Traumas Don’t forget to TAP IN when arriving to the Trauma Bay! ICPM Protocol : PAT092 Care of the Pediatric Trauma Patient Alcohol screening is required for all traumas ≥ 13y – consults, activations, admissions, and discharges.

o Use the CRAFFT screen in the Trauma H&P. o Or if done later .crafft in epic can be doneo Consult Social Work for all positive screens.o 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.

Debbie 10S dwitten1@jhmi.eduLonna 10N lbrady4@jhmi.edu Jane 9N jyorka@jhmi.edu Steph 9S sjacob@jhmi.eduPam PICU pbisker1@jhmi.edu

o Include 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.”

Burns ICPM Protocol : PAT095 Care of the Pediatric Burn Patient The PED burn nurses perform the majority of burn debridement. However, GPS is expected to:

o Assist with debridement if procedure is expected to exceed 30m.o Perform debridement when a burn nurse is unavailable.

In these cases, you must:o Write a procedure note. It cannot be a blurb in the burn consult note or H&P.o Complete a Lund & Browder diagram. Form is available in the PED.

For burn admissions, use appropriate burn order sets:o JHH PICU Burn Admissiono JHH Pediatric Burn Injury Admission Non-ICU

For INPATIENT BURN DRESSINGS, use .pedburndressing (Owner: C. Baldino)o 10S : 9am every day. You must go to assess the burn and write a procedure note. o PICU : 9:30a burn rounds. Schedule dressing change with bedside nurse. You must go to assess the burn

and write a procedure note. o You must write a procedure note. It cannot be a blurb in the daily progress note.

ERAS Label 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)

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BLOOMBERG CHILDREN’S CENTERTHE JOHNS HOPKINS HOSPITALPEDIATRIC SURGERY SERVICE MANUAL

FOR MEDICAL STUDENTS AND RESIDENTSEdited by: Seth Goldstein MD

TABLE OF CONTENTS

I. INTRODUCTION__________________________________________________________1

II. RESIDENT RESPONSIBILITIES__________________________________________2

1. Pediatric Surgery Fellows________________________________________32. Senior Residents and Moonlighters_____________________________33. Day Interns________________________________________________________44. Night Float Intern and Saturday Second Years_________________55. Pediatric Co-Follow_______________________________________________56. GPS Nurse Practitioners__________________________________________67. GPS Clinical Pharmacologist_____________________________________68. GPS Clinical Nutritionist__________________________________________69. Medical Students__________________________________________________610. General Team Responsibilities__________________________________711. EPIC help_________________________________________________________ 9

III. GENERAL ADMINISTRATIVE ISSUES ___________________________________10

1. Who Goes Where?________________________________________________102. Pediatric Interventional Radiology Admissions________________103. Clinics, Conferences And Rounds________________________________11

IV. PROBLEMS OF THE SURGICAL NEONATE______________________________ 12

1. NICU Survival Guide _____________________________________________122. Recognition And Treatment Of Sepsis In Newborns___________143. Tracheo-Esophageal Fistula And Esophageal Atresia._________144. Intestinal Obstruction____________________________________________165. Intestinal Atresia_________________________________________________166. Hirschsprung's Disease__________________________________________177. Meconium Ileus __________________________________________________178. Malrotation________________________________________________________199. Omphalocele & Gastroschisis____________________________________2010. Congenital Diaphragmatic Hernia ______________________________2111. Necrotizing Enterocolitis (NEC)_________________________________2312. Postoperative Enteral Feeding__________________________________24

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V. COMMON PEDIATRIC SURGICAL PROBLEMS__________________________26Seth Goldstein, M.D.

1. Appendicitis_______________________________________________________262. Pyloric Stenosis __________________________________________________273. Intussusception __________________________________________________294. Incarcerated Inguinal Hernia ___________________________________305. Reducible Inguinal Hernias in Infants___________________________316. Foreign Bodies____________________________________________________317. Caustic Ingestions________________________________________________318. Lower GI Bleeds__________________________________________________359. Biliary Atresia/Kasai____________________________________________ 3510. Chest Wall Deformities-Pectus Excavatum_____________________3611. Gastrostomy tubes________________________________________________3712. Empyema__________________________________________________________3913. Spontaneous Pnuemothorax____________________________________40

VI. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD______40Adesola Akinkuotu, M.D.

1. Outpatient Surgery Guidelines__________________________________402. NPO Guidelines ___________________________________________________413. ERAS management______________________________________________ 414. ERAS neonate management____________________________________ 415. Fluid Management and electrolytes_____________________________426. Immunization Status _____________________________________________437. Nutrition basics___________________________________________________438. Parenteral nutrition______________________________________________439. Central Venous Lines ____________________________________________4410. Antibiotic Prophylaxis____________________________________________4611. Tracheostomy_____________________________________________________4612. Chest tubes________________________________________________________4713. Nasogastric tubes_________________________________________________4714. Apnea & Bradycardia Monitoring_______________________________4815. Post-Op Antibiotics_______________________________________________4816. Pediatric Pain____________________________________________________ 48

VII. PEDIATRIC TRAUMA_____________________________________________________49Lisa Puett, RN., Coordinator of Pediatric Trauma & Burn Programs

1. Pediatric Trauma at Johns Hopkins_____________________________492. Evaluation of the Pediatric Trauma Patient____________________50

i. Prearrival_________________________________________________50ii. Primary Survey___________________________________________50

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iii. AMPLE History___________________________________________52iv. Initial Data________________________________________________52v. Secondary Survey________________________________________52

vi. Transfer___________________________________________________521. Head CT Algorithim______________________________53

vii. Tertiary Survey___________________________________________543. Other Important Points__________________________________________54

i. C-spine clearance______________________________________________55ii. Spleen/Liver______________________________________________56

iii. Child Abuse_______________________________________________56iv. Head Trauma_____________________________________________56

VIII. PEDIATRIC BURNS______________________________________________________________57 Lisa Puett, RN., Coordinator of Pediatric Trauma & Burn Programs

1. Policy___________________________________________________________________2. Bravo/alpha burn criteria____________________________________________3. Documentation_________________________________________________________574. Types of burns__________________________________________________________575. Calculating TBSA%_____________________________________________________576. Primary Survey_________________________________________________________587. Secondary Survey_______________________________________________________598. Initial Management_____________________________________________________599. Burn Management in Peds ED_________________________________________5910. Inpatient management_________________________________________________6111. Common Burn Dressings and treatments_____________________________6112. Nutrition________________________________________________________________62

IX. EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)___________________67

1. General Information______________________________________________672. Indications________________________________________________________673. Contraindications_________________________________________________674. Logistics of an ECMO Activation_________________________________685. Technique_________________________________________________________686. ECMO Circuit______________________________________________________697. Management of a Patient on ECMO______________________________698. Completion of an ECMO Run_____________________________________70

APPENDICES______________________________________________________________________72APPENDIX 1 Guidelines for the Mngnt of Appendicitis in Children__72APPENDIX 2 Pediatric Glascow Coma Scale____________________________73APPENDIX 3 ETT Sizes___________________________________________________74APPENDIX 4 Emergency Airway Management of Infant & Child _____75APPENDIX 5 Gastrostomy Tubes _______________________________________78APPENDIX 6 Pediatric Surgery Fellowship Conferences & Training_79APPENDIX 7 Immunization Schedule ___________________________________80

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APPENDIX 8 Emergency Drugs__________________________________________82APPENDIX 9 Guide to Surgical Procedures for Oncology______________83APPENDIX 10 Guidelines for Pediatric Preoperative Evaluation_____85APPENDIX 11 Intrapleural tPA for Empyema__________________________92APPENDIX 12 Guidelines for Catheter related BSIs____________________95APPENDIX 13 Central line lock therapy guidelines____________________97APPENDIX 14 Peri-OP antibiotic prophylaxis guidelines______________98APPENDIX 15 BURN DOCUMENTATION Requirements_______________101APPENDIX 16 BURN WOUND CARE: ED PROCEDURE________________102APPENDIX 17 Non-operative management of liver & spleen injury_105

IMPORTANT PHONE NUMBERS_________________________________________________108NICU SEPSIS GUIDELINES________________________________________________________112PICU ANTIBIOTIC GUIDELINES__________________________________________________114

REFERENCES______________________________________________________________________116

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I. INTRODUCTION

The 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.

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II. RESIDENT RESPONSIBILITIES

1) Pediatric Surgery Fellows

a. There 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.

b. 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.

c. 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.

d. No invasive procedure or major change in the therapeutic management of a patient should be performed without conferring with the Senior or Junior Fellow.

e. The Senior Fellow will make the call schedule for each month.f. The Fellows will provide back-up call from home for weekday nights

and every other weekend.g. The Senior Fellow will assign cases for the next day on PM rounds.h. The Junior Fellow will take in-house call in the senior resident call

pool and cover back-up call on alternating

2) Senior Residents, Trauma Fellows and Moonlighters

a. The call schedule will be posted by the Senior Fellow prior to the start of the rotation.

b. When on-call, the Senior Resident’s primary responsibilities are:i. New Emergency Department surgical consultations

ii. New in-house surgical consultationsiii. Covering notes & calls on the NICU & PICU GPS patientsiv. Notify on-call intern of all admissions **making sure

complete and thorough exams are documented for all admissions.

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Emergency Room admissions. v. For all common pediatric surgical problems (covered in

chapter VI) communicate directly with the on-call attending.vi. Contact the back-up Fellow on call for:

1. Complicated cases2. New NICU admissions3. New PICU Admissions4. ECMO activations5. Operative Trauma6. Major change in patient course (i.e. transfer to the PICU)

vii. Never turf an ER Consult to another service without first asking the Back-up Fellow or the Attending.

viii. The GPS Service does cover:1. Hematuria (possible Wilms’ tumor)2. GYN/ovarian pathology 3. Aerodigestive foreign bodies

ix. Consults may be prioritized based on acuity, but respond to pages immediately and tell the consulting service when to expect you.

x. Do not give phone instructions to obtain advanced imaging or laboratory studies without first examining the patient.

xi. 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!

1. Never be in a closed room with a female patient without a chaperone.

2. Parents are not chaperones. 3. Patients will not have surgery based solely on a

pediatric/medical evaluationxii. Check urine b -HCG for all females older than 10 years

c. Trauma Activations (Also see VIII. PEDIATRIC TRAUMA) i. The senior resident participates in the rapid management of all

trauma patients. ii. The resident will facilitate the work-up;

iii. Ordering a series of tests and then leaving is unacceptable.iv. Activations occur in two types:

1. Alpha – PICU - Resident Airway GPS Senior – All Else2. Bravo – GPS Senior runs entire trauma

v. The use of advanced imaging should be minimized as much as possible in children. (Ask the fellow/attdg with questions)

1. Avoid Neck and Chest CT without strong indicationvi. All patients require Trauma evaluation note-pediatric for their

H&Pd. In-house consults :

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i. Identify if the patient has been seen previouslyii. If operated before, the pt goes to the previous attending

iii. Otherwise, the on-call attending staffs new consultsiv. The surgical team has responsibility for the surgical patients in

the NICU and PICUv. Work closely & collegially with the neonatologists and

intensivists.

e. Daily Work i. The team will meet at 05:30 on weekdays and 06:00 on

weekends in the Garrett conference room.ii. Overnight senior residents present PICU/NICU patients the

night intern will present floor patients.iii. A daily progress note is REQUIRED on each pt in the NICU and

PICU.iv. 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.

v. 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.

3) Day Interns

a. The 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.

b. In addition to fielding floor calls on GPS patients, tasks include:i. Ensure all patients due for surgery within the future 48 hours

have:1. Signed informed consent 2. All appropriate labs3. Blood typed and crossed where indicated4. Adequate bowel prep5. PICU Bed Assignment as required

ii. Keep the OR moving by pre-oping outpatient casesiii. Start the daily text thread before the end of morning roundsiv. Complete all discharge summaries v. Schedule follow-up appointments

vi. Write prescriptions for patients being discharged c. Day Interns will be assigned level-appropriate casesd. Trauma Activations (Also see VIII. Pediatric Trauma)

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i. Interns are expected to respond to all trauma activationsii. Trauma responsibilities include:

1. Complete trauma H&P2. Accompany pt for imaging3. Follow-up radiology reads4. Follow-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

4) Night Float Intern and Saturday Second Years

a. The primary responsibility of the night intern is the care of all floor patients on the GPS service.

b. By agreement, the night intern will also be covering floor patients on the adult thoracic service.

c. 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.

d. On weekends, sign-out will only occur at the 06:00 morning meetinge. In addition to fielding floor calls on GPS patients, tasks include:

i. Ensure all patients due for surgery within the future 48 hours have:

1. Signed informed consent (in-pt only)2. All appropriate labs3. Blood typed and crossed where indicated4. Adequate bowel prep5. PICU Bed Assignment as required

ii. Complete discharge summaries for next-day dischargesiii. Write prescriptions for next-day discharges iv. Assist with overnight admissionsv. Follow-up labs and convey results

vi. Review the add-on list in the O.R. to ensure no patient is overlooked.

f. Postoperative check on all patients operated upon that day.g. Interns will be asked to scrub emergency cases where appropriate

5) Pediatric Co-follow

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The 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.

6) GPS Nurse Practitioners

The 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.

7) GPS Clinical Pharmacologist

The 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.

8) GPS Nutritionist

The 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.

9) Medical Students

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Each 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 Responsibilities

FOR 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 deteriorate

1. Case Assignments: a. Case assignments are made by the Senior Fellow.b. Provide operating room coverage as assigned. c. Residents should be in Pre-op by 7:15 A.M. for first cases.d. All surgical patients must have consent and an H&P update. e. The GPS Service should not be the cause of OR delaysf. ALL RESIDENTS should help complete Pre-Op paperwork during

the dayg. The resident covering a case must perform their own pre-op H&P

Note: This does not have to be the H&P that admits the patient to the OR

h. A resident should scrub on every index case. 2. Pre-Op:

a. Residents are expected to introduce themselves to patients and family, and identify the patient via name bracelet.

b. After introduction: i. H&P is updated

ii. Surgical site is verified and markediii. Informed consent is obtained.

c. Patients cannot be brought back to the OR until all paperwork is completed.

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3. Consents: a. For a minor (under 18 years) parents or legal guardian must sign

consent. b. 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)

c. Consents are signed by patients 18 years and over unless legal authority has been otherwise indicated.

d. Consents must be specific to surgical site indicating left and/or right sides. (“Right” and “Left” must be written out. No abbreviations –“R/L”)

e. Interpreters are available for all non-English speaking families. 4. Weight:

a. Infants under 1 year need daily weights dependent on disease state.

b. Weight is documented in kilograms only. Do not estimate or round off patient weights.

c. Use weight most recent today of surgery.5. Pagers:

During cases, the intern and senior call pagers should be handed off to another resident outside of the OR.

6. Resident Availability: a. Cases will not start without assigned resident in the OR. b. Residents must be present in the OR from the time the patient is

induced until transfer to the PACU or ICU.7. Parent Present Induction:

a. Parent-present induction is common for pediatric surgery.b. Please refrain from any unnecessary talking and noise during

induction.8. Eyewear:

Residents must wear appropriate protective eyewear (side protection too) before scrubbing for all cases.

9. Hand Washing: a. Hand washing is the single most effective way to prevent the

spread of infection and disease.b. Use hand gel before and after each patient encounterc. Use non-sterile gloves to avoid cross contamination.

