Pediatric, Neonatal, and PICU Protocols - AIC Kijabe Hospital · 2020. 3. 22. · / D5LR DISABILITY Unresponsive / Coma / Convulsing Manage airway and give oxygen via facemask, consider

Pediatric,Neonatal,andPICU

Protocols

Lastupdated:MARCH2020

Pleasesendproposedadditionsorcorrectionstoashirk@kijabehospital.org

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TableofContentsPEDIATRICTRIAGE..................................................5RESUSCITATION/DETERIORATION..................8INITIALEVALUATIONOFPEDIATRICPATIENTS..................................................................10PEDIATRICTRAUMA..............................................14PHYSICAL/SEXUALASSAULT..............................15GLASGOWCOMASCALE-CHILDREN.................16

BURNS(>30%transferredtoKNH)..................17PAINMANAGEMENT..............................................18ADMISSIONLOCATION..........................................20SEVEREACUTEMALNUTRITION(<-3SD)........22SEVEREACUTEMALNUTRITION(<-3SD)........23CPweightcurve(girls0-10)...................................25CPWeightcurve(boys0-10).................................26

RICKETS.....................................................................27GASTROENTERITISANDDEHYDRATION........28.......................................................................................30TBINCHILDREN......................................................31ASTHMAANDBRONCHIOLITIS..........................35BronchiolitisManagement.......................................35AsthmaExacerbationManagement.....................36FEVER&NEUTROPENIAINONCOLOGYKIDS39

TrueSEPTICSHOCKatKijabeHospital:first2hours...........................................................................40DIABETICKETOACIDOSIS....................................41

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STATUSEPILEPTICUSINKIJABE........................49SNAKEENVENOMATIONINKIJABE...................50

NEONATOLOGY............................................................52TERMADMISSIONSTONURSERY......................52NeonatalHypoglycemia............................................60NeonatalHyperglycemia..........................................63NeonatalHypernatremicDehydration...............64TotalParenteralNutrition(TPN).........................68TotalParenteralNutrition(TPN):Writing.......71

NEWBORNRESPIRATORYMANAGEMENT......72ApneaofPrematurity.................................................72Oxygensaturationsandaltitude...........................72NasalCannulaandFiO2inNeonates..................73BubbleCPAP..................................................................74Surfactanttherapy.......................................................75PersistentPulmonaryHypertensionoftheNewborn(PPHN).........................................................77MeconiumAspirationSyndromewithPPHN..78MaternalHIV(notadmitted)..................................79NEONATALSEPSIS......................................................80NeonatalRuleOutSepsis(Symptomatic).........80KijabePediatricAntibiogram2016-2018.........85

NeonatalHYPERBILIRUBINEMIA......................86Phototherapy.................................................................87IVIG/ExchangeTransfusion..................................90

PERINATALASPHYXIA..........................................94

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HEARINGSCREENING............................................96PATENTDUCTUSARTERIOSUS(PDA).............97

CRITICALCAREPROTOCOLS...................................99RESPIRATORYCARE..................................................99CPAP............................................................................99HIGHFLOWNASALCANNULA..........................100INTUBATION:SIZESandSUPPLIES...............102INTUBATIONSEQUENCEDRUGS.....................103STANDARDSEQUENCE...........................................103

VENTILATORMANAGEMENT...........................104ANALGESIA&SEDATIONFORVENTILATION...2BENZOS:MIDAZOLAM..................................................4

INOTROPES/PRESSORS..............................................5TypesofShockandPressorTreatment©HLH...6INFUSIONSUMMARY..............................................12ELECTROLYTECORRECTIONSUMMARY.........13

#sFORCONSULTATION/REFERRAL...................14

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PEDIATRICINPATIENTPROTOCOLSPleasenotethatthisbookletismeanttoserveasasupplementtotheexcellentMoHPediatricGuidelines.Whentreatinganybabyorchild,pleasereferfirsttothisbookletaslocalguidelinesreflectlocalconditionsandresources-thentotheMoHbooklet,andiffurtherinformationisrequiredtotheWHOPocketBookofHospitalCareforChildrenorHarrietLaneHandbookforchildren(foundinOPD,nursery,onthepediatricwardsandinICU).

PEDIATRICTRIAGEEverychildpresentingtoMCH/FamilyClinicorcasualtyshouldfirstbeevaluatedandprioritizedbyatriagenurseaccordingto

thefollowingtables.

Ifyouarecalledtoassessatriagecategory1patient(red),youshouldrespondimmediatelyforevaluation/resuscitationandcallconsultant.Onceresuscitated,definitivecarecanbeprioritizeddependingonotherneedsinthehospital.

Allpriority1patientsmustbeadmittedtoHDUorICUafterstabilizationinCasualty.

AllpatientsadmittedtoHDU/ICUshouldbetakentocasualty.

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PEDIATRIC TRIAGE continued PRIORITY1(REDPEWS>3)–NOTIFYPAEDsCOTOCASUALTY.TAKETOCASUALTYIMMEDIATELYFORIMMEDIATEMO/COREVIEWANDNOTIFYCONSULTANT:AIRWAY&BREATHING

1.Head/necktrauma2.Absent/weak/obstructedbreathing3.Severerespiratorydistress/RR>80Cyanotic(blue)

1.Cervicalcollarifhead/necktrauma2.Openairway(chinlift/jawthrust)3.Commencebagvalvemaskifinadequateeffort;4.Applyoxygenviafacemaskifbreathing5.Warmchildonresuscitaire

CIRCULATION 1.Nopulse2.Coldhands/feetwith:-Capillaryrefill>3seconds-Weak+fastorslow(<60)pulse-Slowskinpinchorsunkeneyes

1.CommenceCPRifpulseless.2.Stopactivebleeding3.applyO2vianasalcannulaorfacemask.4.Weighchild(orestimateweightwithBroselowtapeDONOTGUESS.)MUAC:<12.5/malnutrition?Yes:IVaccessandIVglucose,5ml/kgDNS-30min(x3prn);NOFLUIDBOLUSESNo:IVaccess;IOif>5min;Hypovolemicshock:20mL/kgNSbolusx1-2Septicshock(allcases):5-10/kgBOLUSthen4ml/kg/hr1/2D101/2NS/D5LR

DISABILITY Unresponsive/Coma/Convulsing

Manageairwayandgiveoxygenviafacemask,considerintubation.ObtainIVaccess,checkRBS

EXPOSURE Majortraumaorburn>10%

IVaccessx2,informpediatricsurgeon1stoncallimmediately

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PEDIATRICTRIAGEcontinuedTriagecategory2patients(yellow)PEWS2-3shouldbeseenbyadoctororpedsCOwithin10minutesofarrival.Eachofthesepatientsshouldalwaysbediscussedwiththepediatricconsultant.

PRIORITY2(seewithin20min) ApplyoxygenifSaO2<90%

Paracetamol15mg/kgiffever

MO/COtoseeASAP.

IfMO/COnotavailablecall

consultant

Recheckvitalsevery30min.

Anyofthefollowing:-Respiratorydistress/SaO2<90%/RR>60-Severepallorofpalms-Malnutrition:severewasting-Oedemaofbothfeet-Lethargic,irritable,alteredalertness-Severepain(abdomen,genitalia,injury)-Anysickinfantunder2monthsold-Temperature>39⁰C-Poisoningorothertrauma-UrgentreferralletterPRIORITY3(seewithin1hr)Allotherchildrenwithabnormalvitalsigns,feverorwhoneedmedicalreview.PutfileintoGreen“Priority3”Boxtobeseennon-urgently

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RESUSCITATION/DETERIORATIONPediatricpatientstendtodeterioratemorerapidlythanadultpatientsastheyhavelessabilitytocompensateforhemodynamicinstabilitythanadults.Timely

evaluationofdeterioratingpediatricpatientsisessential.

Importantresuscitationpearls:● AIRWAY/BREATHING-Goodbag-valve-maskventilationis

imperativeandpotentiallylifesaving.● CIRCULATION-Donotlookatthemonitororlistentothe

hearttodeterminewhetherCPRshouldbecommenced-anyunconsciouschildwithoutapalpablepulseshouldhaveCPRcommencedimmediatelyirrespectiveofmonitoring.ü Chestcompressionsshouldbecommencedataratioof

15:2(infant/child)or3:1(newoborn)untilintubated.ü Aheartrateonthemonitorwithoutapulsesignifies

PEA("pulselesselectricalactivity")whichshouldbetreatedwithCPR,adrenaline(seedosebelow),andreversalofunderlyingcausesuntilapulsereturns:

ü Reversiblecauseso Hypoxiao Hypovolemiao Hypoglycemiao Hypo/hyperkalemia,hypocalcemiao HydrogenIons(acidosis)o TensionPneumonthoraxo Thrombus(PulmonaryEmbolus,Cardiac)o Tamponadeo Toxins

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● If IV access is not possible within 2 minutes of shock / arrest, an 18 gauge (pink) needle or IO if available should be placed in the proximal tibia or distal femur.

● Adrenaline: 1mL of 1:1000 solution should be diluted in 9mL saline. The pediatric dose is 0.1 mL/kg IV/IO

NOTE ON WEIGHTS AND DOSES ● Weight Do not give drugs or IV fluids before determining

the weight of the baby/ child. If s/he cannot be weighed in casualty, a length-based weight must be obtained using a Broselow or PAWPER tape

● Weight may also be estimated from the child’s age as: [Age x 2] + 4 kg (malnourished) / [Age x 2 ]+ 8kg (well-nourished)

● MUAC (mid upper arm circumference) must also be quickly measured - if MUAC is <13.5 subtract one color category (2 categories if MUAC <11.5) or weight will be overestimated

WARDMANAGEMENTOFDETERIORATINGPATIENT● Anypatientonthepediatricwardwhohasabnormalvitalsigns

willhavecallplacedtotheMO/COintern.Thepatientshouldbeevaluatedinpersonwithin15minutes.

• Ifyouareunabletorespondinpersonwithin15minutes,youshouldcallthepediatricCOorconsultantoncalltoseethepatient.

• Notifytheon-callconsultantassoonaspossibleoftheassessmentandplan.

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INITIALEVALUATIONOFPEDIATRICPATIENTS1. Historyshouldalwaysincludeallofthefollowing:● Examinationofaninfantorchildislikelytomissvital

informationifahistoryisinaccurate.● Pregnancy/birth/developmentalhistoryinanyinfant.● Mostrecentweight,ifknownbythecaregiver.● Allotherroutinehistoryquestions.2. Examinationshouldalwaysincludeallofthefollowing:● Weight,lengthandMUAC(midupperarmcircumference)–

shouldalwaysbemeasuredunlessthechildrequiresimmediateresuscitation,withz-scoreorBMIcalculated.

● Headcircumference-percentileshouldbenoted.● MidUpperArmCircumference(MUAC)(best>6mo)

6-59mo 5-9yr 10-17yr <11.5 <13.5 14.5 Severeacutemalnutrition

associatedwithhighmortality11.5-12.5 13.5-

14.514.5-18.5

Moderateacutemalnutrition(consideradmissionforsupplementaryfood)

12.6-13.5 MildacuteMalnutrition>13.5 Normal

*translatorshouldalwaysbeusedifprimarylanguageisnotKiswahiliorEnglish

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3. Z-scores(seetablesonfollowingpages)Everychildshouldhavelengthforage,&weightforlengthz-scoredocumentedtodetermineifmalnutritionispresent.

4. HIVInvestigation● Wherepossible,allchildrenseeninMCHshouldhaveHIVtesting

(PITC)doneatthebedsidetoenableustomeettheKenyaMoHgoalof>80%ofpatientstestedforHIV.

● AllchildrenadmittedtoKijabeHospitalforanyreasonshouldbetestedforHIVwithresultsclearlydocumented

5. Vitalsigns:normalvaluescanbefoundbelow.AbnormalVSrequiresintervention&notificationofaconsultant.

RESPRATE SaO2 HR SYSTOLICBP

0-3MONTHS 30-60 >90 100-150 65-853-6MONTHS 30-50 >90 90-150 70-906-12MONTHS 25-40 >90 90-150 70-1001–2YEARS 24-35 >90 80-120 80-1052–5YEARS 20-30 >90 75-120 85-1106-12YEARS 15-25 >90 65-110 90-120>12YEARS 12-18 >90 60-100 100-120

*forNeonate,normalMAPisgestationalage(+/-5),olderis(agex1.5+40)

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Z-scoresweightforlength/height(WHOparameters;MUACtiebreaker)

Boys Weight (kg) Length Girls Weight (kg) -5 SD -4 SD -3 SD -2 SD -1 SD (cm) -1 SD -2 SD -3 SD -4 SD -5 SD

1.5 1.7 1.9 2.0 2.2 45 2.3 2.1 1.9 1.7 1.5 1.7 1.8 2.0 2.2 2.4 46 2.4 2.2 2.0 1.9 1.7 1.8 2.0 2.1 2.3 2.5 47 2.6 2.4 2.2 2.0 1.8 1.9 2.1 2.3 2.5 2.7 48 2.7 2.5 2.3 2.1 1.9 2.0 2.2 2.4 2.6 2.9 49 2.9 2.6 2.4 2.2 2.0 2.2 2.4 2.6 2.8 3.0 50 3.1 2.8 2.6 2.4 2.1 2.3 2.5 2.7 3.0 3.2 51 3.3 3.0 2.8 2.5 2.2 2.5 2.7 2.9 3.2 3.5 52 3.5 3.2 2.9 2.7 2.4 2.7 2.9 3.1 3.4 3.7 53 3.7 3.4 3.1 2.8 2.5 2.9 3.1 3.3 3.6 3.9 54 3.9 3.6 3.3 3.0 2.7 3.0 3.3 3.6 3.8 4.2 55 4.2 3.8 3.5 3.2 2.9 3.2 3.5 3.8 4.1 4.4 56 4.4 4.0 3.7 3.4 3.1 3.4 3.7 4.0 4.3 4.7 57 4.6 4.3 3.9 3.6 3.3 3.6 3.9 4.3 4.6 5.0 58 4.9 4.5 4.1 3.8 3.4 3.7 4.1 4.5 4.8 5.3 59 5.1 4.7 4.3 3.9 3.5 3.9 4.3 4.7 5.1 5.5 60 5.4 4.9 4.5 4.1 3.7 4.1 4.5 4.9 5.3 5.8 61 5.6 5.1 4.7 4.3 3.9 4.2 4.7 5.1 5.6 6.0 62 5.8 5.3 4.9 4.5 4.0 4.4 4.9 5.3 5.8 6.2 63 6.0 5.5 5.1 4.7 4.2 4.7 5.1 5.5 6.0 6.5 64 6.3 5.7 5.3 4.8 4.3 4.8 5.3 5.7 6.2 6.7 65 6.5 5.9 5.5 5.0 4.5 5.0 5.5 5.9 6.4 6.9 66 6.7 6.1 5.6 5.1 4.6 5.1 5.6 6.1 6.6 7.1 67 6.9 6.3 5.8 5.3 4.8 5.3 5.8 6.3 6.8 7.3 68 7.1 6.5 6.0 5.5 5.0 5.5 6.0 6.5 7.0 7.6 69 7.3 6.7 6.1 5.6 5.1 5.6 6.1 6.6 7.2 7.8 70 7.5 6.9 6.3 5.8 5.2 5.8 6.3 6.8 7.4 8.0 71 7.7 7.0 6.5 5.9 5.3 5.9 6.4 7.0 7.6 8.2 72 7.8 7.2 6.6 6.0 5.4 6.0 6.6 7.2 7.7 8.4 73 8.0 7.4 6.8 6.2 5.6 6.1 6.7 7.3 7.9 8.6 74 8.2 7.5 6.9 6.3 5.7 6.3 6.9 7.5 8.1 8.8 75 8.4 7.7 7.1 6.5 5.9 6.4 7.0 7.6 8.3 8.9 76 8.5 7.8 7.2 6.6 6.0 6.5 7.2 7.8 8.4 9.1 77 8.7 8.0 7.4 6.7 6.1 6.6 7.3 7.9 8.6 9.3 78 8.9 8.2 7.5 6.9 6.2 6.7 7.4 8.1 8.7 9.5 79 9.1 8.3 7.7 7.0 6.3 6.9 7.6 8.2 8.9 9.6 80 9.2 8.5 7.8 7.1 6.4 7.0 7.7 8.4 9.1 9.8 81 9.4 8.7 8.0 7.3 6.6 7.2 7.9 8.5 9.2 10.0 82 9.6 8.8 8.2 7.5 6.8 7.3 8.0 8.7 9.4 10.2 83 9.8 9.0 8.3 7.6 6.9 7.5 8.2 8.9 9.6 10.4 84 10.1 9.2 8.5 7.8 7.1 7.7 8.4 9.1 9.8 10.6 85 10.3 9.4 8.7 8.0 7.2 7.9 8.6 9.3 10.0 10.8 86 10.5 9.7 8.9 8.1 7.3 8.0 8.7 9.5 10.2 11.1 87 10.7 9.9 9.1 8.3 7.5 8.1 8.9 9.7 10.5 11.3 88 11.0 10.1 9.3 8.5 7.7 8.3 9.1 9.9 10.7 11.5 89 11.2 10.3 9.5 8.7 7.9

