauze dyed red. Apply to graft donor sites. Promotes wound healingAlloderm- artificial dermal replacement used under split thickness skin grafts on full thickness burns. Allows for thinner grafts and better cosmetic outcome.Autograft- grafting of a full thickness burn with the patient’s own skin. May be split thickness or full thickness. Allograft- coverage of a full thickness burn with human skin. Not of the patient’s own skin. Used when not enough of the patient’s skin is available. Usually lasts for 2-4 weeks before autolysing.Xenograft- typically pig skin is used. In the same manner as allograft12. Nutrition: Consults Nutrition consults should be placed for all patients who meet the following criteria: <2 years of age: ≥ 10% TBSA burns3-6 years of age: ≥ 15% TBSA burnsAll ≥ 20% TBSA burns regardless of ageNutrition consults can also be placed for any burn patient if the following criteria are met:Burns to face or handsInhalation injuryOld burn with poor healing Weight loss, concern for malnutrition/neglect, or other nutrition or growth issues PTAOr per the Burn Physician’s discretion *All Burn patients are screened by Pediatric Nutrition with accordance to their Standards of CareOral NutritionFor all burn patients as able, oral feeds/diet should be initiated within 24 hours of injury. Calorie counts and oral nutrition supplements are often initiated to ensure adequate nutritional intake. A 3-day Calorie Count can be ordered for any burn patient where PO intake is of concern. Vitamin and Mineral SupplementationAppropriate vitamin and mineral supplementation should be initiated as soon as able. Age< 3 yrs of age≥ 3 yrsTBSA< 20 %≥ 20 %< 20 %≥ 20 %SupplementationOptional: Multivitamin with mineralsMultivitamin with mineralsOptional:Multivitamin with mineralsMultivitamin with minerals250mg ascorbic acid BID500mg ascorbic acid BIDAquADEK 1 mL daily AquADEK 2 mL daily 100 mg zinc sulfate daily220 mg zinc sulfate dailyEnteral Nutrition Enteral feedings to be initiated as soon as possible for burns ≥ 20% TBSA. ND tube is needed if on increased respiratory support or frequent trips to OR. Enteral feeds that are provided post-pyloric are to continue despite trips to OR. If burn patients with ≥ 20% TBSA and inhalation injury, enteral nutrition support should be considered. Initiating Enteral Nutrition SupportAgeFormulaStarting rateAdvancement<1 year of ageHome formula (if unknown, use Enfamil Infant 20 kcal/oz)5 mL/hr5 mL/hr Q 4-6 hrs to goal rate to provide 1.3-1.5 x maintenance fluid needs (Holliday Segar Equation)>1 -12 years of agePediasure Enteral 30 kcal/oz 10 mL/hr 10 mL/hr Q 4-6 hrs to goal rate to provide maintenance fluid needs (Holliday Segar Equation) ≥13 years of agePromote 30 kcal/oz 20 mL/hr 20 mL/hr Q 4-6 hrs to goal rate to provide maintenance fluid needs (Holliday Segar Equation) *Place nutrition consult when initiating enteral nutrition support. **Be aware of food allergies, formula choice may be adjusted as indicated. (May reach out to GPS or on-call dietitian as needed, via CORUS “Pediatric Nutrition – RD Group Message”) ***GPS RD to make necessary changes as indicated to formula and/or goal volumes, and vitamin and mineral supplementation.Parenteral NutritionIf enteral nutrition is not medically feasible, parenteral nutrition can be provided as a bridge until goal enteral nutrition is achieved. Please consult Pediatric Nutrition for parenteral nutrition recommendations. X. EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)General InformationECMO is a cardiopulmonary bypass system employed to support the patient in severe, medically refractory respiratory or cardiac failureUsed in neonates primarily for respiratory failureIn older pediatric patients ECMO is also used for those needing cardiac supportThere are two types of ECMO:Veno-Arterial – allows for cardiac AND Respiratory supportVeno-Venous – supports only the respiratory systemThe ideal ECMO candidate has: A known, resolvable respiratory or cardiac problemHas not been ventilated for a prolonged period of time Has no evidence of anoxic encephalopathy Indications: Neonatal Respiratory FailureMeconium aspirationPersistent Pulmonary HypertensionCongenital Diaphragmatic HerniaPre-ductal saturations near >90%; pO2 < 50 torrPre-op supportPost-op supportPediatric Respiratory FailureSepsisCardiac supportCardiac stun after congenital repairCardiomyopathy as a bridge to transplantUncommon IndicationsCold water drowningCardiac arrest of unclear etiologyOther, unusual, isolated conditionsClinical criteria indicating ECMO may be of benefitContinued poor respiratory performance while on optimal (not maximal) ventilator support:Oxygenation Index > 40Prolonged A-a gradient > 600,fFour hours of pO2 <60 Contraindications:Grade II or greater intracranial hemorrhageCongenital/genetic abnormalities incompatible with good outcomeDown’s is no longer considered, a priori, a contraindicationProlonged or sustained cardiac arrestCDH with severe pulmonary hypoplasia as seen with depressed pre-ductal saturationsPrematurity (less than 36 weeks)Relative contraindication - weight < 2kg Logistics of an ECMO ActivationThe decision to place a child on ECMO is made by the NICU or PICU attending in concert with GPS Fellow and GPS call AttendingIn preparation for ECMO, the child will be transferred to a PICU ECMO roomThe PICU will obtain informed consentOnce ECMO has been decided upon:The GPS Senior/Fellow should:Notify GPS Fellow and Attending immediatelyPost the case:Procedure: “ECMO Cannulation”Post as Level 1Speak Directly with the OR Charge Nurse at time of postingThe PICU will notify respiratoryRespiratory will prime the ECMO circuitThe PICU will notify Blood bankTechnique:Cannulation is done at the bedside with an OR teamThe patient is positioned on the bed based on the child’s size and the type of ECMO plannedVA ECMO positioningNeonates - head towards the door and at the foot of the incubatorChildren – towards the door in PICU bedECMO pump on patient’s rightNeck is extended with a shoulder rollHead turned to the leftChest and neck are preppedVV ECMO positioningVenous access site towards the doorECMO pump on side of access siteVeno-arterial CannulationTwo cannulas: arterial (carotid) and venous (IJ)Usual size is 12 Fr venous, 10 Fr arterialUsual depth is 10 cm venous, 7 cm arterialExcellent cardiac supportCoronary perfusion is retrograde from archCarotid ligated (not usually repaired)Technique of choice in post-op cardiac patients and septic patientsVeno-venous CannulationOne double lumen cannula, usually placed in the RA via an IJ cutdownUsual size is 12 FrenchUsual depth is RAEcho helpful during placementRequires that no cardiac support is neededExcellent coronary perfusionFlows range 100 to 150 cc/kg/minRecirculation may limit needed flowRecirculation increases with increasing heart failureIncreases with increasing flowCannula position and cannula characteristics somewhat more finickyTechnique of choice in neonatesConversion to VA indicated