Download Trauma Manual

Pediatric Surgery Ward Manual
Kris Milbrandt, MD
Version 1.2 February 2009
Table of Contents
I. Weekly Schedule and Phone Numbers
II. General Information
III. Daily Routine
IV. Fluid and Electrolytes
V. TPN and Enteral Nutrition
a. Feed calculations
b. Feed formulas
pg 11
pg 13
VI. Common Problems
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
Appendicitis
Inguinal hernia
Pyloric stenosis
Head and Neck Masses
Intussusception
Malrotation with midgut volv.
Abdominal wall defects
NEC
Hirschsprung’s disease
Imperforate anus
TEF
Diaphragmatic hernia
Wilm’s tumour
Neuroblastoma
Foreign bodies
pg 17
pg 17
pg 18
pg 18
pg 18
pg 18
pg 19
pg 19
pg 19
pg 20
pg 20
pg 20
pg 20
pg 20
pg 21
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VII. Important Numbers/Calculations/Addendum
VIII. Common Medications
Notes:
3
I. Weekly Schedule and Phone Numbers:
Monday
Tuesday
Wednesday
Thursday
Friday
OR
0800-1600
0800-1200
Clinic
1300-1600
Sigalet/Beaudry
Wong
Eccles
Wong/Brindle
anyone
Wong
Sigalet
Wong
Eccles/Beaudry
Brindle
Eccles
Wong
Eccles
Phone Numbers:
OR desk:
ER:
Recovery Room:
Clinic:
Day Surgery:
Outside Paging:
Locating:
Lab:
Fax:
57862
57070
57857
53265
57855
212-8223
57211
770-3602
57862
Unit 4
Unit 3
Unit 2
Unit 1(onc)
PICU:
NICU(FMC):
Radiology:
Pathology:
NICU – RGH
NICU- PLC
57897
57889
57892
57894
57074
944-1354
57992
57385
943-3563
943-5736
Dr. Milbrandt (Fellow): 2888
52835
Dr. Hyndman(urology)
Dr. Cook (urology)
Dr. Amendy (int.rad.)
3941
6688
6596
Dr. Sigalet: 5166
Dr. Wong: 5454
Dr. Eccles: 5121
Dr. Brindle: 7100
Dr. Beaudry: 4718
Dr. Lau:
5391
52271(Pam)
57253(Bonnie)
57807(Susan)
52848(Elisa)
52850(Gail)
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II. General Information
Responsibilities:
Medical Students: Keep the patient list up-to-date and print lists prior to rounds, collect
charts and vitals, see consults with either the resident or staff on call, follow-up on labs and
X-rays, and attend clinic and OR. Primary obligations are to clinics and consults, as these
provide the most educational benefit. Students should go to the OR with any patients they
have worked-up, and follow them daily during the hospital course. For the first week, they
will be following a resident or fellow to see patients and consults. Following this, they will
be assigned no more than 3 patients to follow on their own with supervision from a resident
or staff.
Residents: Chart on patients, ensure that orders are up-to-date and accurate, aid in teaching
of medical students, follow-up labs and X-rays, and attend clinic and OR. Consults seen
should be discussed with the staff or fellows. Update the patient list to reflect new patients
and changes to existing patients. Dictate any OR cases where you are the principal surgeon
(it’s a good idea to clarify with the staff who will dictate).
The senior resident should anticipate assuming the lead in formulating care plans for floor
patients.
Fellow: Lead/supervise rounds on patients, formulate daily plans, attend and be prepared to
run the OR as well as clinics. Dictate cases if primary operator. Discuss patients with staff.
Review consults with juniors. Coordinate Friday teaching rounds. Lead Wed. morning
teaching sessions.
Rounds:
Begin at 0700 during the weekdays and 0800 on holidays/weekends. Handover and discussion is
from 6:50-7:00 followed by rounds. The patient list should be updated daily and is found in the
pedres drive under the peds surg folder. All inpatients and active consults are to be rounded on prior
to OR, with progress notes written daily. All members of the team are expected to know all
patients. Afternoon rounds(either formal or informal) are typically between 1600-1700.
Call:
Typically call is every fourth/fifth night. Post-call responsibilities are per the PARA contract.
Generally, call is home call. Therefore, if you have to come in between the hours of midnight and
6:00, the expectation is to do ensure adequate patient handover and rounds have occurred within
2hrs(section 14.05f PARA contract). There is no guarantee to be home the following day of home
call if you didn’t have to come in, as outlined in the contract, although we do try to get post call
residents home by noon. Every resident will have 2 weekends (Friday to Sunday) free and usually
work one Fri/Sun and one Sat per month. Medical students and junior residents should plan to take
in-house call, especially at the beginning of the academic year. For weekends, handover can be done
over the phone with the resident/fellow on call the next day. NICU consults need to be discussed
with staff or fellow.
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Teaching Rounds:
The weekly education day is Friday. Fellows, staff, residents and medical students are expected to
attend. Rounds usually begin at 7:30am in conference room 1 on the fourth floor. Residents are free
to attend their departmental rounds Thursday afternoon. If on call, the fellow or staff will cover for
this time. During a one month rotation, medical students and residents should plan one 30-45
minute Power point presentation on a subject related (directly or tangentially) to Pediatric Surgery,
preferably based on a recent case. Feel free to discuss potential topics with the fellows or staff. A
copy of the presentation should be given to the fellow.
In addition, each resident will be given a booklet with a pre and post test as well as a series of cases
with questions to discuss. The pre and post test will be conducted by Dr. Eccles at the start and end
of the resident’s rotation. The cases are for Wed. morning starting at 7am ran by the fellow or staff.
Residents should be read up on the cases and questions prior to the sessions and typically we cover
2-3 questions in sequence.
Vacation:
Can only be taken with prior arrangement with the pediatric surgery program director and fellow. It
cannot be taken by two residents at the same time and should coincide with three or more residents
on the service. Must be arranged at least one month prior to the block starting. No holidays
permitted the last week on June or first week of July.