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CombinationofKenyanMOH,WHO,andNCHSchartstakenfromhttp://motherchildnutrition.org/malnutrition-management/info/nchs-who-

normalized-reference.html

Boys Weight (KG) length Girls Weight (KG) -5 SD -4 SD -3 SD -2 SD -1 SD (cm) -1 SD -2 SD -3 SD -4 SD -5 SD

8.5 9.3 10.1 10.9 11.8 90 11.4 10.5 9.7 8.8 8.0 8.7 9.5 10.3 11.1 12.0 91 11.7 10.7 9.9 9.0 8.2 9.1 9.7 10.5 11.3 12.2 92 11.9 10.9 10.1 9.2 8.4 9.0 9.8 10.7 11.5 12.4 93 12.1 11.1 10.2 9.4 8.5 9.2 10.0 10.8 11.7 12.6 94 12.3 11.3 10.4 9.5 8.6 9.4 10.2 11.0 11.9 12.8 95 12.6 11.5 10.6 9.7 8.8 9.5 10.3 11.2 12.1 13.1 96 12.8 11.7 10.8 9.9 9.0 9.6 10.5 11.4 12.3 13.3 97 13.0 12.0 11.0 10.1 9.2 9.8 10.7 11.6 12.5 13.5 98 13.3 12.2 11.2 10.2 9.3 10.0 10.9 11.8 12.7 13.7 99 13.5 12.4 11.4 10.4 9.4 10.1 11.0 12.0 12.9 14.0 100 13.7 12.6 11.6 10.6 9.6 10.2 11.2 12.2 13.2 14.2 101 14.0 12.8 11.8 10.8 9.8 10.4 11.4 12.4 13.4 14.5 102 14.3 13.1 12.0 11.0 10.0 10.6 11.6 12.6 13.6 14.8 103 14.5 13.3 12.3 11.2 10.1 10.8 11.8 12.8 13.9 15.0 104 14.8 13.6 12.5 11.4 10.3 11.0 12.0 13.0 14.1 15.3 105 15.1 13.8 12.7 11.6 10.5 11.2 12.2 13.3 14.4 15.6 106 15.4 14.1 13.0 11.8 10.7 11.3 12.4 13.5 14.6 15.9 107 15.7 14.4 13.2 12.0 10.8 11.5 12.6 13.7 14.9 16.2 108 16.0 14.7 13.5 12.3 11.1 11.6 12.8 14.0 15.1 16.5 109 16.4 15.0 13.8 12.5 11.2 11.8 13.0 14.2 15.4 16.8 110 16.7 15.3 14.0 12.8 11.5

height 12.1 13.3 14.5 15.8 17.1 110.5 17.1 15.7 14.4 13.1 11.8 12.2 13.4 14.6 15.9 17.3 111 17.3 15.8 14.5 13.2 11.9 12.2 13.5 14.8 16.0 17.5 111.5 17.5 16.0 14.7 13.3 11.9 12.3 13.6 14.9 16.2 17.6 112 17.8 16.2 14.8 13.5 12.1 12.4 13.7 15.0 16.3 17.8 112.5 17.9 16.3 15.0 13.6 12.2 12.5 13.8 15.2 16.5 18.0 113 18.0 16.5 15.1 13.7 12.3 12.7 14.0 15.3 16.6 18.0 113.5 18.2 16.7 15.3 13.9 12.5 12.8 14.1 15.4 16.8 18.3 114 18.4 16.8 15.4 14.0 12.6 12.8 14.2 15.6 16.9 18.5 114.5 18.6 17.0 15.6 14.1 12.6 12.9 14.3 15.7 17.1 18.6 115 18.8 17.2 15.7 14.3 12.8 13.0 14.4 15.8 17.2 18.8 115.5 19.0 17.3 15.9 14.4 12.9 13.1 14.6 16.0 17.4 19.0 116 19.2 17.5 16.0 14.5 13.0 13.2 14.7 16.1 17.5 19.2 116.5 19.4 17.7 16.2 14.7 13.2 13.4 14.8 16.2 17.7 19.3 117 19.6 17.8 16.3 14.8 13.3 13.5 14.9 16.4 17.9 19.5 117.5 19.8 18.0 16.5 15.0 13.5 13.5 15.0 16.5 18.0 19.7 118 20.0 18.2 16.6 15.1 13.6 13.7 15.2 16.7 18.2 19.9 118.5 20.1 18.4 16.8 15.2 13.6 13.8 15.3 16.8 18.3 20.0 119 20.3 18.5 16.9 15.4 13.8 13.9 15.4 16.9 18.5 20.2 119.5 20.5 18.7 17.1 15.5 13.9 14.0 15.5 17.0 18.6 20.4 120 20.7 18.9 17.3 15.6 14.0

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PEDIATRICTRAUMAAnychildwithmajortrauma(mechanism,morethanoneinjury,burns,evenheadtrauma)shouldbeevaluatedinCASUALTY.Thepediatricsurgeryteamshouldbeinformedimmediatelyuponarrival.Ifthereisanydelay(duetothesurgeonsbeingintheoperatingtheatre,etc),thepediatricmedicalconsultantshouldbecalledtoassessthechild.Allchildrenwithmajortraumamustbeadmittedtopediatricsurgery–notorthopedicsorneurosurgery–toensureafulltertiarysurveyoccursandappropriatefollow-upiscompleted.

PrimarysurveyAirway–Ensurec-spinestabilizationwithappropriatelysizedcervicalcollar(Stabilizewithtapedlinensinnocollaravailable)Breathing–Oxygenshouldbeadministeredviaappropriatelysizedmaskforallmajortrauma.Tensionpneumothoraxisaclinicaldiagnosis(decreasedbreathsoundswithincreaseresonancetopercussion+/-trachealdeviation)andneedlethoracostomyshouldbedonewithoutwaitingforx-rayifpresent.Circulation–2IVlinesshouldbeplaced(preferablyinlargeveinssuchastheantecubitalfossa.)Obtainanintraosseousforanypatientwithhypovolemicshockwithin2minutesofarrivalifIVaccessisnotpossible.Disability–GlasgowComaScore(seetable)&pupilsizeshouldberecordedandall4extremitiesshouldquicklybeevaluatedforneurologicalstatus.

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Exposure-allclothingshouldberemovedsothattheentirebodycanbeadequatelyexamined.Rememberthatinfants/childrenmaylostbodyheatquickly,soensureadequatewarmthwithlinens/blanketsandenvironmentalcontrol.Xrays-Allmulti-traumapatientsrequirec-spine,chest,andpelvisx-raysaspartoftheirevaluation.Theywillbedoneontransfertoward/ICUorinICU.(Portablenotavailableincasualty.)SecondarySurvey(todowithpedssurg)Afullhead-to-toeassessmentofeachchildshouldbedonebeforeadmission.Nochildshouldleavecasualtyuntilafullsecondarysurveyhas

beencompleted.

PHYSICAL/SEXUALASSAULTFor a child in whom physical assault or neglect is

suspected, the pediatric consultant must be advised immediately.

For all cases of suspected sexual abuse or assault, immediately call the pediatric surgery consultant

(pre puberty) or OBGYN consultant (post pubertal) on duty prior to examination.

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GLASGOWCOMASCALE-CHILDREN

INFANT<1YEAR CHILD1-4YEARS AGE4+TOADULTEYES

4 Open Open Open3 Opentovoice Opentovoice Opentovoice2 Opentopain Opentopain Opentopain1 Noresponse Noresponse Noresponse

VERBAL5 Coos,babbles Oriented,speaks,

interacts,socialOrientedandalert

4 Criesbutconsolable

Confusedspeech,disoriented,consolable

Disoriented

3 Criespersistentlytopain

Inappropriatewords,inconsolable

Nonsensicalspeech

2 Moanstopain Incomprehensible,agitated

Moans,unintelligible

1 Noresponse Noresponse NoresponseMOTOR

6 Normal,sponta-neousmovement

Normal,spontaneousmovement

Followscommands

5 Withdrawstotouch Localizespain Localizespain4 Withdrawstopain Withdrawstopain Withdrawstopain3 Decorticateflexion Decorticateflexion Decorticateflexion2 Decerebrate

extensionDecerebrateextension Decerebrate

extension1 Noresponse Noresponse Noresponse

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BURNS(>30%transferredtoKNH)Forburns,theextentofallnon-firstdegreeburnsshouldbeestimatedusingtheLund-Browderchartforchildren:ParklandformulatoreplacefluidwithRL:(2016revision)3mlx%BSAxwtkg(½1st8hrs,½next16hr)+Maintenance(4/2/1rule)

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PAINMANAGEMENTMILD/MODERATEANALGESIA;PATIENTS<6MOOLD

DRUG ROUTE DOSE DANGER/COMMENTS

Paracetamol PO/PR 15mg/kgq6hor10mg/kgq4h

Max60mg/kg/24h;adultmax4g/24h

Ibuprofen PO 10mg/kgq6h NOTinactivebleed

MODERATE/SEVEREANALGESIAIN>6MOOLD

DRUG route DOSE ONSET

DURATION DANGER

Morphine IV 0.05-0.1mg/kg/Dose(upto0.2)Max15mg

5-10min

Peak30minLasts2-3h;repeatq2-4hPRN

IVonlyonmonitor(notonfloor!)NOTIN<6MOOLD!!!

PO 0.2-0.5mg/kg/dose

30-60min

4-5h;repeatq4-6hrPRN

Fentanyl*succifchestwallrigidity

IV 1-2mcg/kg/dose

1-2min

0.5-1hr.repeatq2hneo,q1holder

Bradycardia/ChestwallrigidityONLYinICU/HDU

ü NALOXONE0.02-2mcg/kg/doseIVreversessedation!1ampule=0.4mg;dilute1/40.1mgin9mlNS=10mcg/ml;

5kgchild=0.5ml;Mayuseupto10mcg/kgü ForrigidchestinFentanylgive1mcg/kgsuccinylcholine

*considercallinganesthesiaforlocalblocks*

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SEDATIONforPROCEDURES(IVgivenslowpushover2-3minutes)in>6MOOLD.

DRUG RTE DOSE ONSET DURATI

ONDANGER/COMMENTS

Midazolam IV 0.05-0.1mg/kg/dose

1-3m 1-2hrrptq5m

Amnesia/agitationMildrespdepression

PO/PR/IN

0.25-0.5mg/kg/dose0.4/kgwithmaxof10mg

10-30m

1-2h >6molowerdosesinolderpt

Diazepam IV 0.05-0.2mg/kg/dose

1-3m 1hrptq2-4h

Max2mg(infant)5mg(child)in8hr

PO/PR

0.1-0.8mg/kg/dose

30-60m

2-3hrptq6-8h

Ketamine*onlyinICU,ED,orTheatre

IV 0.25-0.5mg/kg/dose

1min 1h Bothsedate/analgesia↑HRBPICPbronchodilationSuccinylcholineforlaryngospasm

ChloralHydrate

PO/PR

25-50mg/kg/24hr

6-8h Max500mg/dose

*ConsiderD10/D25onglovedfingerorgauzeduringLPandcatheterizationforneonates

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ADMISSIONLOCATION VITALS REQUIREMENTSWard

4hourlyorroutinevitalsO2requirement<2L/min

NonarcoticsRoutineIVfluids

HDU

1-2hourlyvitalsrequiredShockorfluidbolusrequiredincasualty/OPDO2requirement2-5L/min,CPAP,HighFlow

IVnarcoticrequirementhypothermia/tempinstabilityfrequentRBSneeded

AutomaticICUadmissionbydiagnosis1. Ventilated2. Pressors3. DKAwithinsulininfusion4. HypernatremiawithNa>180and/orK>85. -5/-6malnutrition

PointSystemtohelpwithNurseStaffingRatios1. Respiratory

a. Ventilation(8points)b. BubbleCPAP(4points)c. HighFlowNasalCannula(4pt)d. FrequentSuctioning(2pt)e. CloseevaluationofTV/RR/O2satsf. Q1-2hournebulization(2pts)

2. Cardiovasculara. Pressors(6pts)b. Q1hrEvaluationofBP(2pts)c. Lineaccess(1pt)d. 1pointforeachsyringepumpinuse

3. Numberofmedicationsa. <6medicines(1pt)b. 7-12medicines(2pt)c. >12medicines(3pts)

4. Frequentreevaluationa. Dressingchanges(1pt)b. Q1hneurochecks(1pt)c. IVfluidsnotonpump(1pt)d. Frequentfeeds(1pt)e. Phototherapy(1pt)f. Labchecks>2xaday(1pt)g. Insulindripwithq1hourRBS(4pts)h. Epiduraldrip(3pts)

21

PEDIATRIC IVF AT KIJABE HOSPITAL ORDERWRITTEN HOWTOMIX USUALRATE/AMOUNTRoutineneonatalfluids(3-28daysofage):4/5D101/5NS(addcalciumforpreterms<34wga)

Forsyringepump:Mix48mL10%dextroseand12mLnormalsalineina60mLsyringeForburette:Mix120mL10%dextrose+30mLNS

~4-5ml/kg/hr(100-150ml/kg/d)

WellnourishedRoutinepediatricfluids(initial):1mo-1yo½D10½NS>1yoDNS**adjustaccordingto48hlabs

Tomixforburette½D10½NS:Mix75mL10%dextroseand75mLNS

<10kg 4ml/kg/hr10-20kg:

40ml/hr+2ml/kg/hrperkgover10kg

20+kg: 60ml/hr+1ml/kg/hrperkgover20kg

Childinshock/arrest:NS(normalsaline)bolus

0.9%normalsalineonlyviaperipheralIVorIO

GE/wellnourished:20ml/kgWellnourished/Septic:5ml/kgx3andmonitorresponseMalnourished:D5LR4ml/kg/hr

Childwithhypoglycemia:D10%bolus

10%dextroseviaIVorIO

2.5ml/kgneonate5ml/kginfant/childtocorrecthypoglycemia,followedbyinfusionorfrequentfeeding

ConsideraddingKCl(potassiumchloride)onthethirddayofadmissionifrequired2-4mmol/kg/dayifthechildhasgoodurineoutputandanormalCrlevel.(usually1.5-3mmol/150cc)

22

SEVEREACUTEMALNUTRITION(<-3SD)INITIALLocationforCare:

● OUTPATIENTpatientswithnocomplications,goodappetite,andproximitytoclinicforclosefollow-up

● INPATIENTo Allpatientswithmedicalcomplication,oedema,lackofappetite,orinabilityforclosefollowup● LocationbyZ-score(w/l)

● lessthan-3SD,admittotheward● lessthan-4SDwO2req,considerHDUadmission● lessthan-5SD,considerICUadmission

INITIALINVESTIGATIONS● RBS

● onpresentationandpre-prandialx3oruntilstable.Rxwithimmediatefeedor2ml/kgD10IVbolus

● HIV(PITC)● Na,K,Cr,Ca,Phosphorous● Urinalysisandurinecx,bloodcx,stoolforO&Pifdiarrhea.● Otherstoonsiderbasedonhistory

● CSF● XrayforTB/Rickets● malariatest(MPS)

IfachildhasCPorDownsyndrome,

weight/lengthshouldbeplottedonadifferentgrowthcurve(seepages24/25)

Thismaynotbemalnutrition!

23

SEVEREACUTEMALNUTRITION(<-3SD)INITIALDIETFOR-3SD

o Ifappetitefair,F75130mL/kg/ddividedq3andadvanceddailyastoleratedifnosignsofrefeeding

o AdvancetoF100130/kg/dwhenF75tolerated(average2days)

o After2daysofF100@130ml/kg/day,changetocatchupfeeds.(writtenbynutrition)

o Ifadmissionisforanotherreason,andmalnutritioniscomplicating,thencatchupfeedscanbestartedonadmission{IFfairappetiteand/orMAM(<-2SD)}

MEDICATIONSforALLmalnutritionadmissionso VitA-50,000U<6m,100,000U6-12mo,200,000U

>12mo)poo Folicacid2.5mg/dpoo Zincsulfate-<6mo10mg(1/2tab);>6mo20mg

(1tab)dailyx2wkso Multivitamin-5ml/dpoo Coartem-<5kg1/2tabBDx3d;5-15kg1tabBD;

15-24kg2tabsBD;25-34kg3tabsBDiffromendemicareaor<-4.(Continue3days;ifendemic)

o Antibiotics-inpatientneedsxpenx2daysthentransitiontoAmoxicillinx5moredays,gentamicinx5days(seeMoHbooklettodose)(Improvesmortalityandweightgain!)

o After7days,giveoralAlbendazole200mg<2years,400mg>2years.

o Checkimmunizationstatusformeaslesvaccine

24

SEVEREACUTEMALNUTRITION(<-4SD)IfSAM<-4SDorkwashiorkor,considerslowerrefeedwF75

F75/F100 Resomal LabsDay1 60ml/kgF75(40kcal) 40ml/kg UECSDay2 80ml/kgF75 20ml/kg Day3 100ml/kgF75 None Day4(outofHDUiftolerated)

120ml/kgF75 None Ph,Na,K

Day5 130ml/kgF75 None Day6&7 130ml/kgF100as

tolerated Na,K,Ph

*basedonanorexianervosarefeedingprotocols&caseseries

Becauseofhigherriskofelectrolyteabnormalityadd:o Phosphorous-"PhosphateSandoz"3mmol/kg/day(1

mmol/kgTID)*1tab=16mmol(x5daysoruntilfullfeeds)(checkPhday4)

o Magnesium-MgSO450mg/kgPOdailyX5daysoruntilfullfeeds*useIVsolution500mg/ml-0.1ml/kgthendilutefororaladministration.*considergivingIVifhypocalcemia

o Potassium(ifK<3)KCL4mmol/kg/day(1mmol/kgQID)*1x600mgtab=8mmol

LabMonitoring:CheckKandPhosphorouseveryotherdayforfirst5daysSIGNSOFREFEEDING:Tachycardia,trendofincreasingheartrate,anyincreaseinoxygenrequirementordecreaseinO2saturations,anemia,hypokalemia(<2.5),weakness,hyperventilation

25

CPweightcurve(girls0-10)

26

CPWeightcurve(boys0-10)

27

RICKETSCa++deficiencymaybeasfrequentinricketsasVitaminD

deficiency.Althoughfurtherresearchisplannedastoitsetiology,itissuspectedthatmixed-flourujismayplayarole.(nowbeing

supplementedwithcalciumifstorebought)DiagnosisatKijabe(Rickets)● Usuallyclinicalbasedonphysicalfindings–palpableorvisible

rosaryespeciallyprominent,flayedradialmetaphysesonwristx-ray.