10. Skin Scrub/Preparation a. Chlorprep is NOT approved for use on children under 2 months

The pediatric patient population is more prone to Betadine burns. b. When prepping avoid dripping Betadine, especially near Bovie padc. Avoid pooling of betadine under the patient.d. Clean Betadine off of the patient at the end of the procedure

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e. All Pectus Excavatum cases should be pre-scrubbed with chlorhexidine hand scrub

11. Post-Op Orders: a. Post-op orders are to be completed immediate after case.b. If a post-op PCA will likely be needed, a pain consultation request

can be submitted prior to induction.c. Post-op orders can be drafted prior to induction and finalized at

the end of the case.d. Please review the need for foley and abx with either Fellow or the

Attending. 12. PACU Surgeon’s Report

a. When the patient is delivered to the PACU the resident or fellow will provide a report of the case to the receiving PACU nurse.

b. Please include:i. Attending

ii. Procedureiii. Complicationsiv. Destination (Floor vs. home)v. Confirmation of Post-op Order Status

Epic 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)

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IV. GENERAL ADMINSTRATIVE ISSUES

1) Who Goes Where?

a. Where do children get admitted?i. Preterm Neonates NICU 8th floor BCC

ii. 0-1yr Newborns 9 South Floor BCCiii. 1yr to 3yrs Infants & Toddlers 9 North Floor BCCiv. 4yrs to 11 yrs School age Children 10 South BCCv. >12yrs Adolescents 10 North BCC

b. Who goes to the PICU?i. Critically ill children

1. Ventilators2. Risk for rapid decompensation3. Neurovascular checks more frequent than q2h4. Post-op cardiac neonates5. All ECMO activations

ii. Use 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.

2) Pediatric Interventional Radiology Admissions

a. Pediatric Interventional Radiology admissions are under the IR Service.b. Pediatric Surgery (GPS – General Pediatric Surgery) co-follows with IR

from 5:30pm to 7am.c. Pediatric hospitalists and GPS co-follow resident follow along with all

children < 2 years old.d. 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.

e. 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).

f. On weekends, the IR fellow on call is responsible for pages on IR service pediatric patients at 3-CVDL

g. On 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.

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h. 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.

3) Clinics, Conferences And Rounds

a. General

i. Morning Rounds begin in the 7th floor Garrett Conference Room at 5:30 AM weekdays and 6:00AM on weekends and holidays.

ii. Evening rounds will be held in the Garrett Conference room at 5pm or when the cases of the day are finished.

b. Conferences (ATTENDANCE IS MANDATORY) **see appendix 6 for times

c. Surgery Clinic:i. Meets daily 8am M, W, F and 2 pm T . No scrubs.

ii. 1 half day per week required by all residentsiii. Postoperative 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.

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V. PROBLEMS OF THE SURGICAL NEONATE

1. NICU Survival Guide

a. Respiratory Norms:i. RR 40-60

ii. O2 Sat 1. >94% in term infant2. 88-95% in chronic preemies

iii. ABG Norms1. pH 7.35 – 7.452. pCO2 35 – 453. For every 10 of change in pCO2, pH changes 0.08

iv. VBG or Cap Norms:1. pH 7.30 – 7.40, 40- 50

b. Pressure-Control Ventilation:i. PIP -peak inspiratory pressure

ii. PEEP -positive end-inspiratory pressureiii. MAP -mean airway pressureiv. Maneuvers to Increase pO2 :

1. Increase FiO2 2. Increase PIP 3. Increase PEEP 4. Increase inspiratory time

v. To decrease pCO 21. Increase rate2. Increase PIP3. Decrease PEEP

c. Oscillatori. MAP: mean airway pressure

ii. delta P: amplitudeiii. increase MAP to increase pO2iv. increase delta P to decrease pCO2

d. Apnea / Bradycardia of Prematurityi. Typical for <35 weeks GA

ii. Usually outgrown by termiii. Treatment options:

1. Watch & wait especially if older2. Caffeine Citrate

a. Load bolus - 20mg/kg; max 40mg/kgb. Maintenance 5-10mg/kg/d; max 20mg/kg/d

3. Aminophylline a. Load Bolus 5-8 mg/kgb. Maintenance 2-6 mg/kg/dose PO/IV q8-12h

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e. Cardiovascular Considerationsi. Norms: Hr 120-160

ii. HR of 80 can be normal for term infantsiii. MAP: approx 3 –5 above GA (35 weeks = MAP 40mmHg)iv. Patent Ductus Arteriosus

1. Murmur2. Increased pulse pressure3. Bounding pulses4. Palmar pulses5. Worsening respiratory parameters 6. Treatment

a. Post Natal Age < 48 hoursi. Indocin 0.1 mg/kg/dose IV q12-24h x 3

b. Post Natal Age 2-7 daysi. Indocin 0.2 mg/kg/dose IV q12-24h x 3

c. Post Natal Age >7 daysi. Indocin 0.25 mg/kg/dose IV q12-24h x 3

d. Contraindicated in renal failure, NEC, bleeding7. Common Pressor medications: (initial; titrate to effect)

a. Dopamine: 2.5 –20 mcg/kg/minb. Dobutamine: 5 – 20 mcg/kg/minc. Epinephrine: 0.05 – 1 mcg/kg/mind. Hydralazine: 0.1 – 0.2 mg/kg/dose IV q 4-6h, or

0.25 –1 mg/kg/dose PO q6-8hf. Fluids, Electrolytes and Nutrition

i. Requirements increase with:1. Decreasing gestational age2. Increasing DOL3. NPO Neonates Require D10 IVF if not on TPN4. Neonate Fluid rates

a. Term: i. start at 80 – 100 cc/kg/d

ii. advance by 20 cc/kg/d to 120 cc/kg/db. 1000-1500gms

i. start at 80 – 100 cc/kg/dii. advance by 20 cc/kg/d to 150 cc/kg/d

c. <1000 gmsi. start at 100-150 cc/kg/d,

ii. use serum sodium (q6 –12h) to guideiii. may raise to 170 –300 cc/kg/d

5. Maintenance electrolytesa. Na: 2-4 mEq/kg/db. K: 2 mEq/kg/dc. Ca Glu: 200 – 800 mg/kg/d divided q6h

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6. TPN:a. <1500gm:

i. AA/IL start at 3g/kg/d ii. Advance to 4g/kg/d

b. >1500gm: i. AA/IL start at 3

ii. Advance to 3.57. Enteral feeds:

a. Enfamil 20 for > 2 kg b. Premature Enfamil 20 for < 2 kgc. D10 = 100g/L = 100mg/ccd. D25 = 250g/L = 250 mg/cce. Bili > 5% of body weight needs phototherapyf. Bili > 10% of body weight need exchange

transfusiong. Increase daily fluids by 10 cc/kg/d with lights.

g. Infectious Disease Considerations:i. Neonate Sepsis caused by:

1. Group B Strep2. E coli3. Listeria

ii. Empiric Treatmenthttp://insidehopkinsmedicine.org/AMP/pediatrics/downloads/nicu_sepsis_guidelines.html

h. Neurological Considerations:i. Routine Head US:

1. <30 weeks a. DOL 1-2b. DOL7-10

2. 30-34 weeks a. DOL 7-10, or if clinical suspicion b. 30 days to look for PVL

3. Eye exams should be obtained for:a. any baby <32 weeksb. 32 –34 weeks on O2c. other suspicionsd. for retinopathy of prematurity

i. At corrected 35 weeks GAii. 4-5 weeks post-natally

2. Recognition and Treatment of Sepsis in Newborns :a. Signs: (Often reported by bedside nurses)

i. Hypothermiaii. Leukopenia

iii. Thrombocytopeniaiv. Mottlingv. Lethargy

vi. Apnea, cyanosis, desats

vii. Poor feedingviii. Irritability

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b. Workup:i. Blood cultures

ii. Urine cultures (bagged specimens are useless)iii. Sputum culturesiv. LPv. CXR

vi. PT, PTT, platelets, CBC and differentialc. Treatment:

i. Empiric antibiotics after workup is initiated (See sect 1.g)ii. Volume Support

iii. Pressors if necessaryiv. Administration of FFP if DIC is present.v. Mechanical Ventilation

3. Tracheo-Esophageal Fistula And Esophageal Atresia:

a. These anomalies are frequently not identified prenatally. The only prenatal hint is usually polyhydramnios.

b. There are 5 variants of the TEF/EA anomalyi. EA with distal Fistula (85%)

ii. Pure EA (7%)iii. EA with Proximal Fistula (3%)iv. EA with Proximal and Distal Fistula (<1%)v. TEF without atresia (4%)

c. 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.

d. Keep the infant’s head at 45 degrees and connect the NGT to continuous low suction to keep the upper esophageal pouch empty.

e. Presence of gas in the stomach suggests a distal fistula.f. 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.

g. If a patient with a distal fistula has a distended abdomen it is a surgical emergency. Gastric distention can cause

i. Cardiac arrest due to pericardial compressionii. Gastric reflux into the trachea with acute pneumonitis

iii. Gastric Ruptureh. EA/TEF is frequently associated with VACTERL anomalies. Asses the patient

for:i. Vertebral Anomalies (6-21%)

ii. Anorectal Anomalies (10-16%)iii. Cardiac anomalies (13-34%)iv. Renal anomalies (5-14%)v. Limb Anomalies (5-19%)

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i. 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.

4. Intestinal Obstruction:

a. Common causes for intestinal obstruction in infants:i. Intestinal atresias

ii. Hirschsprung's Diseaseiii. Meconium ileusiv. Malrotation

b. BILIOUS EMESIS IN AN INFANT IS A SURGICAL EMERGENCY .c. BILIOUS EMESIS IN AN INFANT DENOTES DUODENAL OSBSTRUCTION AND

ISCHEMIC BOWEL FROM A MIDGUT VOLVULUS UNTIL PROVEN OTHERWISE.

d. Obtain an IV and initiate NGT decompression when intestinal obstruction is suspected.

e. 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.

f. 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.

5. Intestinal Atresia:

a. Occurs in the following order of frequency:i. Jejunoileal (50%)

ii. Duodenum (44%)iii. Colon (6%)iv. Pylorus (<1%)

b. 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.

c. Vomiting usually occurs within the first 48 hours of life. Emesis is bilious except in pyloric atresia and very proximal duodenal atresia.

d. Plain films of the abdomen should be obtained in all cases of prenatal polyhydramnios.

e. The more proximal an atresia the less severe the subsequent abdominal distention.

f. Double bubble of duodenal atresia is pathognomonic and no contrast study is indicated. If no double bubble seen, inject air into NGT and repeat AXR

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g. When multiple loops of dilated bowel are seen, suggesting a distal atresia; a UGI is mandatory.

h. 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.

i. 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.

6. Hirschsprung's Disease:

a. 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.

b. Symptoms are non-specific and include episodic abdominal distension, constipation, obstipation or diarrhea.

c. Any newborn that fails to pass meconium in the first 48h after birth should be evaluated for Hirschsprung’s Disease.

d. 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%)

e. 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.

f. 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).

g. 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.

7. Meconium Ileus:

a. 33% of all neonatal small intestinal obstructions are due to meconium ileus secondary to cystic fibrosis.

b. Meconium Ileus is typically the first finding of cystic fibrosis although only about 15% of infants with cystic fibrosis will develop meconium ileus.

c. 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.

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d. These patients will typically present similar to other neonatal obstruction patients:

i. bilious vomitingii. generalized abdominal distention

iii. failure to pass meconium in the first 24 to 48 hourse. The meconium may be palpable as a doughy substance in the dilated loops of

distended bowel. f. 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.

g. 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.

h. 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.

i. 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.

j. Operative indications in meconium ileus:i. Gastrografin enema failure

ii. Calcifications in the abdominal cavityiii. Ill-apperaing infantsiv. If the diagnosis of meconium ileus is in doubt.

k. N-acetylcysteine (mucomyst) or saline enemas can be given to complete the evacuation. Mucomyst can be given through NG tube as well

l. Once the meconium ileus is relieved all these patients need a confirmatory test for CF. Options include;

i. 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.

ii. A buccal smear-only 80-90% sensitive because it looks for only common genetic mutations.

m. All CF infants require vigorous pulmonary therapy. n. When enteral feedings are initiated, a pancreatic enzyme preparation is given

with each feeding. Typically, one pancrease pearl per 10cc of formula

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8. Malrotation:

a. 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:

i. Bilious Emesis (95%)ii. Abdominal Distention

iii. Abdominal Painiv. Inconsolabilityv. Bloody Emesis (due to gastritis)

vi. Bloody Stools (due to necrosis)b. Time of presentation:

i. 30% in first week. ii. 75% in First month

iii. 90% in the first yearc. Findings on plain AXR:

i. Gasless abdomenii. Dilated intestine like SBO

iii. Duodenal obstruction with a double bubbled. If the child is not acutely ill, obtain an UGI to look for position of the ligament

of Treitz.e. Classic Malrotation on UGI:

i. Absent duodenal sweep ii. Duodenum stays to the right of midline and corkscrews down

iii. Duodenum is anterior and/or lateral to the SMAiv. Cecum may be midline

f. Malrotation Anatomy predisposes the bowel to volvulus following normal peristalsis and consists of:

i. Ladd’s bands - fibrous attachments from the retroperitoneum to the cecum which may obstruct the duodenum

ii. Absence of a ligament of Treitz iii. Midline cecum iv. Narrow vascular pedicle

g. Midgut 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.

i. Principal Sign: Sudden onset of bilious emesis ii. 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.

iii. 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.

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iv. After diagnosis complete these Pre-op Maneuvers: 1. NGT2. IV Hydration3. OR4. NO DELAYS!

v. Treatment for Malrotation is the Ladd’s Procedure: 1. Supraumbilical transverse incision. 2. To decompress the volvulus, rotate the small bowel

COUNTERCLOCKWISE. 3. Lyse the Ladd’s Bands4. Place small bowel on the right side 5. Place large bowel on the left (Cecum will lie in the LLQ)6. Perform an appendectomy7. If bowel is dead treat as follows:

a. Short segment -resect with primary anastomosis.b. Short segment w/ questionable viability-resect dead

and bring out stomas. If stomas necrose in 24-48h, re-explore.

c. Large segment (or multiple questionable segments) - Close and do second look in 24-48h.

vi. Malrotation after the 1st year of life: 1. Symptoms may occur in childhood to adults2. Typically vague chronic symptoms3. 10-14% may have acute volvulus. 4. 30% may have intermittent vomiting (bilious), and colicky

abdominal or recurrent partial SBO. 5. Some have malabsorption and FTT.

9. Omphalocele & Gastroschisis:

a. 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.

b. Gastroschisis - a smooth-edged abdominal wall defect adjacent to a normal umbilical cord, typically on the right. The abdominal contents are eviscerated and uncovered.

i. The bowel must be covered promptly to prevent hypothermia. Options include:

1. Warm saline soaked sponges 2. Plastic Bowel bag

ii. Note: Gauze bandages tend to stick to the bowels – Do not use them

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c. These anomalies require lateral support to prevent the mesenteric vessels from becoming kinked. Support them initially as follows:

i. Gastroschsis: 1. place the child in the decubitus position with the defect down

(typically right lateral decub)2. The bowel should be supported by towels

ii. Omphalocele:1. Cover the defect with Xerofrom Gauze2. Place an unwrapped Kerlex roll bilateral to the defect3. Wrap the entire child with an additional Kerlex ventral to

dorsal4. Place child in supine position

d. Treatment maneuvers:i. GI decompression with an NG tube

ii. Rectal exam to evacuate and decompress coloniii. Foley catheter placement to monitor urine outputiv. Empiric intravenous antibioticsv. IV Fluid support

vi. These patients typically require NS boluses to initiate urine e. Rule out associated anomalies,

i. Omphalocele:1. Cardiac 2. Renal 3. Chromosomal (trisomy 13, 18, 21)4. Beckwith-Wiedemann (large tongue, gigantism, hypoglycemia)5. Imperforate anus

ii. Gastroschisis 1. Intestinal Atresia.

f. 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.

g. Nutrition-when ready start feeds low calorie and slowly, daily wgts, strict I/O, any vomiting and # of stools/day.