Trauma:
Code 77 on your pager is a trauma and it is usually followed by a number indicating number of
minutes until arrival. i.e. code 77-10 is a trauma arriving in 10 minutes. The on-call resident/fellow
is expected to attend and write a consult for all code 77’s. We are expected to be there within 20-30
minutes of the trauma arriving, at the latest. The ER doctor is the team leader(TTL). If the resident
on call is a pediatric or junior resident then the fellow or staff will also attend. The staff person
should be called within 20 minutes of seeing the patient. The majority of traumas, if needing
admission, will come to our service with consultation as needed.
On the ward, our nurse practioner will follow up and see all trauma patients and discuss with the
fellow or staff during the weekdays. Residents should be aware of all trauma patients and their
issues, especially for evening, weekends, and when the NP is not available. All trauma patients
should have a tertiary survey at admission or the day following admission including a head to toe
physical, summary of injuries, and pertinent radiological films reviewed. The NP can do this on the
days he/she is available. C-spines can be cleared by senior surgical residents, fellows, or staff.
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III. Daily Routine
Ward Notes:
SOAP:
Subjective: How is the patient feeling, what did the parents and/or nurses note (ie. Any
pain, nausea, constipation, etc)
Objective: Vital signs including heart rate, respiratory rate, saturations, temperature (make
sure it is taken from the same site, eg: axillary), weight, urine output, bowel movements,
emesis, drainage tube outputs
Assessment: Improving, worsening, same; include POD #
Plan: Make a clear plan and course of action
Pearl: listen to the parents - they know the patient the best!
Pearl: listen to the nurses - they know the patient second best.
Booking OR:
Discuss case with staff and/or fellow. Ensure NPO status, obtain consent, H & P, call the OR
desk, and inform nursing, and anaesthesia. Check on the patient’s bloodwork, coags, and need for
cross-match, sickle cell index if needed, antibiotics, or x-rays.
Admissions:
Discuss with staff and/or fellow. The emergency department will call and arrange for bed, if the
child is seen through the ER. Post-op admissions will have a bed. Write orders based on your
mnemonic of choice, ex: ADC VANDIMALS
A dmit to Dr. ________
D iagnosis
C ondition
V itals – include route for temps (po, axillary, etc)
A ctivity – as tolerated, bedrest, ambulation restrictions, etc
N ursing – think head to toe: eg: head of bed elevated, NGT to suction, incentive
spirometry, drains to suction, Foley to gravity, etc
D iet
I VF
M edications
A llergies
L abs
S pecial studies
Pearl The ‘P’s of Prophylaxis: The prophylaxis here is against phone calls from the floor. After
finishing your orders, make sure the 6 P’s have been addressed:
Pain – have you written for pain meds?
Pulmonary – does the patient need incentive spirometry/bubbles, chest physio?
PE – does the patient require DVT prophylaxis (generally No in kids)
Peptic ulcer – does the patient need an H2-Blocker or PPI (particularly in PICU patients this
should be considered)?
Previous Medications – are there any home medications needed (eg inhalers)
Pathogens – does the patient need antibiotics
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Considerations:
NPO
Stop solids/formula 6 hours prior to OR
Stop breast milk 4 hours prior to OR.
Stop clear fluids 3 hours prior to OR.
Cross match
If you anticipate blood loss, cross-match for a least one unit (10cc/kg)in a neonate
and 2 units (20 cc/kg) in older children.
Antibiotics
Typically use amp/gent/flagyl for severe abdominal infections. Give pre-op
antibiotics in suspected appendicitis or other clean-contaminated cases. If inserting a
foreign body, give pre-op antibiotics.
Bowel Prep
Generally give for bowel cases or in large cases with a chance of entering the bowel.
Dose Go-lytely orally or via NGT at 20-30 cc/kg/hr (max 300 cc/hour) for 4-6
hours or until clear stools. Enemas are given as needed.
New addition is Pico-Salax. Tastes better and low volume. Mix 1 sachet in 150 ml
cold water and give 2 doses 6 hrs apart the day before plus lots of clears.
Age 1-6: 40 mls/dose of above mixture
Age 6-12: 75 mls/dose
Age 13-18: all 150ml
PICU
If child born premature, under 37 weeks, and is less than 50 weeks corrected, needs
PICU post op monitoring.
If term(over 37 weeks) baby less than 4 weeks old, needs PICU post op.
Consults:
All are to be reviewed with the staff on-call and/or fellow and need to be seen as soon as possible
that day. To ensure appropriate communication, consults need to come from a representative of the
consulting service and not nursing. Hand the consult sheet to the staff or give it to the secretaries.
Note the attending and date on sheet.
Discharges:
Make sure follow-ups, prescriptions and notes have been arranged.
For Dr. Wong, leave an order to leave chart on ward for him. Otherwise, fill out discharge sheet on
front of chart ensuring a copy for family doctor.
Discharge guidelines for common admissions:
Premature infant hernias - discharge after overnight observation with apnea monitoring if the
baby is stable with no desaturations/apneas. Follow-up with PMD or surgeon prn.
Term infant and older hernias - discharge the same day. Follow-up with PMD or surgeon prn.
Restrict activities for one month.
Incarcerated hernias – discharge once a diet is resumed and pain is controlled (may be same
day). Follow-up in 1-2 weeks.
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Appendectomy – A patient with unperforated appendicitis can go home the next day with
restricted activity for 2-4 weeks. Perforated/gangrenous appendices require 5 days of IV
antibiotics and should be afebrile for 24 hours prior to D/C. May need oral antibiotics
and/or ID consult if still having fevers.
Dictation System:
44444 followed by your number and password. Code 10 for OR dictations, site ID 91 for ACH.
Operative Reports
Name of patient, region number, DOB, date of OR, surgeon, assistants, preop/postop diagnosis,
procedure, type of anaesthesia, and anesthetist
Indications/Brief History
Findings
Procedure
Include type of suture, sponge and instrument count (correct or not, and post-operative plan.
I/Os - especially blood loss, blood products given and urine output
Specimens
Tubes/Drains/wound classification
Send copies to the Attending, yourself, the Primary Care Physician and any other physicians as
appropriate.