TreatmentatKijabe(Rickets)1• OrderVitaminDinjection300,000IUx1atdiagnosisif>6mo

and150,000IUif<6moo ANDGiveelementalCalcium:40mg/kg/day(Neonates50-

150mg/kg/day)usually10mlbd▪ ZedCal(Calcium/VitD):(ElementalCaCarbonate150mg

andD3200iuandZncSulfate2mgandMagnesiumhydroxide25mg)/5ml(PriceZedCal200ml=330KSH)

• Education:Familyshouldknowtocompletelyavoidmixedcerealujis(“AfyaBora”,“TotoAfya”etc.–milletandsorghumandsomesorghumarechiefphytateproblems)

• TopreventvitaminDdeficiency,at-riskchildrenshouldreceive400IUvitaminDdaily;

● NB:1mic=40IUvitD● InjectableVitaminD(200KSHfor3months

28

GASTROENTERITISANDDEHYDRATIONSeenext2pagesforMOHguidelinesforHypovolemicShockandDehydrationinMalnourishedChildrenForchildrenwithonlysomedehydrationandpersistentvomitingconsiderthefollowing:● NoteverychildwithgastroenteritisrequiresIVfluids.● Antiemetics:

o Inchildrenoveroneyearofagewithpersistentvomiting,considergivingondansetronsublingually/orallyat0.15mg/kg(roundtonearest2or4mg)asasinglestatdoseandcommencingORS.

o Infirst5daysofrefeeding,becarefulwithOndansetronbecauseriskofTorsade’sishigherwithelectrolyteabnormality,especiallyhypomagnesemia

o Donotuseotheranti-emeticssuchaspromethazineormetaclopromide/plasilastheyhavepotentialextrapyramidal(dystonic)andsedatingsideeffects.

• Oral/NGrehydration:o ConsiderNGrehydrationinwell-nourishedinfants

under2yearsofage.o Children>2yearsofagemaytolerateorally.

29

From MOH 2016 Pediatric Protocols

30

MOH 2016

Pediatric Protocols

31

TBINCHILDRENDiagnosis(Counsel.Counsel.Counsel.)Diagnosisinkidsismostlyclinicalusingthesecriteria:Presenceof2ormoreofthefollowingsymptoms

● Cough>2weeks● Poorweightgain(orweightloss)● Persistentfeverand/ornightsweats>2weeks● Fatigue,reducedplayfulness,lessactive

PLUS2ormoreofthefollowing:

● Positivecontacthistory(definedaslivinginthesamehouseholdas,orinfrequentcontactwith(e.g.childminder,schoolstaff)anadultoradolescentwithPTB)

● Respiratorysigns● CXRsuggestiveofPTB(whereavailable)● PositiveMantouxtest(whereavailable;unreliableinmalnutrition,disseminatedTB,andHIV)

ThenPTBislikely,andtreatmentisjustified.InterpretationofMantoux• IfhavereceivedBCG,10mmisapositivetest• Ifmalnourished,disseminated,orHIV,5mmispositivebutnegativedoes

notruleoutTB• However, this is ONE criteria, if others are positive and they meet diagnostic

criteria, still treat. Note About Gene Xpert: Sensitivity is about 50% for one sample, 65% for two samples. Please send two samples of induced sputum, but remember even 2 negatives with a good clinical history does not exclude TB. Kids are paucibacillary.

32

TB MEDICATIONS 1. Firstcalculateindividualidealdoseperkgofeachdrugis:

Drug DailyDose-mg/kg(maximum)Rifampicin(R) 10-20(600mg)Isoniazid(H) 10-15(300mg)Pyrazinamide(Z) 25-40(2000mg)Ethambutol*(E) 15–25(1200mg)

2. GuidelineshereforPediatricTBmedicationsareprovidedfreeofchargeasdispersibletablets,MOHrecommendeddosesareasbelow:

IntensivePhase:

Patientweight(kg)

RHZ(75/50/150)

E(100)

Howtoreconstitute

<2 5ml Dissolve1RHZtabin20mLcleanwater,whendissolvedadd1crushedEthambutoltab.Usethissolutiontogivemlasindicatedleft

2-2.9 10ml

3-3.9 15ml4-7.9 1 1 Dissolvethenumberof

tablet(s)in20mlofcleanwaterandgiveallthesolutiontothechild

8-11.9 2 212-15.9 3 316-24.9 4 425-39.9 UseRHZE

150/75/400/275

2tabs40-54.9 3tabs>55 4tabs

33

TB MEDICATIONS (Continuation Phase) Continuationphase:

Patientweight(kg)

RH(75/50) Howtoreconstitute

<2 5ml Dissolve1RHtabletin20mLsafedrinkingwater.UsethissolutiontogivemLasindicatedleft.

2-2.9 10ml3-3.9 15ml

4-7.9 1 Dissolvethenumberoftablet(s)indicatedofRHin20mlcleanwater,giveallthesolutiontothechild.

8-11.9 212-15.9 316-24.9 425-39.9

UseRH150/752tabs

40-54.9 3tabs>55 4tabs

3. Finally,addPyridoxineforallchildrenonTBtreatment

Weight Dose(mg) 25mgtabs 50mgtabs<5 6.25 ½tab3xwk N/A5-7.9kg 12.5 ½tabdaily N/A8-14.9kg 25 1tabdaily ½tabdaily>15kg 50 2tabsdaily 1tabdaily

34

TB MEDICATIONS (Disseminated) TreatmentAllchildrendiagnosedwithpulmonarytuberculosissevereenoughtowarranthospitalization(respiratorydistress,severemalnutrition,miliaryTB)shouldbecommencedona4-drugregimen(RHZE)for2months,followedbya4monthcontinuationphaseofRH.

TBmeningitisorbone/jointshouldbetreatedwith2monthsRHZE/10monthsRH

Isolatecoughingchildrengreaterthan5yearsofageorpatientwithcaregiverwhoissymptomaticwithcough.

TBMeningitisForTBmeningitisinchildren<14years,prednisoloneshouldbeaddedwithomeprazole:

o Prednisolone2mg/kg/day(orequivalentdosedexamethasone:0.6mg/kg/24h)for4weeks,then

o areducingcourseover4weeks(taperby1mg/kg/dayperweek)

o ScreeningafterdiagnosisofTBmeningitis● Givefollowupforhearingscreen● NeedtobefollowedupinPediatricFollowupClinic

OtherIndicationsforsteroidsinTB:pericardialeffusion,meningitis,severeLNburdenwithcompression,severemiliaryTB.

35

ASTHMAANDBRONCHIOLITIS

BronchiolitisManagement● Infantsyoungerthan1yearofagewithwheezeanda

normalorhyperinflatedchestx-rayusuallyhaveadiagnosisofbronchiolitis.

● Othertreatmentisconservative,includingoxygenforhypoxia,nasalsuctioning,andIVfluidsiffeedingisimpaired.

● Bronchodilators,hypertonicsaline,adrenaline,antibiotics,andsteroidsareusuallyofminimalbenefitinbronchiolitis

● ConsidertreatingwithsalbutamolONLYIFthereisastrongfamilyhistoryofatopyandasthmaorahistoryofmultipleepisodesofwheezingafterchestxrayandcardiacexamwithliverspan.(withconsultantconsultation)

Asinglenebulizeddoseofsalbutamolmaybetried–arespiratoryrateshouldbedonebeforeandafterwardstoseeifanyimprovementhasoccurredbeforescheduling!

• ORDERSo IVFfluidswithtachypneao O2forhypoxialessthan90%o Scheduledwallsuctioningwith0.5mlnasal

salinepernostrilont-sheetq6ho Attemptcohortingtoavoidhospital

acquiredbronchiolitisinotherpatients

36

AsthmaExacerbationManagement● Asthmaisusuallydiagnosedovertheageof12months,

usuallyinthecontextofrecurrentwheezingillnesseswithdocumentedresponsetobronchodilators.

● AsthmaexacerbationscanbecategorizedasMild,ModerateorSevere–seetablefordiagnosisandmanagement.

● Childrenwithasthmawhorequireoxygenshouldbeadmittedtothehospitalonnebulizedsalbutamolatleastevery4hours.

● ConsiderHDU/ICUadmissionforanychildrequiringmorethan2L/minoxygenor2hourlysalbutamol.

● AnychildwithsevereasthmashouldbeadmittedtoICUMild SaO2>90%on

roomairShortnessofbreathWheezeorprolongedexpiratoryphaseASSESSQ2HOURS

Ifventolininhaleravailablegive:6puffsofinhalerevery20minutesupto3doses*eachpuffrequires4-6breathsbeforegivingnextpuff.1puff=0.1mgIfinhalernotavailable:Nebulizedsalbutamolsingledose:0.15mg/kgdoseor-2.5mg(<5yearsold)-5mg(>5yearsold)Prednisone1mg/kgPO.Reassessafter1hour,ifbetter,maybedischargedhomewith5-daycourseofprednisoloneandregularsalbutamol.

37

Moderate(callCO)

SaO2<90%onroomairRespiratorydistressWheezeASSESSQ1HOUR

O2Nebulizedsalbutamolevery20minfor3doses.(0.15/kg/dose,roundtoclosest2.5mg)Oralprednisone2mg/kgScheduleipratropium250mcg(4puffs)every4hoursandsalbutamolevery4hoursIfoxygenrequiredorpersistentdistress1houraftersalbutamol,admittoward(<2L/minreq)orHDU(>2L/minreq).

Severe(Callconsultant)

SaO2<90%onroomairBarelyaudiblebreathsoundsPalpablepulsusparadoxusCyanosisASSESSATENDOFEVERYNEB(Q15-30)GetchestxrayassoonasarriveinHDU

O2&nebulizedsalbutamolback-to-backFordosingstartwith0.15mg/kgandequivalentamountNS(roundtonearest2.5mg)ifneedcontinuousneb,0.3-0.5mg/kg/hourObtainIVaccess,startmaintenanceIVF.Prednisone2mg/kgpoorifnottolerating,dexamethasone0.6mg/kgIVq24hConsiderIVMgSO450mg/kgover1hourorIMadrenaline0.01ml/kg1:1000forrapiddeterioration.Considerhighflowandaminophyllineinfusionifstilldeterioratingdespitetheabove.

38

SepsisworkupforfebrilepatientsfromOPD(<60daysofage)● History:

● Temperature>38degrees● Subjectivefeverwithirritabilityoranyotherabnormalvitalssigns

● Investigations:● Bloodcx● CBC● Lumbarpuncture(CSFCellcountanddiff,glucose,microproteinandcultureifcells>/=5(notpretreated)withnormalsugar● SterileUAwithurineculture● ElectrolytesandCrifdehydrationorweightloss

● InitialMEDICATION:● Ampicillin● Gentamicin● IncreasedoseforMeningitis(seeHarrietLane)

● Follow-up● InitialIVFifbabynotfeedingwell● CheckCrevery4daysinonGentamicinorAmikacin● Dischargeifnomeningitis(basedoncellcount/CSFglucose)andculturesnegative

39

FEVER&NEUTROPENIAINONCOLOGYKIDSKijabeHospitaldoeschemotherapyforchildrenwithconditionssuchasWilm’stumor,neuroblastoma,rhabdomyosarcoma,andBurkitt’slymphoma. Chemotherapypatients,ornewlydiagnosedoncologyadmissions,shouldbeassumedtobeimmunocompromisedifpresentingwithfeverorothersignsconsistentwithsepsis.LABINVESTIGATIONS

• CBCwithdifferential,andholdbloodforperipheralbloodfilmifrequired

• UrineCulture• BloodCulture

ANTIBIOTICS(givenwithin30minutesofpresentation)o Firstlineceftriaxoneinfirstpresentationorfrom

home>2weekso Firstlineantibioticchoiceforalloncologypatient

currentlyonchemoispiperacillin-tazobactamIVbecauseofGNRresistance

o AddamikacinIVinANC<500ADMISSION

• Oncologyconsultantshouldbecalledonpresentationforeveryoncologypatientforfurtheradviceonadmissionandtreatment

• NeutropenianecessitatesAUTOMATICadmission• SeeMTRHprotocolforinpatientantibiotictx.

40

TrueSEPTICSHOCKatKijabeHospital:first2hours

WellNourished• 5-10/kgbolusx1ofLRorNSover15minwithclose

monitoringofvitals&examwhilefluidisgoingin.• Furtherbolusesdeterminedbyresponseto

therapy.• Ifshockpersistsafter20cc/kg,considerICU

admissionforpressorsupportwithepinephrine(0.1mcg/kg/min)ornorepinephrine(0.1mcg/kg/min)ifnocardiacdysfunction.

• MaystartepiinfusioninCasualtyifanydelayinadmissionandtitrateupevery15minutes.

Malnourished(<-3SDontableweight/age,length/age,weightforlength)beVERYCAREFULwithfluid.

• Ifalteredmentalstatus,coma-startwith10-15ml/kgofD5LR(ifnotavailableD5NS)over1-2hourswithcarefulmonitoring.

• Ifshockbutalert,nobolusandgentlehydrationwith4/ml/kg/hrDNSorD5LR(stopIVFwhenshockresolved)

ANTIBIOTICS:>6monthsCeftazidimeinitiallythenfocusforsource/historyaddinganaerobic/gram(-)coverage

41

DIABETICKETOACIDOSISDiagnosis● History

o Polyuria,polydipsia,weightloss,vomiting,abdominalpain

● Examinationo Alwaysweighthepatient,orestimatefromBroselow

tape.o Newdiagnosis:estimatedegreeofdehydrationas:

5% Reducedurineoutput,tackymucousmembranes

10% drymucousmembranes,sunkeneyes,tachycardia,deepbreathing,reducedskinturgor

15% CRT>3sec,skinturgor>5sec,weakpulses,hypotension,anuria

o Assesslevelofconsciousness

● INITIALINVESTIGATIONSfromcasualty/OPDo FingerprickRBS–glucose>11mmol/LmayindicateDMo Na,K,glucose,Cro Urinalysisandcultureifanyabdominalpain.o Venousbloodgas(ifavailable)–HCO3willdetermine

severityofDKA● Calculatewithinitialaniongap>18● pH<7.10ORHCO3<7,treatwithinsulininfusion

42

TreatmentDKA–CASUALTY/OPD

● Airway:Nasogastrictubeifvomitingandimpairedconsciousness

● Breathing:Oxygen100%byfacemaskifsignsofshock(poorperipheralperfusion).

● Circulation:Ifshockedgive10ml/kgof0.9%Salineover10-20minutesandrepeatuntilcirculationisrestored.*Donotexceed20ml/kgwithoutdiscussingwithpediatricconsultant.

● Insulin● DonotgiveIMinsulintochildrenwithDKA.Theinitialfocusshouldbefluidresuscitation,whichinitselfwillstarttolowertheserumglucoselevel.● InsulinshouldbedeferreduntilinitiallabresultsarebackanddegreeofDKAcanbedetermined(seetablebelow).

● Diagnosis:Categorization(pHandHCO3)

pH HCO3 MANAGEMENTMILD 7.25-7.30 12-17 MaynotrequireIVinsulinor

IVFMOD 7.10-7.25 7-12 Willprobablyrequireinsulin

infusionandHDU/ICUadmission

SEVERE <7.10 <7 RequiresICUadmission,insulininfusionandIVF

43

TreatmentDKA–ICUMonitoring● Hourlyvitalsigns● Hourlyneurochecks(cerebraledema)

● Notifyforheadache,recurrenceofvomiting,bradycardia,worseningmentalstatus

● Urineoutputviacather● HourlyRBSifoninsulininfusion● Labs

● Na,Kevery4-6hoursuntilacidosishasresolved● Venousgasevery4-6hours● Creatininedaily

IVfluidso Resuscitation:ifshockedgive10ml/kgof0.9%Salineover

10-20minutes,thismayberepeatedifnecessarybutshouldnotexceed30ml/kg.ThisshouldusuallyhaveoccurredinCasualtypriortoarrivalinICU.

o Replacement:clinicalestimatesoffluiddeficitinDKAhavebeenshowntobeinaccurateandmayoverestimatethedeficit.InmoderateDKA-use5-7%dehydration;InsevereDKA-use10%dehydration.

o Fluidmanagementshouldbeginwith0.9%Salinewith4mmol/KClper150mLburetteofpediatricfluids(foratleastthefirst4-6hours),ataMaintenance+(deficitover48hrs)

o IfIVfluidshavebeengivenelsewhere,priortoassessment,thevolumeshouldbeincludedinthefluidcalculations

o Inseveredehydrationandacidosisonlyallowsipsofwateroricetosuck(includeinfluidbalance)

44

TreatmentDKA–ELECTROLYTEMANAGEMENT

● Sodiumo Ifhypernatremiaispresent(correctedNa>150mmol/L)

fluidmanagementshouldbeginwith0.9%Salineandcorrectionoffluidandelectrolytedeficitshouldbeover48-72hours.

o Remember:CorrectedNa=measuredNa+2x[(glucose–5.5)÷5.5]Rememberthatatoorapidfallinserumsodiumwillpredisposetocerebraledema-aimforafallofnomorethan10mmol/Lper24hours.