10. Treatment Protocol For Congenital Diaphragmatic Hernia (CDH):

a. Modern treatment protocol for CDH:i. Delayed surgical repair until resolution of fetal circulation

ii. Minimize iatrogenic barotrauma from excessive ventilation. iii. ECMO if mechanical ventilation is insufficientiv. Note: Timing of surgical repair is dictated by clinical course. Do not

make treatment changes without discussion with the Senior Fellow or the attending.

b. Initial NICU Management:i. Neurological

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1. Head ultrasound2. Minimize Sedation3. Respiratory:

Order of Advancing Ventilator Support:a. Supplemental Oxygenb. SIMV (neonatal pressure support) c. High frequency ventilation (oscillator)d. ECMO

4. Vent Settingsa. Maintain spontaneous respirationsb. Peak inspiratory pressure <25 cm H2O (if possible)c. Rate: Initial settings of 25-35 breaths per minuted. FiO2=1.0

5. Goals:a. Mean airway pressure:

i. <12-13 cm H2O ii. Barotrauma kills CDH babies

b. Preductal oxygenation: Cerebral Perfusioni. pO2>60

ii. O2 Sat >90%. c. Postductal Oxygenation: Distal Perfusion

i. pO2/O2 Sat's will often be <60 /90%ii. Do not use these postductal values to adjust

ventilator settings.d. Permissive hypercapnia:

i. Maintain pH > 7.25ii. Maintain pCO2 <60

e. 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.

ii. Cardiovascular:1. Cardiology consult 2. Echocardiogram on admission3. Conserve IJ and EJ for possible ECMO Cannulation4. Right radial (preductal)5. UA, PT, or DP (postductal)

iii. Drugs: 1. Fentanyl 1-2 mcg/kg PRN for agitation2. Empiric systemic antibiotics

a. Zosynb. Amp/Gent

3. Pressorsa. Dopamineb. Dobutamine

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iv. Lab studies:1. Pre- and postductal ABG's q 1 hour2. Hematocrit, lytes, ionized Ca q 6 hours 3. PT, PTT q AM4. CBC, Chem 20 q AM5. Type and Screen

11. Necrotizing Enterocolitis (NEC):

a. 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 feeds.

b. Commonly seen associated with: i. RDS

ii. Apneic spellsiii. Low Apgarsiv. Premature rupture of the membranesv. Breech delivery

vi. Exchange transfusionsvii. Cesarean section

viii. Umbilical artery catheter.c. Clinical findings:

i. Bloody diarrheaii. Abdominal distention

iii. Poor feedingiv. Increased apneic spellsv. Lethargy

vi. Prolonged gastric emptying (read as: Increased aspirates)vii. Bilious emesis

d. NEC is frequently evaluated with serial radiographs. The main findings are: i. Dilated bowel –earliest sign

ii. Intramural gas (pneumatosis)1. Not indicative of severity2. May disappear without actual improvement

iii. Portal venous gas1. Usually indicates increased severity2. May disappear without actual improvement

iv. Pneumoperitoneum.e. Tissue damage is typically focused on the ileum, cecum, and right colon.

Findings of increasing severity include:i. Mucosal ulceration

ii. Submucosal hemorrhage iii. Necrosis of the entire bowel wall.

f. Pneumatosis is found in the submucosa and subserosa.

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g. Treatment: i. NPO

ii. NG suctioniii. Broad-spectrum antibiotics for 7-10 days empirically.iv. Serial Radiographsv. Serial CBC, platelet count, blood pH, electrolytes.

vi. Contact precautionsvii. Slowly increase feeds then increase calories

h. Surgical Indications:i. Absolute

1. Pneumoperitoneum - most sensitive film is lateral decubitusii. Relative

1. Abdominal wall cellulitis 2. Palpable mass on abdominal exam3. Persisting isolated dilated loop of bowel4. Failure to respond to medical therapy

a. Thrombocytopeniab. Acidosisc. Severe hemodynamic instability

i. Pre-Op Preparation:i. Check CBC, PT/PTT, Electrolytes, and ionized Calcium

ii. If platelets < 100K, order 2 units of platelets.iii. Move promptly to OR

12. Postoperative Enteral Feeding:

a. Initiation of feedsi. Term newborns:

1. 150 cc/kg/day of 20-kcal/30cc formula q3-4h 2. Goal: Weight gain of 20-30 grams/day

ii. Premature infants1. Higher volume because of evaporative losses2. More frequent feeding3. Gavage may be necessary 4. Continuous feeds may be easiest

iii. Postoperatively1. After passage of flatus and stool 2. Begin with D5W or Pedialyte.3. Examine frequently for abdominal distention

b. Gastroesophageal Refluxi. Common in infants and is temporary.

ii. Medical management 1. Feeding upright in a chair 2. Leaving infant in chair at least one hour after feeding3. Thickening feeds with cereal.

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4. Medications a. Ranitidine PO 2-4mg/kg/day Q12b. Lansoprazole

i. <10 wks old: 0.2-0.3 mg/kg/dayii. >10 wks old: 0.5-1 mg/kg/day

c. Gastric Residuals:i. For bolus feeds

1. Hold for residual >1/2 of previous feedii. For continuous feeds

1. Check residuals every 4 hours2. Hold feeds if residual exceeds half the amount infused in 4

hours.iii. Infants usually tolerate increasing volume more readily than

increasing concentration of feedings. iv. Increasing osmolarity leads to diarrheav. Increasing volumes leads to gastric residual and/or vomiting.

d. Infant formulas:i. Term Infant

1. First Year of Lifea. Breast milk

i. Ideal for infantsii. Well tolerated

iii. Easily digestedb. Formula

i. Standard - Similac/Enfamil/SMA1. Lactose is carbohydrate2. Casein/Whey is protein

2. After Year Onea. Cow's milk b. Training Foods

ii. Special Cases1. Lactose Intolerance and Allergy

a. Soy Formulas - Isomil/Prosobee i. Sucrose & starches are Carbohydrate

ii. Soy is the protein source2. Malabsorption, short bowel, gastroschisis, CF

a. Hydrolyzed Formulas -i. Nutramigen, Pregestimil,, Neocate

ii. Sucrose & starches are Carbohydrate iii. Pre-digested proteins (hydrolyzed casein)

b. Free-Amino Acid Based Formulasi. Elecare; Neocate (Infant & Jr)

ii. Corn Syrup are solidsiii. Protein is free amino acids

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VI. COMMON PEDIATRIC SURGICAL PROBLEMS

1) Appendicitis

a. Basicsi. The most frequent surgical consultation in the emergency department

ii. The most common abdominal surgical problem in childhood. iii. Early appendectomy for non-perforated appendicitis typically results

in hospital discharge within two days.iv. Children less than 2 years of age typically present with a perforated

appendixv. Do NOT start antibiotics for “appy rule out” overnight admissions

when presentation is equivocalb. Presentation:

i. Abdominal pain begins as periumbilical visceral pain ii. Typically migrates to the right lower quadrant – focal peritonitis

iii. Perforation typically occurs at around 36 hours (± 10 hours) after pain begins

iv. Abdominal pain usually precedes vomiting.v. Associated symptoms:

1. Anorexia2. Nausea3. Vomiting

c. Examinationi. Fever and leukocytosis tend to be minimal in early appendicitis

ii. Consistent, localized point tenderness is the cardinal signiii. Psoas and Rovsing signs are variableiv. Rectal examination may reveal

1. Retrocecal appendicitis2. Pelvic mass3. Phlegmon4. Abscess

v. Use a pelvic exam to rule out GYN pathology in sexually-active young women

d. Labsi. BMP and CBC

ii. Pregnancy test if >10 years olde. Imaging

i. No imaging is needed if the history and physical examination strongly suggest appendicitis.

ii. A calcified fecalith on KUB is strong evidence for appendicitis1. Found in only 10-15% of cases

iii. Ultrasound is the most common imaging strategy used in children1. Typically used for all females2. Used in males for non-classic presentation

iv. CT’s are rarely obtained in children

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v. MRI A/P appendicitis protocol if further imaging neededvi. Antibiotics -The Johns Hopkins Guidelines for the Management of

Appendicitis in Children is found in APPENDIX 1f. Perforated Appendicitis:

i. Patients with prolonged symptoms (>5 days) prior to presentation may have perforated appendicitis with phlegmon or abscess seen on imaging

ii. Non-operative management may be appropriateiii. IR consultation for drainage/aspiration of abscessesiv. Broad spectrum antibiotics, IVFsv. Consider Interval appendectomy in 6-8 weeks esp if + fecalith

2) Pyloric Stenosis

a. Basicsi. Typically occurs in the first 3-6 weeks of life

ii. Extremely rare prior to week of life 3iii. Male predominance 4:1

b. Presentationi. Classic: worsening vomiting over several days leading to projectile

NON-BILIOUS vomiting after EVERY feed. ii. Lack of vomiting after every feed should prompt a search for other

causesiii. If vomiting has lasted several days the pt may appear toxic

c. Examination:i. Classic: a palpable ”olive” in the RUQ

ii. If present no further diagnostic tests are necessaryiii. To palpate:

1. Give the infant a pacifier 2. Elevate the baby's feet 3. Palpate over the spine at the midline 4. Palpated by rocking superiorly and inferiorly

d. Imagingi. Ultrasound is imaging study of choice

1. Positive US findingsa. Wall thickness > 3mm ANDb. Channel Length >16mm

ii. UGI if diagnosis is in question

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e. Pre-operative maneuversi. Note: pyloric stenosis is NOT a surgical emergency

ii. Electrolytes must be corrected prior to induction of anesthesiaiii. Long-term vomiting leads to hypokalemic hypochloremic metabolic

alkalosis iv. This MUST be corrected like so:

1. Make sure the vomiting is NOT biliousa. If it is get an UGI ordered and contact the Senior Fellow

2. If vomiting is non- bilious, check UOP if low then “3.”3. Use NS blouses of 20 cc/kg to induce UOP

a. If no urine in 1 hr; repeat NS Bolus4. Obtain labs or review OSH labs

a. If electrolytes come back with HCO3 > 30 give D5 1/2NS at 1.5 x maint

b. Add 20 mEq of KCl/L to fluids after good UOP has been established.

5. Check labs every 6 hours.6. Pre-op Goals: (Anesthesia will not put the pt to sleep

otherwise)a. Cl> 90 ANDb. HCO3 < 30 AND c. Normal K

7. No need to repeat labs once:a. D5 1/2 NS w/ 20MEq of KCl/l is running b. Goal lytes are obtainedc. UOP is good

v. Postoperative management:1. Note: Warn parents that post-op pyloric pts frequently vomit2. Feeding may resume 6 hrs post-op and are spaced out Q3hrs3. The first feed is 15 ml of Pedialyte4. If tolerated the next feed is 30 ml Pedialyte5. If tolerated switch feeds to 30 ml of formula6. If tolerated advance to goal volume formula feed7. Pt may d/c home once tolerating two consecutive ad lib goal

feeds8. If a pt vomits, repeat the vomited feed/volume at the next

feeding time until tolerated then continue to advance feeds as indicated.

9. If the bowel lumen is injured intra-opa. NGT suction x 2 daysb. IV ABX

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3) Intussusception

a. Basicsi. An invagination of a portion of the intestine into the lumen of an

immediately adjoining part.ii. Typical age range: 4 months to 2 years

iii. Peak incidence at age 8 monthsiv. Outside this age range consider a lead point for the intussusception:

1. Meckel's diverticulum2. Intestinal polyp

v. Typical location - ileocecal valveb. Presentation and Examination

i. Classic triad: (rarely are all found)1. Intermittent colicky abdominal pain2. Abdominal "sausage-like" mass3. Currant jelly stools.

c. Imagingi. Ultrasound is the diagnostic test of choice

1. Positive tests yield a target sign2. If found a therapeutic air contrast enema is needed.

d. Treatmenti. Air contrast enema

1. Should not be performed if the child has peritoneal signs2. Both confirmatory and therapeutic3. If successful, enemas can be repeated 2 more times if the pain

returns4. Surgery is not needed if reduction is complete.5. General principles

a. A functioning IV must be in place b. Give prophylactic ABX (cefoxitin) x 1 for concern of

translocationc. Reduction is successful when there is free reflux of air

or contrast into the ileumd. Repeat attempts can be made if the baby's condition

will permit.ii. Surgery

1. Required for all children with peritoneal signs2. Mandatory if reduction cannot be accomplished3. A sick child should go to the OR after

a. IVFb. IV ABXc. NGT placement

4. Resection may be required

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e. Post Reduction Carei. Admitted GPS for 24 hours observation even after non-operative

reductionii. NPO for the first 6 hours; then gradually advance the diet

iii. High temperatures typically follow reductioniv. If symptoms recur, enema reduction should be repeated againv. The recurrence rate after enema or surgical reduction is ~ 5%.

4) Incarcerated Inguinal Hernia

a. Basicsi. Typically found in infants during the first year of life (F>M)

ii. Girls typically have sliding hernia w ovary/tube in canaliii. Most can be reduced manually which obviates the need for emergency

surgeryb. Reduction techniques:

i. Infant needs to be calm- sweety dipped pacifierii. ED can provide conscious sedation.

iii. Very steep Trendelenburg position assists in reducing the hernia.iv. Have an assistant hold the infant above the knees in a frog leg position

to relax the abdominal wall.v. Technique:

1. Use one hand to put traction on external ring, apply steady even pressure to hernia into the canal

2. A considerable length of steady pressure (5 minutes) may be required to produce the desired reduction

3. Should feel the hernia “pop” into the abdomen on reduction4. Try to milk the bowel contents out of the incarceration, until it

is less edematous and can be put back into the abdomen.vi. Some hernias reduce easily; others require several attempts.

vii. If successful, the patient is always admitted1. Repair is performed electively within the next 24-48 hours

after the edema has resolved2. The infant should have serial examinations to rule out re-

incarcerationviii. Emergency surgical intervention is required if the hernia cannot be

reduced, or if there is post reduction evidence of intestinal obstruction, or nonviable bowel

c. Hydrocelei. It is imperative to differentiate an incarcerated hernia from a

hydrocoele of the cord1. Hydrocoele of the cord is often tense2. Hydrocoele in the first year rarely requires operative

intervention.3. Clues to distinguish a hydrocoele from a hernia:

a. Transillumination - hydroceles are filled with clear fluid

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b. Non-tenderc. Swelling discontinuous with inguinal ring

ii. These infants can be sent home & booked for elective surgeryd. Complications

i. Infarction of the testicle1. Reduction will usually reinstitute blood flow to the testis.

e. Incarcerated inguinal hernias in girls invariably are sliding hernias containing ovary and tube

i. If asymptomatic, these can be repaired on a semi-elective basisii. The blood supply to the ovary is usually not impaired, and the vessels

are small in comparison.

5) Reducible hernias in premature and complicated full-term infants:

a. If consulted on an inpatient preemie with multiple problems either:i. Repair within 4 days prior to discharge home

b. Babies < 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 monitoring

6) Foreign Bodies

a. Basics:i. Requires a high index of suspicion and a low threshold for endoscopic

examination if there is any question of aspiration of a foreign bodyii. Excessive morbidity and mortality results from unaddressed foreign

body aspirationsiii. Most common in the toddler age groupiv. First get AP & lateral CXR to determine the location of the object

1. Radiopaque will show location2. Radiolucent FBs (wood, plastic, food) will not be seen on CXR

a. Esophageal: Obtain esophagram if high index of suspicion

b. Airway: often presents as hyperinflation on CXR of affected side- Ball valve effect in bronchus

i. Inspiration/expiration CXRii. Lateral decubitus CXR

1. Affected (down) side will have absence of mediastinal shift from gravity

b. Laryngeal foreign bodies i. A foreign body lodged in the oropharynx or glottis may warrant

immediate attention to clear the airway:1. Heimlich maneuver2. Direct laryngoscopy3. Bronchoscopy

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ii. If possible, a mask airway should be maintained and more controlled laryngoscopy performed in the operating room.

iii. 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 ideal

c. Tracheobronchial foreign bodies i. Less than 10% of foreign bodies are located above the carina

ii. Majority located in the right main stem bronchusiii. History alone may be sufficient to warrant admission and endoscopy,

even in the absence of physical and X-ray findingsiv. Plain 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.