when perfusion inadequate or cardiac support neededECMO Circuit:Polyvinylchloride tubing"Better bladder”Bubble detectorPumpSilicone membrane oxygenatorWarmer (countercurrent heat exchanger)In-line ABG assessment devicesThe circuit is primed with:Plasmanate (a balanced electrolyte solution)Albumin (pacifies the circuit so that blood products don’t react to the foreign surface)HeparinNew washed packed cells that displace the plasmanateThe circuit is: Matched to patient serum K levels, pH (bicarbonate added) Kept anticoagulatedactivated clotting time (ACT) is kept prolonged at 1.5-2.0 times normalManagement of the Patient on ECMOInitial flow established for:Saturations > 90%Decreased shunt fractionNormal blood pressurePressors may be weanedVentilator settings, which may have been maximized, are reducedVentilator switched from oscillator or jet to conventionalSettings lowered to ideal settings (PIP 18, rate 20, 25% O2)Subsequently, flows may be weaned against PaO2 (VV) or SVO2 (VA)Heparin is administered by drip and adjusted for goal ACT ~ 200No IM meds, heel sticks, etcNo other heparin in drips, linesCefazolin is sufficient antibiotic coverage absent sepsisSedation without paralysis (one dose of paralytic is used during cannulation)Goal is spontaneous breathing on low vent settingsTPN is started on the second day of ECMOFat emulsion is safe but is given post oxygenatorPlatelet count must be kept near 100KHematocrit is kept 35-40% by transfusion as neededVolume expansion is achieved by blood first, then LRNeurologic examination and head US are routine daily in order to detect ICH earlyICH may force an abrupt end to the ECMO run despite poor respiratory functionComplicationsGeneralized bleedingDIC may superveneCryoprecipitate and FFP may rarely be neededProducts should be given post oxygenatorACT goal drop to ~180Sepsis should be suspectedIntracranial hemorrhageMay be due to:Generalized bleeding HypertensionHypertension - Aggressively treated with NitroprussideVV ECMO may not provide adequate support requiring conversion to VA ECMOCheck cannula position with echoRecirculation may be too high a fraction of flowHeart may be failingSurgery may be required while on ECMO (usually to correct CDH)Amicar is used (100 mg/kg bolus and drip of 30mg/kg/hrCompletion of the ECMO RunConditions for a decannulation trialFlows of 20-25cc/kg/minSaturations in the mid or higher 90sEuvolemiaMinimal vent settingsOff pressorThe circuit is divertedECMO is Re-instituted if:Vent pressures are above 20Respiratory rates above 40FiO2 > .40 Key features of trial off ECMOHeparin must be given to the patient to ensure anticoagulation with the cannulae in placeCannulae are flushed and clamped; the bypass bridge is openedIf child fails trial, the cannulae are unclamped (venous first in VA ECMO) and the bridge clamped.If trial is successful, the circuit is discardedDecannulation Requires the OR teamThe cannulae are removedKey features of this procedureParalysis will be needed to prevent air embolus from spontaneous respiration during vein manipulationArtery is ligatedThe vessels may be fragile after a long run and rapid hemorrhage can result from cannula removalThe wound is drainedAPPENDIX 1. Guidelines for the Management of Appendicitis in ChildrenSimple AppendicitisDefinition: Appendicitis without visible perforation of the appendix and/or the presence of stool in the abdomen or pelvisPre-operative antibiotics:Previously healthy: Ceftriaxone and IV metronidazole (see Table for dosing); penicillin allergy: ErtapenemHealthcare-associated (e.g., recently hospitalized, notable underlying medical conditions, or known to be colonized with Pseudomonas aeruginosa): Piperacillin-tazobactam; penicillin allergy: IV ciprofloxacin and IV metronidazole Post-operative antibiotics:Post-operative antibiotics are not recommended for simple appendicitis without concern for umbilical wound contamination (in which case 24 hours of IV antibiotics (see above) can be considered)Cultures: Routine cultures are not recommended for simple appendicitis, unless it is healthcare-associatedGangrenous AppendicitisDefinition: Appendicitis that does not meet criteria for perforated appendicitis, but with visible necrosis of appendiceal tissueReasonable to consider 24-48 hours of IV antibiotics as outlined under “Simple Appendicitis” Perforated AppendicitisDefinition: Appendicitis with visible perforation of the appendix and/or stool in the abdomen or pelvisPre-operative antibiotics:Previously healthy: Ceftriaxone and IV metronidazole (see Table for dosing); penicillin allergy: ErtapenemHealthcare-associated: Piperacillin-tazobactam; penicillin allergy: IV ciprofloxacin and IV metronidazole Post-operative antibiotics:Patients should receive a minimum of 24 hours of the same pre-operative IV antibiotics following appendectomyPatients who are afebrile for 24 hours and able to tolerate enteral therapy should be converted to PO amoxicillin/clavulanate for a total treatment duration of 5 days after the date of surgeryAlthough amoxicillin/clavulanate has activity against only approximately 43% of Escherichia coli, initial IV therapy in combination with source control will significantly reduce the bacterial burden by the time this drug is administeredPatients with a confirmed penicillin allergy or with healthcare-associated appendicitis should receive PO ciprofloxacin and PO metronidazole Patients who do not meet above criteria should remain on IV antibiotic therapy until clinical improvement is observedPatients who remain febrile or who fail to show clinical improvement (i.e. continued pain, nausea, vomiting, etc.) by post-operative day #6 should undergo an ultrasound or CT scan with IV contrast to rule out abscessIf no intra-abdominal abscess is observed, please consider consulting pediatric infectious diseases for possible changes to the antibiotic regimen Cultures:Routine cultures are NOT recommended for perforated appendicitis, unless it is healthcare-associatedIntra-abdominal AbscessDrainage is always preferred when intra-abdominal abscesses are presentIf the abscess is unable to be drained percutaneously, enteral therapy can still be considered as a valid treatment optionStudies have demonstrated similar efficacy rates when comparing enteral vs. IV therapy in adult patients with intra-abdominal abscessesTreatment:Patients presenting initially with abscess should receive at least 24 hours of IV antibiotic therapy as outlined under “Simple Appendicitis”Patients who are afebrile for at least 24 hours and are able to tolerate enteral therapy may be converted to PO ciprofloxacin and PO metronidazole for a total treatment duration of 7-10 daysBecause of the increased activity of ciprofloxacin compared to amoxicillin-clavulanate against E. coli, this agent (in combination with metronidazole) is recommended for ALL age groups with undrained abscessesFor patients who return with an abscess following operative or non-operative appendicitis management, piperacillin/tazobactam