● Potassiumo Insulinadministrationandthecorrectionofacidosiswill

drivepotassiumbackintothecells,decreasingserumlevels.Thereforepotassiumreplacementshouldalwaysprecedeinsulintherapy,unlesshyperkalemiaoranuriaispresent.

o IfserumK<2.5mmol/Ladminister1mmol/kgofKClslowlyover1hourIVwithcardiacmonitoring.WithholdinsulinuntilK>2.5mmol/L

o IfserumK2.5-3.5mmol/Ladminister6-9mmolKClper150mLburetteofIVfluidsandmonitorKhourly

o IfserumK3.5-5.0mmol/Ladminister4-6mmolKClper150mLburetteofIVfluidstomaintainKat3.5-5.0mmol/L

o IfserumK>5.0mmol/LdonotgiveIVKCL.MonitorKhourlyuntilK<5.0mmol/L,thenadminister4-6mmolKClper150mLburetteofIVfluidstomaintainserumKat3.5-5.0mmol/L

45

TreatmentDKA–INSULININFUSION

● Insulin

o Insulinisrequirednotonlytopushglucoseintracellularly,buttocorrecttheacidosis.

o Insulintherapyshouldnotbestarteduntilthecirculatingvolume(i.e.peripheralperfusion)hasbeenrestored,theserumpotassiumisknownandappropriatepotassiumreplacementhascommenced.

o Rememberthatduringthefirst60-90minutesofrehydration,thebloodglucosemayfallsubstantiallyevenwithoutinsulintherapy

o InsulinDose:● 0.1units/kg/hr(50unitssolubleinsulindilutedin50mlsof0.9%Saline,1unit=1ml).● Alowerinsulindosageof0.05u/kg/hrmaybe

consideredinchildren<5yrsofage(moresensitivetoinsulin)andinchildrenwithknowndiabeteswhohavealowerbloodglucoseduetopartialinsulintreatmentpriortopresentation.

● Keepinsulininfusionuntilacidosisresolved!

o Afterresuscitation,thedesiredrateoffallinbloodglucoseis4-5mmol/hour

46

GLUCOSEandFLUIDADJUSTMENT

o WhentheRBSfallsto12-15mmol/L,add5%DextrosetotheIVfluidstokeepbloodglucoseinthedesiredrangeof8-12mmol/L.IfnecessarymoredextrosemaybeaddedtotheIVfluids

o Theinsulininfusionshouldnotbestoppedorreducedbelow0.05u/kg/hruntiltheacidosishasresolvedi.e.venousCO2>15.

TransfertoORALFluidsandSUBCUTANEOUSInsulin:o Oralfluids-inseveredehydrationandacidosisonly

allowsipsofwateroricetosuck(includeinfluidbalance).Oralfluidsshouldonlybeofferedaftersubstantialclinicalimprovementandcessationofvomiting(mildacidosisandketosismaystillbepresent).WhenoralfluidsaretoleratedtheIVfluidsshouldbereduced.

o Insulin-Theinsulininfusioncanbeincreasedtocoveroralcarbohydrateintakepriortothecommencementofsubcutaneous(SC)insulin.Thebasalinsulininfusionrateisusuallydoubledfor30minutesforsnacksand60minutesformeals.TransfertoSCinsulinandthepediatricwardcanbemadewhentheacidosishasresolvedandoralintakeistolerated.

47

TreatmentDKA/DIABETES–PEDIATRICWARD

● ChildrenwithnewlydiagnosedmildDKAorthosetransferredfromICUmaybestartedonSCinsulinandadiabeticdiet.

● Insulinfornewlydiagnoseddiabeticsisusuallydosedat0.8units/kg/day.(0.8xwtinkg)o 2/3ofthisdoseshouldbegiveninthea.m.asMixtard

70/30o 1/3ofthisdoseshouldbegiveninthep.m.asMixtard

70/30● RBSshouldbeorderedat6am(beforebreakfast),atnoon

(beforelunch),at6pm(beforedinner)andatmidnight.● Remember:the6pminsulindosecontrolsthemidnight

and6amRBSlevel.Thuseachmorningthepediatricconsultantshouldlookatthemidnightand6amRBSonroundsanddecide6pminsulindosewillbe.Similarly,the6aminsulindosecontrolsthenoonand6pmRBS.Thusthenoon&6pmRBSshouldbereportedtotheon-callpediatricconsultantat6pmforadecisionastothenextmorning's6amdoseofinsulin.

● Slidingscalesshouldrarelybeusedinchildren-

donotusewithoutaconsultant'sinput.Ifused,aruleofthumbthatmaybehelpfulisthefollowing:Takethechild'sestimatedtotaldailyinsulindose.Foranewlydiagnosed30kgchild,thiswillbe30x0.8=24unitsperday.Divide80bythedailydose:80/24=3.3

48

Thisnumberishowmuch1unitofregularinsulinwilllowerthechild'sbloodsugarby.Tightcontrolinanewdiabeticisdifficult,sogoalRBSshouldbe6-10.Soaslidingscaleforthischildwouldbe:Bloodsugarlevel

Action

<4 Givesugarcontainingbeverageifconscious;Give2-5mL/kgD10IVifalteredconsciousstate

4-7 Nil7-10 Nil11-13 Give1unitregularinsulinSC13-16 Give2unitsregularinsulinSC17-19 Give3unitsregularinsulinSC>19 Give4unitsregularinsulinSC

49

STATUSEPILEPTICUSINKIJABECheck RBS , if below 2.5 give glucose bolus of D10 2-5ml/kg

100% Oxygen. Secure Airway. Treat fever. Check Na/Ca. Treat aggressively with AEDs.

NEONATES: load with Phenobarbital 20mg/kg , can repeat in 10 upto max of 40mg/kg. Consider phenytoin. CHILDREN: Diazepam 0.2 mg/kg/dose* IV over 1-2 min or 0.5 mg/kg/dose PR x 2 (max 10 mg; rapid onset, but more hypotension and respiratory depression) OR Midazolam 0.2 mg/kg/dose IV/IM/buccal – (max 7 mg) or May REPEAT above Benzodiazepines q 5-10 minutes up to 3x IF STILL SEIZING……. Phenytoin* load 10-20 mg/kg over 20-30 minutes (may cause low BP, especially with fast administration) – onset 5-10 minutes IF STILL SEIZING…….. Give an additional 5-10 mg/kg Phenytoin Phenobarbital load 10-20 mg/kg over 10-15 minutes- onset 15-30 minutes - high risk for respiratory depression and hypotension IF STILL SEIZING Phenobarbital additional 5-10 mg/kg IF STILL SEIZING…….. Consider Levetiracetam 40 mg/kg ng load on empty stomach IF STILL SEIZING. .Midazolam load 0.2 mg/kg then infuse 2-6 mcg/kg/min

50

SNAKEENVENOMATIONINKIJABESnakebiteisuncommoninKijabe,butlocalspeciesinclude:

● Hemotoxic-puffadders,Kenyahornedviper,Gaboonvipers,sawscaledvipers,boomslang

● Neurotoxic-spittingcobras● Neuro/Cardiotoxic–mambas

ThereisanantivenomavailableinKenyacalled“FavAfrica”fromSanofi.Ittreatsenvenomationbyalloftheabovesnakes(exceptforBoomslangwhichrequiresSAIMRBoomslangantivenom).ThecostisaboutKsh10,000per10mlamp,andinitialdosingforallagesis20ml(remember,theantivenomdosetreatsacertainamountofsnakevenom,whichisindependentofbodyweight).OnlyonevialiskeptinKijabepharmacyforemergencies,soas

onevialisgivenotherswillneedtobeordered.FavAfricaisimportedbyLaborexKenya(ph2542215876;2542217028;254722203040,emailevelyn.otieno@laborex-kenya.cominNakuru.Whenantivenomisavailable,administerpermanufacturer’sdirections.Atestdosewillneedtobegivenbeforethefull2vials,asallergicreactionispossible.

51

SNAKEENVENOMATIONINKIJABE(continued)Ifsuspiciousofenvenomationandantivenomisrequired,ensurethefollowingstepsarealsotaken:1. Immobilizetheaffectedextremityatorbelowthelevelof

theheart.Donotuseatourniquet,butuseelasticbandagestotheentirelimbtoreducelymphaticdrainage.

2. AdmitthechildtopediatricHDUforfrequentmonitoring.3. Placereferencemarksformeasuringcircumferenceof

affectedextremitytoenvenomationsite.Measureevery15minandtraceleadingedgeofswellingwithskinmarkers.

4. Ifhemotoxicenvenomationlikely(puffadders,Kenyahornedviper,Gaboonvipers,sawscaledvipers),sendCBC,PT/INR,PTT.

5. Removeringsandconstrictiveitems6. ObtainIVaccessinunaffectedlimb(2sitesarepossible)7. Vitalsignseveryhouruntilcontrolofenvenomation

achieved8. Forseverepain,givemorphine0.1mg/kgIVevery2hours

PRN9. Formildtomoderatepainuseparacetamol10. Fornausea,considerondansetron~0.15mg/kgSL(roundto

nearest2mg)

52

NEONATOLOGY

TERMADMISSIONSTONURSERY● RiskofSepsis(>1riskfactorsconsiderruleout)

o PROM>18hourso Peri-partummaternalfevero Chorioamnionitiso Pretermwithspontaneouslaboro Donotadmit,noculturedone,butdodangersignscounselingwithmomandschedule48-72hourfollowupatMCH/preferredfacilityo AddtoSpreadsheetonNurserycomputer

● RuleoutSepsis(startantibiotics)o Anyneonatalfever/hypothermia(<35.8rectal)o Sodium>160o Significantresuscitationo ProlongedO2requirementatbirth(>4hours)+Cxrayo >1maternalriskfactors(seeabove)o Orders:Bloodculture(BCxonlyifDOL1),CBC,UA,UCx,CSF

● RiskofHypoglycemia(notadmittedifRBSnormal)o Weight>4.2kgo Infantofadiabeticmother,IUGR/SGAo Orders:StatRBS,q2hourRBSx4,12hr,24hrs,ifanyneedforD10(3/kg),startD10atmaintenanceforage

● RiskofJaundice(notadmitted)o Rhesusnegativemomso Orders:DCTandBloodGroup,Cordbloodbili,6hourbili,24hourbili

● Concernforhypernatremiao Weightlossinnewborn>7.5%o Orders:Na,K,Cr,IfNa>150,thenmaintenanceIVF+EBM

53

PRETERMADMISSIONSEveryeffortshouldbemadeforcoordinationbetweenOBandPedstoensureorganizedresuscitationofapretermbaby

• AllmomsanddadsshouldbecounselledonpretermcomplicationssuchasRDS,NEC,IVH,andexpectedlengthofstaypriortodelivery

• InKijabeweresuscitateallbabiesborn>500gmwitheyelidsthatarenotfused

• Pretermadmissionorders• Surfactantforanybaby<1000gm/<28wgawithin

thefirsthour(docounselingbeforedeliveryifpossible)andupto3times.Seebelowforspecifics.

• PlaceonCPAPimmediatelyindeliveryroomafterinitialresuscitation

• If<1300gm,placeUVCandcheckplacementbyx-ray(shouldbeinIVCasitentersrightatriumimmediatelyabovediaphragm)

• Incubatorcarewithouthumidification• Minimalhandling• Suctioningeveryshifttoclearnose• NGplacedfortrophicfeedsstartingat48hr

● TPNforpretermsdiscussedbelowalongwithadvancementoffeeds

● Meds:Amp,Gent,AminophyllinedosedperHarrietLane● Studies:CBC,BloodCulture,Chestxray

54

FLUIDS,ELECTROLYTES&NUTRITION

IVFluids

Day1

Dailyincrease

Maximum(totalfluidsIVF+feeds)

Term(>37wksGA)

60ml/kg/d 20ml/kg/d ~150ml/kg/d

Preterm(<37wksGA)

80ml/kg/d

20ml/kg/d ~180-200ml/kg/d

Extremepreterm(<1000gm)

100ml/kg/d 20ml/kg/d ~180-200ml/kg/d

OnDay1and2IVFshouldbeD10Wonly.OnDay3addelectrolytes-changeto4/5D10+1/5NS.

● IVcomponentshouldrarelyexceed130ml/kg/dduetoriskofPDA(exception:Hypernatremiawithnomilk)

● Rarelyincreasetotal(Feeds+Fluids)to>150ml/kg/dwhileonIVFduetoincreasedriskofPDAandhighglucoseloadusingD10.

● Afterday5,ifneonateisNPO,IVFforpreterm130/kg/dayandterm150/kg/day.

● MayincreasetomaximumtotalIV+POof200cc/kg/dayasneededtooptimizeweightgainwhentoleratingfullenteralfeeds.

55

NEONATALElectrolyteRequirementsGlucose

● WantRBS>2.5● Glucoseinfusionrateadequatewithabove4ml/kg/day

Sodium● Withholdininitialfluidsbecauseofriskofhypernatremia● Typicaldailyneed3meq/kg/d

Potassium

● RarelyaddedtoIVFforsafetyconcerns.● Typicaldailyneed1-3meq/kg/day

Calcium

● Majorityofcalciumistransferredinthethirdtrimester,thuspreterminfants(<34weeks)havelowtotalbodycalciumlevelsandareatriskforneonatalricketsevenwhenserumlevelsareinnormalrange.

● Beginningonday3oflifeadd200mg/kg/daydividedintototalIVfluidinfusiongivenandcontinueuntilpatienton100cc/kg/dayfeeds.(NoteCaGluconateisinmgnotmeq.)

● Caution:Calciumcanbecaustictoveins● Addsupplementationwithoralcalcium/vitaminDwhen

weswitchtofullfeeds.

56

NEONATALNutrition

● Expectedweightloss:upto7.5%inlargepretermsandterms,10-15%inVLBW(<1500g)infants.

● WeighinfantdailyoraltdaysifunstableonCPAP● Shouldregainbirthweightby2weeksofage● Frequency:>1500gmormultiplesq3hfeeds,otherwise

q2hfeeds

Feedingrequirementguidelines

BW Initialfeedvolume Dailyincrease

<1250g 5-10ml/kg/d 20ml/kg/d1250-1500g 10-15ml/kg/d 20ml/kg/d>1500g 20ml/kg/d 20ml/kg/d

*ifbabyistoleratingfeedswellwithlowresiduals(<50%),considerincreasingvolumemorefrequentlythanonceaday(suchaseveryotherfeed).

Caloricneeds

<37weeksgestation >37weeksgestation

Kcal 115-130kcal/kg/d 100-120kcal/kg/dProtein 3-4g/kg/d 2.5-3g/kg/dGain 15-20g/kg/d 25-30g/d

Thereisoftensomedailyvariabilityinweightgain,socalculatea3-dayaveragewhichshouldbeapproximately1-2%ofbodyweightperday.

57

NEONATALNutrition

Tocalculatecaloriesababyisreceiving:

● IVfluids:D10W (0.1gdextrose/ml) 0.34kcal/ml4/5D101/5NS (0.08gdextrose/ml) 0.27kcal/ml

● Breastmilk/Termformula(Nan,etc) 0.67kcal/ml• FortifiedEBM:

PreNan/Nutriprem¼scoopper20mlsyringeEBM6kcal/¼scoopFM851scoopper20mlEBM 3.4kcal/scoop

● Pretermformula 0.8kcal/mlConsiderfortificationoffeedsforVLBWbabies(BW<1500gm)oncethebabyhasreachedfeedsof150ml/kg/dofenteralfeeds

58

Supplementsforbabiesborn<37weeksgestationor<2kgBW

Allsupplementsareusuallycontinueduntilthebaby1yearold.DonotstartIron/MVIbeforefullfeeds.

VitaminK● Allbabiesshouldreceivesoonafterbirth-ifbornat

homeshouldreceiveonadmissionif<14daysold● Dose:1mgIM(>1.5kgBW);0.5mgIM(BW<1.5kg)

Iron:2-6mg/kg/dofelementaliron/d.● SupplementinVLBWinfantoncefeeds>130ml/kgare

achieved.● Donotstartironuntil2weeksofage.● Itisimportanttonotewhichironsupplementisbeing

providedbypharmacy.o FerroBcontainsgreenironcitrate(200mg/5ml),

whichis13%elementaliron(5.2mgelementaliron/ml)–usualdose0.5-1ml/daybesuretocalculateactualdose.

o Ferroussulfate100mg/5mlis20%elementaliron(4mgelementaliron/ml).