1. Obtain Insp/Exp films or lateral decub CXRv. Management

1. The Storz rigid bronchoscope or optical forceps greatly facilitate foreign body removal from the tracheobronchial tree

2. A 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 forceps

vi. The consequences of the neglected foreign body are quite serious and include:

1. Atelectasis2. Recurrent pneumonia3. Eventual destruction of the segment or lobe

vii. Since there is minimal morbidity using the miniaturized bronchoscope, an aggressive approach is warranted

viii. All patients should have a postoperative CXR

d. Esophageal foreign bodies i. An esophageal foreign body can cause respiratory distress in small

childrenii. Objects 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, diaphragm

iii. Diagnostic tests1. CXR will locate the object if it is radio-opaque

a. PA and lateral to determine position and possibility of 2 objects

i. Disk batteries have step off on lateral projections2. Abdominal film will determine if the object has slipped through

to the stomach3. Esophagram is occasionally required

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iv. Management:1. Endoscopic (rigid or flexible) under general anesthesia

typically during business hoursa. Overnight presentations should be admitted to floor

NPO 2. Sometimes a long laryngoscope will be sufficient to allow

removal with either foreign body forceps or a Fogarty catheter3. Passage of the scope beyond the site of impaction is generally

not necessary and can increase the risk of esophageal perforation

4. Consider a postoperative CXR to check for pneumomediastinum if multiple passes of the scope

v. Disk batteries require emergent endoscopic retrieval 1. Can cause caustic injury and full thickness lesion2. Require level 1 to OR

e. Gastrointestinal foreign bodies i. Once in the stomach, most ingested foreign bodies will safely traverse

the GI tract, usually within 4-5 daysii. One exception is magnets - Multiple magnets should be removed

aggressivelyiii. The problem sites are:

1. Pylorus2. Ligament of Treitz3. Ileocecal valve

iv. If the object is radio-opaque, it can be followed with serial X-ray filmsv. The 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-up

vi. If after 4-6 weeks the object is still in the stomach, it can be retrieved by EGD

7) Caustic Ingestions

a. Basicsi. All patients with suspected caustic ingestion are admitted for

esophagoscopy under general anesthesia in 12-18 hr from injuryii. Although most patients with esophageal injury show burns of the

oropharynx as well, this is not a completely reliable guidelineiii. Upper airway injury as well as face and hands should be assessediv. Pharyngeal burns may be so severe as to require tracheostomyv. Symptoms can occur between 1-5h after ingestion

b. Typesi. Acids: Toilet bowl cleaners, rust removers (HF1).

1. These cause coagulation necrosis.2. Tend to injure the stomach.

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ii. Bases (alkali): 1. NaOH, KOH, ammonia, electric dishwasher soaps, some

denture cleaners, non-phosphate detergents, hair strengtheners.

2. These cause liquefaction necrosis.3. May involve full thickness injury.4. Tend to injure the esophagus.

iii. Caustic flakes or powder tend to stick and cause localized oropharyngeal and upper esophageal injury.

1. Lead to segmental strictures.iv. Bleaches: Clorox (Na Hypochlorite).

1. Experimentally causes superficial burns and ulceration, no strictures.

v. Disk batteries: 1. Experimental model – 1 hour = mucosal injury, 2-4 hours =

muscularis injury, 8-12 hours = perforation.vi. Pills: Can get stuck and adhere to mucosa.

1. NSAIDS – hemorrhage and stricture. 2. Potassium Chloride – strictures, hemorrhage, death. 3. Quinidine – strictures.

c. Always think about battered child syndrome, Munchausen’s by proxy (8%). i. 78% of poisonings occur with patient near parent.

ii. Get social services involved if story is incongruous with injuries.d. Management –

i. Acute:1. DO NOT INDUCE VOMITING, DO NOT LAVAGE2. NPO and IVF.3. Wash skin and eyes; wash out mouth with water or milk. 4. CXR and KUB for sx of respiratory distress, odynophagia,

drooling, abdominal pain.5. Esophagoscopy 24-48 hours post injury.

a. Do not evaluate distal to lesion.b. Avoid in patients with severe oropharygneal burns or

laryngeal edemac. Repeat evaluation in ~2weeks

6. Barium swallow in 2-3 weeks.ii. In patient:

1. Moderate burns – Inpatient 2 weeks, abx and steroids2. Severe or full thickness – as above, omit steroid

administration. 3. Consider esophageal silastic stent with distal penrose to

prevent GER or NGT for 6 weeks as sole treatment. 4. If full thickness stomach injury gastrectomy/esophagectomy. 5. Esophageal stricture: develops in 7-15%. Long term risk of

cancer.

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8) Lower GI Bleed:

a. NEONATES: Condition - Workupi. Swallowed maternal blood - Apt test

ii. Hemorrhagic disease of the newborn – Coags, Vit K deficiency NGT, Thrombocytopenia from multiple causes, UGI

iii. Anal fissure - Anal examiv. NEC - KUB, cross table lateralv. Malrotation and volvulus – UGI

vi. Allergic colitis from formula – Eosinophiliab. INFANTS 3-18mo: Condition – Workup

i. Anal fissure - Anal examii. Intussusception - Colon study-air or contrast

iii. Intestinal volvulus - KUB, Small Bowel Follow Throughiv. Ectopic gastric mucosa - Meckel's scan for ectopic gastric mucosav. Gastroenteritis – Coags, NGT

c. TODDLERS and PRESCHOOL: Condition – Workupi. Anal fissure – Anal Exam, Coags, NGT

ii. Rectal prolapse - Anorectal examiii. Gastroenteritis – KUBiv. Meckel`s diverticulum - Meckel`s scanv. Juvenile polyp - Upper and lower endoscopy

vi. Trauma - RBC scand. OLDER CHILDREN and TEENS 6-18y: Condition – Workup

i. Polypoid diseases - Coags, KUB, NGTii. Ulcerative colitis - Upper and lower endoscopy

iii. Hemorrhoids - Anorectal examiv. Meckel`s - Meckel`s scan

9) Biliary Atresia a. Background– rare 1:18 K infants, non-hereditary, leading cause of liver

transplants in infants/toddlersi. Cause- unknown

b. Symptoms-persistent hyperbilirubinemia > 2 wks of age                               Acholic stools                               Poor weight gain                               Poor feeding                               Sleepy                               Dark urine

c. Differential Diagnosis- Hereditary disorders (Alagilles, Wilsons, Primary Sclerosing cholangitis)

                               Viral hepatitis                               Autoimmune hepatitis                               Toxicity d/t exposure ie: acetaminophen OD

d. Work up--   Blood test screening for genetic disorders

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                              Hepatic duplex                              HIDA scan- NPO & no narcotics x 4 hrs prior                              Liver biopsy

Intraoperative cholangiograme. Treatment - Kasaif. Post-op Kasai Management:

i. Medications1. Actigall: Oral - 10mg/kg/dose – BID (helps absorb bile acids

decrease pruritis)2. Bactrim: Oral - 5mg/kg - Daily (cholangitis prophylaxis)3. ADEK: Oral - 2mL - Daily 4. Ranitidine: Oral - 2mg/kg – BID 5. Tylenol: Oral - 12.5mg/kg/dose - q 12 hours PRN

Additional Medications: depending on clinical picture/lab values

6. K : oral 2.5mg MWF (only with abnormal coags)1. In INRis hight (>1.2) then they will start it here

and stay on until GI f/u apt7. Spironolactone: start 1mg/kg BID to 2mg/kg/BID

a. Can be TID based on clinical exam, may increase frequency if clinically needed

b. Initiate after POD4 if pt is edematous and having increase abdominal girth post op

iii. Strict I/O-monitor for ascites, edema, color of urine, strict I&Os1. monitor stools for color, hematochezia

iv. Monitor BP/persistent portal hypertension, varaciesv. acetaminophen Q 12 hrs, narcotics & other meds given at longer

intervals ie:Q6+ hrs d/t poor clearance r/t liver failurevi. Enteral feeds after bowel function returns:

1. Breast milk , BM with MTC oil (per nutrition)/ Pregestimil (short chain fatty acid formula- best tolerated and absorbed)

vii. Things to be aware of while on floor: 1. Abdominal distention2. Nausea3. Vomiting 4. Clay/gray color stools 5. Bilious emesis6. Tea color urine 7. Itchy/yellow skin

13. Chest Wall Deformities-Pectus Excavatum

a. Backgroundi. Caused by overgrowth of costal cartilages causing sternum to angle

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posteriorly toward spineii. Male to female ratio 3:1.

iii. Etiology unknown but ~ 30% incidence in relativesiv. Often apparent at birth but may increase in severity with growthv. Associated Anomalies:

1. Marfan’s Syndrome2. Scoliosis

vi. Indications for Repair1. Severity and symptoms2. Psychosocial issues

b. Managementi. Preop: may have any of following:

1. CT with Haller index2. PFT’s3. Echocardiogram

ii. Intraop: Nuss Procedure1. Prep with chlorhexidine hand scrub2. Small bilateral intercostal incisions3. Large clamp passed across mediastinum from left to right4. Stainless steel bar custom shaped to desired contour passed

across mediastinum concave side up5. Bar then flipped to elevate chest wall6. Bar secured with stabilizers & wire to remain in 3 years

iii. Postop: Nuss Procedure1. CXR (AP, possible lateral) in PACU to check bar position2. PCA for 2-3 days managed by the Pediatric Pain Team3. Convert to oral pain meds on 2nd or 3rd POD4. Will need narcotic Rx for home pain management5. Post-op clears, then advance diet as tolerated6. OOB and early ambulation, incentive spirometer7. If urinary retention, place foley for 24 hours

iv. Bar removal1. Typically 3 years after placement2. Outpatient procedure3. Minimal pain meds (No narcs typically)4. NO POST-OP CXR unless symptomatic

a. Desatsb. Major Chest pain

14. Gastrostomy tube a. Indications

i. Nutritional supplementation: 1. Failure to thrive2. Oral Aversion3. Oromotor Dysfunction & Dysphagia

ii. Medication administration

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b. Work-Upi. Many of these children require a concomitant Nissen

ii. Work up must determine1. Normal Rotation2. Gastric Feeding tolerance by NGT3. Bolus NGT feeding Tolerance

iii. UGI – REQUIRED to rule out Malrotation (not to determine reflux)iv. pH probe to prove reflux in symptomatic child w/ bolus tolerancev. Malro get’s a Ladd’s

vi. Reflux or Bolus intolerance gets a Nissenc. Placement methods

i. Open – Cardiac Infantsii. Percutaneous (PEG) - > 1y/o

iii. Laparoscopic – Neonates and Infantsd. Types of gastrostomy tubes

i. Malencot or Pezzar: used if decompression is necessaryii. Balloon gastrostomy tube (MIC)

iii. Balloon gastrostomy button (MIC-Key) e. Post Operative Management

i. NPO following the placement of the G-tubeii. Ask attending if toradol OK

iii. Feeds may initiate at midnight on POD#0 or POD#1am1. For smaller children

a. Pedialyte @ 5ml/hr x 4 hours then; b. Switch to pre-op formula at 10ml/hr;c. Increase feeds by 5ml q4hrs until at goal

2. For older children (>1 year)a. Start with Pedialyte @ 10ml/hr x 4 hours then; b. Switch to pre-op formula at 20ml/hrc. Increase feeds by 10ml q4hrs until at goal

3. Gtube 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 attending

iv. Tubes are changed electively in clinic at 12weeks (earliest 6-8weeks)f. Complications

i. Leak: Refer to Wound and Ostomy nurses ii. Accidental dislodging

1. Early inadvertent removal- notify Fellow or Attending before attempting replacement

2. Within 2 weeks of insertion:a. Re-insert tube or foley immediately b. Obtain a g-tube study with contrastc. Do not force the tube ind. If a foley was used and the contrast study shows access to the

stomach, re-insert a g-tube

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e. If 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 OR

3. Radiologic confirmation is not necessary for accident dislodgement in a tube that has a matured tract

4. Prompt response to calls about dislodged GTs are critical as tract may close within hours

iii. Excessive granulation tissue or redundant gastric mucosa1. Can be cauterized w silver nitrate sticks

15. Empyema a. Causes

i. Pneumonia- most commonii. Extension of mediastinal, retropharyngeal, paravertebral infections

iii. Thoracic surgery or traumab. Stages

Stage Time after onset Fluid characteristics TreatmentExudative 24-72hrs Thin fluid, few cells Drainage (CT or

needle)Fibrino-purulent

5-10 days Fibrinous debris, many PMNs, loculated septations

Fibrinolysis +/- thoracoscopy

Organizing 2-4 weeks Thickened pleura Pleurectomyc. Organisms

i. Staph aureus – most commonii. Strep pneumoniae

iii. Haemophilus influenzaiv. Pseudomonas aeruginosa

d. Presentationi. Hx of URI w fever and cough

ii. Pleuritic chest pain and resp distressiii. Lethargy, tachycardiaiv. Diminished breath sounds and dullness to percussion on exam

e. Work upi. CXR

ii. US 1. Usually adequate for diagnosis2. ID locuated fluid collections

iii. CT Chest for special circumstancesiv. Thoracentesis

1. Complicated pleural effusiona. pH <7.2b. glucose < 60mg/dLc. LDH >1000 un/L

f. Treatment

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i. IV ABX, may require PICC for homeii. Early- chest tube drainage alone

iii. Advanced (loculations)- 1. Chest tube drainage and fibrinolysis w tPA2. VATS w drainage and decortication

a. Dr Lukish uses tPA post opiv. See appendix for tPA procedure guidelines

16. 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 illness

a. Causesi. Blebsii. Unknowniii. Infectiousiv. CPAM

b. Symptomsi. Ipsilateral chest painii. Dyspneaiii. Diminished breath soundsiv. Tracheal shift

c. Diagnosisi. CXR

d. Managementi. < 20%  lung volume and asymptomatic

             100% O2 & observe ii. > 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 CT

iii. Recurrent spontaneous pneumo             Place chest tube/Pigtail and obtain CT

iv. VATS for blebectomy and pleurodesis if CT + blebs on ipsilateral side, blebs on contralateral size just observe           

VII. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD

Many 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.

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a. Outpatient Surgery Guidelines

i. Please refer to Appendix 10 for broad coverage of outpatient surgery guidelinesii. NPO Guidelines

1. Patients should be awakened and offered fluids the night prior to surgery2. <2 Years Old:

a. NPO for solids at midnightb. NPO for milk/formula 4 hours prior to surgeryc. NPO for clear liquids 2 hours prior to surgery

3. >2 years old and oldera. NPO for solids and milk at 8 hoursb. May have clear liquids up to 2 hours prior to surgery

4. Clear liquids include breast milk unless a bowel prep is required5. Patients should be sent home on pain medications:

a. Tylenol only for child < 6 months of ageb. Oxycodone for older children when extent of operation warrants

6. Follow-up: Return to clinic in 2 weeks unless it is a line removal

b. In-Patient guidelines i. ERAS Protocol

1. Start IVF D5 ½ c 20k2. Clear liquid diet until 4am then NPO3. Neomycin 23mg/kg/dose (max dose 1gram)x 2 given PO at 1hr & 4 hrs

after admission4. Neomycin 500mg/ml in syringe to be sent to OR w/pt day of surgery5. Erythromycin 30mg/kg/dose(max dose 1gram)x 2 given at 1 & 4 hrs

after admission6. Bisacodyl 30 mg x 1 dose given at 3 hrs after admission (for pts 12yr >)7. Miralax 238 gms given with 32 oz of Gatorade on admission, (pts 10

yr+) To be finished within one hour 8. 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.9. Gabapentin 5mg/kg (max dose 300mg) QHS x1 for patients 2yrs and up10. Wash pt with chlorhexidine wipes the night before and morning of

surgeryii. ERAS protocol for Neonates (pre-term to 37)

1. IVF to run at 60cc/kg2. Pedialyte started at 90cc/kg3. Check glucose every 4 hours4. Neomycin 23mg/kg/dose (max dose 1gram) x 2 given PO at 6pm &

11pm the night before surgery5. Neomycin 500mg/ml in syringe to be sent to OR w/pt day of surgery6. Flagyl 7.5mg/kg/dose (max dose 500mg) x 2 given PO at 6pm & 11pm

the night before surgery

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7. Wash patient with Sage CHG 2% cloths applied to the abdomen the night before and the morning of surgery

c. NPO Guidelines

i. Medications: Can be given with a sip of water except for the following which should not be given within 8 hours of surgery:

1. White liquid antacids (Mylanta, Maalox)2. Stool softeners (carafate, senna, miralax)3. ACE inhibitors (captopril, lisinopril, enalapril)4. ARBs (losartan, valsartan, irbesartan)

ii. Solid foods, milk, meat-8 hours (or after midnight) before arrival at the hospitaliii. Infant formula - 6 hours prior to arrival at the hospital/ first case startiv. Breast milk - 4 hours prior to arrival at the hospital/ first case startv. Clear liquids - 2 hours prior to arrival at the hospital/ first case start2

d. Fluid Management

i. Indications for pre-operative IV fluids1. Vomiting, diarrhea, fever or preoperative bowel preparation2. Delay of surgery more than 6 hours in infants or 8 hours in children

ii. Maintenance IV fluids1. Newborn

a. Day of Life #1: 80ml/kg/d of D10Wb. Day #2: 100ml/kg/d of D10 1/4NSc. Glucose 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)2. Older children

a. 100ml/kg/day or 4 ml/kg/hr for first 10kgb. 50ml/kg/day or 2 ml/kg/hr for second 10kgc. 20ml/kg/day or 1 ml/kg/hr for every kg over 20d. Remember “4-2-1” Rule (When wt> 20 kg add 40 to wt in kg for maint

rate)e. Standard maintenance IV fluid: D5 1/2NS with 20mEq/L KCl

3. Electrolytesa. Daily sodium: 2-5mEq/kg/dayb. Daily potassium: 1-2.5mEq/kg/day

4. Blood productsa. Estimated blood volume

i. Newborn 90cc/kgii. Child 80cc/kg

iii. Adult 70cc/kgb. PRBCs 10cc/kg will raise Hct by 3-4%c. Platelets 1 unit/10 kg will raise count by 25,000d. FFP 10-15 ml/kg for coagulopathy

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e. CRYO 1 unit/5kg to replace Fibrinogen5. GI losses: Over 30cc/kg/day Replace all with cc per cc.

a. Gastric: i. Infants: D5 1/2NS with 20mEq/L KCl or if on formula or TPN can

use normal saline ii. Older: NS w 20mEq/L KCl

iii. Distal GI losses: D5LRe. Immunization status -See Appendix 7 for immunization schedule1

f. Nutritional basics i. Growth parameters

1. Measure weight daily2. Measure length weekly (in NICU)3. Follow growth parameters closely in making decisions on nutrition4. Average weight gain

a. Premie <2kg: 15-20 g/dayb. Premie >2 kg: 20-30 g/dayc. 0-3 months: 25-35 g/dayd. 3-6 months: 20 g/daye. 6-12 months: 12 g/dayf. 12-18 months: 8 g/day

ii. Calories 1. Term neonate 100-120 kcal/kg/day2. Preterm 120-130 kcal/kg/day3. Very low birth weight (<1kg)>150kcal/kg/day

g. Parenteral Nutrition

i. Indications:1. Prolonged period of fasting (> 5 days)2. Malnutrition

ii. Can be initiated using peripheral or central venous access1. If peripheral access is used, the PN solution must be diluted to avoid phlebitis

and sclerosis –osmolality <10002. If PN is to provide for >3days; recommend central access to optimize nutritional

provision without osmolality limits3. Full CPN requires that central line be at the junction of the SVC and right atrium

iii. Daily fluid requirements for pediatric population1. 0-10kg 100ml/kg2. 10-20kg 1000ml + 50ml/kg >10kg3. 20+kg 1500ml + 20ml/kg > 20kg

iv. Main components1. Lipids

a. Initiated at 1g/kg/day b. slowly increased with maximum dose of 3g/kg/dayc. Check weekly triglycerides and adjust lipids PRN

2. Dextrose

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a. Preterm 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/min

b. Term 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 lines

3. Proteina. <1kg – start at 1.5 g/kg advance by 1g/kg to goal of 3.5-4 g/kgb. 1-2kg start at 2 g/kg/day advance by 1g/kg to goal of 3-3.5 g/kgc. >2 kg and term infants start at 2g/kg and go up 2-3 g/kg to goal of 2.5-3.5

g/kgd. Adolescents start at goal of 0.8-2.5 g/kg

4. CPN should also contain water and fat-soluble vitamins as well as trace elements5. All patients on TPN should get daily electrolytes in the initiation phase 6

6. All TPN orders must be entered into POE and on Hopkins Pediatric CPN portal7. Completed forms are faxed to the pharmacy daily at 5-02838. Guidelines for advancement and calorie, fluid, and protein recommendations for

parenteral nutrition can be found in Nutrition Assessment note in POE

h. Central Venous Lines i. Access points usually include:

1. internal jugular2. subclavian3. femoral

ii. If access is obtained from an upper vein, the goal is to ensure that the line is at the cavoatrial junction on chest x-ray

iii. Non-tunneled central lines:1. Used for short or medium-term access2. Include Arrow and Cook

iv. Tunneled central lines:1. Usually placed in the operating room under fluoroscopy2. Brands: Cook, Broviac, Hickman3. Instill heparin flush to fill catheter if not in use

v. Totally implanted central venous lines (Ports)1. Used for long-term, intermittent access such as for patients with malignancies,

hematologic illnesses or renal failure2. These are accessed with special non-coring (Huber) needles. 3

3. Per Hopkins policy, nurses are not allowed to access until POD#5 after placement

4. Be sure to ask team if they will need it accessed in the operating room5. Instill heparin flush (final flush dosing) to fill tube if not in being used 6. GPS requires ANC >= 500 to place a port

vi. Complications1. Line break: Call the GPS senior or fellow to discuss – Repair kits exist

a. Contact fellow prior to repairing line

44

b. This is considered an urgent procedure and repair should be performed expeditiously before the line is lost

c. Repairing and salvaging lines is especially important for patients on long term TPN (ie short gut) and have had multiple repeated line placements

d. Repair kits are located in Peds ED or Interventional radiology e. Know the size and type of catheter in patient, repair kit must match sizef. Technique

i. Clamp the line proximal to the break, ii. Prime the repair segment with saline flush.

iii. Squeeze the silicone glue into the barrel of a 3cc syringe and apply the blunt tip.

1. Do not squeeze the glue into the needle until ready to use.

iv. Prep the line sterilely and lay on a sterile towel.v. Cut with disposable scissors.

vi. Partially insert the metal piece of the repair segment into proximal stump and apply glue to metal segment circumferentially before fully inserting.

vii. Apply more glue around connection and slide clear plastic sleeve over the repair site.

viii. Inject as much glue as possible inside the sleeve. ix. Gently try to flush the line with saline.

1. If it flushes then follow with heparin flush. 2. If resistant, stop.

x. No further flushes should be attempted for 12-24 hours. xi. At that time tpa may be instilled if the line still cannot be

flushed. g. 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.

2. Line occlusion: a. Make sure that the line is unclampedb. Test the line yourselfc. Call VAT to declot with tPA

i. TPA should be applied for 2-4 hours, at least 2 attempts, if still not resolved, consider leaving TPA in overnight

3. Catheter site infectiona. Erythema or drainage from the insertion siteb. Send peripheral and central blood culturesc. Treat with local wound care and empiric antibiotics until cultures result

then de-escalated. Remove if:

i. Continued local infection despite 48-72hr abxii. Developing systemic infection

iii. Fungal infection

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iv. Ongoing sepsisv. Persistent + cultures on appropriate ABX

4. Central line associated blood stream infection (CLABSI)a. See guidelines in Appendix 12 and 13b. Obtain peripheral and central line blood culturesc. Treat with empiric antibioticsd. Tunneled catheters are treated with intent to sterilizee. Cultures are drawn dailyf. Antibiotic locksg. Hydrochloric Acid may be required by protocol to clear line

i. Antibiotic prophylaxis

i. Most important method of preventing surgical site infections is proper hand scrubbingii. Clipping, if necessary, should be done just prior to surgery

iii. Systemic prophylaxis should be given only when risk of wound infection and benefits of prophylaxis outweigh risks of adverse drug reactions

1. Clean cases : Respiratory, GI, or GU tract or oropharygeal cavity is not entereda. Risk of infection is low at 1-2% therefore prophylaxis is NOT neededb. Exceptions include implantation of prosthesis, open-heart surgery,

exploration of body cavity in neonates or neurosurgical cases2. Clean-contaminated: Respiratory, GI or GU tract is entered in a controlled

setting.a. Risk of infection is approximately 3-15%

3. Contaminated: Include open wounds, cases in which there has been a break in sterile technique, exposed viscera at birth, congenital anomalies

a. Risk of infection is approximately 15%4. Dirty: Included penetrating trauma >4hrs, devitalized tissue, wound with

infection/ perforated viscus. 4

iv. Antibiotic should be administered within 60 minutes of incisionv. Antibiotic should be re-dosed if

1. case >4hrs2. >30% blood volume loss3. >1500ml if >50kg and normal renal function

vi. See Appendix 14 for specific prophylaxis guidlines5

j. Tracheostomy

i. Usually performed in the operating room as an elective case on a child who is already intubated

ii. The operation1. Transverse incision in the lower neck and dissecting down to the trachea2. The trachea is incised

a. just below the isthmus of the thyroid b. no higher than the second tracheal ring

3. A stay suture on each side of the tracheostomy with polypropylene sutures and labels for “right” and “left”5

46

4. The ETT is withdrawn under direct vision5. Use a cuffless tube6. First trachea change to be done by GPS senior at 7 days

iii. Respiratory distress in a patient with new tracheostomy1. Suction first but only for a moment 2. Pull up on the stay sutures and remove the trach tube3. Re-insert endotracheal tube and replace tracheostomy when airway is well-

established

k. Chest tubes

i. Indications: 1. Pneumothorax2. Hemothorax3. Pleural effusion

ii. Insertion site:1. Pneumothorax: place on the anterolateral aspect of the chest wall2. Hemothorax/ pleural effusion: Place posterolaterally

iii. Insertion Technique1. Prep and drape the skin and anesthetize with local anesthetic 2. Make a small incision in the mid-axillary line at the level of the nipple3. Use a curved hemostat to tunnel superiorly and above the higher rib into the

pleural cavity4. Once in the pleural cavity spread the hemostat to create a tract5. Insert the chest tube into the pleural cavity and ensure that all holes are

intrathoraciciv. Obtain a post-insertion chest x-ray to confirm the positionv. Chest tube removal

1. Chest tubes should be removed after: a. being placed on water seal b. CXR evidence of post-seal resolution of hemo/ pneumothorax

2. NOTE: Lukish wants ALL his Chest tubes removed ON Suctiona. Take off water seal two hours prior to pullb. He only wants symptomatic post-pull CXR

3. Chest tubes should be removed at the end of inspiration or with a vasalva maneuver

4. If the patient, is cooperative, you can ask them to blow like they are blowing on a birthday cake

5. Once the tube is removed, cover with xeroform and an occlusive dressing such as a Tegaderm

6. Obtain a post-pull CXR an hour afterwards

l. Nasogastric tubes

i. Used for gastric decompression and enteral feedsii. Use sump tubes for decompression

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iii. Confirm the position of the tube by instilling a small amount of air while auscultating over the stomach

iv. If the NG tube output is high, get an abdominal xray to confirm its placementv. Gavage feeds in neonates and infants for:

1. lack of gag2. weakness3. rapid respiratory rate

vi. Requires 1:1 replacement when volumes are high

m. Apnea and Bradycardia monitoring

i. Ex-preemie infants (<37 wks) up to 52 wks post-conceptual age require overnight apnea and bradycardia monitoring for recovery from anesthesia with narcotics

n. Post-operative antibiotics

i. Indicated in the setting of post-operative surgical site infection or abscess.ii. Wound infection: signs include erthyema, leukocytosis

iii. Treat with oral or IV antibiotics depending on severityiv. Abscess

1. Definitive treatment is incision and drainage2. Once the wound is opened, pack with aquacel or wet-to-dry saline solution and

let it heal with secondary intention4

o. Pediatric Pain Tips i. PCA’s can only be ordered by the Pediatric Pain Team

ii. You cannot order a narcotic and sedative together as it is considered conscious sedation (ie oxy and valium)

iii. If the Pain team is involved, no other narcotics, sedatives, analgesics can be ordered by our service.

iv. 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/GTube

v. Order ketorolac ATC for lap chole/appy, hernia, GC fistulas. May also order morphine prn and acetaminophen for breakthrough pain

vi. NSAIDs not ordered for onc , hemophiliac, chronic renal disease, ICH, liver/spleen/kidney lacs.

vii. No acetaminophen for liver failure patientsviii. Procedures-

1. Bedside procedures- removal of chest tubes/drains/TPA instillation/wound VACs/wound exploration

2. Discuss time of procedure with patient and nurse. 3. If patient has PCA instruct pt/nurse to give bolus doses as allowed starting 30

min prior to procedure4. If PO meds instruct nurse to give oral pain meds/anxiolytics one hour prior to

procedure5. Central lines cannot be removed at the bedside

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VII. PEDIATRIC TRAUMA

I. Pediatric Trauma at Johns HopkinsA. Policy: Care of the Pediatric Trauma Patient PAT092.B. “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.

C. Three categories of pediatric trauma activation:a. Alpha trauma: highest priority; unstable patients or injuries that may quickly

result in instability.b. Bravo trauma: high priority; stable patients with a significant mechanism of

injury or specific types of injuries. c. 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.

d. PED Trauma Activation Criteria1. Mechanisms not meeting above criteria

e. GPS Consult Criteria1. NAT work up

f. PED trauma requiring chest or abdominal CT

D. Team members who respond to pediatric trauma activations include:a. GPS attending (required for Alpha traumas only)b. GPS fellow/senior resident-team leaderc. GPS intern/NPd. PICU fellow and attending for airway management (Alpha traumas only)e. ED attendings:

1. on odd days- pediatric emergency medicine attending2. on even days- adult emergency medicine attending

f. PED resident and AED residentg. PED Nursingh. PICU Nursing (Alpha traumas only) i. Respiratory Therapy (Alpha traumas only) j. Pharmacy (not available 24/ 7) ); If needed during off shifts can activate an

RRTk. Radiologyl. Additional ancillary services, i.e., Social Work, Chaplain, Security.

E. All team members require yellow gown and role name tag upon entering room.F. Establish roles early prior to patient arrival.G. 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 necessary.

H. Complete 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.

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I. Use the pediatric trauma-specific order sets for all trauma admissions.J. Consult other services as needed through PING.K. Procedures, e.g., central lines, chest tubes, etc.: document a procedure note in eMR.L. 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 PatientA. Pre-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.

B. Primary Survey a. EMS 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).

b. 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 needed

c. Perform ABCDE evaluation per ATLS protocol.d. Airway

i. Indications for rapid-sequence intubation: 1. GCS82. Significant facial trauma with poor airway control3. Airway obstruction4. Shock unresponsive to fluid resuscitation 5. Failure to adequately oxygenate6. Paralysis secondary to high spinal cord injury7. Blunt chest trauma compromising ventilation

ii. Endotracheal tube size can be estimated by:1. The size of the child's little finger or nares2. According to the following formula for children 1-10 years old:

(Age in years/4) + 4.iii. A surgical airway is indicated when orotracheal intubation is

unsuccessful or contraindicated.1. Surgical cricothyroidotomy is rarely indicated in children.2. A needle cricothyroidotomy is instead preferred.

a. Can support patients for 30-45 minutes with transtracheal jet ventilation.

b. With patient supine and the neck prepped:i. Palpate the cricothyroid membrane.

ii. Assemble a 12- or 14-gauge catheter over a needle.

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iii. Connect it to a small syringe.iv. Puncture the skin midline over the cricothyroid

membrane.v. Direct the needle at 45 degree angles caudally.

vi. Insert the needle through the lower half of the membrane while aspirating.

vii. After aspiration of air, advance the catheter inferiorly while withdrawing the stylet/ needle.

viii. Attach the catheter to oxygen tubing and secure it to the neck.

e. Breathingi. Listen for bilateral breath sounds.

ii. Emergent needle decompression of tension pneumothorax & chest tube placement, as needed

iii. Operative indications: 1. Initial chest tube output > approximately 15-20 mL/kg 2. Ongoing output of > approximately 5 mL/kg

f. Circulationi. Confirm the presence of a pulse and begin compressions if not

present.ii. Obtain non-invasive blood pressure.

iii. Obtain two large-bore IVs.iv. Use intraosseous access or place a central line if adequate peripheral

IV access cannot be obtained quickly (within 2-3 attempts).v. Control any external hemorrhage.

vi. 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.

vii. Children can maintain nearly normal vital signs even with severe hemorrhage.

