ICPM Protocol: PAT092 Care of the Pediatric Trauma Patient  Alcohol Screening Is Required for All Traumas ≥ 13Y – Consults, Activations, Admissions, and Discharges

Home , Lund and Browder chart

Traumas  Don’t forget to TAP IN when arriving to the Trauma Bay!  ICPM Protocol: PAT092 Care of the Pediatric Trauma Patient  Alcohol screening is required for all traumas ≥ 13y – consults, activations, admissions, and discharges. o Use the CRAFFT screen in the Trauma H&P. o Consult Social Work for all positive screens. o Add to “Scut List” on GPS list.  For admission orders, use JHH Pediatric Trauma Admission.  KKI Head Injury Clinic referral is required for all admissions with skull fracture, bleeds, or concussions. Email patient information to appropriate case manager – she will make referral on Monday.

Debbie 10S [email protected] 10N Donna 9N [email protected] Steph 9S [email protected] Pam PICU [email protected]

o Include KKI Head injury Clinic contact information in the discharge instructions: “KKI will contact you within the next two weeks. If you do not hear from them, please call (443) 923-9400.” Burns  ICPM Protocol: PAT095 Care of the Pediatric Burn Patient  The PED burn nurses perform the majority of burn debridements. However, GPS is expected to: o Assist with debridement if procedure is expected to exceed 30m. o Perform debridement when a burn nurse is unavailable. In these cases, you must: o Write a procedure note. It cannot be a blurb in the burn consult note or H&P. o Complete a Lund & Browder diagram. Form is available in the PED.  For burn admissions, use appropriate burn order sets: o JHH PICU Burn Admission o JHH Pediatric Burn Injury Admission Non-ICU  For INPATIENT BURN DRESSINGS, use .pedburndressing (Owner: C. Baldino) o 10S: 9am every day. You must go to assess the burn and write a procedure note. o PICU: 9:30a burn rounds. Schedule dressing change with bedside nurse. You must go to assess the burn and write a procedure note. o You must write a procedure note. It cannot be a blurb in the daily progress note. ERAS  Label all ERAS patients on GPS list with one-liner, e.g., “ulcerative colitis s/p ileocecectomy with ileocolic anastomosis – ERAS”  In addition to routine daily progress note, write a POD2 note using EPIC SmartPhrase: ERASPOD2 (owners: I. Leeds/ M. Fannon)

i BLOOMBERG CHILDREN’S CENTER THE JOHNS HOPKINS HOSPITAL PEDIATRIC SURGERY SERVICE MANUAL FOR MEDICAL STUDENTS AND RESIDENTS Edited by: Seth Goldstein MD

TABLE OF CONTENTS

I. INTRODUCTION ______1

II. RESIDENT RESPONSIBILITIES ______2

1. Pediatric Surgery Fellows ______3 2. Senior Residents and Moonlighters ______3 3. Day Interns ______4 4. Night Float Intern and Saturday Second Years ______5 5. Pediatric Co-Follow ______5 6. GPS Nurse Practitioners ______6 7. GPS Clinical Pharmacologist ______6 8. GPS Clinical Nutritionist ______6 9. Medical Students ______6 10. General Team Responsibilities ______7 11. EPIC help______9

III. GENERAL ADMINISTRATIVE ISSUES ______10

1. Who Goes Where? ______10 2. Pediatric Interventional Radiology Admissions ______10 3. Clinics, Conferences And Rounds ______11

IV. PROBLEMS OF THE SURGICAL NEONATE ______12

1. NICU Survival Guide ______12 2. Recognition And Treatment Of Sepsis In Newborns ______14 3. Tracheo-Esophageal Fistula And Esophageal Atresia. ______14 4. Intestinal Obstruction ______16 5. Intestinal Atresia ______16 6. Hirschsprung's Disease ______17 7. Meconium Ileus ______17 8. Malrotation ______19 9. Omphalocele & Gastroschisis ______20 10. Congenital Diaphragmatic Hernia ______21 11. Necrotizing Enterocolitis (NEC) ______23 12. Postoperative Enteral Feeding ______24