59

Multivitamin:● MixavitInfantdrops:0.6ml/day(containsVitA5000iu;

VitD400iu;B11.5iu;B21.2mg;B60.5mg;VitC50mg;Nicotinamide10mg)

● Regularmultivitamin2.5mL/day(5mlcontainsVitA2500iu;VitD250iu;B11mg;B20.5mg;B60.5mg;B122mcg;d-panthenol0.5mg;niacinamide5mg)

● AbidecMultivitaminDrops:1ml/daycontains(1333IUretinol,400IUergocalciferolsolution,0.4mgthiaminehydrochloride,0.8mgriboflavin,0.8mgpyridoxinehydrochloride,8mgnicotinamide,and40mgascorbicacid)

● Lasomin-Z:0.5ml/day.1mlcontainsVitB11mg;VitB20.5mg;nicotinamide10mg;VitaminA2500iu;ascorbicacid40mg;Zinc13.3mg;VitaminE2.5iu;Vitd3200iu;Dexpantenol15mg;lysine10mg

CalciumandVitaminD:OnfullfeedsstartZedCal2.5mldaily.VitaminDSupplementation:VitaminDrequirementsareVitaminD2400IU/d.MakesureMVI+ZedCalisadequateatdischarge.

Folate:2.5mg/week

60

NeonatalHypoglycemia2Evaluation● Riskfactors:3

LGA,SGA,InfantofDiabeticMother,<37wksor>42wks,5minuteAPGAR</=5,temperature<36degreesonadmission,sepsis

● StatRBS,q2hourRBSx4,ifanyneedforD10(RBS<2.4),startD10atmaintenanceforage

● Donotforgettofeedearly(assoonaspossibleafterbirth)andfrequently(every2-3hours).

● Whenbloodsugarischecked,itshouldbedonebeforeoneofthefeedings(notshortlyafter).

● SymptomsofHypoglycemialethargy,poorfeeding,irritability,emesis,tachycardia,jitteriness,cyanosis,seizures,respiratorydistress,apnea,tempinstability,tachypnea,pallor.

● CHECKBLOODGLUCOSESTATifthereareSYMPTOMS

2Rozance,P,Hay,W.HypoglycemiainNewbornInfants:FeaturesassociatedwithAdverse

Outcomes.BiolNeonate2006;90:74-86.3AsymptomaticSGAbabies,postdatebabiesandprematures>35weeksshouldbechecked

immediatelyshouldnothaveanydelayinbreastfeeding,considercheckingimmediatelyafterbirthandfeedingsoonthereafter.

61

Treatment:NeonatalHypoglycemiaBloodglucose Action*Ifsymptomsofhypoglycemiaarepresentatanytime,actionshouldbetakenirrespectiveofmeasurebloodsugarlevel>2.5mmol/L(nosymptoms)

Breastfeed/syringefeedCheckPRNifsymptomsoccur

2–2.5mmol/Lbeforefeeds

FEEDIMMEDIATELYEBMor10ccofD10orallyifmomnotavailableandnotifyPedsRCOIFnosymptoms&babyactive,alertandvigorousTHEN,Re-checkbloodglucoseq1huntilRBS>2.5ontwoconsecutivepre-feedingchecks,thenprnsymptoms.Ifbloodglucose<2.5afterfeed,startIVF

<2mmol/Lwithorwithoutsymptoms

Administer2.5ml/kgIVD10(notethisdiffersfromthe5ml/kgusedforolderinfantsandchildrenwithhypoglycemia).Feedimmediatelyifawake,alertandabletobreastfeed.Ifunabletobreast-feedbesurebolusisfollowedbyglucoseinfusionatarateof6-8mg/kg/min=3.6-4.8ml/kg/hrofD10(use4ml/kg/hrasquickestimate).Re-checkbloodglucosein20to30minutes.

PersistenthypoglycemiadespiteD10infusionwithGIR6-12mg/kg/min

CallPEDIATRICCONSULTANT-considerconcentratingashighasD12.5%viaperipherallineforhigherconcentration,willneedcentralline-MonitorGIRanddonotincreasemorethan2mg/kg/mininordertopreventinsulinsurgeandreboundhypoglycemia.-Towean,decreasebyGIR1-2or1-2mL/hr,witheachq2-3hourpre-prandialglucosecheck.-IfRBSbelow2.5,gobacktopreviousrate.

ConsiderGlucagoninfusionpersistentdespiteinterventionsabove.

62

NeonatalHypoglycemia:Dextrosefluids Formulas make stronger dextrose concentrations:

Add the volume of 50% dextrose to D10 to make total 100ml

Desired conc. Volume of D10 Volume of D50 D12% 95ml 5ml D14% 90ml 10ml D16% 85ml 15ml D18% 80ml 20ml D20% 75ml 25ml

Add the volume of 50% dextrose to 0.9%NS to make 100ml Desired conc. Volume of NS Volume of D50

7.5% 85ml 15ml 10% 80ml 20ml 12% 76ml 24ml 14% 72ml 28ml 16% 68ml 32ml 18% 64ml 36ml 20% 60ml 40ml

63

NeonatalHyperglycemia• If RBS >20mmol/L → treat any underlying cause → reduce glucose infusion rate to 6 mg/kg/min → consider start insulin (if hyperglycemia persists despite previous 2 interventions) – CALL CONSULTANT

• For insulin therapy, start at 0.05units/kg/hr Ø Do not include insulin drip to total fluid volume intake Ø Check RBS in 1 hour from initiation, after a dose change,

and discontinuation of insulin • Glucose monitoring during insulin infusion:

If RBS is at… When to recheck… >15mmol/L Repeat in 1 hr >15mmol/L on repeat check Increase insulin dose by

0.01unit/kg/hr 10-15mmol/L Repeat in 1 hr 10-12 mmol/L on repeat check

Decrease insulin dose by 0.01unit/kg/hr

< 10 mmol/L Discontinue insulin drip and repeat in 1 hr x 3

• INVLBW,hyperglycemiaisassociatedwithIVH,NEC,andlateonsetsepsis

• Glucoseinfusionrate(GIR)(mg/kg/min)=[rate(ml/hr)x%dextrosex0.166]÷wt(kg)

64

NeonatalHypernatremicDehydration

FrequentlytherearepresentationstoKijabeHospitaloftermbabieswithover20%weightloss,severedehydrationandshock.Severehypernatremiacarriesasignificantriskofcerebraledemaiflevelsdropmorethan10mmol/Lper24hours,andsuchbabiesmusthaveconsultantoversight.INITIALSTEPS● Headtotoeexaminationforsignsofinfection,

dehydration,congenitalanomaly,andshock.● ImmediateconsultantorCOnotificationforsignsof

shock/weightlossover15%● StartIV.Ifskinpinch>2secandCRT>3sec,then

10ml/kg0.9%NSbolus● Considerasecond10/kg0.9%NSbolusifsignsofshock

havenotimprovedin30min,butdonotgivemorethan20/kgintotalboluses.

● NasogastrictubeasfoleyformeasurementofUOPif>15%weightloss

● Initialorders:CBC,Na,K,Cr,Urea,BloodCx,UrineCxwhenurineobtained,Bilirubin(T/D),VBG

●

65

NeonatalHypernatremicDehydrationMedications• CommenceIVampicillinandcefotaximeuntilcreatinineis

known(changetoGentamicinifCrnormalizes)• IfPlatelets<50,000,docefotaxime+piperacillintazobactam

forCSFandgramnegativecoverage• Renallydoseallmedications• StartAminophylline1mg/kgIVbidx5daystoimproverenal

afferentcirculationifCr>1(77)

InitialFluidrehydration(beforelabsback)● %Weightlossshouldbecalculated

BirthWeight–Currentweight=deficit.Deficit/Birthweight=%weightlosso Ifbirthweightisunknown,aclinicalestimateof

dehydrationshouldbeusedtoestimatewtlosso Fluiddeficit/maintenanceshouldbegivenasIVF

withD5NSuntiltheinitialsodiumlevelisknowntoavoidcerebraledema,thenadjustedwithNaresulted

● EstimatedNabasedonPercentageWeightLoss:KijabedataFORMULA:{1.34x(%wtloss)}+145

o 7%-12%:150-160o 12%-15%:160-170o 15%-20%:170-180o >20%:>180

No matter total replacement required,

DO NOT exceed 180ml/kg/day IVF or 200 ml/kg/day in total fluids- more than this risks cardiac overload.

Better to max at 200ml/kg/d over more days!

66

NeonatalHypernatremicDehydrationManagementwhenSodiumResulted(callconsultant>160)INITIALLOCATION

● ICU:Na>180● HDU:Na>160● Floor:Na>150withnormalK/Cr/MentalStatus

FLUIDTYPEandRATE

Na IVfluidtype Deficitover(hrs)>170 D5NS 96155-170 1/2D101/2NS 72<155 4/5D101/5NS 48

Total fluid rate = {deficit / hours as above} + daily maintenance fluid rate (see page 54)

FEEDSà IfnobloodyaspiratesonNGinsertion,thefirst20

ml/kg/dayshouldbegivenasNGfeeds(EBMorformula)à Increasedailyastoleratedtofullfeeds(watchfor

refeeding)INVESTIGATIONS● Na160-180:q12hourNa● Na>180,q8hrNaandK● Crevery24hours

67

NeonatalHypernatremicDehydrationAdditionalOrders

• CranialUltrasoundwithin24hoursifNa>170• CheckRBSandseeNeonatalHyperglycemia

protocolforRBS>20mmol/l• Hyperkalemia,ifpresent,shouldbetreated

accordingtostandardprotocolsfoundintheHarrietLaneHB.

• IfCr>2,placeNGtubeasfoleycathetertomonitorstricturineoutput

Ifnourineoutputat24hours,refertoKNHwithcalltoNephrologistorMPShahifinsuranceorcivilservant

68

TotalParenteralNutrition(TPN)o TPNisveryexpensiveandrunstheriskofcomplicationssuch

assepsis,centralvenouscathetercomplications,cholestaticliverdiseaseandhyperlipidemia.

o Goalsforoptimalnutritionforbabies:BabieswhoaresolelyonTPNonlyrequire80-100non-proteinkCal/kg/d.ForthoseonamixofenteralfeedsandTPN,caloriesshouldbecloserto120kCal/kg/d.

o TPNuseshouldbelimitedtoprematurebabies(<30wga,<1300gm)whoareatriskforextrauterinegrowthrestriction(EUGR)andneurodevelopmentaldelayaswellasthosewithsurgicalneedssuchasgastroschisis,atresias,andileuswhereenteralnutritionwillbecompromisedforextendedperiodtime.

o ItshouldonlybestartedafteradiscussionwithaPediatric,PediatricSurgicalorIntensiveCareConsultant.

o Ifcentralline(UVC)isplaced,itspositionmustbeconfirmedviaCXRpriortoinfusion.

o ComponentsofTPNatKijabeo AminoAcids(protein)-Aminosteril8%o Lipids(fat)-Intralipid20%o Dextrose(carbohydrates)-UseDextrose50%(D50%)o TraceElements-Peditraceo SolubleVitamins-Soluvito Electrolytes(Na,Cl,K,Ca,Ph,Mg)-normalsaline,KCL,calcium

gluconate,magnesiumsulfideo Sterilewater

69

TotalParenteralNutrition(TPN):StartingProteinAminosteril8%• PretermNeonate:

• startwith1-1.5g/kg/day• advance0.5-1g/kgeachdayastoleratedtogoal• goal=3.5-4g/kg/day

• TermNeonates,infant:• startat1-1.5g/kg/day&advance0.5-1g/kg/daytogoal• goal=3g/kg/day

• Child&adolescents(considerKabiven19startingat25/kg)• startat1-1.5g/kg/day&advance0.5-1g/kg/daytogoal• goal=2-3g/kg/day

• Cautions• Moreinproteinlosingenteropathy• StopinrenalfailureifBUN>30mmol/L

FATIntralipid20%• PretermNeonates:

• startwith0.5-1g/kg/day• advance0.5g/kg/day• goal=3g/kg/day• Monitortriglyceridelevelsdailyif<1kg,unstablesepsis,steroids-keep

below2.5mmol/L• Termneonates,infantandchild:

• startwith1g/kg/day• advanceby0.5-1g/kg/dayastolerated• goal=3g/kg/day• checkTGwhenatgoal,keepbelow2.5mmol/L

• Cautions• Infantsonphototherapyforjaundice-considerlimitinglipidsto0.5-1

g/kg/day(increasedriskofkernicterus)• Infantsonlong-termPNmaydevelopPNassociatedliverdisease

(PNALD)duetoinflammation&cholestasisfromIVlipidtherapy• PNALDshouldbeconsideredwhenconjugatedbilirubinis≥25mmol/L• Therapyislimitingintralipidto1g/kg/day• SomeVLBWinfantswithPNALDmayrequire2g/kg/dayforgrowth

70

TotalParenteralNutrition(TPN):StartingCarbohydrateD50%• PretermandTermNeonates:

• startwithaGIRof4-6mg/kg/min• advance1-2mg/kg/mindailyastoleratedbyRBSchecks(or2.5%

dextrose)• goalGIR=11-12mg/kg/min• monitorRBStrendsandurineketones(ifhyperglycemia)• needminimumofD5%inTPNtoavoidketosis

• InfantandChild:assesstolerancetocurrentdextroseandadvance1-2mg/kg/min(or5%)dailyastolerated

• GIRcalculation• IVrate(mL/hr)xDextroseconcentration(%)x0.167• weight(kg)

• Cautions• Advanceinsmallincrementsinheadtraumaandadolescents• Withfastadvance:fattyliver,AST,ALT

GIRMaximumRatesAGE GIRMaximum(Mg/kg/min)Pretermneonate 12-15Termneonate 141moto1yr 121yearto7years 10>12years 7

ELECTROLYTES(addday3oflifeandadjustbasedonlabs)• PretermNeonates:

• sodium(normalsaline)=2-4meq/kg/day• potassium(KCL)=0-2meq/kg/day• calcium(calciumgluconate)=200mg/kg/day• adjustbasedonlabdata

• TermNeonates:• sodium(normalsaline)=2-4meq/kg/day• potassium(KCL)=0-2meq/kg/day• adjustbasedonlabdata

71

TotalParenteralNutrition(TPN):WritingOrderoncedailybefore3pm,pickedupbynurseat5pm

1. Peditrace:

a. order:1bottle,infusion,10days,1vialb. Underboth“PharmacyNotes”and“PatientNotes”type:“forTPN-see

AminosterilOrder”2. Soluvit:

a. Order:1bottle,infusion,10days,1vialb. Underboth“PharmacyNotes”and“PatientNotes”type:“forTPN-see

AminosterilOrder”3. Electrolytes:

a. Order:1bottle,infusion,10days,1vialb. Underboth“PharmacyNotes”and“PatientNotes”type:“forTPN-

seeAminosterilOrder”c. InformnursingelectrolytesarefortheTPNandnottogiveseparatelyd. DonotaddphosphoroustoTPN,itwillprecipitate

STOPPINGTPN

● Stoplipidswhentolerating80ml/kg/dayEBM● StopTPNwhentolerating100ml/kg/day

72

NEWBORNRESPIRATORYMANAGEMENT

ApneaofPrematurity● AminophyllineisavailableatKijabehospitalforinfants

withAOP.Itsusemaybeconsideredininfants<34weeksGA,andwillusuallyberequiredforinfants<1500gm.

● Dose:8mg/kgloadingdose,then2.5mg/kg/doseBDmaintenance

● Aminophyllinecanusuallybediscontinuedby34wksiftherehavebeennoapneasfor5-7days.(mayrequireupto37weeks)

● Changeaminophyllinetooralwhentoleratingfeeds.

Oxygensaturationsandaltitude● Kijabeislocatedatanaltitudeofalmost2250meters.

Neonatesbornatorabove2100metersexhibit"normal"oxygensaturationlevelsbetween91%to96%ratherthantheexpected97%foundatsealevel.Thesereferencevaluesforvaryingaltitudescanguideclinicianstoavoidhypoxemiaorhyperoxia.(RavertP,DetwilerTL&DickinsonJK.Meanoxygensaturationinwellneonatesataltitudesbetween4498and8150feet.AdvancesinNeonatalCare2011Dec;11(6):412-7)

73

NasalCannulaandFiO2inNeonates

ThelowestpossibleFiO2shouldbegiventoprematurebabiestomaintainSaO2of90-93%.SmallerbabiesreachaFiO2of100%withverylittleflow.Thusif1L/minof100%O2hasbeenreachedfora1kgbaby,thereisnoreasontoincreaseflowrate,butconsidertransitioningthebabywithrespiratorydistresstonasalbubbleCPAPorventilatorsupportifnotacandidateforCPAP.Flow 1kg 2kg 3kg 4kg Child0.25L/min 31% 27% 26% 21%0.5L/min 61% 41% 34% 31% 22%1L/min 100% 61% 47% 41% 25%2L/min 100% 100% 74% 61% 29%3L/min 100% 100% 100% 80% 33%Thistableadaptedfromequations(3)and(4)in:BenaronDA&BenitzWE"MaximizingtheStabilityofOxygenDeliveredViaNasalCannula"Arch.Pediatr.AdolescMed148:294-300,March1994

Facemask/NRBshouldneverbegivenwith<5Lofflowandshouldbeusedasabridge,notfinalsolutionforoxygenation.