is recommended as initial IV therapy and after meeting the above criteria, conversion to PO ciprofloxacin and PO metronidazole is recommendedCultures:Intra-abdominal fluid cultures are always recommended for patients who return with an abscess following operative or non-operative management of appendicitisNon-operative management (NOM):Non-operative management of simple appendicitis has been shown to be effective in some patients Factors that may increase risk of failure for NOM include: symptoms >48 hours or presence of appendicolith or abscessNOM can be an effective option, but recurrence may occur in approximately 10-30% of patients in 1 yearTreatment:Patients should receive at least 24 hours of IV antibiotic therapy as outlined under “Simple Appendicitis”After a minimum of 24 hours, patients without a documented penicillin allergy who are afebrile for 24 hours and are able to tolerate enteral therapy should be converted to PO amoxicillin/clavulanate for 7 daysPatients with a documented penicillin allergy or healthcare-associated infection should receive PO ciprofloxacin and PO metronidazole for the same durationPatients with signs of worsening clinical status or who fail to show clinical improvement within 24 hours of initiation of treatment should be considered as failures of NOMDosing and Activity of Select Antibiotics for the Treatment of AppendicitisAntibioticDosing (assuming normal renal function)Activity at JHH in Children(% Susceptible)E. coliPseudomonasAmoxicillin/clavulanate45 mg/kg/day PO divided q8h; max 500 mg/dose430Ceftriaxone50 mg/kg/dose IV IV/IM q24h, max 2 g/dose900Ciprofloxacin10 mg/kg/dose IV q8h, max 400 mg/dose IV20 mg/kg/dose PO q12h, max 750 mg/dose PO7983Ertapenem3 mo to 12 yr: 15 mg/kg/dose IV q12h; max 500 mg/dose>12 yr: 1 g IV q24h970Metronidazole10 mg/kg/dose IV/PO q8h, max: 500 mg/dose--Piperacillin/Tazobactam100 mg/kg/dose of piperacillin component IV q6h, max: 4000 mg of piperacillin/dose9286Selected References:Minneci PC et al. JAMA Surg 2016: 151(5): 408-15. [Effectiveness of Patient Choice in Non-operative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis]Talishinskiy et al. J Pediatr Surg 2016: 51(7), 1174-6. [Factors associated with failure of nonoperative treatment of complicated appendicitis in children]McCutcheon et al. J Am Coll Surg 2014; 218(5): 905-13. [Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis]Mahida JB et al. J Pediatr Surg 2016 51(6): 908-11. [High failure rate of nonoperative management of acute appendicitis with an appendicolith in children]Park HC et al. World J Surg 2011: 35(5), 1118-22. [Oral antibiotics for intra-abdominal abscesses]228600012636500APPENDIX 2. PEDIATRIC GLASCOW COMA SCALEPatients > 1 yearPatients < 1 yearScoreEYE OPENINGSpontaneouslySpontaneously4To verbal commandTo shout3To painTo pain2No responseNo response1MOTOR RESPONSEObeysSpontaneous6Localizes painLocalizes pain5Flexion- withdrawalFlexion- withdrawal4Flexion-abnormal (decorticate rigidity)Flexion-abnormal (decorticate rigidity)3Extension (decerebrate rigidity)Extension (decerebrate rigidity)2No responseNo response1> 5 years2-5 years0-23 monthsVERBAL RESPONSEOrientedAppropriate words/ phrasesSmiles and coos appropriately5Disoriented/ confusedInappropriate wordsCries and is consolable4Inappropriate wordsPersistent cries & screamsPersistent inappropriate crying and/ or screaming3Incomprehensible soundsGruntsGrunts, agitated and restless2No responseNo responseNo response1Total Pediatric Glasgow Coma Scale (3 – 15)APPENDIX 3. ENDOTRACHEAL TUBE SIZESFrom: accessed 6/4/2013.APPENDIX 4. EMERGENCY AIRWAY MANAGEMENT OF THE INFANT & CHILDRespiratory Distress:The first step in the management of respiratory distress is to ventilate the child using a bag valve mask and 100% oxygen. Prepare for success by placing the child’s head in the “sniffing position;” with the neck in extension and chin up to the ceiling.Note: Do not use this maneuver in a child on C-Spine precautions.Suction all secretions and other material from the patient's nose and oropharynx.Using the proper size mask, form a seal by holding the mask in place with your non-dominant hand.Thumb and index finger around the base of the maskFifth digit hooked under the angle of the mandibleFlex your arm at the elbow to maintain a jaw thrust An oral airway can be used to ensure that the tongue is not occluding the airway.Observe the chest rise and listen to breath sounds to confirm adequate ventilation.Note: Over pressurization can cause a pneumothorax more easily in infants and children than adults.Endotracheal Intubation:On the Hopkins GPS service, endotracheal intubation is only to be performed by a resident or fellow under supervision of an anesthesiologist. Pediatric intubation is similar to an adult intubation however several anatomic differences must be accounted for: 1) a child’s larynx is more anterior than adults; 2) the trachea narrows below the epiglottis in children < 8 yrs old. Therefore, when you lift the epiglottis with the tip of the laryngoscope the cords will not be not as distal as you may expect. Passing the endotracheal tube (ETT) via the right corner of the mouth along the blade will provide an unobstructed view. For younger children the use of a cuffed ETT is usually not necessary. A properly fitted tube should allow a leak at 20 mm Hg inspiratory pressure.If you are concerned that a child will need long-term positive pressure ventilation - Call for help. Anesthesia, PICU staff and the Difficult Airway Response Team (DART) are available to help you.As long as a patient can be adequately ventilated using bag valve mask ventilation there is no rush to intubate. Prepare for intubation by acquiring the following items:SuctionAn ETT styletAn end-tidal CO2 IndicatorAn ETT tube clamp or; benzoin and tapeMedicationsPropofol 2.5-3.5 mg/kg IV over 20 secondsSuccinylcholine 1 mg/kgKetamine 1-3 mg/kg IV if hemodynamically unstableLaryngoscope:< 2 yrs old, use a Miller blade (Straight) Size 0 – PrematureSize 1 – InfantSize 2 - ChildAge 2-5 yrs, either a Miller or a MacIntosh blade.Age >5 years, use curved MacIntosh blade. The appropriate size ETT and one smallerSize can be determined in the following ways:For preemies use 2.5 - 3.0 mm IDETT size (mm) = [(Age in years + 16) / 4] - 0.5ETT diameter = patient’s little finger diameterOnce all the supplies above have been collected, an endotracheal intubation may be undertaken using the following steps:Assemble the laryngoscope – TEST THE LIGHTAssemble the suctionPlace the sytlet in the ETTAsk an assistant to apply cricoid pressureAdminister Propofol of KetamineAdminister SuccinylcholineScissor the teeth apart with your right handUse the laryngoscope to VISUALIZE THE CHORDS. NO BLIND INTUBATIONS Place the tube through the chords to a length of:Tube length (cm) = 12 plus age (yrs) / 2The tube should pass easily. DO NOT APPLY FORCE Use a smaller ETT if your initial attempt met resistanceLook, Listen, TestLook for chest riseListen for