1. The primary response to hypovolemia in children is tachycardia.

2. Hypotension is a LATE sign of shock in children (may not occur until after 40% of blood volume is lost).

viii. Indications for an ED thoracotomy: 1. Penetrating injury with loss of vital signs en route/ within 5

minutes of arrival to ED.2. Blunt or penetrating injury with loss of vital signs in the ED.

g. Deformity & Disability: i. Perform a brief neurologic exam, e.g., GCS, pupils, etc.

ii. Check pelvis stability and look for long bone fractures.h. Exposure:

i. Remove all clothing.ii. Try to keep patient warm thereafter, e.g., warm blankets, warmed IV

fluids, level one warmer, bear-hugger, etc.

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iii. Ensure there are no chemicals on the patient.

C. Obtain an AMPLE History a. Allergiesb. Medicationsc. Past medical historyd. Last meale. Events leading to injury and environment of injury

D. Initial Data Collection a. Trauma Lab Panelb. CXR (if mechanism warrants)

i. Advanced tip: place a CXR plate on stretcher prior to patient arrivalc. Pelvic XRd. FAST

E. Secondary Survey a. Perform a complete head-to-toe examination.b. Log-roll the patient with the C-spine stabilized to examine.

i. The back for spinal tenderness/deformity. ii. Perform a rectal examination.

iii. Remove the hard board before rolling the patient back. Leaving patients on the hard board can quickly lead to skin breakdown.

c. Additional procedures (NG/OG, Foley catheter, change to padded rigid cervical collar (Aspen of Miami J/ Jr.), additional IV access, etc.) are performed as needed

i. Do not place an NG if there is concern for naso/oropharyngeal trauma or skull fracture.

ii. do not place a Foley catheter if urethral injury is suspected

F. Transport/Additional Studies a. Head CT should be used selectively to avoid the long-term risks of cancer

associated with radiation.b. Add CT of the face if facial fractures are suspected based on the physical

exam.c. Utilize the PECARN algorithm to identify which pediatric trauma patients

should undergo head CT.

The PECARN Algorithm

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Suggested 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.

d. Obtain plain films of the cervical spine rather than CT to avoid thyroid radiation, even if CT is performed of the head or chest.

e. Get CT of the abdomen/pelvis as needed based on physical exam findings and mechanism.

f. Get plain films for any significant findings on examination of the extremities:i. One joint above.

ii. One joint below.

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g. 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.

h. Labsi. Consider CMP/amylase/lipase/urinalysis to screen for abdominal

injury.ii. Get CBC, coagulation profile, and type and screen if any concern for

bleeding.i. 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.

G. Tertiary Survey a. To be completed when the patient is alert and no distracting injuries remain.b. C-spine can be “cleared” during this examination.

i. 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).

ii. 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.

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A. C-spine clearance- please write a procedure note if you clear the collar

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Other Important PointsA. Spleen/Liver

a. SEE APPENDIX 17 for management algorithm .b. Commonly injured in blunt trauma.c. Most isolated spleen/liver injuries in children can be treated NON-

operatively.d. Operative management of spleen/liver injuries is indicated for ongoing

hemorrhage and/or refractory hemodynamic instability.e. Grading for splenic injury

i. Grade I: subcapsular hematoma 10% of surface area, capsular laceration 1 cm depth.

ii. Grade II: subcapsular hematoma 10–50% of surface area, intraparenchymal hematoma 5 cm in diameter, laceration 1-3 cm depth not involving trabecular vessels.

iii. 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.

iv. Grade IV: laceration involving segmental or hilar vessels with major devascularization (> 25% of spleen)

v. Grade V: shattered spleen, hilar vascular injury with devascularized spleen

f. Grading for liver injuryi. Grade I: subcapsular hematoma 10% of surface area, capsular

laceration 1 cm depth.ii. Grade II: subcapsular hematoma 10-50% of surface area, laceration 1-

3 cm in depth.iii. Grade III: subcapsular hematoma > 50% of surface area or expanding

or ruptured, laceration > 3 cm in depth.iv. Grade IV: parenchymal disruption of 25-75% of hepatic lobe, 1-3 cm

laceration of Couinaud’s segments in a single lobe.v. Grade V: parenchymal disruption of > 75% of hepatic lobe, > 3 cm

laceration of Couinaud’s segment in a single lobe, juxtahepatic venous injuries.

vi. Grade VI: hepatic avulsion.B. Child Abuse

a. Pay attention for suspicious injuries, signs on physical examination, and conflicting stories or inconsistencies in the history that raise concern for child abuse.

b. Document all noted injuries in detail.c. Work-up for abuse generally consists of a skeletal survey with addition of

head CT, brain MRI, and/or abdominal CT, as indicated.d. 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

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probability for retinal hemorrhages! Therefore, an ophthalmic exam is not necessary.

e. Social work/CPT consult. Any concern for child abuse MUST be reported to CPS for investigation.

C. Head Traumaa. Surgical 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.

b. 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).

c. ICP monitor may be required with loss of neurologic exam in setting of head trauma.

d. Skull fracturesi. Categorized as:

1. Open or closed, based upon the presence or absence of an overlying scalp laceration in continuity with the fracture site.

2. Depressed or non-depressed, based upon the relationship of the bone fragments to each other.

ii. Depressed skull fractures often cause injury to the underlying brain and are often open.

iii. Depressed skull fractures are treated surgically with debridement and elevation when any of the following indications are present:

1. The depression is greater than the thickness of the skull (approximately 8-10 mm).

2. A focal neurologic deficit results from compression of the brain parenchyma.

3. A significant underlying intracranial hematoma is present.4. Pneumocephalus is seen.5. The frontal sinus is involved.6. Gross cosmetic deformity exists.7. Gross wound contamination is present. 8. Intraparenchymal bone fragments are seen, indicating

laceration of the dura mater and an increased risk of infection.iv. Non-operative management is appropriate for patients with

depressed skull fractures (even if open) that possess none of the above findings.

v. 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.

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IX. PEDIATRIC BURNS

1. Policy: Care of the Pediatric Burn Patient PAT095.2. All burns > 20% TBSA are activated as Alpha traumas and should have an

expeditious admission to the PICU or OR. 3. See Appendix 12 for documentation requirements for pediatric burn patients.4. Types of burns

a. Superficial [1st degree]i. Damage limit: epidermis

ii. Appearance: red and dryiii. Sensation: pain or tingling at siteiv. Typical Causes:

1. Sunburn2. Hot liquid splashes 3. Flash burns.

v. Natural healing time: 5-7 daysvi. Treatment: oral analgesics and topical moisturizers

b. Superficial & Deep Partial Thickness [2nd degree] i. Damage Limit: Dermis; Portion of hair follicle remains

ii. Appearance: red, white or tan, possibly mottled with blistersiii. Sensation: Extreme pain; sensitive to cold airiv. Typical Causes:

1. Contact2. Severe heat flashes 3. Immersion

v. Natural healing time: 1. Superficial partial thickness: 1-2 weeks2. Deep partial thickness: 2-3 weeks

vi. Treatment: debridement & dressing; possible grafting for deep partial thickness.

c. Full thickness [3rd degree]i. Damage Limit: Sub-dermal tissue; No hair follicle remains

ii. Appearance: Skin white, brown, deep red; dry and leatheryiii. Sensation: Little to no pain at siteiv. Typical Causes:

1. Flame2. Grease 3. Chemical 4. Electrical – usually associated with internal burns

v. Natural healing time: never vi. Treatment: Excision and grafting

5. Calculating burn % TBSA: a. Only second and third degree burns are included in % TBSA:

i. Palm method

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1. Entire palmar surface and fingers of CHILD’s hand = 1%2. Fast but crude estimation

ii. Lund and Browder chart*

Lund and Browder Chart 

Age (years)Superficial

Partial Thickness

Deep/ Full Thickness

Area (%) 0-1 1-4 5-9 10-15 >15Head 19 17 13 10 7Neck 2 2 2 2 2Trunk Ant. 13 17 13 13 13Trunk Post. 13 13 13 13 13Right Buttocks 2.5 2.5 2.5 2.5 2.5Left Buttocks 2.5 2.5 2.5 2.5 2.5Genitalia 1 1 1 1 1Upper Right arm 4 4 4 4 4Lower Right arm 4 4 4 4 4Upper Left arm 3 3 3 3 3Lower Left arm 3 3 3 3 3Right hand 2.5 2.5 2.5 2.5 2.5Left hand 2.5 2.5 2.5 2.5 2.5Right thigh 5.5 6.5 8.5 8.5 9.5Left thigh 5.5 6.5 8.5 8.5 9.5Right leg 5 5 5.5 6 7Left leg 5 5 5.5 6 7Right foot 3.5 3.5 3.5 3.5 3.5Left foot 3.5 3.5 3.5 3.5 3.5

TOTAL:

6. Primary Survey: a. History:

i. Mechanism and source of injuryii. Time of injury

b. Airway and breathingi. Airway patency

ii. Respiratory rateiii. Respiratory effortiv. Singed nasal/ facial hairv. Carbonaceous sputum

vi. Monitor pulse oximetryvii. Administer oxygen if necessary

viii. Have a LOW THRESHOLD FOR INTUBATION

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c. Circulation and cardiac statusi. Inspect heart rate and blood pressure for hypovolemic shock

ii. Monitor for dysrhythmias iii. Check pulses in all extremitiesiv. Monitor urine output with Foley catheter

d. STOP THE BURNING PROCESSe. Examine body surface

i. Remove clothing.ii. Calculate body surface area percentage and determine depth.

iii. Cover and dress wounds properly. See APPENDIX 16: BURN WOUND CARE: ED PROCEDURE.

iv. Elevate burned extremities and check hourly, especially for circumferential burns.

v. Assess for compartment syndrome.

7. Secondary Survey a. Neurologic evaluationb. Check for concurrent injuryc. Pain managementd. Obtain labs

i. CBCii. CMP

iii. Arterial blood gase. Obtain a CXR and c-spine and pelvic films, if applicable.

8. Fluid Resuscitation a. Fluid resuscitation is required for all burns > 20% TBSA.b. Avoid boluses if possible.c. The goal is to initiate fluid resuscitation upon admission to the PICU. See

also, Fluid Resuscitation for the PICU Burn Patient MDU042. i. If transport from the PED trauma bay to PICU is expected to be < 60

minutes,1. 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.

2. For patients > 40kg and hemodynamically stable, defer fluid resuscitation in the PED trauma bay and initiate fluid resuscitation upon admission to the PICU.

ii. 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.

d. PICU nurse manages the hourly fluid titrations based on urine output.

9. Burn Management in the Peds ED

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a. An Alpha trauma will be activated for:i. Burns with signs of inhalation injury.

ii. Burn injuries > 20% TBSA.b. Criteria for GPS consult/Burn center referral:

i. Partial thickness (2nd˚) burns ≥ 10% TBSAii. Partial thickness burns that involve face (>1%), hands or feet (when a

joint is crossed), genitalia, perineum or major jointsiii. Full thickness burns of any sizeiv. Electrical burns including lightening injury

1. Obtain EKG & CK levelv. Chemical burns

1. Contact Poison Control 1-800-222-1222 for recommendations (alkali vs. acidic)

vi. Circumferential partial – full thickness injuryvii. Burn injury of any size in patients with pre-existing medical

conditions that could complicate management, prolong recovery or effect mortality

viii. SW concerns cannot be resolved or there is a concern for non-accidental trauma (NAT)

ix. Home caregiver is unable to demonstrate ability to provide effective wound care

x. Other injuries at the discretion of the PED provider.

c. ED policies for burn debridementi. Ask for the PED Burn Nurse when you arrive for consultation.

ii. Administer tetanus prophylaxis, if necessary.iii. Most burns can be debrided in ED except:

1. Burns requiring > 30 minutes of sedation with 2 providers (i.e., GPS and PED burn nurse) debriding.

2. Unstable or intubated patients requiring PICU.3. Patients requiring escarotomies.4. ED attending does not feel can provide adequate sedation, e.g.,

patients ≤ 3mon of age or cardiac comorbidities.iv. PED burn nurse program

1. Trained RNs perform debridement & dressings.2. Will help facilitate procedural sedation.3. Will complete L&B for burns they debride.4. Require assistance from GPS for debridement/ dressings

taking > 30min with one provider.5. Bedside RN will complete wound photography. Photos are

available under the MEDIA tab in EPIC.

d. DEBRIDEMENT & DRESSINGSSEE APPENDIX 16: BURN WOUND CARE: ED PROCEDURE

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10. Inpatient management a. PED, 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.

b. Burn Management on 10 Southi. DRESSING CHANGES

1. Pre-medication for dressing changes begins at 08:00.2. Dressing changes begin at 09:00 in the treatment room. 3. If there is a preference for dressing change order, please call

the 10 South Charge RN BEFORE 08:00 with preferred patient order.

c. Burn Management in the PICUi. Multidisciplinary burn rounds occur at 09:30.

ii. DRESSING CHANGES1. There is not a set time for dressing changes. Time should be

coordinated with AM bedside nurse ASAP.2. Occur in the patient’s room or OR.

iii. PAIN1. Pediatric Pain Team should be consulted on all burns.2. Work collaboratively with the Pain Team and PICU to develop

the best plan for the patient. 3. Patient needs to tolerate dressing change without sedation to

be transferred to floor.iv. Fluid resuscitation

1. See Section IX.8.2. Avoid boluses if possible.

v. Nutrition1. Enteral/ oral feeds should be started within 24h of injury,

when possible.2. Patients with ND tubes DO NOT need to be NPO for

procedures; however, this is at the discretion of the Anesthesiologist.

3. If patient is on vasopressors, enteral feeds may not be an option. Define acceptable vasopressor levels for feeding with the PICU team.

vi. Pharmacology >30% burn1. Oxandrolone 0.1mg/kg/dose BID (max dose of 10mg) to be

started 24-48 post resuscitation 2. Propranolol 2mg/kg/day Q4-6 hours initially and may increase

to 4mg/kg/day as a goal of reducing tachycardia by 20%

11. Common burn dressings and treatments

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a. Silvadene (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.

b. Sulfamylon (mafenide): white cream, Painful Administration, bacteriostatic, good penetration of eschar. Used commonly on ear burns. Side effects: metabolic acidosis due to carbonic anhydrase inhibition

c. Bacitracin- clear ointment, painless administration, poor penetration of eschar. Commonly used on face. Often used with overlying Adaptic or Xeroform. Side effects: Rash

d. Silver 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)

e. Mepilex AG – Silver impregnated dressing, self-adhesive silver containing foam dressing.

f. Adaptic – Petrolatum covered synthetic mesh.g. Biobrane- synthetic mesh with silicone (transcyte without fibroblasts on the

one side)h. Scarlet red- fine mesh, semi-occlusive gauze dyed red. Apply to graft donor

sites. Promotes wound healingi. Alloderm- artificial dermal replacement used under split thickness skin

grafts on full thickness burns. Allows for thinner grafts and better cosmetic outcome.

j. Autograft- grafting of a full thickness burn with the patient’s own skin. May be split thickness or full thickness.

k. 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.

l. 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 burns 3-6 years of age: ≥ 15% TBSA burns All ≥ 20% TBSA burns regardless of age

Nutrition consults can also be placed for any burn patient if the following criteria are met: Burns to face or hands Inhalation injury Old burn with poor healing Weight loss, concern for malnutrition/neglect, or other nutrition or growth issues

PTA Or per the Burn Physician’s discretion

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*All Burn patients are screened by Pediatric Nutrition with accordance to their Standards of Care

Oral 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 %Supplementation

Optional: Multivitamin with minerals

Multivitamin with minerals

Optional:Multivitamin with minerals

Multivitamin with minerals

250mg ascorbic acid BID

500mg ascorbic acid BID

AquADEK 1 mL daily

AquADEK 2 mL daily

100 mg zinc sulfate daily

220 mg zinc sulfate daily

Enteral 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 Support

Age FormulaStarting

rate Advancement<1 year of age

Home formula (if unknown, use Enfamil

Infant 20 kcal/oz)

5 mL/hr 5 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 age

Pediasure 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 age

Promote 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.