V. COMMON PEDIATRIC SURGICAL PROBLEMS ______26 Seth Goldstein, M.D.

1. Appendicitis ______26 2. Pyloric Stenosis ______27 3. Intussusception ______29 4. Incarcerated Inguinal Hernia ______30 5. Reducible Inguinal Hernias in Infants ______31 6. Foreign Bodies ______31 7. Caustic Ingestions ______31 8. Lower GI Bleeds ______35 9. Biliary Atresia/Kasai______35 10. Chest Wall Deformities-Pectus Excavatum ______36 11. Gastrostomy tubes ______37 12. Empyema______39 13. Spontaneous Pnuemothorax______40

VI. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD _____ 40 Adesola Akinkuotu, M.D.

1. Outpatient Surgery Guidelines ______40 2. NPO Guidelines ______41 3. ERAS management______41 4. ERAS neonate management______41 5. Fluid Management and electrolytes ______42 6. Immunization Status ______43 7. Nutrition basics ______43 8. Parenteral nutrition ______43 9. Central Venous Lines ______44 10. Antibiotic Prophylaxis ______46 11. Tracheostomy ______46 12. Chest tubes ______47 13. Nasogastric tubes ______47 14. Apnea & Bradycardia Monitoring ______48 15. Post-Op Antibiotics ______48 16. Pediatric Pain______48

VII. PEDIATRIC TRAUMA ______49 Lisa Puett, RN., Coordinator of Pediatric Trauma & Burn Programs

1. Pediatric Trauma at Johns Hopkins ______49 2. Evaluation of the Pediatric Trauma Patient ______50 i. Prearrival ______50 ii. Primary Survey ______50

iii iii. AMPLE History ______52 iv. Initial Data ______52 v. Secondary Survey ______52 vi. Transfer ______52 1. Head CT Algorithim ______53 vii. Tertiary Survey ______54 3. Other Important Points ______54 i. C-spine clearance ______55 ii. Spleen/Liver ______56 iii. Child Abuse ______56 iv. Head Trauma ______56

VIII. PEDIATRIC BURNS ______57 Lisa Puett, RN., Coordinator of Pediatric Trauma & Burn Programs

1. Documentation ______57 2. Types of burns ______57 3. Calculating TBSA% ______57 4. Primary Survey ______58 5. Secondary Survey ______59 6. Initial Management ______59 7. Burn Management in Peds ED ______59 8. Inpatient management ______61 9. Common Burn Dressings and treatments ______61 10. Nutrition______62

IX. EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) ______67

1. General Information ______67 2. Indications ______67 3. Contraindications ______67 4. Logistics of an ECMO Activation ______68 5. Technique ______68 6. ECMO Circuit ______69 7. Management of a Patient on ECMO ______69 8. Completion of an ECMO Run ______70

APPENDICES ______72 APPENDIX 1 Guidelines for the Mngnt of Appendicitis in Children _ 72 APPENDIX 2 Pediatric Glascow Coma Scale ______73 APPENDIX 3 ETT Sizes ______74 APPENDIX 4 Emergency Airway Management of Infant & Child ____ 75 APPENDIX 5 Gastrostomy Tubes ______78 APPENDIX 6 Pediatric Surgery Fellowship Conferences & Training 79 APPENDIX 7 Immunization Schedule ______80 APPENDIX 8 Emergency Drugs ______82 APPENDIX 9 Guide to Surgical Procedures for Oncology ______83

iv APPENDIX 10 Guidelines for Pediatric Preoperative Evaluation ____ 85 APPENDIX 11 Intrapleural tPA for Empyema ______92 APPENDIX 12 Guidelines for Catheter related BSIs ______95 APPENDIX 13 Central line lock therapy guidelines ______97 APPENDIX 14 Peri-OP antibiotic prophylaxis guidelines ______98 APPENDIX 15 BURN DOCUMENTATION Requirements ______101 APPENDIX 16 BURN WOUND CARE: ED PROCEDURE______102 APPENDIX 17 Non-operative management of liver & spleen injury_105

IMPORTANT PHONE NUMBERS ______108 NICU SEPSIS GUIDELINES ______112 PICU ANTIBIOTIC GUIDELINES ______114

REFERENCES ______116

v I. INTRODUCTION

The purpose of this manual is to assist you in the management and care of the infants and children on the Johns Hopkins General Pediatric Surgery (GPS) service.