breath soundsTest for End-tidal CO2Secure the tube with an ETT ClampManaging the Intubated Patient:Request a stat portable chest x-ray to confirm tube placement above the carinaProvide 100% oxygen and wean O2 for sats >92%Initiate a maintenance sedative:Propfol 125 to 300 mcg/kg/min IVKetamine 0.01 to 0.03 mg/kg/min IVInitial Ventilator Settings:Tidal volume 7-10 cc/kgPeak Inspiratory Pressure (PIP) - 25 cm H2OPost-End Expiratory Pressure (PEEP) - 5 cm H2ORate – 30 breaths per minuteFIO2 – 100% PEEP at least 2-4 cm H2O ("physiologic PEEP").Always humidify and heat gases.APPENDIX 5. GASTROSTOMY TUBESAPPENDIX 6: PEDIATRIC SURGERY FELLOWSHIP CONFERENCES & TRAININGJohns Hopkins HospitalMondayTuesdayDepartment of Surgery M&M, 6:30a-7:30a, Chevy Chase AuditoriumPediatric Surgery Teleconference Lecture, 7:30a-8:30a, Garrett RoomDivision M&M, 830-930a, Garrett RoomTumor Board, 12-1p, 11N Conference RoomOnce a month there is radiology conference in place of division M&MWednesday1st Wed of Month: Trauma and Burn M&M, 7-8a, Garrett Room4th wed of Month: Trauma and Burn PI, 7-8a, Garrett RoomODD months 4th wed of the Month, Trauma and Burn Research meeting, 4-5pm, Garrett RoomThursdayDepartment of Surgery Grand Rounds, 6:30a-7:30a, Chevy Chase AuditoriumAPPENDIX 7. CDC IMMUNIZATION SCHEDULEAPPENDIX 8. EMERGENCY DRUGSEmergency DrugsHypoglycemia1 cc/kg of 25-50% dextrose IV push over 5 minutesHypokalemia:Maintenance requirement of 2 mEq/kg/dayFor emergency replacement:1/2 mEq potassium/kg/hr x 2 hrs in IV via pump.Repeat serum potassium after 2-3 hrs.Hyperkalemia:Slow rate of increase, no EKG changes, K<7: Kayexalate p.o. or enema 1 gm/kg (in sorbitol or D10W):Rapid rate of increase, + EKG changes, K>7 (urgent):Na bicarbonate 2mEq/kg IV pushGlucose 50% 1cc/kg IV pushCa gluconate 10% 0.5cc/kg IV pushInsulin 0.5u/kg IV while infusing D20WMetabolic acidosis (treat a base deficit greater than 5):mEq of NaHCO3 base deficit x weight in kilograms x 0.4.Correct half of the deficit with NaHCO3 over 8-12 hours by adding 1/2 mEq NaHCO3 to each cc of IV fluid.Normal Vital Signs by Age:AgeWeight (kg)Heart rateResp rateBP (Sys)Preemie 1135-145 55-6550±10Newborn 2-3125-13535-4560±101 month 4-6120-130 25-3080±106months 7-9120-130 25-30 90±251 year 10-11110-120 20-24 96±302-3 yrs12-15100-11016-2299±254-5 yrs16-1895-10514-2099±206-8 yrs19-2690-10012-20105±1310-12 yrs27-4285-9012-20112±19>14 yrs>5075-8510-14120±20APPENDIX 9. A USER’S GUIDE TO SURGICAL PROCEDURES FOR ONCOLOGYSafetyLine requests by the oncology service REQUIRE documentation regarding type of line, how many lumens, if a port, whether to leave accessed. This documentation should be found in EPIC. If not found, then oncology service needs to be contacted to avoid an incorrect procedure for the patient. SchedulingThe number one complaint in the OR about oncology procedures is the last minute addition of LPs, BM, echo, eye exams, and other ‘minor’ add-ons that significantly increase the length of time of a scheduled procedure. This has an enormous impact on our ability to complete our OR list in a timely fashion and disrupts the flow of emergent add-on cases. It is imperative that as soon as you know an additional procedure is indicated, you adjust the posting and/or notify the OR front desk 56520 so that additional time can be allotted.Outpatients: For patients requiring outpatient line placement or removal, Please contact the office directly at 52717 to schedule.The EPIC note must be in the chart for line placement and signed by the attending. Please Provide the following information:Type of line neededIf an LP/BM is to be posted as part of the procedure (with onc attdg name)If the patient is to be a same day admission to oncologyIf there is anything unusual or special about the patient or procedure requested please send an email to the fellow.As a general rule we would like to see outpatient lymph node biopsies in our clinic prior to scheduling them to ensure there is a surgically accessible node. Call 52717 to schedule an appointment. For more exotic outpatient biopsy requests, please email the fellow to facilitate discussion and scheduling.Inpatients: The GPS senior pager (33982) is the first contact for new consults An EPIC note is required for lines and signed by attendings.We need to know if an LP/BM is to be performed at the same sitting. We will do our best to schedule these lines as soon as possibleWe do not usually have open block time sitting available to fill with oncology patients. If there is no open time for the next business day, lines are scheduled into the urgent/emergent or work-in OR rooms and are at the mercy of every other service who posts emergency cases. Therefore, if we post a line for the next day, it is not likely that we will be able to give you a precise time even on the morning of the case. CONSENTS FOR LP/BM MUST BE ON THE PATIENT’S CHART BY 7AM ON THE DAY OF THE PROCEDURE. IF THERE IS NO ONCOLOGY CONSENT, THE PATIENT WILL NOT BE BROUGHT TO THE PREOP AREA AND MAY LOSE THEIR OR TIME.Preparation for ORANC: There is no lower limit for ANC for Hickman catheters. Based on published data, we prefer to avoid placing ports in patients with an ANC < 500 due to high risk of wound complications. Call to discuss in specific cases.Platelet count >50 is acceptable for line placement. All patients with platelets <50 should have a unit of platelets available for transfusion at the time of the procedure. Please clarify plan for additional transfusions with GPS for patients with platelets <30.APPENDIX 10. GUIDELINES FOR PEDIATRIC PREOPERATIVE EVALUATION Phone ContactsPediatric Anesthesia Office410-955-7610Bloomberg 6321Pediatric Anesthesia In-Patient Consults410-955-7610Preoperative Evaluation Center Appts410-955-6495JHOC BasementWilmer Preoperative Evaluation410-955-5730Wilmer 340Pediatric Anesthesia Remote Posting410-502-2637Department of Social Services410-361-2235Fax NumbersPediatric Anesthesia Office Fax410-502-5312Bloomberg 6321Preoperative Evaluation Center Fax410-614-8204; 866-341-2834Wilmer Preoperative Evaluation Fax410-614-0316Wilmer 340Pediatric Anesthesiology Attending PagersIvor BerkowitzSally BitzerAnna BrownNick DalesioRichard ElliotJim FacklerAllison FernandezJessica GeorgeRobert GreenbergRichard HardartEric JacksonRahul KokaSabine Kost-Byerly3-20993-69594-32243-38754-22143-37583-50433-77233-20443-54393-45794-09453-8837Sapna KudchadkarBenjamin LeeJenny LeeJackie MartinConnie MonittoNina NamiDolores NjokuShivani PatelDeborah SchwengelHal ShaffnerJoanne ShayMonica WilliamsMyron Yaster4-26374-04213-98123-20723-20583-64373-21093-77553-20623-21123-23033-31633-2064These guidelines apply to all pediatric patients who are scheduled to receive anesthesia or sedation by the Department of Anesthesiology and Critical Care Medicine for any type of surgery, treatment or diagnostic procedure.Preoperative History, Physical and Anesthesia AssessmentThe surgical preoperative history and physical must be performed within 30 days of the scheduled