Clinic letter
Always send a note to the referring doctor on new patients. Excessive detail not usually needed
unless the child has complex issues.
Discharge summary
Include date admitted, date discharged, admitting diagnosis, procedures, and course in hospital.
Also important are medications given at discharge and the follow-up plans. Send a copy to the
Primary Care Physician. We can generally just fill out the form found at the front of the chart for
most of our patients. Dr.Wong likes to do his own so just leave an order to keep the chart on the
ward for him.
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IV. Fluids and Electrolytes:
Maintenance IV fluid:
Generally use D5-10% ¼ NS in neonates, D5% ½ NS in infants and younger children, and
add 20 mEq KCl/L . In older children, >5 years old, use NS or RL immediately post-op and then
use D5% ½ NS + 20 meq KCl for maintenance.
IVF Rate Approximation:
1st 10 kg- 4 ml/kg/hr
2nd 10 kg - 2 ml/kg/hr
each kg>20 - 1 ml/kg/hr
Deficits:
5% dehydrated - dry mucous membranes, axillae, groin.
10% dehydrated - loss of skin turgor, sunken eyes, severe thirst, tachycardia
15% dehydrated - low BP, lethargic, CNS changes
Note: this determination is very rough and inaccurate. Always follow the vitals and urine
output and the response to your treatment to indicate any further intervention needed.
(i.e. a second or third bolus, ? colloid, ? pressors)
A bolus is 10-20 cc/kg given over ½-1 hour and not anything less! May use RL or NS for
first few boluses. If considering pentaspan, albumin or blood, talk with staff or fellow.
Albumin - transfuse as a 5% solution, 5-10 ml/kg. If extremely hypo-albuminemic, may use
25% and give 1 g/kg
Blood -PRBC is dosed as 10 -20ml/kg over 2-4 hrs& will raise the blood count by about
10.
-Platelets at 5-10ml/kg to max 300 ml will increase count by 50-100
* use irradiated platelets if the patient is immunocompromised.
-FFP is dosed at 10-15 ml/kg and can be given as fast as needed
On-going losses:
Replace NGT losses 1:1 with NS plus 20 mEq KCl/L every 4-8 hours if significant.
All infants should have a urine output of at least 1 cc/kg/hr.
Daily Requirements:
Na - 3-4 mEq/kg/day
K1-2 mEq/kg/day
Mg - 0.5-1.5 mEq/kg/day
Ca - 200-400 mg/kg/day
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V. TPN and Feeds
Don’t rely on others to figure this out for you- check the calculations yourself.
Requirements:
Age (years) Calories (kcal/kg/day) Lipid (g/kg/day) Protein (g/kg/day)
<1
100 – 120
3-4
2.5-3.5
1–3
80 - 100
3-4
1.5 – 2.5
4-10
60 - 80
2-3
1 – 2.5
>10
60 – 90
1.5-3
1-2
Growth Rates
Preterm: 15-25g/d
Term to 1 yr: 15-30g/d
1-2yr: 6-8g/d
2-5y: 160-200g/month
Guidelines
Above requirements are guidelines- will need to increase based on stressors such as surgery, burns,
infection, activity level, etc.
Aim to give 40-60% as CHO, 20-30% as lipid, and 10-15% as protein.
Central TPN can be given up to 20-25% dextrose (CHO) although normal is around 15%
Peripheral TPN max is 12.5% dextrose (CHO) or 4% amino acid
When starting or stopping TPN, need to wean slowly especially in neonates
i.e. start protein at 1g/kg and lipid at 1 g/kg
When changing TPN, except rate, need to fill out new TPN sheet
TPN is NOT meant to acutely fix large electrolyte disturbances
TPN sheets need to be filled out by 11am
Accepted triglyceride level is under 4.0 mmol/L
Standard multivitamins are added to all TPN. Occasionally, a very long term TPN infant will need
to have additional trace elements added or iron- which is a pain because the iron needs a special
filter!
Always add ranitidine for most of our patients to the TPN(2-4mg/kg/d) and stop it if ordered
previously as a separate injection.
Almost always add heparin (0.5u/ml) to the TPN for CVL prophylaxis.
Almost always check off the notify dietician box and use them- they are a great resource for fine
tuning issues and complex patients.
Calculations
Important values:
1 g of CHO = 3.4 kcal
1 g of protein = 4 kcal
1 g of lipid = 10 kcal
D10W is 10% dextrose which is 100 g/liter or 1 g/10 ml or 3.4kcal/10ml or 0.34 kcal/ml
20% lipid = 200 g/1 liter or 2 g/10 ml or 20 kcal/10ml or 2kcal/ml
11
3% Travasol (protein)= 30 g/1 liter or 0.3 g/10 ml or 1.2kcal/10ml or 0.12 kcal/ml
Sample: 10 month old 10 kg infant with central line
Maintaince IV fluid is 40 ml/hour or 960-1000 ml in a day.
Energy required is 1000 kcal/day (100 kcal/day x 10 kg)
Goal - 600 kcal from CHO, 300 kcal from lipid, 100 kcal from protein
Day 1 start low:
1gm protein/kg/d= 10 gm protein(Travasol)/24hrs
Standard bag is 2.5% or 25 grams/1000ml or 0.025grams/ml
10gm/ 0.025 (gm/ml)= 400 ml of 2.5% solution/ 24 hrs
40ml/24 hrs= 16.7ml/hr of Travasol
10 grams protein=40kcal
1gm fat/kg/d= 10 gms/lipid/24hrs
Standard lipid is 20% or 200 grams/1000ml or 0.2gm/ml
10 gm/ 0.2 (gm/ml)= 50 ml of 20% lipid/24hrs
50ml/24hrs= 2.1ml/hr of lipid
10grams lipid=100 kcal
CHO- since this is mixed with the Travasol, you will get the same volume of CHO
as amino acid, in this case 400ml over the 24 hrs. We can vary the CHO
concentration but in general will start at 10-12.5 % and work up over a few days to
15-20%.