Children are not simply small adults! Many of the basic guidelines of adult surgery still apply but if you are not sure about something, please say, "I don't know." Another team member or nurse probably does and avoiding mistakes is our highest priority.

Please try to be understanding of the parents of our patients. By the time their child has come to the attention of a pediatric surgery service they are usually worried, anxious, and stressed. Treat them in a polite and supportive manner and they will eventually become great bedside allies during their child’s admission. If the parents ask a question for which you are not certain of the answer always say, “I don’t know. I will ask the team."

This manual is not a textbook and is not intended to replace appropriate reading and case preparation. It is a working document that is intended to improve the functioning of the GPS service and will be revised frequently to account for changes on the GPS service. If you have a suggestion to make this manual more effective please bring it to the fellows’ attention. It will be incorporated into future editions.

Printing of this handbook was generously funded by the Department of Pediatric Surgery through the Garrett Fund.

II. RESIDENT RESPONSIBILITIES

1) Pediatric Surgery Fellows

a. There are two accredited fellows in the Johns Hopkins Pediatric Surgery Training Program: the senior fellow; and the junior fellow. In addition there is one non-accredited international fellow. The Accredited Fellows have independent operating privileges for life threatening emergencies only. In all other cases, patients must have an admitting attending, which is determined by the Fellows. b. The Senior Fellow is in the second year of fellowship training and is responsible for the care of all patients on the GPS service. His/her beeper is always on and he/she is always available for questions and help. He/she must be informed of all admissions and consults in a timely manner. c. The Junior Fellow spends the first month of fellowship rotating with the NICU and PICU teams, followed by one month on the GPS service and six months as the Chief Resident of the GPS service at the University of Maryland. In April of their first year, the Junior Fellow returns to the Hopkins GPS service in preparation for their Senior Fellow year. The International Fellow will counter rotate to Hopkins when the Junior Fellow is at Maryland and return to Maryland when the Junior Fellow returns to Hopkins. d. No invasive procedure or major change in the therapeutic management of a patient should be performed without conferring with the Senior or Junior Fellow. e. The Senior Fellow will make the call schedule for each month. f. The Fellows will provide back-up call from home for weekday nights and every other weekend. g. The Senior Fellow will assign cases for the next day on PM rounds. h. The Junior Fellow will take in-house call in the senior resident call pool and cover back-up call on alternating

2) Senior Residents, Trauma Fellows and Moonlighters

a. The call schedule will be posted by the Senior Fellow prior to the start of the rotation. b. When on-call, the Senior Resident’s primary responsibilities are: i. New Emergency Department surgical consultations ii. New in-house surgical consultations iii. Covering notes & calls on the NICU & PICU GPS patients iv. Notify on-call intern of all admissions **making sure complete and thorough exams are documented for all admissions.