procedure. (This is a Joint Commission regulation.)The preoperative history and physical examination may be done by the staff of the Johns Hopkins Preoperative Evaluation Center (PEC) or by the surgical/procedural staff prior to the procedure. Alternatively, the patient’s primary care physician may complete a full history and physical examination (not a clearance note).For more complicated cases or in situations involving specific anesthesia- related questions and concerns, an anesthesia consult should be specifically requested. These patients will be seen by anesthesia residents and the case will be discussed with a pediatric anesthesia attending in order to address preoperative concerns in an optimal fashion (See Section VI).PEC appointments may be scheduled by calling 410-955-1147. Secretaries can make appointments via the EPIC system. Preoperative Evaluation Center (JHOC) Fax: 410-614-3230Pediatric Anesthesia INPATIENT Consults may be scheduled by phone at 410-955-7610; or by contacting the Pediatric Anesthesia OR coordinator 410-955-6520.Preoperative screening paperwork from a primary care provider must be forwarded to the Preoperative Evaluation Center prior to scheduled procedure for review. Pre-surgical laboratory tests must be done by an accredited laboratory facility and the results must be forwarded to the PEC prior to scheduled procedure. All Blood Bank specimens must be drawn at Johns Hopkins or an approved Johns Hopkins facility.Updates of current medical records, without a visit to the PEC or primary care provider, may be done if there has not been any significant change in the patient’s overall medical conditions and if:The most recent evaluation was performed < 30 days prior to the scheduled surgery, The procedure was postponed for a non-medical reasonThe patient undergoes a scheduled series of procedures (e.g. radiation oncology).Criteria for Having a Procedure as an OutpatientFull term infants (defined as > 37 weeks post-conception at birth) without significant medical problems who are at least 48 weeks post-conception at the time of scheduled procedure.Premature infants (defined as < 37 weeks post-conception at birth) with no medical problems who are at least 52 weeks post-conception.Premature infants with medical problems may need to be at least 60 weeks post-conception, at the discretion of the anesthesiologist.Infants who have required supplemental oxygen or apnea monitoring must be symptom-free and have not required any supplemental oxygen or monitoring for at least six months and be > 60 weeks post-conception at the time of scheduled procedureOlder children with significant medical problems should be evaluated as candidates for outpatient surgery on a case-by-case basis. Patients with central sleep apnea or severe obstructive sleep apnea must be cleared by an anesthesiologist as candidates for outpatient surgery.SchedulingPatients should be scheduled so that the cases move from youngest to oldest child when possible. Patients with a family or personal history of malignant hyperthermia (MH) or conditions associated with increased risk of malignant hyperthermia, should be scheduled as the first case of the day.Patients scheduled for MRI who have risk of post-anesthetic problems (e.g. those with hypotonia, apnea, and possible recurrence of brain tumor) should be scheduled to start as early as possible to allow sufficient time for extended post-anesthetic observation prior to discharging home.Diabetics should be scheduled as the first case of the day whenever possible.Guidelines for Preoperative TestingSee Appendix E for Specific DiagnosesNo tests are required for healthy children expected to have minimal loss of blood with the procedure.Hemoglobin for premature infants < 60 weeks post-conception having outpatient procedures.Type and Screen or Type and CrossPer surgeon’s posting.Pediatric cardiac surgery patients who weigh < 20 kg need 1 unit RBC and 1 unit FFP (thawed) for the pump prime in addition to the needs for the case.Outpatients coming for surgery may have a Blood Bank sample sent that won’t expire for 30 days if they meet the following requirements:Have not been transfused during the past 3 monthsHave not been pregnant during the past 3 monthsHave no history of antibodiesHave the sample drawn while they are outpatientsIn order for a Blood Bank sample to be good for 30 days, the Blood Bank Requisition MUST have the following information about the patient written on the requisition:No transfusions or pregnancy for the past three monthsSeen in Outpatient Clinic 290, 291 or 292 If the above info is not specifically written on the requisition, the blood sample is only good for three days (just like an inpatient). If the patient is found to have an antibody, the sample will be good for only 3 days. Pregnancy testing: All females who have begun their menstrual periods should have a preoperative pregnancy test.Anesthesia ConsultsAnesthesia consults are indicated for children who have significant medical conditions that can impact the safe delivery of anesthesia that include, but are not limited to:Abnormal airway anatomy or syndromes with known difficulty airway (e.g. Treacher-Collins, Goldenhar, Pierre-Robin, Cornelia deLange, Hurler’s, Hunter’s)History of difficult airway or significant life threatening intraoperative or perioperative complications in the past.Cystic fibrosisDiabetesHeart disease that is symptomatic, presence of cyanosis or heart failureHypoxemiaLiver failure or liver transplantMalignant hyperthermia (patient or family history)Oxygen-dependent, BIPAP, or home ventilator therapyOrgan transplant patients (patients who have had or will have organ transplant)Renal failureSickle cell (SS, SC or S-thal) diseaseScoliosis (non idiopathic or curve > 60 degrees)Severe central or obstructive sleep apnea coming for surgery other than tonsillectomySkeletal dysplasiaNeuromuscular disordersMetabolic disordersFormer premature infant with ongoing oxygen requirement or severe chronic lung diseaseConsultations should be scheduled with the PEC no less than one week or no more than 30 days prior to surgery to allow time for further testing/consultation if indicated. Prior to date of consultation, parent questionnaire should be forwarded to the PEC with the patient’s date of surgery and name of surgeon. For patients followed elsewhere, all available medical records should be forwarded to the PEC in advance of the date of the visit to the PEC, or brought by the patient.Cardiology ConsultsRefer patients with an unevaluated or new heart murmur to a cardiologist.Guidelines for patients with known congenital heart disease:If the patient’s diagnosis is an asymptomatic ASD or VSD, the evaluation should be within one year unless recent cardiologist’s note states otherwise.If the patient is s/p cardiac surgery, and is totally asymptomatic with respect to heart disease, routine follow-up diagnostic studies should occur prior to the scheduled procedure.The cardiologist should