12.5% CHO= 125grams/1000ml or 0.125gm/ml
400ml x 0.125gm/ml= 50 grams CHO
50 grams CHO= 170kcal
We now would be giving the child a total fluid intake (TFI) of 18.8ml/hr or 451ml/24hrs and total
calories of 310kcal or 31kcal/d. You will need to make up the remainder of the child’s fluid
requirements until at full TPN with an additional maintaince line of D5.45 and 20 meq/KCL to total
40ml/hr or a TFI 100cc/kg/d. This assumes no other fluids are given such as iv meds which always
need to be considered. Make sure nursing decreases your maintaince iv as the TPN rates are
increased.
Over the next few days we will increase our fat and protein load and CHO concn if needed to make
up calories. You will need to order TPN bloodwork and follow the triglyceride level, urea, and
glucose.
Day 2- increase travasol to 2gm/kg/day and lipid to 2 gm/kg/day and CHO to 14%
Day 3- increase travasol to 3 gm/kg/day and lipid to 3 gm/kg/day and CHO to 15%
Protein- 3gm/kg/day= 30gm/day=30gm/0.025(gm/ml)=1200ml of 2.5% solution
- 1200ml/24 hrs= 50ml/hr
- 30 grams protein/d=120kcal/d
Lipid- 3 gm/kg/day= 30gm/day=30gm/0.2(gm/ml)=150ml of 20%lipid in 24hrs
- 150ml/24hrs=6.25ml/hr
- 30 grams lipid/d= 300 kcal/d
CHO- 15% solution= 150 grams/1000ml= 0.15 grams/ml
- 1200ml(because that’s the volume of travasol we are giving)/24hrs
12
-
1200ml x 0.15grams/ml= 180 grams CHO/ 24hrs= 612 kcal/24hrs
----------------Total calories- 1032 kcal (103 kcal/kg/d) 120kcal protein(11.6%) + 300 kcal lipid(29%) + 612
kcal CHO(59%)
Total fluid  1350ml or 1350ml/10kg=135cc/kg/d
Extra thoughts:
You will notice that the TFI is higher than what the actual fluid requirement is in order to meet the
caloric requirements. This is true even for oral feeds and is usually of no concern. However, it
comes into play in situations such as renal failure or in neonates requiring meds that need lots of
fluid to push with them, such as antibiotics or morphine infusions. In these cases, we end up
sacrificing calories in order to get the meds in and keep our TFI generally under 150-160cc/kg/d.
You can concentrate some things in order to get more calories in- such as increasing your CHO
conc or giving more fat or concn meds. Generally increasing your protein concentration doesn’t
help much for extra useful calories but can help reduce the total TPN volume if needing to fluid
restrict.
Be careful in children with increased bilirubin or urea as they will not tolerate high protein loads.
When weaning, infants will not tolerate a sudden drop. We usually will decrease the travasol by
about 80% of the increase in feeds and lipid by 20%. i.e. feeds are increased by 10cc/kg/d so
decrease the travasol by 8cc/kg/d and lipid by 2cc/kg/d. Be careful once total rates of travasol and
lipid falls below about 8cc/hr as the lines tend to clot and nursing will not run it slower. You then
may have to “cycle” the TPN by decreasing the hours ran(i.e. 20 hrs, then 16, then 12, then 8) to
give the same total volume but allow the rates to be higher and lock the line off in between. Once
the infant is on full feeds, we usually can stop the TPN but make sure to check a chemstrip around
30 mins and 2hrs. In older children or those not on TPN for more than a week you can wean them
much faster.
Read the TPN sheet front and back- it has lots of info and as each hospital is a little different it is
important to know the basic premises for TPN calculations and not just be able to fill a sheet out or
copy it from last week!
Check the gastroschisis section for extra comments on these babies and TPN.
Enteral Feeds
Breast milk and most other standard formulas are 20 kcal/30 ml. Formulas can be concentrated to
give 24, 27, and 30 kcal/30 ml solution. The higher the concentration the worse they taste! In
addition, there is evidence to suggest that highly concentrated formulas (such as a 27 or 30) are a risk
factor for NEC so avoid them in newborns in particular.
COW MILK-BASED
Used from 0 – 12 months when breast-feeding not chosen.
Examples: Enfamil A+, Enfalac with Iron, Enfamil Lactose-Free, Enfapro A+(6+ months), *Nestle
Good Start, Nestle Follow-up (6 + months), *Similac Advance with Iron, *Similac Lactose-Free,
*Similac Advance Step 2 with Iron (6 + months)
COW MILK-BASED – LACTOSE FREE
Lactose is a sugar found in milk. An enzyme called lactase breaks lactose down. Lactase is
produced in the mouth of infants and in cells lining the small intestine. If intestinal cells are
13
damaged (bacterial infection or a virus or medications such as antibiotics), they cannot produce
enough of the enzyme to adequately digest lactose, creating a secondary lactose intolerance (the
presence of lingual lactase makes a primary intolerance uncommon).
Symptoms of lactose intolerance are: abdominal bloating, cramps, gas and diarrhea can occur.
Examples: *Similac Advance Lactose-Free, Enfamil Lactose-Free
SOY-BASED FORMULA
Used when a milk-free formula is needed. Used when a sensitivity to cow’s milk protein. Used for
lactose intolerance. Used for cultural reasons/vegetarian.
Examples: *Isomil, *Isomil Step 2, *Enfamil Soy (Prosobee) sucrose free, Nestle Alsoy, Nestle
Follow-up Soy
ELEMENTAL FORMULA
Used when a severe cow’s milk allergy. Used for malabsorption.
Examples: *Nutramigen (casein hydrolysate), *Pregestimil (casein hydrolysate, MCT oil), *Alimentum
(casein hydrolysate) MCT oil and sucrose),*Neocate (synthetic amino acids, MCT
oil)
PRETERM HUMAN MILK FORTIFIER
Added to breast milk to add extra calories, protein, calcium, vitamin D, phosphorus, iron, etc. For
premature hospitalized infants with a birth weight <1.8 kg; used in NICU setting only.