2 Emergency Room admissions. v. For all common pediatric surgical problems (covered in chapter VI) communicate directly with the on-call attending. vi. Contact the back-up Fellow on call for: 1. Complicated cases 2. New NICU admissions 3. New PICU Admissions 4. ECMO activations 5. Operative Trauma 6. Major change in patient course (i.e. transfer to the PICU) vii. Never turf an ER Consult to another service without first asking the Back-up Fellow or the Attending. viii. The GPS Service does cover: 1. Hematuria (possible Wilms’ tumor) 2. GYN/ovarian pathology 3. Aerodigestive foreign bodies ix. Consults may be prioritized based on acuity, but respond to pages immediately and tell the consulting service when to expect you. x. Do not give phone instructions to obtain advanced imaging or laboratory studies without first examining the patient. xi. All females with abdominal/pelvic pain who may be sexually active must have a pelvic exam by a surgical resident or gynecologist and always with a female nurse present! 1. Never be in a closed room with a female patient without a chaperone. 2. Parents are not chaperones. 3. Patients will not have surgery based solely on a pediatric/medical evaluation xii. Check urine b -HCG for all females older than 10 years c. Trauma Activations (Also see VIII. PEDIATRIC TRAUMA) i. The senior resident participates in the rapid management of all trauma patients. ii. The resident will facilitate the work-up; iii. Ordering a series of tests and then leaving is unacceptable. iv. Activations occur in two types: 1. Alpha – PICU - Resident Airway GPS Senior – All Else 2. Bravo – GPS Senior runs entire trauma v. The use of advanced imaging should be minimized as much as possible in children. (Ask the fellow/attdg with questions) 1. Avoid Neck and Chest CT without strong indication vi. All patients require Trauma evaluation note-pediatric for their H&P d. In-house consults:

3 i. Identify if the patient has been seen previously ii. If operated before, the pt goes to the previous attending iii. Otherwise, the on-call attending staffs new consults iv. The surgical team has responsibility for the surgical patients in the NICU and PICU v. Work closely & collegially with the neonatologists and intensivists.

e. Daily Work i. The team will meet at 05:30 on weekdays and 06:00 on weekends in the Garrett conference room. ii. Overnight senior residents present PICU/NICU patients the night intern will present floor patients. iii. A daily progress note is REQUIRED on each pt in the NICU and PICU. iv. Senior residents are expected to ensure that each of their cases is appropriately pre-op’d. They are to notify a fellow if discrepancies are identified. v. During the day, one senior resident (typically the on-call senior) will have the consult pager at all times. They are responsible for coordinating the work up of all daily elective admissions and new consults. This is a shared responsibility - not only for the on-call residents. All team members may be asked by the senior with the pager to see new consults or admissions. 3) Day Interns

a. The primary responsibilities of the day intern is the care of all floor patients on the GPS service as well as facilitation in the preoperative holding area. b. In addition to fielding floor calls on GPS patients, tasks include: i. Ensure all patients due for surgery within the future 48 hours have: 1. Signed informed consent 2. All appropriate labs 3. Blood typed and crossed where indicated 4. Adequate bowel prep 5. PICU Bed Assignment as required ii. Keep the OR moving by pre-oping outpatient cases iii. Start the daily text thread before the end of morning rounds iv. Complete all discharge summaries v. Schedule follow-up appointments vi. Write prescriptions for patients being discharged c. Day Interns will be assigned level-appropriate cases d. Trauma Activations (Also see VIII. Pediatric Trauma)

4 i. Interns are expected to respond to all trauma activations ii. Trauma responsibilities include: 1. Complete trauma H&P 2. Accompany pt for imaging 3. Follow-up radiology reads 4. Follow-up labs *Consent etiquette: In the majority of cases, obtaining signatures on a consent form should simply be formalizing a discussion that has already occurred between surgeon/fellow and patient/parents. Interns should be prepared to answer basic questions but not feel responsible for achieving informed consent. In other words, it is fine to get the signature even if there are further questions that you need to ask for help or backup with. Lastly, remember that the witness is simply certifying that the signatory is indeed the person indicated on the form, they are not a “double check” to make sure everyone understands the risks and benefits. DSS consent # is 410 361-2235 or 800 332-6347