see patients with symptomatic heart disease within 30 days of surgery and the cardiologist should know when the patient is having surgery. The cardiology service should be informed of any child with symptomatic or complex congenital heart disease who is to be admitted to the hospital after surgery.Fasting GuidelinesFrom the time the patient is told to arrive at the hospital, make patient NPO: Two (2) hours for clear liquidsfour (4) hours for breast milksix (6) hours for infant formula (for infants < 1 year of age)eight (8) hours (or NPO post midnight for first case starts) for solids and milk.See Appendix C for NPO Instruction handout in English, French, Spanish and Arabic.Please note: although guidelines allow infant formula six hours prior to anesthesia in patients less than one year of age with normal gastric emptying, the parent/guardian handout does not include these instructions for infant formula because parents/guardians have misinterpreted the instructions in the past. This misinterpretation has resulted in cancellations.Possible Reasons for CancellationDecisions for cancellation on the day of surgery are always at the discretion of the attending anesthesiologist and attending surgeon.For patients seen in PEC, the PEC staff shall contact attending anesthesiologists and attending surgeons of the following conditions, which may indicate the need to delay or reschedule the surgery at a later date:Upper respiratory infection (URI) that involves purulent (yellow or green) nasal discharge, productive cough, fever, rhonchi or wheezing. Patients coming for elective procedures should ideally have no URI symptoms for at least 2 weeks prior to anesthesia.Asthmatic patients who have had an asthma exacerbation during the past week may need to have elective procedures postponed. Patients who have poorly controlled asthma should be referred to their primary care provider for further medical treatment and delayed until asthma is thought to be as well-controlled as possible, unless a pediatric anesthesia attending overrides this.Chicken pox exposure: Any child with exposure within the past 21 days must be postponed until the 21 day incubation period has passed. A child with recent chicken pox may have surgery after all lesions are crusted over. Children with chicken pox or an exposure in the past 21 days should not come into the Hospital at all, even for the preoperative evaluation.NPO violationsParental Refusal of Blood ProductsInform attending anesthesiologist and surgeon of situation as soon as possible.Advise parents that many measures will be utilized to avoid the need for a blood transfusion; if the anesthesiologist believes it is needed to preserve the life of the child they will administer blood. No child (minor) will be allowed to die due to the desire of the parent/guardian not to have the child transfused. (See Interdisciplinary Clinical Practice Manual Policy #MEL003 “Refusal of Transfusion of Blood or Blood Products” section on Minors.)Guardianship DocumentationInform Pediatric Anesthesiology Office (5-7610) of patients requiring Department of Social Services (DSS) consent as soon as possible. Patients requiring DSS consent should be seen in the Preoperative Evaluation Center several days prior to the procedure so that anesthesia consent forms are signed and available prior to the day of the procedure.Foster Care: Children in foster care or in the care of relatives/friends must have informed consent signed by a legal guardian or by authority of the court. The legal guardian must have guardianship papers when the child is brought to the hospital for treatment. A copy of the papers shall be placed in the patient’s medical record. (See Interdisciplinary Clinical Practice Manual #MEL002: V. Treatment of a Minor.) A fax cover letter to obtain DSS signed consent is attached as Appendix D. DSS phone contact for consents: 410-361-2235.Contacting an Anesthesiology AttendingFor a patient issue on the day of surgery, contact the Pediatric Anesthesia Coordinator via the OR desk (5-8075). To speak directly with a pediatric anesthesiologist regarding a future patient, you may call 5-7610 during regular business hours to identify an anesthesiologist assigned on a particular date.APPENDIX 11: Procedure: Intrapleural Alteplase (tPA) for Loculated Pleural Effusion,Pediatric Patients OnlyOBJECTIVESTo induce localized fibrinolysis of a loculated pleural effusion in order to achieve one of the following therapeutic objectives:Promote drainage of chest tube or pleural catheter (e.g. Cook pigtail or Teleflex ) leading to reduction of the pleural effusionDecrease the potential need for a surgical or invasive treatment approachINDICATIONS FOR USELoculated pleural effusions resulting in a non-draining chest tube or pleural catheterRESTRICTIONSIntrapleural administration requires approval from Pediatric Intensive Care Unit attending, or General Pediatric Surgery attending.CONTRAINDICATIONS FOR USEPositive air leak in patient’s chest tube or pleural catheter.WARNINGS/PRECAUTIONSAll major and relative contraindications for thrombolytic therapy as outlined in “Thrombolytic agents (intravenous), management of a patient receiving continuous GEN388”.DEFINITIONStPA (tissue plasminogen activator)A serine protease enzyme the catalyzes the conversion of plasminogen to plasmin, the enzyme responsible for clot breakdownLoculated pleural effusionA pleural effusion in which pleural fluid has become walled-off or encapsulated between visceral layers of the pleural prohibiting drainage and access to antibiotic therapyDwell timeThe period post administration of tPA inwhich the chest tube or pleural catheter isclampedRESPONSIBILITYAuthorized PrescriberEvaluate response to therapy (e.g., chest tube or pleural catheter drainage output, improvement of signs/symptoms, evaluation of chest CT or radiograph)Evaluate and treat side effects of therapy (e.g., tension pneumothorax during administration, signs/symptoms of hemorrhage post administration)Order every 12 hr hematocrit during tPA therapy.Registered NurseAssess and monitor patient status and parameters including:Air leak in chest tube or pleural catheterVital signs at baseline and post administrationSigns/symptoms of tension pneumothorax during dwell time (dyspnea, deviated trachea, asymmetrical chest movement)Signs/symptoms of hemorrhagePharmacyPrepare and dispense the tPA (alteplase) in the appropriate syringe as requested.When requested, provide drug information including, but not limited to, dosing, side effects, adverse events, drug interactions, monitoring and compatibilities.PROCEDUREAdministration in PediatricsAdministration should be performed by either a Pediatric Intensive Care Unit (PICU) or General Pediatric Surgery (GPS) attending physician, a fellow under the supervision of the attending physician, or a resident under the supervision of the attending physician, familiar with chest tubes. Prior to administration, the nurse and physician will check for the presence