74

BubbleCPAP• NasalprongbubbleCPAPhasbeenausefuladjunctinmanagement

ofourpretermbabies.DatasuggeststhatearlyCPAPadministrationisaseffectiveasprophylacticsurfactant,thusprophylacticCPAPshouldbeconsideredforinfantsasriskforRDS(NEJM2010;362:1970-9.)

● ConsiderCPAPfor:respiratorydistress,atelectasisonCXR,apnea/bradycardiaofprematurity,meconiumaspiration,BPD,tracheomalaciaorforrespiratorysupportafterextubation.

● Contraindications:congenitaldiaphragmatichernia,tracheo-esophagealfistula,cleftpalate,choanalatresia,omphalocele,gastroschisis

● Specialconsiderations:inanydiseasethatcausesdecreasedpulmonarybloodfloworincreasedexpiratoryresistance,CPAPmaybeharmful.Usewithcautioninmeconiumaspiration,pulmonaryhypertension,TetralogyofFallot,bronchiolitisandconsiderlowerPEEPof2-4cmH2O

● Nasalprongsizesshouldbe:(donotcut!)<700gms Size0

700–1000gms Size11000–2000gms Size22000–3000gms Size33000–4000gms Size4

>4000gms Size5

● InitialsettingsforCPAP:

Flow-5-10L/minPEEP–usually5cm/H2O(bluetubeis5cmbelowthesurfaceofthewater),if>8,considerventilatorFiO2–aslowaspossibletomaintainSaO2>90%

• WeanPEEPbasedonSilvermanAndersonScore(seeabove)

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Surfactanttherapy● Ourpharmacysurfactant,whichcostsbetween20,000-40,000KSH

per4-6mL(dependingonsupplier)andisnotcoveredbyNHIF.● Risksandbenefits(pneumothorax,pulmonaryhemorrhage)should

becarefullyexplainedtotheparentsbeforeadministration(ideallypriortodeliveryofthebabywherepossible).Specificconsentforthecostofthemedicationshouldbeobtained&documented.

● Ifthefamilycannotaffordsurfactant,buttheclinicianfeelsthatitmaybealife-savingdrug,consideraccessingtheKijabeHospital“NeedyChildren’sFund“topayforavialfortheparents.

CONSIDERPROPHYLACTICSURFACTANT• Foranyinfantbornatlessthan28weeksgestationwhoappear

vigorousatdelivery(<1hour–immediatelyonarrivaltonursery)• Forinfants28-30wksgestation

o ifantenatalsteroidshavenotbeengiventomomo ORinfantrequiressignificantresuscitationinthedelivery

room,andtheinfantcontinuestohaveO2requirement>30%• Astreatmentforanyinfant<36wkswhohasrespiratorydistress

withanO2requirement>30%&achestx-rayconsistentwithRDS.• ForanyinfantatriskofRDSwhoisdeterioratingtothepointof

requiringintubationandventilation

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GIVINGSURFACTANTDose:100mg/kg,givenviaETTin2-3equalaliquots.• Baby’soxygenationshouldbeoptimizedwhilethe

Surfactantiswarmedtoroomtemperature(~5minholdinginthehand,or20minoncountertop).

• Thefulldoseshouldbedrawnintoasyringe,Attach5Ffeedingtubetothesyringeandprime.ForsmallsizeETT(<=2.5)thatwillnotallowpassageof5Ffeedingtube,thesurfactantmaybeadministereddirectlyintotheETTfollowedbybaggingtodistributethedose.

• Thedoseshouldbegivenin2-3equalaliquotswiththebabylyingsupine(evidencenolongersupportslyingontherightthenleftsides)

• Ensurethefeedingtube(ifused)isfeddowntheETTtojustproximaltotheETTtip.

• instilleachaliquotover2-3seconds• ventilatethebabymanuallyforatleast20-30secondsin

thatposition• Allow1-2minutesrecoverytimebetweenaliquots,ensuring

theSaO2isadequatebeforenextdose.• Extubateafteradministration.Ideally,thebabyshouldnot

besuctionedforatleastthenext2hours(preferably4-6hours).

Upto3dosesmaybegiveninthefirst72hoursoflife.Its

efficacyafter2dosesand3daysiscontroversial.Thebaby’sFiO2requirement,ifmeasured,shouldbeatleast10%higher

thanafterthefirstdoseofsurfactant.

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PersistentPulmonaryHypertensionoftheNewborn(PPHN)● Definition-Persistenceofthenormalfetalinutero

circulationpatternofelevatedpulmonarypressuresandthusminimallungbloodflow,withshuntingofbloodrighttoleftacrosstheductusarteriosusorforamenovaleduetofailureofnormaldropinpulmonaryresistanceafterbirth.

● Risk:MAS,asphyxia,surfactantdeficiencyinterminfants

● DiagnosisofPPHN–infantwithatriskconditionandlabileoxygenation.

o Pre(righthand)andpost-ductal(lowerextremity)saturationdifference>10%

o Nodifferenceinpreandpost-ductalsatsdoesnotexcludePPHN

o Echocardiogram● Goal–preventorreverseshunt

o Decreasepulmonarypressures▪ Oxygen-anticipatePPHNinatriskpatientsand

aggressivelyimproveoxygenationwithO2,CPAP,ventilation.Untilbloodgasesareavailableaimfor100%saturationinthesepatients

▪ Sildenafil1-2mg/kgviaNGevery6hours

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MeconiumAspirationSyndromewithPPHN▪ Preventacidosis–goalisnormalpH,not

alkalosis.CanusehyperventilationorNaHCO31meq/kgslowIV

▪ Sedation–Fentanylinfusiononceintubated1-3mcg/mg/hr(canaddMidazolambuttargetMAP50-60)

▪ Paralysis–pancuroniumorrocuroniumifintubated&neededformovementconsultantuseonly.

▪ Sildenafil-1-2mg/kgviaNGevery6hours.o Increasesystemicpressures–Ideallywouldliketo

raisesystemicpressuresaboveknownpulmonarypressurevalues,howeverinoursettingpulmonarypressurevaluesarenotavailable.Thus,suggestDopamineinfusiontotargetgoalMAPin50-60s.▪ DopamineInfusion-Dose5-15mcg/kg/min

(seeCriticalcarehandbook)▪ Beginlowandtitrateupwardsbasedonclinical

response.DobutamineandNorepihavebeenshowntohelpaswellinsmallstudies.

o Treatunderlingcause–antibiotics,surfactant

● PatientswithPPHNareextremelylabileforthefirst3to4days.Weaninterventionsslowlyinreverseorderinwhichtheywerestarted.Weanoxygenbyintentionalsteps,notbysaturations–aninfantcan

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suddenlydropfrom100to50%saturatedwithasmallchangeinoxygendelivered

● Patientsoftenhavetherapyofchoice–somerespondbettertooxygen,orhighermeanBP,orsedation–observewhatworksbestforanindividualinfant.

● HarrietLaneSildenafildosinginPulmonaryhypertension

● PO:0.5-3mg/kg/doseQ6-12hr● IV(casereportfromneonates>34wkand<72hour)ICU

● Startwith0.4mg/kg/doseIVover3hr,followbyinfusionof1.6mg/kg/24hrforupto7days

MaternalHIV(notadmitted)• HIVpositivemotherswillusuallyhavebeenstarted

onHAART• AllbabiesbornofHIVpositivemothersshouldhave

PCRsentatbirthandagainat6weeksofage• BothAZTandNVPshouldbestartedatbirthfor6

weeks,thenNVPuntil6weeksaftercompletecessationofbreastfeeding(seeMoHguidelines)

• Age/Weight DosingNVP DosingAZT<2kg 2mg/kg/doseOD 4mg/kg/doseBD2-<2.5kg 10mg(1ml)OD 10mg(1ml)BD>2.5kg 15mg(1.5ml)OD 15mg(1.5ml)bd

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NEONATALSEPSIS

NeonatalRuleOutSepsis(Symptomatic)PresentationSymptomsandsignsofsepsisinaninfantafterDOL1maybeverynon-specificandrequireahighindexofsuspicion.Thesemayinclude:● Temperatureinstability,fever>38&hypothermia<36● Lethargy/irritability● Tachycardiaintheabsenceoffever● Perfusionchanges–mottling,pallor,coolextremities● Vomitingandabdominaldistension● Respiratorychanges–apnea,tachypnea,newonset

distress,O2requirement>4hours• Anybabyrequiringsignificantresuscitationatbirth• Meconiumaspirationsyndrome(O2requirement)• Pretermwithoutmaternalfactors• Sodium>160• Considerwith>1riskfactorsforRiskofsepsis*Ifanyofthesesymptoms/signsarepresent,asepsisworkupshouldbestronglyconsidered,evenintheabsenceoffever.DefinitionofFever:Rectaltemperaturesarethestandardfordetectingfeverininfantslessthanthreemonthsofage.● Fever=arectaltemperatureof38ºC(100.4ºF)

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o Bundling:Bundlingofinfantsinclothingorblanketsgenerallycausesanelevationinskintemperatureratherthanrectaltemperature.

o Fevermaybeattributedtobundlingintheinfantwithnohistoryoffever,whoappearswell,hasanormalphysicalexamination,andwhoserectaltemperatureis<38ºCimmediatelyafterunbundling.GroverG;BerkowitzCD;LewisRJ;ThompsonM;BerryL;SeidelJ.Theeffectsofbundlingoninfanttemperature.Pediatrics1994Nov;94(5):669Bundledinfantsvsunbundledinfant.Themeanskintemperatureofbundledinfantsincreasedby2.67degreesC/hr;meanrectaltemperatureincreasedby0.06degreesC/hr.Themeanskintemperatureofnonbundledinfantsincreasedby1.5degreesC/hr;meanrectaltemperaturedecreasedbylessthan0.01degreeC/hr.Comparingbundledinfantstononbundledcontrols,therewasasignificantriseinskintemperature(P=.0001)butnotinrectaltemperature.

SeriousBacterialinfection(SBI)● Neonatesmaymanifestfeverastheonlysignof

significantunderlyinginfection4● Theincidenceof(SBI)ishigherininfantslessthan

threemonthsofage,particularlythoseunder28days,thanatanyothertimeinchildhood.

● 7%ofallfebrileinfants(>39ºC)under3monthsofagehadaseriousbacterialinfection(SBI)(bacteremia,bacterialmeningitis,bacterialpneumonia,skinandsofttissueinfections,osteomyelitis,bacterialgastroenteritis,septicarthritis,orurinarytractinfection5),viralinfectionbeingthemostcommoncauseoffever.

● TwostudiesperformedaftertheintroductionofvaccinationagainstHIBfounda13%incidenceofSBIinfebrileneonatesunder29daysofage.

● Oneobservationalstudyfoundthatthe98infants(under3monthsofage)withtemperature≥40ºChada29percentabsoluteincreaseinprevalenceofSBI(38versus9percent).

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BacterialPathogens● AKenyanstudyof552positivebloodculturesrevealedthe

mostcommonpathogensidentifiedininfantswithbacteremiaincluded:<7daysofage:Ecoli13%,Acinetobacter10%,Klebsiella10%,S.aureus9%,GroupBStrep7%;>7daysofage:GroupAstrep13%,S.pneumo11%,Saureus11%,GroupBstrep10%,Kleb9%,Acinetobacter9%.

SourcesofInfection● OffebrileinfantsevaluatedforanSBI,theincidenceofboth

bacteremiaandbacterialmeningitisdecreasedwithincreasingage:o 3and1.1%respectively,ininfants0–1monthofage;o 1.4and0.4%respectivelyininfants>1–2monthsofageo 0.7and0%ininfants>2–3monthsofageo UTIisthemostcommoncauseofSBI,althoughinthe

firstweekoflifeitisquiteuncommon.● UTIandageofneonate

● UTItypicallypresentsinthesecondweekafterbirthinterminfantsandlaterinpreterminfants.

● AlthoughUTIisunusualduringthefirst3daysafterbirth,wetestallsymptomaticinfants>24hoursofage.

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Sepsisworkupforsymptomaticinpatientneonate:● ObtainCBC,bloodcx,UA,urinecxandlumbarpuncture● StartampicillinandgentamicinIVwithinonehourof

presentation(seetablefordoses).● Urinecultureif>24hours.Urineshouldbeobtained

byeitherin/outcatheterorsuprapubicbladderaspiration.ThereisahighrateoffalsenegativeUAinthisagegroup,thusurinecultureshouldbeusedasthegoldstandard.(+)Nitritesbutnot(+)LEareconsiderapositiveUA.

● Ifthebabyisafebrileandfeedingwell,andblood/urine/CSFculturesarenegativeat48hours,THENpatientcanbedischargedhome.

● Ifthesecriterianotmet,treatwith7daysAmp/Gent.● Urineculturepositive:treatforatleast7daysif

pansensitive,10daysifMDR.● Bloodculturepositive:treatfor10days● BabieswithpositiveWBC(>5)orpositiveG(+)CSF

culturesshouldbetreatedfor14days(or21daysforGramnegativepathogens.

● LPshouldberepeatedifnotimprovedafter48hoursorifculturepositiveatday10toconfirmtheinfectionhascleared.

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Sepsisworkupfor“septiclooking”neonates● Iftheneonatehassignsofsepticshock(poorperfusion

withprolongedCRT,weakorboundingpulses),assess&treatABCswithoxygen,normalsalinebolus10mL/kg.

● Bloodculture&CBCshouldbedrawnimmediately,andAmpicillin/Gentamicincommencedassoonaspracticallypossible(within1hour).

● Ifthebabystillhasweakpulsesafter1-2normalsalineboluses,considerationshouldbegiventostartingpressors(epiornorepi)

● Lumbarpunctureandurinecultureshouldbeperformedassoonasthebabyisclinicallystable.

● AmpicillinandGentamicinshouldusuallybecontinuedforatleast7daysifpatientpresentedwithsepticshock.

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KijabePediatricAntibiogram2016-2018

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NeonatalHYPERBILIRUBINEMIA6Evaluation:NB:IfjaundiceissevereorthebabyhasANYsymptoms,putbabyunderphototherapywhileawaitinglevels.

● Anybabyinthenurserywithclinicaljaundiceshouldbeevaluatedwiththefollowing:o Totalbilirubin/Directbilirubin;o Hemoglobinlevel.

● IfababyisseverelyjaundicedorMaternalbloodgroupisOorrhesus-,orifthebabyisanemic,thenobtain:o Cordbloodatdeliveryifpossibleo DirectCoombstest(DCT)andBloodgroup

● Furtherinvestigations(suchassepsisworkup,LFTsetc)shouldbeperformedforanybabywithexchangelevelbilirubins,risingbilirubin>5daysoflife,directbilirubinmorethan20%oftotalbilirubin,oraspertinenttohistoryoffeverorothersepsisriskfactors.

6Managementofhyperbilirubinemiainthenewborninfant35ormoreweeksofgestation.Pediatrics2004;114:297.

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PhototherapyIndications in term babies Forbabieswithagestationalageof35+weeks,thenomogrambelowshouldbeused:(usemiddlelineassumingG6PDwithunknownprevalence)

Ifthecurrentbilirubinleveldoesnotmeetcriteriaforphototherapy,thebilirubinlevelshouldberecheckedaccordingtothefollowingnomogram:

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GUIDELINEFORRISKOFNEEDINGINTERVENTIONFORJAUNDICE

Highrisk:recheckT-biliin6-12hours Highintermediaterisk:recheckT-biliin24hours Lowintermediaterisk:recheckT-biliin24-48hours

Lowrisk:recheckT-biliasneeded Indications in preterm babies ● Forbabieswithagestationalageoflessthan35weeks

andapostnatalageoflessthan7days,indicationsaremorecontroversialandshouldalwaysbediscussedwiththeconsultant.

● RefertoNIHJaundicetreatmentchartsonNurseryDesktopforspecificlevelsinpreterms.

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● Thetablebelowisareasonableindication:Gestage Phototherapy

level(TBinmg/dL)

Weight

(grams)

Phototherapylevel

(mg/dL)<28

weeks>5

500-1000

5-7

28-29weeks

6-8

30-31weeks

8-10 1000-1500 7-10

32-33weeks

10-12 1500-2500 10-15

>34weeks

12-14 >2500 >15

22,28;HarrietLaneHandbook.Monitoring while under phototherapy: ● Ifphototherapyisstarted:

o Ensuregoodeyeprotectionwithoverhead.o Skinmustbeexposedinorderforphototherapyto

beeffective–ensureonlyasmallnappy,therestofthebodymustbenaked.

o Continuefeeds.Iftotalbilirubinisrapidlyrisingorclosetoexchange,giveEBMviasyringewhilepatientisunderphototherapytominimizetimewithouttherapy.

● Ifphototherapyiscommenced,ordertotalbili(+/-directbili)forfollowingmorning

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● Iftotalbilirubinisrapidlyrising,approachingexchangelevel,ifortherearesignsofhemolysis(+DCT,lowHb)totalbilirubinshouldbemonitoredafter6hoursofintensivephototherapyandhydration.

● Generalphototherapyguidelines:● ensurethedistancebetweenthebabyandthelights30cm(andnomorethan45cm)● considerreplacingthelightbulbsifusedformorethan6months(orusagetime>2000hrs)● Turnchildfromtimetotimefromsupinetoprone● Makesuretomonitorthebaby’stemperatureatleastevery4hours.