Examples: *Similac Human Milk Fortifier
PRETERM FORMULA
Preterm formula is designed to meet the increased nutrient requirements of the rapidly growing
hospitalized premature infant. Formula should be changed to a post-discharge preterm formula
(Similac Advance Neosure, or Enfamil EnfaCare A+ - see below) when the infant is >2.0kg or ready
for discharge.
Examples: *Similac Special Care 20 (with iron), *Similac Special Care 24 (with iron)
PRETERM POST-DISCHARGE FORMULA
Preterm post-discharge formula is designed to meet the increased nutrient requirements of the
premature infant with birthweights less than 1500 g once they are >2.0 kg or discharged home from
the hospital. Preterm post-discharge formula is higher in protein, calcium, phosphorus, B vitamins
and calories (with added DHA & ARA to improve growth and brain/eye development), when
compared with regular term infant formulas. Preterm post-discharge formula is preferably used
until 12 months adjusted age.
Examples: *Similac Advance Neosure, Enfamil EnfaCare A+
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ORAL/TUBE FEEDING PRODUCTS
ENTERAL FORMULAS
INDICATIONS OF USE
*PediaSure, * PediaSure with Fibre Ages 1-10 yrs. Oral and tube
feeding.
Poor intakes. 1 kcal/ml.
*Ensure, Boost
Oral and short-term tube feeding.
Poor intakes. 1 kcal/ml.
*Ensure with Fibre, Boost with
Oral and short-term tube feeding.
Fibre
Poor intakes. Dietary fibre needed.
1 kcal/ml.
*Osmolite 1 cal
Tube feed without fibre.
1 kcal/ml.
*Jevity 1 cal
Tube feed with fibre.
1 kcal/ml.
ENTERAL (ELEMENTAL)
*Neocate Junior, Vivonex Pediatric Used for ages 1-9 yrs.
Malabsorption.
Allergies.
SUPPLEMENTS
*Beneprotein
Protein powder used to increase
protein.
*MCT Oil
Fat malabsorption, used to increase
calories.
*Canola Oil
Used to increase calories.
*Polycose Powder
Used to increase calories. Glucose
polymers.
*Duocal Powder
Used to increase calories.
Combination of glucose polymers
and fat.
A fibre supplement that can be
added to tubefeeds and won’t
precipitate out.
*Benefiber
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VI. Typical problems/Key Points:
The following is just a brief summary of some common pediatric surgical problems. As with
anything in medicine, nothing is 100% and good judgment and communication with staff/fellow are
important.
Tubes and Drains
NG tubes come in 8-10 Fr for infants and 12-14 Fr for older children and may be single or double
lumen. Single lumen tubes must use intermittent low suction. The double lumen, Salem sump tubes
should be on continuous low suction. Irrigate the single lumen tubes, or the suction (main) tube of
the Salem, q 2-6 hr with 2-5 cc saline. As a general rule, do not irrigate the blue sump port; but you
can clear it with a small amount (5-10 cc) of air. Never connect the blue port to suction.
G-tubes are typically done with a temporary PEG. This tube is later changed to a MicKey button
which has a foley style balloon on it. Continuous or bolus feeds are used. If it falls out and the tube
is under one month old, call the fellow/staff, immediately, place an appropriate sized Foley catheter
and obtain an upright abdominal x-ray. Do not initiate feeds until the tube position is confirmed. If the tube
is >1 month old, use an appropriate sized Foley or a MicKey button (the family usually has this).
Confirm a gastric position through aspiration of gastric contents.
J-tubes can be of a MicKey style, transpyloric via nasal/oral, or a surgical stoma. Feeds are given
continuously and not by bolus. A J-tube that has fallen out requires immediate replacement as the
tract can close quickly. Replacement commonly requires fluoroscopy assistance to ensure
appropriate intraluminal positioning, so call the staff/fellow to help arrange for a radiologist to assist
with replacement.
Chest tubes are connected to a Pleur-Evac and placed to suction or water seal. Suction is set at -10 to
20 cm water of suction. When using suction, the regulator should be set to just make the third
chamber bubble, as increasing beyond this does not help. Water seal means that the Pleur-Evac is
disconnected from continuous suction but the stop-cock is left open. Never clamp a chest tube without
discussing with the fellow or staff.
Chest tube removal is done after discussion with the fellow or staff. Ask for help with removal if
you are not experienced with this. Keys points are: have all supplies (scissors, gauze, occlusive
dressing) close at hand; pull the tube on Full Inspiration (debateable!).
Drains are of various types. They may provide active suction (Jackson-Pratt or Blake drains), allow
gravity drainage (Malecott), or work by simple capillary action (Penrose). Check with staff as to
when they want a drain removed. If placed intra-operatively, the drain often has a skin stitch that
needs to be cut. If placed by interventional radiology, the drain often has an intra-luminal stitch
which must be cut/released to free the pigtail portion.
Central lines are at several locations including IJ (internal jugular), EJ (external jugular), subclavian,
femoral, or PICC. The cuffed external catheters are Hickmans or Broviacs while the subcutaneous
permanent devices are one or two lumen Portacaths. PICC lines and percutaneous central lines
(single/double/triple lumen lines, Cordis introducers) may be pulled at the bedside, with pressure
held for several minutes after removal. Tunnelled and subcutaneous lines should be removed in the
16
OR. If there is a problem with a line, obtain a chest x-ray to access the position of the line tip and
talk with staff/fellow. For consults, if it is for an insertion find out the type of line needed. For
Broviac’ s, Dr. Amendy can do them so they should consider that option. We have to do Port’s but
make sure the Port is needed. In addition, we generally will not put in double lumen Ports. For
removals, the consulting service needs to check who put it in. Dr. Amendy takes out his own lines
or deals with problems on lines he put in unless on a holiday or weekend. We do NOT do PICC’s.
Appendicitis
Presentation: Classically, generalized abdominal pain that eventually localizes to the RLQ. But
remember that appendicitis is the Great Masquerader.