of any air leak in the chest tube or pleural catheter as this is a contraindication to the protocol.RN will obtain baseline vital signs at the time of administration and every 15 minutes during the dwell time.Administering Physician will be available during the dwell time.The Pharmacy will dispense a standardized tPA concentration of 0.1mg/ml in Normal Saline (NS 0.9%NaCl) in a slip tip syringe.Children < 1 year of ageDose: 2 mg tPA/ 20ml in NSChildren > 1 year of ageDose: 4 mg tPA/40 ml in NSThe administrating physician will:disconnect the chest tube or pleural catheter at the connectionclosest to the patient’s chest after the suction has been turned off.inject the tPA dilution aseptically directly into the lumen of the chest tube or pleural catheter. The end of the chest tube or pleural catheter will be raised above the level of the patient to promote gravitational flow of the solution into the chest.place a clamp on the chest tube or pleural catheter closest to the chest, to prevent backflow of the solution. After clamping the chest tube the pleural catheter can be reconnected.The clamp will remain in place for a dwell time of 1 hour, after which the clamp will be removed by the administering physician and the suction of -20cm H2O will be re-started to allow for drainage.Intrapleural tPA may be administered, in an aseptic manner, at the time of chest tube or pleural catheter placement with 2 additional doses each given 24 hours apart. A patient may receive a maximum of 3 doses during a 48 hour treatment period at the discretion of the authorizing prescriber. If administered to a previously placed chest tube or pleural catheter then physician can administer 3 doses, in an aseptic manner, each dose separated by 24 hours at the discretion of the authorizing prescriber.On day 3, the patient should undergo repeat ap/lat CXR to assess radiographic response. Transthoracic ultrasound may be ordered to assess for residual localized effusion at the discretion of the authorizing prescriber.AssessmentRN will check vital signs 15 minutes after administration and every 1 hour while tube is clamped.RN will monitor for signs of tension pneumothorax while clamp is in place every 15 minutes.RN will monitor for signs and symptoms of hemorrhage throughout the entire course of treatment.InterventionsRN shall turn and reposition the patient every 15 minutes to promote an even distribution of tPA within the pleural space as tolerated.RN shall notify physician of any adverse events or reactions as described under “Reportable Conditions”.RN shall measure amount of drainage from the chest tube or pleural catheter throughout the course of treatment.Reportable Conditions to PhysicianPositive air leak of chest tube or pleural catheter Signs or symptoms of hemorrhageDrop in hematocritVital sign abnormalitiesChest discomfort or painSigns or symptoms of tension pneumothorax including respiratory distressAbsence of drainage once chest tube or pleural catheter is unclampedAPPENDIX 12: Guidelines for Central Line Related Blood Stream InfectionsAPPENDIX 13: Central Line Lock Therapy for Treatment of CRBSIAPPENDIX 14: Perioperative Antibiotic ProphylaxisAPPENDIX 15: BURN DOCUMENTATION REQUIREMENTSH&P and lund & BrowderREQUIRED for all burn patients seen in the PED. The L&B is completed by whoever debrides the burn (PED Burn RN vs. GPS); then, scanned into EPIC.Burn Order SetREQUIRED for all burn admissions: Burn Injury Admission PED. This order set lists required & recommended consults/ interventions for burn patients.Daily NotesREQUIRED for all burn patients and should include specifics on:% TBSAIVF/ Parkland ResuscitationUOP i.e. during Parkland – is the patient meeting the goal?NutritionPain planID, if necessarySpecific dressing instructions for each woundPlan for next 24 hoursPlan discussed with bedside RN and PICU Provider (if in the PICU).Procedure NotesREQUIRED for all burn dressing changes. Use the Procedure Note – Burn Dressing Change TEMPLATE. This will ensure you cover all documentation requirements. Be specific when describing burn appearance & dressings used on each wound.Operative NotesAll OR procedures REQUIRE a narrative operative note.A brief operative note can be documented in POE; however, a narrative op note is still required.Burn ClinicOpen most Mondays, Wednesdays & Fridays mornings.Patient must call to make an appointment! 888-KID-BURNDischarge instructions should advise families to pre-medicate patient with OTC or Rx medication 30 minutes before appointment.APPENDIX 16: BURN WOUND CARE: ED PROCEDUREIndicationsInterventionsSuspected or reported chemical burns without powder for patients < 2 years old, or patients ≥ 2 years with <10% TBSA involvementDon personal protective equipment, including gloves, non-permeable gown and mask with face shield.Remove all of the patient’s clothing.Irrigate with saline copiously until GPS makes recommendations to PED prescriber.Suspected or reported chemical burns without powder for patients ≥ 2 years and patients with ≥ 10% TBSA involvementDon personal protective equipment, including gloves, non-permeable gown and mask with face shield.Remove all of the patient’s clothing.Irrigate with running water copiously until GPS makes recommendations to PED prescriber.Suspected or reported chemical burn with powderDon personal protective equipment, including gloves, non-permeable gown and mask with face shield.Remove all of the patient’s clothing.Brush off all visible powder off skin using gloved hands.Await GPS attending or fellow recommendations.Suspected or reported electrical burnsAwait GPS recommendations for wound care.Suspected or reported thermal burns with no loose tissue or blisters (superficial)Wash burned area with warm normal saline and mild soap.Obtain order for moisturizing cream.Apply moisturizing cream.Suspected or reported thermal burns with loose tissue and blisters, determined to be admitted by GPSPre-debridement:Discuss pain plan with prescriber and obtain orders. Complete pre-debridement wound photography.Wash burned area with warm normal saline and mild soap.Debride loose tissue and blisters.Single blisters < 2 cm may be left plete post-debridement wound photography.Apply thin layer of bacitracin to non-adherent mesh dressing, then apply to burned areas and secure with several layers of gauze roll and elasticized net plete Lund & Browder diagram and obtain attending co-signature.Suspected or reported thermal burns with loose tissue and blisters, with no GPS consult or GPS determined patient will be dischargedPre-debridementDiscuss pain plan with prescriber and obtain orders. Complete pre-debridement wound photography.Wash burned area with warm normal saline and mild soap.Debride loose tissue and blisters.Single blisters < 2 cm may be left plete post-debridement wound photographyApply silver-impregnated foam dressing to moist, well-debrided areas. Do not apply silver-impregnated foam dressing to face, genitalia, palmar surface of the hands or soles