● Intensivephototherapy:considerbankanbiliblanketwithreflectivesurface.

IVIG/ExchangeTransfusion● Immediateinterventionwithexchangetransfusionis

recommendedif:o Infantshowssignsofsevereacutebilirubin

encephalopathyoro Bilirubinis>30(513)

● TheKenyanMoHrecommendationssuggestIVIG/exchangetransfusionifbabyhasgestationalage<37wksANDageis72hoursormoreif:Bilirubininmicromole/litre≥gestationalage×10

i.e.Bilirubininmg/dlx17.1≥gestationalagex10

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● NomogramforIVIG/exchangetransfusionforbabies

withagestationalage35+wks:

● Forbabieswithagestationalage<35weeks,IVIG/exchange

transfusionshouldbedoneatthediscretionofthepediatricconsultant,andwillusuallybedoneforanybabyexhibitingneurologicsignsofhyperbilirubinemia.

Thetablebelowmayalsoserveasaguide:Weight(grams) BilirubinLevel

(mg/dl)Bilirubin/Albumin

ratio(mg/g)500-1000 12-15 4.0-5.21000-1500 15-18 5.2-6.01500-2500 18-20 6.0-7.2>2500 >20 7.2-8.0

Datafrom:HarrietLaneHandbook(bilirubinlevels)andAhlfors,CR,Amin,SB,Parker,AE.Unboundbilirubinpredictsabnormalautomatedauditorybrainstemresponseinadiversenewbornpopulation.JPerinatol2009;29:305

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● Ifababyhasbeenadmittedfromanoutsidehospitalandtotalbilirubinis<5mg/dLaboveIVIG/exchangelevel,firstplaceunderintensivephototherapy(seeabove)withaggressiveIVFhydrationandrepeattotalbiliin6hours.

● Duringthistime,donotremovepatientfromphoto.

IVIG–dosingandprocedure• InformtheparentsofthecostofIVIG–around20,000KSH

for2.5gramvialor37,000for5gmvial.Parentsmaybeaskedtobringcash–butdonotdelayadministrationifcashisnotavailableandthefinanceteamcanassesslater.

• IVIGdose:500-1000mg/kg/doseover6-8hrs(easiesttoroundtonearest2.5gor5gascomesin5gvials)

• Beginat0.01mL/kg/min(0.6ml/kg/hr),doublerateevery15–30min,max.of0.08mL/kg/min(4.8mL/kg/hr).

• Monitorcontinuouslyforadverseeffects(tachypnea,tachycardia,hypotension).Ifadversereactionsoccur,stopinfusionuntilsideeffectssubside,andmayrestartatratethatwaspreviouslytolerated

Exchange Transfusion - Procedure:

● BloodshouldbeOnegative,oratleastRh–equivalentofbaby’sblood,andfreshwholeblood

● Ifthebabyisafewdaysoldandtheumbilicalstumpisdried,youmayneedtorequestthepediatricsurgicalteamtoobtainaUVCorfemoralline

● Exchange2timesthebloodvolumewholeblood(~160ml/kgtotal).

●

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Exchange Transfusion – Procedure Continued ● Ifthebabyhasareasonableumbilicalstump,asknurses

forexchangetransfusionkit.Inadditiontothekit,youwillneedequipmenttoplaceanumbilicalcatheter:

o anumbilicalcatheter-use5Frsinglelumenumbilicalvenouscatheteror5FrNGT

o an11bladeo 3-5x5ccsyringes(toflushline)o an18gneedle(todrawflush)o a3-4.0nylonstitch(tosuturecatheterinplace);o 2threewaystopcocks,ando onetegaderm

● Thenurseswillplacebabyonresuscitaireandimmobilize.TheywillalsoplacebabyoncontinuousmonitoringandplaceanNGTandevacuatestomachcontents.PatientwillhaveaPIVwhereIVFwillcontinuetoinfuse.

● Placeumbilicalcatheter(seeHarrietLaneHandbookforprocedureandmeasurementoflengthofinsertion).Ifunabletoobtainanumbilicalline,procedurecanbeperformedviafemoralline(femorallineneedstobeareasonablesize,largerthana24GIVcannula,otherwisetheexchangewilltaketoolong).

● Freshbloodispreferablebutwholebloodisokay.● Exchangeslowly(2-3ml/kg/min)in15-20mlaliquots● Calciumcitrateisusedasananticoagulantinwholeblood.

Onedoseofcalciumgluconate100mg/kg(1mL/kg)shouldbegivenIVmidwaythroughtheexchangetransfusion.

● Aftertheprocedure,ordertotalbili,directbili,CBCwithdiff,CrandCa.

● Patientcanfeed4hoursafterprocedure.

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PERINATALASPHYXIA● Definedasevidenceofmetabolicacidosisandearlyonsetof

neonatalencephalopathyintheabsenceofotheretiologies(infection,traumaetc).

● Oftensuggestedintrapartumbysuddensustainedfetalbradycardiaorabsenceoffetalhearttonesinthepresenceofvariable,persistentorlatedecelerations;Apgarscoreof</=5atgreaterthan5minutesoflife.

● Ifpatienthas5minuteAPGAR</=5,mechanicalventilationdoesnotimproveoutcomeandshouldnotbeinitiatedinoursetting.(Considercordgasifpossible.)

ThompsonScore

The HIE score (Thompson score) is a clinical tool comprising of a set of clinical signs associated with CNS dysfunction. It is used to assess status of a child following birth asphyxia [10–13]. ... Infants with score 1–10 are considered to have mild HIE, 11–14 have moderate HIE and 15–22 are considered to have severe HIE

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PERINATALASPHYXIAcontinued● SanartClassification:

o StageI–hyperalert,uninhibitedMorolasting<24ho StageII–obtunded,hypotonic,decreased

spontaneousmovemento StageIII–stupor,flaccid,seizures,hypertonic.

● Management–WedonothaveadequateabilityfortemperaturemonitoringinKijabetofollowaprotocolforactivehypothermia.

● However,afterresuscitationofapossibleasphyxiatedbabydoNOTactivelyrewarm,I.e.donotturnonresuscitaireheater(maydopassivecoolingto35).

● Work-up:RBS,bloodculture,CBCatbirth,andNa,K,Cr,andSGOTat48hours.Considercordgasifpossible.

● Medications:● ConsiderPhenobarbital15mg/kgIVloadifMod/Severe

then3-5mg/kg/dIVdividedq12(maintenance).● Forpersistentseizures,additionalphenobarbitalboluses

mayberequireduptoacumulativemaximumof40mg/kg.Forbreakthroughseizuresonphenobarb,givediazepam0.1mg/kgIVover3-5minnomorethan12hourly.

● Feeding:holdfeedsfor24hoursbecauseofriskofintestinalischemiaandsubsequentNEC.

● Aminophylline:incaseofsignificantapnea,consideringloadingandmaintenancedoseofaminophylline

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HEARINGSCREENINGScreeningshouldhappenoneverybabythatisborninKijabe

Foroutbornbabies,ENTdepartmentatKijabewillperformotoacousticemissionscreeninghearingtestsonat-riskbabies.Theseinclude:

● BW<1500grams● Gentamicin/Amikacincourse>72hours● Meningitis● Anoxicbraininjury● Craniofacialabnormalities● Babieswhohavereceivedexchangetransfusionor

IVIG● SuspectedordocumentedTORCHinfection

Arunninglistofbabiesrequiringscreeningshouldbepostedinthenurserytofacilitatetheteamfindingat-riskneonates.

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PATENTDUCTUSARTERIOSUS(PDA)IbuprofenoralforPDAclosure:Indications:● Ifclinicallyyouthinkyouhaveahemodynamicrelevant

PDA(watchifnoclinicaladverseeffects)● Murmur@2ndintercostalspaceleftsternalborder● Bounding(pronounced)pulses;palmarpulses● Oxygenrequirement>25-30%;● Oxygensaturationsthataremorefluctuantthanusual

(e.g.1minute100%,theotherminute75%)● NB:IfECHOnotavailable,PDAdependentheartlesion

muchlesscommoninpretermbabiesthanPDA.Dosing:● Oralregimen:

o 10mg/kgasfirstdoseo 5mg/kgasseconddose(24hoursafterfirstdose)o 5mg/kgasthirddose(24hoursafterseconddose)

● AdministrationofIbuprofensyrup:Dilutetheamountin2mlofNS,giveviaNGtube.Afterthat,flushtheNGwith2mlofNormalSaline.(thisalsodilutestherelativelyhighosmolalityofthesyrup).

● Moststudiestreatonday3-4oflife,butatKijabepossiblyday5-6oflife(orlateriftheproblemariseslater)-bestdonewithinthefirst7daysoflife.Ifyoudoitlater,itwillbelesseffective.

● IftreatingPDA,alsoconsiderfluidrestrictionuntilthePDAisclosed(nomorethan150ml/kg/dayoftotal

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intake).Ifgrowingwell,thenrestrictevendownto120ml/kg/day.Considerfortifiers

● ContraindicationsfortreatmentofPDAwithIbuprofen:o Knownintraventricularhemorrhagegrade3or4o CurrentsuspicionofNECo Platelets<60000o Activebleeding(e.g.bloodystools)o Creatinine>1.7mg/dl

● Retreatment:o IfafterafullcoursethePDAhasnotclosedandis

clinicallyrelevant,considerasecondcourse(10mg/kgeachtime,24hoursapart)orparacetamol(seebelow)

o ifstillpatentandsignificant,anechoshouldbedone(ifnotdoneearlier).IfasignificantPDAisconfirmedthensurgicalPDAligationisneeded.

o ConsidertransfusiontomaintainHbof15gm/dlOralparacetamol(acetaminophen)forPDAThe literature suggests that paracetamol 15 mg/kg/dose q6h for 3 days is effective in closing PDAs in preterm babies in between 72.5% to 81.2% of cases. (Le J, Gales MA, Gales BJ. Acetaminophen for patent ductus arteriosus. Ann Pharmacother. 2015 Feb;49(2):241-6. )

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CRITICALCAREPROTOCOLS

RESPIRATORYCARE

CPAPIf the baby is has a reasonable respiratory effort with CPAP and has a relatively low oxygen requirement, then it is safer to use CPAP than intubation (unless the baby has multiple apneas on CPAP). Babies managed on CPAP rarely have issues with low CO2. If a baby’s respiratory effort becomes significantly labored with severe thoracic retractions despite CPAP, then it is likely a more significant ventilation (CO2) or oxygenation problem and intubation may be needed. Consider surfactant as adjunct in Neonates Contraindications: CDH, recent intestinal surgery.

Age

Central

Line

Chest Tube

Foley NG Suction

ETT at gum

LMA size

1 -6 mo 4-5 10-12 6 8 8 9-10 cm 1-1.5 1 yr 4-5 16-20 8 10 8 12 cm 1-2 2 yrs 5 18-20 8 10 8 14 cm 2 4 yrs 5 18-22 10 12 10 15 cm 2-3 6 yrs 5 20-22 10 12 10 15 cm 3 8 yrs 5-7 20-24 12 14 10 18 cm 3-4

10 yrs 7 24-34 12 16 12 18 cm 4-5 12 yrs 7 24-34 12 16 12 20 cm 5 Adult 7 24-34 14-18 18 12-14 20-22

cm 5

ETT size: (age in yrs/4) + 4 ETT Distance to gum: ½ age + 12 or 3X ETT Size

Cuffed ETT for all significant resp disease – may need to subtract ½ size

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HIGHFLOWNASALCANNULAHNFChasbeenshownto:

• Reduceworkofbreathing • Significantlyreduceintubationrates:Re-intubationrateswent

from37%to7%inthelargestPICUstudytodate• ReducePICUlengthofstay• Provideslow-levelpositivepressure(PEEP)andaidsinlung

recruitment• ExactamountofPEEPisvariable(2-5cmH2O)anddependson

flowrates,nasalcannulafittonares,andwhethermouthisopenorclosed

• ProvidesCO2“washout”ofrespiratoryphysiologicdeadspace• Warmthandhumiditykeepsecretionsmoist,improve

mucociliaryclearance,andinhibitinflammatoryreactionsandnasopulmonarybronchoconstrictionreflexestriggeredbycoldanddryair

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HIGHFLOWNASALCANNULA

*Weanby1LPMevery2hoursifabovecriteriamet!

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INTUBATION:SIZESandSUPPLIESFor neonates, ETT size can be estimated by dividing the gestational age in

weeks by 10, and taped at a depth of 6 + weight (kg). The following table may be a more precise guide:

Gestational age

Weight (gm)

Laryngoscope ETT size Depth at lip (cm)

23-24 500-600 Miller 00 *

2.5

5.5 25-26 700-800 6 27-29 900-1000 6.5 30-32 1100-1400

Miller 0 * 3.0 7

33-34 1500-1800 7.5 35-37 1900-2400 3.5 8 38-40 2500-3100 Miller 1 8.5 41-43 3200-4200 4.0 9

6mo to 2y Miller 1 3x Tube diameter 2year to

teen Miller 2 (Age+16)/4

Adults Miller 3 * Infants <1000 gm usually only intubated to give surfactant but are not ventilated.

For older children, ETT size can be calculated using the following formula: ETT = (Age in years) + 4 4 Depth of insertion at the lip for oral intubation can be estimated at:

3 x ETT size (cm)

Measure Cuff pressures every shift if cuffed.

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INTUBATIONSEQUENCEDRUGSPRE-INTUBATION: Preoxygenate with 100% oxygen for at least 3 minutes. Have available: Good IV, suction, oral airway, alternative ETT and blade sizes, proper LMA. Cricoid pressure prn and in rapid sequence. Have NS available for hypotension with PPV. (asthma, dehydration, etc.) STANDARD RAPID SEQUENCE – CONSULTANT MUST BE PRESENT Atropine 0.02 mg/kg IV (min. 0.1 mg; max: child 1 mg) (<1yr c succ)

Ketamine 1-2 mg/kg IV Succinylcholine 1-2 mg/kg IV OR Vecuronium 0.1-0.2mg/kg IV Midazolam 0.1-0.2 mg/kg IV (after intubation) STANDARDSEQUENCEAtropine 0.02 mg/kg IV (min. 0.1 mg; max: child 1 mg) (<1 year) Fentanyl 3-6 mcg/kg IV OR Morphine 0.1 mg/kg IV Midazolam 0.1-0.2 mg/kg IV Vecuronium 0.1-0.4 mg/kg IV OR Rocuronium 1 mg/kg IV ASTHMA (Think fluid bolus first) Atropine 0.02 mg/kg IV (min. 0.1 mg; max: child 1 mg) (<1year) Ketamine 1-2 mg/kg IV Vecuronium 0.1-0.4 mg/kg IV HEMODYNAMIC INSTABILITY (Think fluid bolus!) Atropine 0.02 mg/kg IV (min. 0.1 mg; max: child 1 mg) (<1year) Ketamine 1-2 mg/kg IV Vecuronium 0.1 mg/kg IV HEAD INJURY Atropine 0.02 mg/kg IV (min. 0.1 mg; max: child 1 mg) (<1yr) Or Lignocaine 1mg/kg IV or to the cords Phenobarbital 20 mg/kg IV (If Normotensive) OR Ketamine 1-2 mg/kg (If Hypotensive) Vecuronium 0.1-0.4 mg/kg IV (only if normotensive)

Ketamine, Morphine, Midaz, Vecuronium can all be given IM if no IV. Atropine may be given via ETT. Consider Lignocaine 1 mg/kg IV for all older

children and adults prior to sedation and paralytics

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VENTILATORMANAGEMENTGE Ventilators Our nurses are extremely helpful in setting up the ventilator initially and running calibration.

How to set the ventilator up initially (generally): 1. FiO2 to meet desired saturation goals 2. Rate 20-40 3. PIP to ensure TV of 6-8/kg 4. PEEP 5 For a preterm less than 32 weeks: start with PIP 23 / PEEP 5 For a term neonate or any child: start with PIP 20 / PEEP 5 Then change settings (within a few minutes) according to stiffness of the lung (oxygen requirements, x-ray, chest rising clinically)

• FiO2 should be set as required. Aim for as low a FiO2 as

tolerated for SaO2 90-95, except in pulmonary hypertension when SaO2 97-100 are preferable. No premature baby should have 100% saturations if on supplemental oxygen to avoid damage to eyes and lungs – sats 88-90% is acceptable at Kijabe’s altitude of 7000 ft.

Respiratory Rate/ I-time • As a general rule of thumb, the ratio of inspiratory to

expiratory time should be 1:2. • Appropriate respiratory rate: for respiratory distress

syndrome in a premature ~40bpm; for a term baby with meconium aspiration ~30bpm; for a toddler ~25bpm, for a child ~20bpm, for a teenager ~15bpm

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• Do not let expiratory time go below 0.5 seconds, so if the set rate is >60 (rare) then decrease inspiratory time instead.

• The baby should ideally "over breathe" the ventilator by around 10-15 breaths per minute.

• If a baby was vigorous prior to intubation and the respiratory rate has been set to 40/min and the baby is not over breathing after around 20 minutes, then the rate should be decreased

• In a healthy lung (e.g. neurologic injury/seizures), the set rate may need to be lower (20-25/min in a term neonate).