Investigations: CBC and diff and physical exam are the most important. If the story, exam and CBC
support acute appendicitis, then no U/S is needed. Use an U/S if the diagnosis is uncertain (e.g.
ovarian pathology vs. appendicitis). Always obtain a urine dip and B-HCG in females who have
working ovaries. Observation in the ER or on the floor is a reasonable “investigation” in unclear
cases. Rarely do we perform CT’s in children.
Key Points: Once the diagnosis has been established, and OR is planned, start antibiotics(a/g/f or
cefoxitin and flagyl) and pain medications . The most important aspect of pre-op preparation is the
fluid resuscitation. Make sure at least a 20cc/kg fluid bolus has been given, as most patients have
been NPO and/or vomiting prior to seeking medical attention. If a patient is to be observed to
allow an appendicitis to declare itself, do not start antibiotics or any pain medication stronger than
Tylenol. If patients appear toxic with a tachycardia and narrowed pulse pressure, discuss immediately
with staff/fellow. Do not under-estimate the fluids they will need!
In nonruptured appy’s- no post op antibiotics needed(or just 1 dose) and no routine post op
bloodwork. In perforated appendicitis, continue the A/G/F with a CBC and gent level post op day
3.
Alvarado score:
Symptoms- migratory RLQ pain, anorexia, nausea or vomiting(1 point each)
Signs- tender RLQ(2 points), rebound pain into RLQ(1 point), temperature over 37.5(1 point)
Labs- leukocytosis(>10)(2 points), neutrophilia(1 point)
5-6 points- maybe appy
7-8 points- probable appy
9-10 points- get the damn appendix out
Inguinal Hernia
Key Points: Determine if the groin mass is truly a hernia, versus a non-communicating hydrocele or
lymph node. You will be able to get your finger “above” a hydrocele, but not a hernia. You will be
able to reduce a hernia, not a hydrocele. Keys for reduction include gentle, constant pressure from
below, with a supporting finger at the external or internal ring. Operative reduction is required if
manual reduction fails.
Pyloric Stenosis
Presentation: Most commonly a 4 - 6 week old baby with persistent, progressive, projectile non-bilious
vomiting.
Investigations: Electrolytes and a blood gas are important for baseline chloride, sodium, potassium and
base deficit levels.
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Pearl- If an ultrasound was performed elsewhere, and read as pyloric stenosis, do not trust
the result unless the patient brings the actual films. Even then, it is safer to repeat the U/S if
an olive is not felt.
Pearl- you can remember the measurement cut off by remembering pi: 3.14. Thickness at
least 3mm and length at least 14 mm.
Key Points: Fluid resuscitation is the immediate objective, surgery is secondary. Start with a fluid
bolus of NS at 20 cc/kg, and then run a maintenance rate using an appropriate solution based on
electrolyte deficits- usually D5.45 plus 20meqKCL at 1.5x maintaince overnight will correct it.
Anaesthesia will almost never take the infant the same day they present to our hospital even if
electrolytes are normal. Any alkylosis must be corrected before OR so if any concerns repeat the
lytes and cap gas after overnight resuscitation. Also, consider need for PICU post op monitoring as
these infants are usually right on the age cut off. Need for an NG is staff dependant.
Head and Neck Masses
Presentation: Frequently seen as a child/infant with unilateral submandibular swelling. There is often
a recent history of URI and an enlarged, tender lymph node.
Key Points: U/S is not needed initially. If the mass is firm and there are no other concerning issues
(e.g. TB or atypical mycobacterium), the best treatment is by observation, antibiotics, +/- hot
compresses. If the mass becomes soft and fluctuant an I and D is indicated. Be careful with
posterior triangle masses.
Intussusception
Presentation: Typically a 3 month – 3 year old child who has a sudden onset of severe abdominal pain
with his/her legs drawn up to the chest followed by a period of almost complete resolution. There
may be a history of recent URI/adenitis.
Investigations: Abdominal x-ray may show a cut off point in the transverse colon, an empty RUQ,
SBO or it may be normal. An ultrasound will help confirm the diagnosis. An air/contrast enema is
diagnostic AND therapeutic.
Key Points: A member of the surgical team must be present during the air enema reduction. Our
hospital usually performs a water soluble reduction so we do not have to be at the bedside. Unless
asked otherwise, always call the fellow when you are seeing a patient with possible intussusception.
Patients are admitted after successful reduction for observation, as an intussusception may recur.
Malrotation with Midgut Volvulus
Presentation: A newborn with bilious emesis. Bile is green.
Investigations: Definitive diagnosis is by UGI, showing a duodenum that does not return to the left of
midline &/or shows “cork-screwing.” An ultrasound may diagnose the condition based on an
abnormal relationship of the SMA and SMV, but an UGI is still needed for confirmation.
Key Points: Diagnosis requires a high clinical suspicion, urgent abdominal x-rays and an emergent
UGI (yes, surgery and radiology staff must come in at 3 AM). Initial treatment requires an NGT,
IVF and a fluid bolus.
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Pearl - Bilious vomiting in a newborn is a surgical emergency until proven otherwise.
Abdominal Wall Defects
Presentation: Usually diagnosed on prenatal U/S. Gastroschisis typically is lateral to the umbilicus
with no overlying sac. Other congenital problems are rare. Omphalocele is a central abdominal
defect with an overlying sac protecting the bowel. Other midline deformities frequently accompany
an omphalocele (e.g. cardiac malformations, midline craniofacial abnormalities). These children need
lots of fluid (130-160 cc/kf/d) early on.
Key Points: Treatment at time of delivery is to cover the eviscerated bowel with warm saline-soaked
gauzes and a bowel bag/saran wrap. Depending on the size of the defect, closure is either primary
or delayed (with a Silo to allow staged reduction of the bowel). Prolonged ileus after reduction is the
rule.