of feet. Dressing should overlap the surrounding unburned skin by a minimum of 2 cm.Secure with several layers of gauze roll and elasticized net plete Lund & Browder diagram and obtain attending co-signature.Suspected or reported burn injuries with signs of spontaneous healing, including scabbing, presence of epithelial islands, blanching, pink and dryObtain order for moisturizing cream.Wash area with warm normal saline and mild soap.Apply moisturizing cream to area using massage. ANATOMICAL CONSIDERATIONSBurns of the facePre-debridementDiscuss pain plan with prescriber and obtain orders. Complete pre-debridement wound photography.Wash burned area with warm normal saline and mild soap.Debride loose tissue and blisters.Single blisters < 2 cm may be left plete post-debridement wound photographyAfter debridement, apply thin layer of bacitracin. NOSE and EARS: Instead of bacitracin, apply thin layer of mafenide acetate cream.EYES: Instead of bacitracin, apply ophthalmic erythromycin to burns within an inch perimeter of the globe.Burns of the hands and feetPre-debridementDiscuss pain plan with prescriber and obtain orders. Complete pre-debridement wound photography.Wash burned area with warm normal saline and mild soap.Debride loose tissue and blisters.Single blisters < 2 cm may be left intact.Sterile scissors and tweezers may be used to de-roof blisters and remove sloughing plete post-debridement wound photography.Apply thin layer of bacitracin to non-adherent mesh dressing. Wrap fingers and toes individually and apply roll gauze and elasticized net dressing. Maintain neutral to extended anatomical position with access to fingertips and toes for circulation assessment.Burns of the genitaliaPre-debridementDiscuss pain plan with prescriber and obtain orders. Complete pre-debridement wound photography.Wash burned area with warm normal saline and mild soap.Debride loose tissue and blisters.Single blisters < 2cm may be left plete post-debridement wound photography.Apply thin layer of bacitracin to non-adherent mesh dressing and place on burned areas.For continent patients, apply gauze wrap and secure with elasticized net dressing.For incontinent patients, apply diaper; dressing change should be completed after each bowel movement.If concerned for urinary obstruction secondary to genital edema, discuss with GPS attending or fellow prior to inserting a Foley catheter.-20955022352000APPENDIX 17: Non-operative management of liver & spleen injuriesSPECIFIC DIAGNOSIS GUIDELINESClinical Diagnosis or ProcedureCBCBasic Metabolic ChemistryComprehensive ChemistryPTPTTT&SECGCXRNotesCong. Adrenal Hyperplasia, orAdrenal Insuff.XPreop endocrine consultation for corticosteroid / mineralocorticoid replacementAnemia historyXCBC if untreated, or not followed by PMD, or if recent Hgb is not documentedAsthma See notesIf patient has asthma exacerbation associated with URI, then surgery should be postponed for 4 weeks and the patient should receive nebs and steroids (prednisone 1 mg/kg qd) for 3 days preop. If a patient has asthma exacerbation with no URI symptoms and the patient's asthma is well-controlled otherwise, then surgery should be postponed for one week and the patient should receive nebs and steroids (prednisone 1 mg/kg qd) for 3 days preop.Prednisone 1 mg/kg qd starting 3 days before procedure and given the day of procedure if: Oral or IV steroids have been prescribed in the past 6 monthsPt is on continuous meds for asthma or had active wheezing in past 2 months.If patient's asthma is not well-controlled, obtain pulmonary consult. Pulmonary or PMD evaluation if pt:Wheezes dailyHad 3 acute episodes in past 6 months requiring physician-directed treatmentIf pt is wheezing during preop visit – may need CXR; check with attending.Cardiac surgeryXXXXXXXCoagulopathiesXXMay require factor levels or Hematology Consult for perioperative managementCraniosynostosisXXXCystic FibrosisCXR only if significant pulmonary compromise exists; consult attending anesthesiologistDiabetes insipidusXConsult attending anesthesiologist re: perioperative vasopressinDiabetes mellitusXDetermine if endocrinologist has made plans for perioperative care with insulin infusion or insulin pump use.Consult attending anesthesiologist, try to schedule as first case or as early AM caseDown Syndrome (Trisomy 21)Thyroid function and C-spine films if not previously doneFailure to thriveXXXIf not already done as part of workupHeart Failure or HypertensionXXXXIf on ACE inhibitor or diuretic, discuss with attending whether to hold AM dose on day of surgery. Liver diseaseConsult attending anesthesiologistNeuromuscular disConsult attending anesthesiologistRenal diseaseXXDetermine if nephrologist has plans for perioperative care.Scoliosis repairXSee noteSee noteSee noteXSee noteSee noteChemistries only if indicated by medication or associated illness.PT/PTT only if there is a history of bleeding in patient or family, or if taking valproic acid (Depakene) or carbamazepine (Tegretol) CXR in past 12 months unless asymptomatic, totally healthy & only idiopathic scoliosisEcho if pt has cardiac, neuromuscular or metabolic disease; and for heart size and function if curve > 60 degrees with associated co-morbidities such as MRCP or spina bifidaPFT per anesthesia attending if curve > 60 degrees and age > 6 years and mentally capable; also may be requested by surgeon for muscular dystrophy patientsSeizure history andKetogenic dietXXXXMay need these labs if on tegretol, depakote or zarontinIf receiving carbamazepine, phenobarbital or phenytoin, may need drug levelsSickle Cell DiseaseXXXXXSee noteAll patients with sickle SS, SC, or S-thal disease must have Hematology consult.After pt’s final preop transfusion ,obtain hematology studies and %Hgb SCXR if history of cardiac or pulmonary involvementSleep Apnea, Severe: defined as either RDI or AHI > 10 or oxygen sat nadir < 70% during sleep.Hb in some casesGenerally needs monitored bed postop (all CMSC beds have monitoring capability); decision for ICU, if not ordered by surgeon, should be made by attending anesthesiologist consult or attending assigned to case. If sleep study has been done, obtain report. Review case with attending anesthesiologistREFERENCESSources“Recommended immunization schedule for persons aged 0 through 18 years – 2013” “Pediatric Fasting Guidelines for Surgery”. , n.p. Web 2. Oct. 2012Vegunta, Ravindra. “Vascular Access.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 110-116Slater, J; Krummel TM. “Surgical Infectious Disease.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. “Pediatric Perioperative Antibiotic Prophylaxis to Prevent Surgical Site Infection” n.p Web 5 May 2013Othersen Jr, BH; Hebra, A. “ Tracheal Obstruction and Repair.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 272-273Mehta, N; Jaksic T. “Nutritonal Support of the Pediatric Patient.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 19-31 ................
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