Pressures • Set the PEEP (“Expiration”): 5-8 is usually adequate for

a term baby (start at 5) • Set the PIP (“Inspiration”): 17-27 is usually adequate for

a term baby (17 for a health lung, 22-27 for meconium). On GE vent this is added to PEEP (so if PEEP is 5, goal 17 total, set PIP to 12)

• Optimal tidal volume is 6-8/kg. Set the pressures to optimize tidal and monitor chest rise, which should be a smooth physiological movement up and down.

• Lung compliance (stiffness of the lung) can change within a few hours in the same baby, so spontaneous respiratory rate, tidal volume, and chest rise should be monitored frequently to see if rate or PIP need to be altered

Monitoring & Extubation • ETT should be suctioned regularly. Poor

humidification of inspired gasses while intubated can lead to dried secretions causing airway obstruction.

• Small HME filters are available which trap an infants' own vapors during expiration which then humidify the

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following inspiration. These filters should be changed every 1-2 days

• Blood gases are available in Kijabe and should be measured once the baby is stable on the ventilator. The desired range for arterial CO2 in a premature or term baby is 40-60 mmHg, never less than 35.

• If a baby is breathing well spontaneously over a low set rate of 20-25 with minimal pressures and FiO2, extubation can usually occur from those settings

Minute volume in mL = tidal volume x frequency ÷1000 - tidal volume for a child: ~6-8 mL/kg - respiratory rate: for an adult: 12/min, for a 15 year old: 15/min, for a 6 year old: 20/min, for a 1 year old: 25/min, for a 3 month old 30/min e.g.. for 6 year old, 20 kg child: MV = 7x20 x 20 ÷1000= 2

1

Ventilation Summary Table (child)

Healthy lung:

Sick lung:

PEEP 5 > 5 (up to 10, rarely up to 15 in adults only) (the more oxygenation problem, the higher the PEEP needs to be)

Insp. Pressure above PEEP

10 Around 20

Peak pressure (check plateau pressure daily)

15 Around 25 or higher

Desired tidal volume

7cc/kg 7cc/kg

Use pediatric HME filters for humidification and warming for all patients.

2

ANALGESIA&SEDATIONFORVENTILATION

Narcotics: FENTANYL INDICATIONS FOR USE: Used for sedation in ventilation and post trauma pain control and neonates AVAILABLE AS: AMP 100mcg/2ml (50mcg/1ml) DOCTORS ORDER: Order in mcg/kg/hr (eg. 1mcg/kg/hr to attain adequate sedation) USUAL DOSE: Neonate and younger infant 1-5 mcg/kg/hr (tolerance may develop); Older infant and child 1 mcg/kg/hr; titrate to effect; usual infusion range 1-3 mcg/kg/hr

Minimum rate is 0.5 ml/hr (0.5mcg/kg/hr) and maximum rate is 5 ml/hr (5mcg/kg/hr) for neonate and 3ml (3mcg/kg/hr) for child

3

Narcotics: Morphine Morphine • Should be strongly considered for any intubated trauma patient,

who by the nature of their injuries will have pain. • Signs of pain in a sedated patient include tachycardia,

hypertension, dilated pupils and agitation (although these may be also signs of airway obstruction so monitor airway patency closely).

• IV boluses: May be required initially in doses of 0.05-0.1mg.kg IV in order to gain initial pain control, but repeated boluses may cause hypotension and myocardial depression. * For non-intubated patients, consider ordering morphine every 3-4 hours PRN. For anyone with long bone fracture in the first 48 hours of hospitalization, converting to oral morphine/paracetamol as tolerated. * Also consider regional anesthesia where appropriate rather than systemic opiates (such as a fascia iliaca block for femur fracture).

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61 mcg/kg/min

100 mlx x Wt

(kg)=

mg drug

1 ml/hr

BENZOS:MIDAZOLAM

INDICATIONS FOR USE: Used for sedation in ventilation and status epilepticus AVAILABLE AS: AMP 5mg/5ml (1mg/1ml) DOCTORS ORDER: Doc should order in mcg/kg/min (e.g. 0.5-1mcg/kg/min to attain adequate sedation) USUAL DOSE: Neonate <32 wk gestation: 0.5 mcg/kg/min >32 wk gestation 1 mcg/kg/min Infant and child 1-2 mcg/kg/min TO CALCULATE DRIP RATE:

1. Calculate milligrams of Midazolam in 100ml of NS to run at 1mg/kg/min= 1ml/hr

2. Divide milligrams obtained in above equation by 2 to calculate the milligrams/50ml syringe.

3. Draw up appropriate mg of drug and add to NS to equal 50 ml total (eg if 5mg, then draw up 5ml of and add to 45 ml of NS)

• Note that benzodiazepines do not have a sedative effect on all children – around 1/6 may have a paradoxical reaction with agitation which is independent of dose.

• IV boluses: May be required to facilitate rapid sequence intubation. Doses range from 0.1 mg/kg for mild sedation to 0.3 mg/kg IV for

deep sedation, but note that hypotension is a dose-dependent side effect and caution should be used in trauma patients.

5

INOTROPES/PRESSORS

Note: Give adequate volume resuscitation first. Vasopressors/inotropes will only work if a patient is not hypovolemic. In very unstable patients pressors may be started while volume is being given.

Consider for children with self-limited illnesses with a good prognosis, such as acute onset of septic shock or anaphylaxis

Central venous pressures are not able to be measured, nor are arterial pressures. Children for whom pressors are considered to be of likely benefit must have appropriate sized blood pressure cuffs for q15 min measurement of MAP. All drugs dosed in mcg/kg/minute should be mixed according to the rule of 6’s found in front cover of the Harriet Lane. Our infusion pumps run 50cc syringes, so you will divide your final number in half to get the amount in 50cc

6

TypesofShockandPressorTreatment©HLHType of Shock

HR Pre load

CardiacContrac

SysVR

Treatment

Hypovolemic ↑ ↓↓ +/- ↑ High Flow O2 Evaluate perfusion after 30 mL/kg total volume bolused, then consider pressors

Septic (early, warm)

↑ ↓↓ +/- ↓ High-flow O2 Fluids / Antibiotics Pressors ( Norepinephrine epinephrine)

Septic (late, cold)

↑ ↓↓ ↓ ↑ High-flow O2/ fluids Antibiotics

Pressors (epinephrine, norepinephrine, vasopressin)

Anaphylactic ↑ ↓↓ ↓ ↓ High-flow oxygen Epinephrine (IM) Fluid resuscitation

Neurogenic ↑ ↓↓ +/- ↓↓ Fluid resuscitation Pressors (norepinephrine)

Cardiogenic ↑ ↑ ↓↓ ↑ High-flow oxygen Fluid resuscitation (5–10 mL/kg) CHF management

(CPAP/BiPAP, diuretics, ACE inhibitors)

Inotropes (milrinone, dobutamine)

7

NOREPINEPHRINEIVInfusionINDICATIONS FOR USE: Used for Cardiac and circulatory Failure. Stimulates Beta 1 and Beta 2 and Alpha receptors. AVAILABLE AS: AMP 1mg/ml for 1:1000 solutions DOCTORS ORDER: Order in mcg/kg/min with MAX/MIN MAPS USUAL DOSE: 0.05-2 mcg/kg/min TO PREPARE FOR USE: 1. Calculate milligrams of Norepinephrine in 100ml of NS to run at

0.1mcg/kg/min= 1ml/hr 2. Divide milligrams obtained in above equation by 2 to calculate the

milligrams/50ml syringe. 3. Draw up appropriate mg of drug and add to NS to equal 50 ml total

(eg if 1mg, then draw up 1ml of and add to 49 ml of NS)

Minimum rate is 0.1 ml/hr (0.01mcg/kg/min) and maximum rate is 20ml/hr (0.5mcg/kg/min)

60.1 mcg/kg/min

100 mlx x Wt

(kg)=

mg drug

1 ml/hr

8

T h e im a ge p a rt w ith

r e lat io ns h ip ID rI d1 3 w a s n ot fo u n d in th e

f ile .

60.1mcg/kg/min

100mlx x Wt

(kg)=

mgdrug

1ml/hr

EPINEPHRINEIVInfusion INDICATIONS FOR USE: Used for Cardiac and circulatory Failure. Stimulates Beta 1 and Beta 2 and Alpha receptors. AVAILABLE AS: AMP 1mg/ml for 1:1000 solutions DOCTORS ORDER: Doc should order in mcg/kg/min with Max/Min MAPS Usual Dose 0.01-1 mcg/kg/min TO PREPARE FOR USE: • Calculate milligrams of Epinephrine in 100ml of NS to run at

0.1mcg/kg/min= 1ml/hr • Divide milligrams obtained in above equation by 2 to calculate the

milligrams/50ml syringe. • Draw up appropriate mg of drug and add to NS to equal 50 ml total (eg if

1mg, then draw up 1ml of and add to 49 ml of NS)

Minimum rate is 0.1 ml/hr (0.01mcg/kg/min) and maximum rate is 10ml/hr (1mcg/kg/min)

9

65 mcg/kg/min

100 mlx x Wt

(kg)=

mg drug

1 ml/hr

DOPAMINEinfusionINDICATIONS FOR USE: Used as an inotropic agent in the treatment of neonatal shock . Stimulates alpha 1, Beta 1 and Beta 2 receptors. AVAILABLE AS: AMP 200mg/5ml solution (40mg/1ml) DOCTORS ORDER: Doc should order in mcg/kg/min (e.g. 5mcg/kg/min to increase cardiac output) USUAL DOSE: 2-20 mcg/kg/min TO PREPARE FOR USE: • Calculate mg of Dopamine in 100ml to run at 5 mcg/kg/min = 1ml/hr • Divide milligrams obtained in above equation by 2 to calculated the

mg/50ml syringe. • Draw up appropriate mg of drug and add to NS to equal 50 ml total

(eg if 100mg, then draw up 2ml of dopamine & add to 48 ml of NS)

Minimum rate should be 0.5ml/hr (2.5 mcg/kg/min) and max rate should be 4ml/hr (20mcg/kg/min)

10

T h e im a ge p a rt w ith

r e lat io ns h ip ID rI d1 3 w a s n ot fo u n d in th e

f ile .

65mcg/kg/min

100mlx x Wt

(kg)=

mgdrug

1ml/hr

DOBUTAMINEInfusionINDICATIONS FOR USE: Used as an inotropic agent in the treatment of cardiac decomposition. Stimulates Beta 1 and Beta 2 receptors. AVAILABLE AS: AMP 50mg/1ml solution DOCTORS ORDER: Doc should order in mcg/kg/min with Max/min MAPS USUAL DOSE: 2-20 mcg/kg/min TO PREPARE FOR USE: Calculate mg of Dobutamine in 100ml to run at 5 mcg/kg/min = 1ml/hr

Divide milligrams obtained in above equation by 2 to calculated the mg/50ml syringe.

Draw up appropriate mg of drug and add to NS to equal 50 ml total (eg if 100mg, then draw up 2ml of dobutamine and add to 48 ml of NS)

Minimum rate should be 0.5ml/hr (2.5 mcg/kg/min) and max rate should be 4ml/hr (20mcg/kg/min)

11

VASOPRESSINinfusionINDICATIONS FOR USE: Use for septic shock resistant to epinephrine/norepinephrine in volume optimized patients with normal cardiac function as adjunct AVAILABLE AS: AMP 20 U/2ml (10 U/1ml) DOCTORS ORDER: Doc should order in mcg/kg/hr (eg. 1mcg/kg/hr to attain adequate sedation) USUAL DOSE: Neonate and younger infant 0.00017-0.008 U/Kg/min via continuous IV infusion in combination with other pressors ; Adult 0.01-0.04 U/min via continuous IV infusion TO CALCULATE DRIP RATE: You need to know:

o DR’s order e.g. 0.01 units/kg/hour

o Final concentration of drug e.g. 2units/ml

o Use the formula below to calculate mls/hr (pump rate)

TO PREPARE FOR USE: 0.01 Units/kg/hr 50 x _____________________ x wt (kg) = units drug / 50ml 1ml/hr

Minimum rate is 0.5 ml/hr (0.005units/kg/hr) and maximum rate is 4 ml/hr (0.04units/kg/hr)

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INFUSIONSUMMARY1. Dopamine: 6 x [ (5mcg/kg/min) / (1ml/hr) ] x wt (kg) = mg/100 ml 2. Dobutamine: 6 x [ (5mcg/kg/min) / (1ml/hr) ] x wt (kg) = mg/100 ml 3. Epinephrine: 6 x [ (0.1mcg/kg/min) / (1ml/hr) ] x wt(kg) = mg/100ml 4. Norepinephrine: 6 x [ (0.1mcg/kg/min) / (1ml/hr) ] x wt(kg) = mg/100ml 5. Vasopressin: 50 x [ (0.01 units/kg/hr) / (1ml/hr) ] x wt(kg) = units/50ml 6. Midazolam: 6 x [ (1mcg/kg/min) / (1ml/hr) ] x wt(kg) = mg/100ml 7. Fentanyl: 50 x [ (1 mcg/kg/hr) / (1ml/hr) ] x wt(kg) = mcg/50ml 8. Insulin: Mix 50units/50ml. 1 ml/hr = 1unit/hr.

Constant Weight (KG)

Concentration

Range ml/hr

PRESSORS Dopamine 6 x (5mcg/kg/min)

(1ml/hr) x Wt (kg)

X Mg/100ml

0.5-4ml/hr

Dobutamine 6 x (5mcg/kg/min) (1ml/hr)

X Mg/100ml

0.5-4ml/hr

Epinephrine 6 x (0.1mcg/kg/min) (1ml/hr)

X Mg/100ml

0.1-10 ml/hr

Norepinephrine

6 x (0.1mcg/kg/min) (1ml/hr)

X Mg/100ml

0.1-20ml/hr

Vasopressin 50 x (0.01 Units/kg/hr) (1ml/hr)

X Unit/50ml

0.5-4ml/hr

SEDATION Midazolam 6 x (1mg/kg/min)

(1ml/hr) X Mg/100ml

0.5-2ml/hr

Fentanyl 50 x (1 mcg/kg/hr) (1ml/hr)

X Mcg/50ml

0.5-5ml/hr

OTHER Insulin 50 units in 50 ml ------------- 1unit/1ml Per

weight/RBS

13

ELECTROLYTECORRECTIONSUMMARYAdrenalCrisisHydrocortisone: 50-100 mg/m2 IV bolus, followed by infusion in D5NS of 50-100 mg/m2/day OR divide q4-6hr bolus dosing (Physiologic replacement 8-12 mg/m2/day) Dexamethasone: (initial bolus dose – to not interfere with stim test) – 4 mg/m2 IV HYPERKALEMIACorrection(EKGPEAKEDTWAVES,WIDEQRS,Sinewave)1) Ca gluconate 100 mg/kg (1 cc/kg) IV over 2-5 min. Adults: 500 mg to 3 mg. 2) Sodium Bicarbonate 1-2 meq/kg IV over 5-10 minutes (flush IV if Ca given!) 3) D10 (5 mL//kg) IVmixed with regular insulin 0.1 U/kg 4) Salbutamol – 2.5-5 mg nebulized 5) Kayexalate 1 g/kg in 4 cc of 10% glucose PR (infants) or 10% sorbitol (child)

HYPONATREMIACorrectionFor neurologic symptoms or serum Na less than 120 mEq/L – 6 mL/kg of 3% NaCl IV over one hour will increase serum sodium by 5 mEq/L (goal 125)- see electrolyte correction sect SIADH: (Euvolemia, Hi Urine osm, Low Serum osm, low UOP) – fluid restriction Cerebral Salt Wasting (Hypovolemia) – Rehydration, correct Na (see below), consider florinef * consider using medcalc.org to calculate correction over 2 days

HYPOGLYCEMIAGlucose 0.5 to 1 g/kg IV over 5 min: D10 (2.5 ml/kg Neonate; 5 mL/kg Child) Glucose infusion rate (mg/kg/min) =[rate (ml/hr) x % dextrose x 0.166]÷wt(kg)

OTHERBicarb 0.5 – 2 mEq/kg over 5-10 min [Base Deficit x wt (kg) x 0.3] = mEq dose) Hypocalcemia: Ca gluconate 50-100 mg/kg IV (0.5-1 cc/kg)- better for PIV– max dose 2g. Infuse over 30-60 min. Push if urgent. Monitor ECG for bradycardia! Hypomag. (presumed) 25-50 mg/kg MgSo4 IV over 2-4 hours x 3 doses Hypokalemia 0.5-1 mEq/kg KCl IV over 1-2 hours (must be on monitor!); in IVF Hyponatremia (goal Na –actual Na) x 0.6 x wt (kg) = mEq Na to be given. 3 % Saline (513mEq/L)OR 1 cc = 0.5 mEq Na. Normal Saline (154 mEq/L OR 1 cc = 0.15 mEq Na) Max rate increase ½ - 1 meq/L rise per hour. (medcalc.org) Hypernatremia (Na >170 DNS, Na 155-170 ½ D10 1/2NS, Neonate: maintenance + deficit in neonate over 48-97 hours); child use medcalc.org to calculate rate.

14

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Pediatric, Neonatal, and PICU Protocols - AIC Kijabe Hospital · 2020. 3. 22. · / D5LR DISABILITY Unresponsive / Coma / Convulsing Manage airway and give oxygen via facemask, consider