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**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.

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X. EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

a. General Information

i. ECMO is a cardiopulmonary bypass system employed to support the patient in severe, medically refractory respiratory or cardiac failure

ii. Used in neonates primarily for respiratory failureiii. In older pediatric patients ECMO is also used for those needing cardiac supportiv. There are two types of ECMO:

1. Veno-Arterial – allows for cardiac AND Respiratory support2. Veno-Venous – supports only the respiratory system

v. The ideal ECMO candidate has: 1. A known, resolvable respiratory or cardiac problem2. Has not been ventilated for a prolonged period of time 3. Has no evidence of anoxic encephalopathy

b. Indications:

i. Neonatal Respiratory Failure1. Meconium aspiration2. Persistent Pulmonary Hypertension3. Congenital Diaphragmatic Hernia

a. Pre-ductal saturations near >90%; pO2 < 50 torrb. Pre-op supportc. Post-op support

ii. Pediatric Respiratory Failureiii. Sepsisiv. Cardiac support

1. Cardiac stun after congenital repair2. Cardiomyopathy as a bridge to transplant

v. Uncommon Indications1. Cold water drowning2. Cardiac arrest of unclear etiology3. Other, unusual, isolated conditions

vi. Clinical criteria indicating ECMO may be of benefit1. Continued poor respiratory performance while on optimal (not maximal)

ventilator support:2. Oxygenation Index > 403. Prolonged A-a gradient > 600,f4. Four hours of pO2 <60

c. Contraindications:

i. Grade II or greater intracranial hemorrhageii. Congenital/genetic abnormalities incompatible with good outcome

1. Down’s is no longer considered, a priori, a contraindication

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iii. Prolonged or sustained cardiac arrestiv. CDH with severe pulmonary hypoplasia as seen with depressed pre-ductal saturationsv. Prematurity (less than 36 weeks)

vi. Relative contraindication - weight < 2kg

d. Logistics of an ECMO Activation

i. The decision to place a child on ECMO is made by the NICU or PICU attending in concert with GPS Fellow and GPS call Attending

ii. In preparation for ECMO, the child will be transferred to a PICU ECMO roomiii. The PICU will obtain informed consentiv. Once ECMO has been decided upon:

1. The GPS Senior/Fellow should:a. Notify GPS Fellow and Attending immediatelyb. Post the case:

i. Procedure: “ECMO Cannulation”ii. Post as Level 1

c. Speak Directly with the OR Charge Nurse at time of posting2. The PICU will notify respiratory

a. Respiratory will prime the ECMO circuit3. The PICU will notify Blood bank

e. Technique:

v. Cannulation is done at the bedside with an OR teamvi. The patient is positioned on the bed based on the child’s size and the type of ECMO

plannedvii. VA ECMO positioning

1. Neonates - head towards the door and at the foot of the incubator2. Children – towards the door in PICU bed3. ECMO pump on patient’s right4. Neck is extended with a shoulder roll5. Head turned to the left6. Chest and neck are prepped

viii. VV ECMO positioning7. Venous access site towards the door8. ECMO pump on side of access site

ix. Veno-arterial Cannulation9. Two cannulas: arterial (carotid) and venous (IJ)

a. Usual size is 12 Fr venous, 10 Fr arterialb. Usual depth is 10 cm venous, 7 cm arterial

2. Excellent cardiac support3. Coronary perfusion is retrograde from arch4. Carotid ligated (not usually repaired)5. Technique of choice in post-op cardiac patients and septic patients

x. Veno-venous Cannulation

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10. One double lumen cannula, usually placed in the RA via an IJ cutdowna. Usual size is 12 Frenchb. Usual depth is RAc. Echo helpful during placement

11. Requires that no cardiac support is needed12. Excellent coronary perfusion13. Flows range 100 to 150 cc/kg/min14. Recirculation may limit needed flow

d. Recirculation increases with increasing heart failuree. Increases with increasing flow

15. Cannula position and cannula characteristics somewhat more finicky16. Technique of choice in neonates17. Conversion to VA indicated when perfusion inadequate or cardiac support

needed

f. ECMO Circuit:

xi. Polyvinylchloride tubingxii. "Better bladder”

xiii. Bubble detectorxiv. Pumpxv. Silicone membrane oxygenator

xvi. Warmer (countercurrent heat exchanger)xvii. In-line ABG assessment devices

xviii. The circuit is primed with:a. Plasmanate (a balanced electrolyte solution)b. Albumin (pacifies the circuit so that blood products don’t react to the foreign surface)c. Heparind. New washed packed cells that displace the plasmanate

xix. The circuit is: a. Matched to patient serum K levels, pH (bicarbonate added) b. Kept anticoagulated

i. activated clotting time (ACT) is kept prolonged at 1.5-2.0 times normal

g. Management of the Patient on ECMO

xx. Initial flow established for:a. Saturations > 90%b. Decreased shunt fractionc. Normal blood pressure

xxi. Pressors may be weanedxxii. Ventilator settings, which may have been maximized, are reduced

a. Ventilator switched from oscillator or jet to conventionalb. Settings lowered to ideal settings (PIP 18, rate 20, 25% O2)

xxiii. Subsequently, flows may be weaned against PaO2 (VV) or SVO2 (VA)xxiv. Heparin is administered by drip and adjusted for goal ACT ~ 200

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a. No IM meds, heel sticks, etcb. No other heparin in drips, lines

xxv. Cefazolin is sufficient antibiotic coverage absent sepsisxxvi. Sedation without paralysis (one dose of paralytic is used during cannulation)

18. Goal is spontaneous breathing on low vent settingsxxvii. TPN is started on the second day of ECMO

19. Fat emulsion is safe but is given post oxygenatorxxviii. Platelet count must be kept near 100K

xxix. Hematocrit is kept 35-40% by transfusion as neededxxx. Volume expansion is achieved by blood first, then LR

xxxi. Neurologic examination and head US are routine daily in order to detect ICH early20. ICH may force an abrupt end to the ECMO run despite poor respiratory function

xxxii. Complications21. Generalized bleeding

a. DIC may superveneb. Cryoprecipitate and FFP may rarely be neededc. Products should be given post oxygenatord. ACT goal drop to ~180e. Sepsis should be suspected

22. Intracranial hemorrhagea. May be due to:

i. Generalized bleeding ii. Hypertension

1. Hypertension - Aggressively treated with Nitroprusside23. VV ECMO may not provide adequate support requiring conversion to VA ECMO

a. Check cannula position with echob. Recirculation may be too high a fraction of flowc. Heart may be failing

24. Surgery may be required while on ECMO (usually to correct CDH)a. Amicar is used (100 mg/kg bolus and drip of 30mg/kg/hr

h. Completion of the ECMO Run

xxxiii. Conditions for a decannulation trial25. Flows of 20-25cc/kg/min26. Saturations in the mid or higher 90s27. Euvolemia28. Minimal vent settings29. Off pressor

xxxiv. The circuit is divertedxxxv. ECMO is Re-instituted if:

i. Vent pressures are above 20ii. Respiratory rates above 40

iii. FiO2 > .40 xxxvi. Key features of trial off ECMO

a. Heparin must be given to the patient to ensure anticoagulation with the cannulae in

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placeb. Cannulae are flushed and clamped; the bypass bridge is openedc. If child fails trial, the cannulae are unclamped (venous first in VA ECMO) and the

bridge clamped.d. If trial is successful, the circuit is discarded

xxxvii. Decannulation a. Requires the OR teamb. The cannulae are removedc. Key features of this procedure

i. Paralysis will be needed to prevent air embolus from spontaneous respiration during vein manipulation

ii. Artery is ligatediii. The vessels may be fragile after a long run and rapid hemorrhage can result

from cannula removaliv. The wound is drained

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APPENDIX 1. Guidelines for the Management of Appendicitis in ChildrenI. Simple Appendicitis

Definition: Appendicitis without visible perforation of the appendix and/or the presence of stool in the abdomen or pelvis Pre-operative antibiotics:

o Previously healthy : Ceftriaxone and IV metronidazole (see Table for dosing); penicillin allergy: Ertapenemo Healthcare-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:

o 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-associated

II. Gangrenous Appendicitis Definition: Appendicitis that does not meet criteria for perforated appendicitis, but with visible necrosis of appendiceal tissue Reasonable to consider 24-48 hours of IV antibiotics as outlined under “Simple Appendicitis”

III. Perforated Appendicitis Definition: Appendicitis with visible perforation of the appendix and/or stool in the abdomen or pelvis Pre-operative antibiotics:

o Previously healthy : Ceftriaxone and IV metronidazole (see Table for dosing); penicillin allergy: Ertapenemo Healthcare-associated : Piperacillin-tazobactam; penicillin allergy: IV ciprofloxacin and IV metronidazole

Post-operative antibiotics:o Patients should receive a minimum of 24 hours of the same pre-operative IV antibiotics following appendectomyo Patients 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 surgery Although 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 administered Patients with a confirmed penicillin allergy or with healthcare-associated appendicitis should receive PO ciprofloxacin and PO

metronidazole o Patients who do not meet above criteria should remain on IV antibiotic therapy until clinical improvement is observedo Patients 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 abscesso If no intra-abdominal abscess is observed, please consider consulting pediatric infectious diseases for possible changes to the antibiotic regimen

Cultures:o Routine cultures are NOT recommended for perforated appendicitis, unless it is healthcare-associated

IV. Intra-abdominal Abscess Drainage is always preferred when intra-abdominal abscesses are present If the abscess is unable to be drained percutaneously, enteral therapy can still be considered as a valid treatment option Studies have demonstrated similar efficacy rates when comparing enteral vs. IV therapy in adult patients with intra-abdominal abscesses Treatment:

o 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 days Because 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 abscesseso For 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 recommended Cultures:

o Intra-abdominal fluid cultures are always recommended for patients who return with an abscess following operative or non-operative management of appendicitis

V. Non-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 abscess NOM can be an effective option, but recurrence may occur in approximately 10-30% of patients in 1 year Treatment:

o Patients should receive at least 24 hours of IV antibiotic therapy as outlined under “Simple Appendicitis”o 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 days Patients with a documented penicillin allergy or healthcare-associated infection should receive PO ciprofloxacin and PO

metronidazole for the same durationo Patients 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 NOMVI. Dosing and Activity of Select Antibiotics for the Treatment of Appendicitis

Antibiotic Dosing (assuming normal renal function)

Activity at JHH in Children

(% Susceptible)

E. coli Pseudom

onas

Amoxicillin/clavulanate

45 mg/kg/day PO divided q8h; max 500 mg/dose 43 0

Ceftriaxone 50 mg/kg/dose IV IV/IM q24h, max 2 g/dose 90 0Ciprofloxacin 10 mg/kg/dose IV q8h, max 400 mg/dose IV

20 mg/kg/dose PO q12h, max 750 mg/dose PO

79 83

Ertapenem 3 mo to 12 yr: 15 mg/kg/dose IV q12h; max 500 mg/dose

>12 yr: 1 g IV q24h

97 0

Metronidazole 10 mg/kg/dose IV/PO q8h, max: 500 mg/dose - -

Piperacillin/Tazobactam

100 mg/kg/dose of piperacillin component IV q6h, max: 4000 mg of piperacillin/dose

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Selected References:1. 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]2. Talishinskiy et al. J Pediatr Surg 2016: 51(7), 1174-6. [Factors associated with failure of nonoperative treatment of complicated appendicitis in children]3. McCutcheon et al. J Am Coll Surg 2014; 218(5): 905-13. [Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis]

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4. 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]5. Park HC et al. World J Surg 2011: 35(5), 1118-22. [Oral antibiotics for intra-abdominal abscesses]

APPENDIX 2. PEDIATRIC GLASCOW COMA SCALE

Patients > 1 year Patients < 1 year Score

EYE OPENING

Spontaneously Spontaneously 4To verbal command To shout 3To pain To pain 2No response No response 1

MOTOR RESPONSE

Obeys Spontaneous 6Localizes pain Localizes pain 5Flexion- withdrawal Flexion- withdrawal 4Flexion-abnormal (decorticate rigidity) Flexion-abnormal (decorticate rigidity) 3Extension (decerebrate rigidity) Extension (decerebrate rigidity) 2No response No response 1

> 5 years 2-5 years 0-23 months

VERBAL RESPONSE

Oriented Appropriate words/ phrases

Smiles and coos appropriately 5

Disoriented/ confused

Inappropriate words

Cries and is consolable 4

Inappropriate words

Persistent cries & screams

Persistent inappropriate crying and/ or screaming 3

Incomprehensible sounds

Grunts Grunts, agitated and restless 2

No response No response No response 1Total Pediatric Glasgow Coma Scale (3 – 15)

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APPENDIX 3. ENDOTRACHEAL TUBE SIZES

From: http://www.docstoc.com/docs/29667541/Size-and-length-of-endotracheal-tube-%28ETT%29-Pre-pubertal-children accessed

6/4/2013.

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APPENDIX 4. EMERGENCY AIRWAY MANAGEMENT OF THE INFANT & CHILD

1. Respiratory Distress:

a. The first step in the management of respiratory distress is to ventilate the child using a bag valve mask and 100% oxygen.

b. 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.

c. Suction all secretions and other material from the patient's nose and oropharynx.

d. Using the proper size mask, form a seal by holding the mask in place with your non-dominant hand.

i. Thumb and index finger around the base of the maskii. Fifth digit hooked under the angle of the mandible

iii. Flex your arm at the elbow to maintain a jaw thrust e. An oral airway can be used to ensure that the tongue is not occluding the

airway.f. Observe the chest rise and listen to breath sounds to confirm adequate

ventilation.g. Note: Over pressurization can cause a pneumothorax more easily in

infants and children than adults.

2. 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.

a. 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.

b. As long as a patient can be adequately ventilated using bag valve mask ventilation there is no rush to intubate.

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c. Prepare for intubation by acquiring the following items:i. Suction

ii. An ETT styletiii. An end-tidal CO2 Indicatoriv. An ETT tube clamp or; benzoin and tapev. Medications

1. Propofol 2.5-3.5 mg/kg IV over 20 seconds2. Succinylcholine 1 mg/kg3. Ketamine 1-3 mg/kg IV if hemodynamically unstable

vi. Laryngoscope:1. < 2 yrs old, use a Miller blade (Straight)

a. Size 0 – Prematureb. Size 1 – Infantc. Size 2 - Child

2. Age 2-5 yrs, either a Miller or a MacIntosh blade.3. Age >5 years, use curved MacIntosh blade.

vii. The appropriate size ETT and one smaller1. Size can be determined in the following ways:

a. For preemies use 2.5 - 3.0 mm IDb. ETT size (mm) = [(Age in years + 16) / 4] - 0.5c. ETT diameter = patient’s little finger diameter

Once all the supplies above have been collected, an endotracheal intubation may be undertaken using the following steps:

1) Assemble the laryngoscope – TEST THE LIGHT2) Assemble the suction3) Place the sytlet in the ETT4) Ask an assistant to apply cricoid pressure5) Administer Propofol of Ketamine6) Administer Succinylcholine7) Scissor the teeth apart with your right hand8) Use the laryngoscope to VISUALIZE THE CHORDS.

NO BLIND INTUBATIONS9) 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 resistance

10)Look, Listen, Testa. Look for chest riseb. Listen for breath soundsc. Test for End-tidal CO2

11)Secure the tube with an ETT Clamp

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3. Managing the Intubated Patient:a. Request a stat portable chest x-ray to confirm tube placement above the

carinab. Provide 100% oxygen and wean O2 for sats >92%c. Initiate a maintenance sedative:

i. Propfol 125 to 300 mcg/kg/min IVii. Ketamine 0.01 to 0.03 mg/kg/min IV

4. Initial Ventilator Settings:a. Tidal volume 7-10 cc/kgb. Peak Inspiratory Pressure (PIP) - 25 cm H2Oc. Post-End Expiratory Pressure (PEEP) - 5 cm H2Od. Rate – 30 breaths per minutee. FIO2 – 100% f. PEEP at least 2-4 cm H2O ("physiologic PEEP").g. Always humidify and heat gases.