CHIRP team: At ACH, we have a group that manages most of the short gut and gastroschisis
children. This consists of Dr. Sigalet, Dr. Boctor(GI), occasionally Dr. Brindle, and members from
dietary, nursing, social work, and house staff for Surg and GI. We meet formally as a group Tues at
8am to discuss all patients and informally Thurs. As a guideline, the gastroschisis babies will all have
issues with motility and even if no complications will be in hospital around 50 days. Feeds are
started slowly once there is signs of gut function, usually at about 1 week post closure, at 10cc/kg/d
of EBM or formula. This is increased 10cc/kg/d as the child tolerates it and faster once beyond
about 50% of goal converting eventually to bolus feeds as soon as practical. After about 5cc/hr, we
initiate small bowel overgrowth prophylaxis with either po flagyl(10mg/kg bid) for 1 week, followed
by a week break, then 1 week oral gentamicin(2.5mg/kg bid), then one week break, and then back to
flagyl. In addition, many may require promotility agents such as maxeran, domperidone,
erythromycin, or cisapride. The TPN is carefully monitored and we tend to keep the lipid low, 23gm/kg/d, to reduce the risk of cholestasis. If this becomes an issue, we switch the infants to
Clineoleic and /or Omegavan which is a fish oil based lipid that has antiinflammatory properties and
“cures” the hyperbilirubinemia.
NEC
Presentation: A newborn, usually a preemie, who becomes symptomatic as enteral feeds are advanced.
Not uncommonly, the first post-natal days are uneventful. The baby becomes increasingly septic,
with feeding intolerance, OB+ stools, and thrombocytopenia.
Investigations: An abdominal x-ray may show pneumotosis intestinalis or portal vein gas. Serial AXRs
are needed (e.g. q6 hours) and an ultrasound, when done at ACH, is very useful as well.
Key Points: Start treatment with an NGT, NPO, IVF and IV antibiotics. Hematologic and electrolyte
abnormalities should be corrected. TPN is required. Laparotomy or drainage is generally
mandatory for free air. Laparotomy is considered for a worsening condition despite optimal medical
management, or a “fixed” loop of bowel on serial x-rays.
Hirschsprung’s Disease
Presentation: Suspect this disease in a newborn who fails to pass meconium in the first 24 hours.
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Investigations: A barium enema may be helpful. The normal bowel is the dilated portion while the
narrow, “normal” caliber bowel is the abnormal, aganglionic section. A suction rectal biopsy or a
deep open rectal biopsy is required for diagnosis
Key Points: The rectal biopsy kit is obtained from the surgery clinic. The procedure requires at least
one assistant to be performed safely.
Imperforate Anus
Investigations: Physical exam. Supportive tests include: x-ray spine/chest, passage of an NGT, U/S
kidneys, examine limbs, ECHO, spinal/sacral U/S.
Key Points: Inspect anus, looking for an anterior/vaginal fistula. Be sure to check for other
VACTERL anomalies (vertebral, anal, cardiac, tracheoesophageal, renal, limb).
Esophageal Atresia/Tracheoesophageal Fistula
Presentation: May be diagnosed/suggested on prenatal U/S showing polyhydraminos. Post-natally,
the babies are seen to have copious oral secretions requiring frequent suctioning and an NGT
cannot be passed beyond 10 cm.
Investigations: Chest and abdominal x-rays are needed to check for the position of the NGT and to
note any air in the bowel which would indicate a distal fistula.
Key Points: Look for associated VACTERL anomalies as noted above. An ECHO is needed before
operative repair. If the baby has passed urine, a renal ultrasound is not required pre-operatively, but
is needed post-operatively to evaluate the kidneys.
Pearl - if suspecting a TE fistula, do not force the NG!
Diaphragmatic Hernia
Presentation: Frequently diagnosed prenatally on U/S. Otherwise may be diagnosed on CXR to
evaluate a newborn with respiratory distress.
Investigations: A CXR is diagnostic, especially if an NGT is seen to remain in the chest.
Key Points: Initial treatment is to stabilize the baby in the NICU and deal with the pulmonary
hypertension and pulmonary hypoplasia first. Paralysis is not required unless simple support is not
sufficient. Severe cases may require ECMO and transfer to Edmonton.
Wilms’ Tumor
Presentation: This mass is frequently asymptomatic and is noted by the primary care physician or the
parents.
Investigations: CT abdomen/chest is needed as well as an U/S to assess the involvement of the
IVC/renal vessels.
Neuroblastoma
Presentation: The child presents with a large mass. 50% of cases present before age 3, 90% present
before age 9.
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Investigations: Check urine for catecholamines, VMA, and HMA. A CT scan of the
Chest/Abd/Pelvis is needed to determine resectability.
Foreign Bodies
Investigations: A PA and a Lateral CXR are needed for localizing the ingested/aspirated foreign body.
Key Points: Most ingested foreign bodies that are able to pass into the stomach will not cause
problems - including sharp objects and batteries. Suggest a high fiber diet and checking stool for
passage of the object. If a FB becomes stuck in the esophagus, it requires urgent endoscopic
removal. Any passed object that fails to move over several days on repeat x-rays, that is associated
with worsening abdominal pain, bowel obstruction or that results in free air requires urgent
operative intervention. Other relative indications for removal are a large object (>5cm), a
symptomatic patient (vomiting, hemetemis), 2 or more magnets which may cause a fixed obstruction
or perforation between bowel loops or a predisposition for distal obstruction (Crohn’s disease,
previous adhesive SBO, known strictures).
If the patient is stridorous and/or shows the object to be in the tracheo-bronchial tree on CXR,
prepare for urgent bronchoscopic removal.
VII. Important Numbers/Calculations/Addenda
Physiology:
Vital Signs:
Infant
RR
40
HR
160
SBP
80
Preschool
30
140
90
School
20
120
100
Blood volume = 80 ml/kg
Body weight (kg) = (2 x age) + 8
Endotracheal tube size = (age yrs)/4 + 4 [or the patient’s little finger size]
Bougie guide for dilations/gastric wraps:
Weight (kg)
2.5 – 4.0
4.0 – 5.5
5.5 – 7.0
7.0 – 8.5
8.5 – 10
10 – 15
Bougie Size (Fr)
20 – 24
24 – 28
28 – 32
32 – 34
34 – 36
36 – 38
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Tidbits:
 When obtaining consent for consult patients, always get the witness signature
part filled out and witnessed by nursing
 Order an IV fluid bolus on-call to radiology when ordering an U/S, they need a
full bladder for a good study
 If 5 minutes late to OR - expect to assist. If 10 minutes, don’t scrub
 Dr.Wong sits when operating- prepare for that. He also likes to use a
standardized post op sheet found in the OR.