4) Night Float Intern and Saturday Second Years

a. The primary responsibility of the night intern is the care of all floor patients on the GPS service. b. By agreement, the night intern will also be covering floor patients on the adult thoracic service. c. A sign-out will occur between the day intern, the night intern, and the NP on weekdays at 17:00. Please attend promptly and arrange a meeting with the thoracic service either before or after. d. On weekends, sign-out will only occur at the 06:00 morning meeting e. In addition to fielding floor calls on GPS patients, tasks include: i. Ensure all patients due for surgery within the future 48 hours have: 1. Signed informed consent (in-pt only) 2. All appropriate labs 3. Blood typed and crossed where indicated 4. Adequate bowel prep 5. PICU Bed Assignment as required ii. Complete discharge summaries for next-day discharges iii. Write prescriptions for next-day discharges iv. Assist with overnight admissions v. Follow-up labs and convey results vi. Review the add-on list in the O.R. to ensure no patient is overlooked. f. Postoperative check on all patients operated upon that day. g. Interns will be asked to scrub emergency cases where appropriate

5) Pediatric Co-follow

5 The GPS service has a pediatric co-follow who is a senior pediatrics resident. The Co-follow’s role is to ensure that normal pediatric care needs are met for each of our patients. They need to be notified of all patients admitted to the GPS service under two years of age. They will provide advice on immunizations, normal post-discharge pediatric follow-up and other issues related to the non-surgical care of children. Please be aware that a pediatric co-follow consult may be called on any other GPS patient in the hospital. This privilege is extended to the nursing staff. If the nursing staff feels a GPS patient would benefit from a hospitalists evaluation, the co-follow will be called for a consult.

6) GPS Nurse Practitioners

The GPS pediatric nurse practitioners (NP) are an integral part of the team. In conjunction with the Day Intern, the inpatient NPs help care for the floor patients on a daily basis, prepare patients for discharge, coordinate consults etc. The NPs have extensive experience caring for infants and children and are available to all the surgical residents for consultation regarding feeding issues, rashes, ear checks, wound care, stoma care, G-tube problems, IV access, well-child care, common pediatric illnesses, and parental anxiety. Please do not hesitate to call upon them. THEY KNOW A LOT AND CAN BE VERY HELPFUL TO YOU IF YOU ASK. The nurse practitioners are also available to assist residents with their assigned patients when the resident is absent or in the OR.

7) GPS Clinical Pharmacologist

The GPS teams rounds daily with a clinical pharmacologist. The role of the pharmacologist is to prevent adverse drug interactions; ensure that patients receive the correct doses of medication; and define appropriate course lengths. Having a clinical pharmacologist on the service represents a significant asset to the GPS service. Any medication related questions should be referred to the clinical pharmacologist.

8) GPS Nutritionist

The GPS service has a clinical nutritionist available for help with enteral or TPN feeding plans. Plans can become quite complicated and typically require both a TPN and enteral component. The clinical nutritionist becomes an invaluable addition to the team when management of multi-modality nutrition becomes necessary. Please refer all nutrition questions to the clinical nutritionist.

9) Medical Students

Each month there are 1-2 medical students on service. These medical students are an integral part of the service and their participation is welcomed. Residents are responsible to provide the students with a wide exposure to many topics in pediatric surgery. Participation in the care of patients is proportionate to their level of experience and expertise. Nevertheless, medical students do not have the same obligations to the service as residents.

Student should expect to scrub in cases daily. Discuss with the fellow or senior resident the night prior about the cases and read about the topics and patients prior to coming to the operating room. Introduce yourself to the patient and family in the pre-op area and perform exam with resident. Each student should spend at least 1 half day in clinic per week.

General Team Responsibilities

 FOR ANY PATIENT CARE PROBLEM THAT ARISES, ALWAYS FEEL FREE TO INVOLVE THE SENIOR RESIDENTS AND FELLOWS.  All senior residents/fellows will welcome your call at anytime.  Check all ICU and other seriously ill patients again and again and again! Do not wait to be called! Find problems and fix them!  The younger and smaller the patient, the faster they can clinically deteriorate

1. Case Assignments: a. Case assignments are made by the Senior Fellow. b. Provide operating room coverage as assigned. c. Residents should be in Pre-op by 7:15 A.M. for first cases. d. All surgical patients must have consent and an H&P update. e. The GPS Service should not be the cause of OR delays f. ALL RESIDENTS should help complete Pre-Op paperwork during the day g. The resident covering a case must perform their own pre-op H&P Note: This does not have to be the H&P that admits the patient to the OR h. A resident should scrub on every index case. 2. Pre-Op: a. Residents are expected to introduce themselves to patients and family, and identify the patient via name bracelet. b. After introduction: i. H&P is updated ii. Surgical site is verified and marked iii. Informed consent is obtained.