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APPENDIX 5. GASTROSTOMY TUBES

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APPENDIX 6: PEDIATRIC SURGERY FELLOWSHIP CONFERENCES & TRAINING

Johns Hopkins HospitalMondayTuesday Department of Surgery M&M, 6:30a-7:30a, Chevy Chase Auditorium

Pediatric 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&M

Wednesday 1st 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 Room

Thursday Department of Surgery Grand Rounds, 6:30a-7:30a, Chevy Chase Auditorium

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APPENDIX 7. CDC IMMUNIZATION SCHEDULE

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APPENDIX 8. EMERGENCY DRUGS

1. Emergency Drugsa. Hypoglycemia

i. 1 cc/kg of 25-50% dextrose IV push over 5 minutesb. Hypokalemia:

i. Maintenance requirement of 2 mEq/kg/dayii. For emergency replacement:

1. 1/2 mEq potassium/kg/hr x 2 hrs in IV via pump.iii. Repeat serum potassium after 2-3 hrs.

c. Hyperkalemia: i. Slow rate of increase, no EKG changes, K<7: Kayexalate p.o. or enema 1

gm/kg (in sorbitol or D10W):ii. Rapid rate of increase, + EKG changes, K>7 (urgent):

1. Na bicarbonate 2mEq/kg IV push2. Glucose 50% 1cc/kg IV push3. Ca gluconate 10% 0.5cc/kg IV push4. Insulin 0.5u/kg IV while infusing D20W

iii. Metabolic acidosis (treat a base deficit greater than 5):1. mEq of NaHCO3 base deficit x weight in kilograms x 0.4.2. 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:Age Weight (kg) Heart rate Resp rate BP (Sys)

Preemie 1 135-145 55-65 50±10Newborn 2-3 125-135 35-45 60±101 month 4-6 120-130 25-30 80±106months 7-9 120-130 25-30 90±251 year 10-11 110-120 20-24 96±302-3 yrs 12-15 100-110 16-22 99±254-5 yrs 16-18 95-105 14-20 99±206-8 yrs 19-26 90-100 12-20 105±1310-12 yrs 27-42 85-90 12-20 112±19>14 yrs >50 75-85 10-14 120±20

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APPENDIX 9. A USER’S GUIDE TO SURGICAL PROCEDURES FOR ONCOLOGY

Safety

Line 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.

Scheduling

The 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,

1) Please contact the office directly at 52717 to schedule.2) The EPIC note must be in the chart for line placement and signed by the attending.

Please 3) Provide the following information:

a. Type of line neededb. If an LP/BM is to be posted as part of the procedure (with onc attdg name)c. If the patient is to be a same day admission to oncology

4) If 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

1) An EPIC note is required for lines and signed by attendings.2) We need to know if an LP/BM is to be performed at the same sitting. 3) We will do our best to schedule these lines as soon as possible

We 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

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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 OR

ANC: 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.

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APPENDIX 10. GUIDELINES FOR PEDIATRIC PREOPERATIVE EVALUATION

Phone ContactsPediatric Anesthesia Office 410-955-7610 Bloomberg

6321Pediatric Anesthesia In-Patient Consults 410-955-7610Preoperative Evaluation Center Appts 410-955-6495 JHOC BasementWilmer Preoperative Evaluation 410-955-5730 Wilmer 340Pediatric Anesthesia Remote Posting 410-502-2637Department of Social Services 410-361-2235

Fax NumbersPediatric Anesthesia Office Fax 410-502-5312 Bloomberg

6321Preoperative Evaluation Center Fax 410-614-8204; 866-341-2834Wilmer Preoperative Evaluation Fax 410-614-0316 Wilmer 340

Pediatric Anesthesiology Attending PagersIvor BerkowitzSally BitzerAnna BrownNick DalesioRichard ElliotJim FacklerAllison FernandezJessica GeorgeRobert GreenbergRichard HardartEric JacksonRahul KokaSabine Kost-Byerly

3-20993-69594-32243-38754-22143-37583-50433-77233-20443-54393-45794-09453-8837

Sapna KudchadkarBenjamin LeeJenny LeeJackie MartinConnie MonittoNina NamiDolores NjokuShivani PatelDeborah SchwengelHal ShaffnerJoanne ShayMonica WilliamsMyron Yaster

4-26374-04213-98123-20723-20583-64373-21093-77553-20623-21123-23033-31633-2064

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These 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.

I. Preoperative History, Physical and Anesthesia Assessment

The 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.

o Preoperative Evaluation Center (JHOC) Fax: 410-614-3230

Pediatric 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 reason The patient undergoes a scheduled series of procedures (e.g. radiation oncology).

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II. Criteria for Having a Procedure as an Outpatient

1. Full 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.

2. Premature infants (defined as < 37 weeks post-conception at birth) with no medical problems who are at least 52 weeks post-conception.

3. Premature infants with medical problems may need to be at least 60 weeks post-conception, at the discretion of the anesthesiologist.

4. 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 procedure

Older 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.

III. Scheduling

Patients 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.

IV. Guidelines for Preoperative Testing

See Appendix E for Specific Diagnoses

No 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.

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Type and Screen or Type and Cross Per 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 months Have not been pregnant during the past 3 months Have no history of antibodies Have the sample drawn while they are outpatients

In 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 months Seen 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.

V. 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 fibrosis Diabetes Heart disease that is symptomatic, presence of cyanosis or heart failure Hypoxemia Liver failure or liver transplant Malignant hyperthermia (patient or family history) Oxygen-dependent, BIPAP, or home ventilator therapy Organ transplant patients (patients who have had or will have organ transplant) Renal failure Sickle cell (SS, SC or S-thal) disease Scoliosis (non idiopathic or curve > 60 degrees) Severe central or obstructive sleep apnea coming for surgery other than tonsillectomy Skeletal dysplasia Neuromuscular disorders Metabolic disorders Former premature infant with ongoing oxygen requirement or severe chronic lung disease

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Consultations 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.

VI. Fasting Guidelines

From the time the patient is told to arrive at the hospital, make patient NPO: Two (2) hours for clear liquids four (4) hours for breast milk six (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.

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VII. Possible Reasons for Cancellation

Decisions 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 violations

VIII. Parental Refusal of Blood Products

Inform 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.)

IX. Guardianship Documentation

Inform 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.

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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.

X. Contacting an Anesthesiology Attending

For 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.

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APPENDIX 11: Procedure: Intrapleural Alteplase (tPA) for Loculated Pleural Effusion,Pediatric Patients Only

1) OBJECTIVESa) To induce localized fibrinolysis of a loculated pleural effusion in order to achieve

one of the following therapeutic objectives:i) Promote drainage of chest tube or pleural catheter (e.g. Cook pigtail or Teleflex )

leading to reduction of the pleural effusionii) Decrease the potential need for a surgical or invasive treatment approach

2) INDICATIONS FOR USEa) Loculated pleural effusions resulting in a non-draining chest tube or pleural catheter

3) RESTRICTIONSa) Intrapleural administration requires approval from Pediatric Intensive Care Unit

attending, or General Pediatric Surgery attending.

4) CONTRAINDICATIONS FOR USEa) Positive air leak in patient’s chest tube or pleural catheter.

5) WARNINGS/PRECAUTIONSa) All major and relative contraindications for thrombolytic therapy as outlined in

“Thrombolytic agents (intravenous), management of a patient receiving continuous GEN388”.

6) DEFINITIONStPA (tissue plasminogen activator)

A serine protease enzyme the catalyzes the conversion of plasminogen to plasmin, the enzyme responsible for clot breakdown

Loculated pleural effusion

A pleural effusion in which pleural fluid has become walled-off or encapsulated between visceral layers of the pleural prohibiting drainage and access to antibiotic therapy

Dwell time The period post administration of tPA inwhich the chest tube or pleural catheter isclamped

7) RESPONSIBILITYa) Authorized Prescriber

i) Evaluate response to therapy (e.g., chest tube or pleural catheter drainage output, improvement of signs/symptoms, evaluation of chest CT or radiograph)

ii) Evaluate and treat side effects of therapy (e.g., tension pneumothorax during administration, signs/symptoms of hemorrhage post administration)

iii) Order every 12 hr hematocrit during tPA therapy.b) Registered Nurse

i) Assess and monitor patient status and parameters including:(1) Air leak in chest tube or pleural catheter

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(2) Vital signs at baseline and post administration(3) Signs/symptoms of tension pneumothorax during dwell time (dyspnea,

deviated trachea, asymmetrical chest movement)(4) Signs/symptoms of hemorrhage

c) Pharmacyi) Prepare and dispense the tPA (alteplase) in the appropriate syringe as

requested.ii) When requested, provide drug information including, but not limited to, dosing,

side effects, adverse events, drug interactions, monitoring and compatibilities.

8) PROCEDUREa) Administration in Pediatrics

i) Administration 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.

ii) RN will obtain baseline vital signs at the time of administration and every 15 minutes during the dwell time.

iii) Administering Physician will be available during the dwell time.iv) The Pharmacy will dispense a standardized tPA concentration of 0.1mg/ml in

Normal Saline (NS 0.9%NaCl) in a slip tip syringe.(1) Children < 1 year of age

(a) Dose: 2 mg tPA/ 20ml in NS(2) Children > 1 year of age

(a) Dose: 4 mg tPA/40 ml in NSv) The administrating physician will:

(1) disconnect the chest tube or pleural catheter at the connection closest to the patient’s chest after the suction has been turned off.

(2) 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.

(3) 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.

vi) 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.

vii)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

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doses, in an aseptic manner, each dose separated by 24 hours at the discretion of the authorizing prescriber.

viii) 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.

b) Assessmenti) RN will check vital signs 15 minutes after administration and every 1 hour while

tube is clamped.ii) RN will monitor for signs of tension pneumothorax while clamp is in place every

15 minutes.iii) RN will monitor for signs and symptoms of hemorrhage throughout the entire

course of treatment.c) Interventions

i) RN shall turn and reposition the patient every 15 minutes to promote an even distribution of tPA within the pleural space as tolerated.

ii) RN shall notify physician of any adverse events or reactions as described under “Reportable Conditions”.

iii) RN shall measure amount of drainage from the chest tube or pleural catheter throughout the course of treatment.

9) Reportable Conditions to Physiciana) Positive air leak of chest tube or pleural catheter b) Signs or symptoms of hemorrhagec) Drop in hematocritd) Vital sign abnormalitiese) Chest discomfort or painf) Signs or symptoms of tension pneumothorax including respiratory distressg) Absence of drainage once chest tube or pleural catheter is unclamped

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APPENDIX 12: Guidelines for Central Line Related Blood Stream Infections

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APPENDIX 13: Central Line Lock Therapy for Treatment of CRBSI

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APPENDIX 14: Perioperative Antibiotic Prophylaxis

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APPENDIX 15: BURN DOCUMENTATION REQUIREMENTS

1) H&P AND LUND & BROWDER

A) REQUIRED 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.

2) BURN ORDER SET

A) REQUIRED for all burn admissions: Burn Injury Admission PED. This order set lists required & recommended consults/ interventions for burn patients.

3) DAILY NOTES

A) REQUIRED for all burn patients and should include specifics on: % TBSA IVF/ Parkland Resuscitation UOP i.e. during Parkland – is the patient meeting the goal? Nutrition Pain plan ID, if necessary Specific dressing instructions for each wound Plan for next 24 hours Plan discussed with bedside RN and PICU Provider (if in the PICU).

4) PROCEDURE NOTES

A) REQUIRED 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.

5) OPERATIVE NOTES

a) All OR procedures REQUIRE a narrative operative note.b) A brief operative note can be documented in POE; however, a narrative op note is

still required.

6) BURN CLINIC

a) Open most Mondays, Wednesdays & Fridays mornings.i) Patient must call to make an appointment! 888-KID-BURNii) Discharge instructions should advise families to pre-medicate patient with OTC

or Rx medication 30 minutes before appointment.

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APPENDIX 16: BURN WOUND CARE: ED PROCEDURE

Indications Interventions

Suspected or reported chemical burns without powder for patients < 2 years old, or patients ≥ 2 years with <10% TBSA involvement

Don 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 involvement

Don 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 powder

Don 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 burns

Await 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 GPS

Pre-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 intact. Complete 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 dressing.

Complete Lund & Browder diagram and obtain attending co-signature.

Suspected or reported thermal burns with loose

Pre-debridement Discuss pain plan with prescriber and obtain orders.

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tissue and blisters, with no GPS consult or GPS determined patient will be discharged

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. Complete post-debridement wound photography

Apply 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 dressing.

Complete 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 dry

Obtain order for moisturizing cream. Wash area with warm normal saline and mild soap. Apply moisturizing cream to area using massage.

ANATOMICAL CONSIDERATIONSBurns of the face Pre-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 intact. Complete post-debridement wound photography

After 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 feet Pre-debridement Discuss pain plan with prescriber and obtain orders.

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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 skin. Complete 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 genitalia Pre-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 < 2cm may be left intact. Complete 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.

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APPENDIX 17: Non-operative management of liver & spleen injuries

SPECIFIC DIAGNOSIS GUIDELINESClinical Diagnosis or Procedure

CBC Basic Metabolic Chemistry

Comprehensive Chemistry

PTPTT

T&S ECG CXR Notes

Cong. Adrenal Hyperplasia, orAdrenal Insuff.

XPreop endocrine consultation for corticosteroid / mineralocorticoid replacement

Anemia history X CBC if untreated, or not followed by PMD, or if recent Hgb is not documentedAsthma

See notes

If 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 months Pt 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 daily Had 3 acute episodes in past 6 months requiring physician-directed treatmentIf pt is wheezing during preop visit – may need CXR; check with attending.

Cardiac surgery X X X X X X XCoagulopathies X X May require factor levels or Hematology Consult for perioperative managementCraniosynostosis

X X X

Cystic Fibrosis CXR only if significant pulmonary compromise exists; consult attending anesthesiologistDiabetes insipidus

X Consult attending anesthesiologist re: perioperative vasopressin

Diabetes mellitus

X Determine 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 done

SPECIFIC DIAGNOSIS GUIDELINESClinical Diagnosis or Procedure

CBC Basic Metabolic Chemistry

Comprehensive Chemistry

PTPTT

T&S ECG CXR Notes

Failure to thrive

X X X If not already done as part of workup

Heart Failure or Hypertension

X X X X If on ACE inhibitor or diuretic, discuss with attending whether to hold AM dose on day of surgery.

Liver disease Consult attending anesthesiologistNeuromuscular dis

Consult attending anesthesiologist

Renal disease X X Determine if nephrologist has plans for perioperative care.Scoliosis repair

X See note See note See note

X See note

See note

Chemistries 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

scoliosis Echo 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 bifida

PFT per anesthesia attending if curve > 60 degrees and age > 6 years and mentally capable; also may be requested by surgeon for muscular dystrophy patients

Seizure history andKetogenic diet

X X X X May need these labs if on tegretol, depakote or zarontinIf receiving carbamazepine, phenobarbital or phenytoin, may need drug levels

Sickle Cell Disease

X X X X X See note

All patients with sickle SS, SC, or S-thal disease must have Hematology consult. After pt’s final preop transfusion ,obtain hematology studies and %Hgb S CXR if history of cardiac or pulmonary involvement

Sleep Apnea, Severe: defined as either RDI or AHI > 10 or oxygen sat nadir < 70% during sleep.

Hb in

some

cases

Generally 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 anesthesiologist

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REFERENCES

Sources1. “Recommended immunization schedule for persons aged 0 through 18 years – 2013” http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-schedule.pdf2. “Pediatric Fasting Guidelines for Surgery”. www.hopkinschildren.org , n.p. Web 2. Oct. 20123. Vegunta, Ravindra. “Vascular Access.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 110-1164. Slater, J; Krummel TM. “Surgical Infectious Disease.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 5. “Pediatric Perioperative Antibiotic Prophylaxis to Prevent Surgical Site Infection”

http://www.insidehopkinsmedicine.org/amp/pediatrics/downloads/PeriOp_AbxProphylaxis_Prevent_SSI.pdf n.p Web 5 May 20136. Othersen Jr, BH; Hebra, A. “ Tracheal Obstruction and Repair.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 272-2737. Mehta, 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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