 Know about the “dibble of Dave” by the end of your rotation
 Dr. Eccles using subcu Vicryl to close- make sure to dictate that!
 Dr. Brindle likes to make cinnamon buns with the umbilical stump in
gastroschisis so keep it moist. As well, she likes to go through the umbilicus
and do a pursestring suture in the fascia when doing laparoscopic cases.
 Dr. Beaudry does not use morphine after a nonperf’d appy so don’t order it
 Dr. Lau does open appy’s- prepare for it and know the anatomy
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VIII. Medications and Dosing:
NB: For all neonatal dosing, check the pharmacy on-line website or ward manuals. If in doubt, contact Pharmacy.
Medication
Route
Codeine
po/IM
Morphine
Demerol(rarely used)
Tylenol
IV
IV
IV/IM
po/pr
Ibuprofen
Fentanyl
Toradol
po
IV
IV
Chloral hydrate
po
Midazolam
po
IV
Ativan
Gravol
Metaclopramide (Maxeran)
Odansetron (Zofran)
Ampicillin
Gentamicin
Pre: 0.0 - 2 mg/L
Post: 5 - 10 mg/L
Flagyl
Vanco
Pre: 5 – 9 mg/L
Post: 25 – 40 mg/L
25 mg/kg
0.5-0.75 mg/kg (max 15 mg)
0.1 mg/kg
May Add: fentanyl (IV) at 1 mcg/kg for
procedures
IV
0.05-0.1 mg/kg
Antiemetics
IV/po/pr 0.5-1.0 mg/kg
(max 50 mg/dose or 5 mg/kg/day))
IV
0.1 mg/kg (1-6 yrs)
IV
0.5 mg/kg (>6 yrs)
IV
0.1 mg/kg to max 4mg/dose
po
0.2 mg/kg
Antibiotics
IV
25-50 mg/kg/dose
(max 10 g/day)
IV
2.5 mg/kg/dose- check levels with 3rd or 5th dose
po
IV/po
IV
IV
IV
Ciprofloxacin
Dose
Analgesia
0.5-1.0 mg/kg
(max 60 mg/dose)
Wt(kg) x mg morphine/100cc N.S.(most common)
0.05-0.1mg/kg
1.0 mg/kg
10-15 mg/kg
(max 75 mg/kg/day or 4g/day whichever is less)
5-10 mg/kg
1-4 mcg/kg
0.3mg/kg to max 20mg/dose
Sedatives
50-75 mg/kg/dose (max 1 g)
po
IV
10 mg/kg/dose
(max 500 mg q8h)
10 – 15 mg/kg/dose
(12 – 16 yo)
10 – 15 mg/kg/dose
max 1 g/dose
(1 mo – 12 yo)
10 – 20 mg/kg/dose
(Neonates, dose changes age & wgt, check before
dosing)
10-15 mg/kg/dose
(max 750 mg/dose)
10-15 mg/kg/dose
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Interval
q4h prn
1-3cc/hr
2-4h prn
q3-4h prn
q4-6h prn
q4-6 h prn
q2-4h prn
q6h prn
Preprocedure
q8h prn
q8h prn
q8h prn
q4-6h prn
qid
qid
q8-12h
q8-12h
q6h
q8h
q8h
q12h
q6-8h
q6-24h
q12h
q12h
(max 400 mg/dose)
240-400 mg/kg/DAY divided
(max 3.375 g/dose)
Clindamycin
IV
5-10 mg/kg/dose
(max 4.8 g/day)
Cefazolin (Ancef)
IV
25 mg/kg/dose
Cefoxitin
IV
40 mg/kg/dose
Cefotaxime
IV
50 mg/kg/dose (for children <50 kg)
1-2 g/dose (for children >50 kg)
Cloxacillin
IV
25-50 mg/kg/dose
Pen G
IV
100,000 Units/kg/dose
Amoxi-Clavulin
po
45mg/kg divided bid
(dose reflects Amoxicillin quantity)
Keflex
po
25-50 mg/kg/dose
Septra
po
3-5 mg/kg/dose
(dose reflects Trimethoprim quantity)
Erythromycin
po
10 mg/kg/dose
Miscellaneous Drugs
Ranitidine (Zantac)
IV
1 mg/kg/dose
po
2 mg/kg/dose
Lansoprazole (Prevacid)
po
0.75 mg/kg/dose
(max 30 mg)
Benadryl
IV
1 - 2 mg/kg for anaphylaxis
IV
1 mg/kg/dose
Lasix
IV
0.5-1.0 mg/kg/dose
Bupivicaine (Marcaine)
SQ
3 mg/kg/dose
0.25%
0.8 – 1 mL/kg/dose
Lidocaine 1% Plain
5 mg/kg/dose (0.5cc/kg)
Lidocaine 1% with Epi
7 mg/kg/dose
Simethicone (Ovol) drops
0.25-0.5 ml/dose
Naloxone (Narcan)
0.1 mg/kg dose
Electrolytes/Minerals
Magnesium
IV
25-50 mg/kg for 2-4 doses
Phosphate
IV
5-10 mg/kg over 6hrs
for acute hypophosphatemia
Iron
2 mg elemental iron/kg/dose
When replacing deficits, always repeat levels to check progress.
Tazocin (Pip/Tazo)
IV
Helpful References:
“Pediatric Surgery” by Ashcraft and Holden
“Pediatric Surgery” by Grosfeld, O’Neill, Fonkalsrud, Coran
“Clinical Paediatric Surgery” by Jones et al.
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q6h or q8h
q6h or q8h
q8h
q6h
q6h or q8h
q6h
q4h
q12h
q6h
q12h
q6h
qid
BID
BID
q6h
qAC
q2-3 min
q6h
TID
Notes:
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