7 c. Patients cannot be brought back to the OR until all paperwork is completed. 3. Consents: a. For a minor (under 18 years) parents or legal guardian must sign consent. b. Be aware that foster parents are not always legal guardians, and that social services may be involved. c. Consents are signed by patients 18 years and over unless legal authority has been otherwise indicated. d. Consents must be specific to surgical site indicating left and/or right sides. (“Right” and “Left” must be written out. No abbreviations –“R/L”) e. Interpreters are available for all non-English speaking families. 4. Weight: a. Infants under 1 year need daily weights dependent on disease state. b. Weight is documented in kilograms only. Do not estimate or round off patient weights. c. Use weight most recent today of surgery. 5. Pagers: During cases, the intern and senior call pagers should be handed off to another resident outside of the OR. 6. Resident Availability: a. Cases will not start without assigned resident in the OR. b. Residents must be present in the OR from the time the patient is induced until transfer to the PACU or ICU. 7. Parent Present Induction: a. Parent-present induction is common for pediatric surgery. b. Please refrain from any unnecessary talking and noise during induction. 8. Eyewear: Residents must wear appropriate protective eyewear (side protection too) before scrubbing for all cases. 9. Hand Washing: a. Hand washing is the single most effective way to prevent the spread of infection and disease. b. Use hand gel before and after each patient encounter c. Use non-sterile gloves to avoid cross contamination. 10. Skin Scrub/Preparation a. Chlorprep is NOT approved for use on children under 2 months The pediatric patient population is more prone to Betadine burns. b. When prepping avoid dripping Betadine, especially near Bovie pad c. Avoid pooling of betadine under the patient. d. Clean Betadine off of the patient at the end of the procedure

8 e. All Pectus Excavatum cases should be pre-scrubbed with chlorhexidine hand scrub 11. Post-Op Orders: a. Post-op orders are to be completed immediate after case. b. If a post-op PCA will likely be needed, a pain consultation request can be submitted prior to induction. c. Post-op orders can be drafted prior to induction and finalized at the end of the case. d. Please review the need for foley and abx with either Fellow or the Attending. 12. PACU Surgeon’s Report a. When the patient is delivered to the PACU the resident or fellow will provide a report of the case to the receiving PACU nurse. b. Please include: i. Attending ii. Procedure iii. Complications iv. Destination (Floor vs. home) v. Confirmation of Post-op Order Status

Epic Help We have created a list of smart phrases that you can use to make your life on GPS easier (see below)by stealing them from Cathy Baldino or Michelle Felix. You have to use the .gpstraumaevaluation for all traumas and .pedburndressing for any dressing changes that you do.

.GPS______(head, babyhead, abdomen, lung, foreign body, ostomy, tef, esoph dilation, pectus, ACE, burn, central line, port, drowning, collar care, collar clearing, gcfistula, GJT, liverspleen, NOS, progress note, transfer, woundvac)

9 IV. GENERAL ADMINSTRATIVE ISSUES

1) Who Goes Where?

a. Where do children get admitted? i. Preterm Neonates NICU 8th floor BCC ii. 0-1yr Newborns 9 South Floor BCC iii. 1yr to 3yrs Infants & Toddlers 9 North Floor BCC iv. 4yrs to 11 yrs School age Children 10 South BCC v. >12yrs Adolescents 10 North BCC b. Who goes to the PICU? i. Critically ill children 1. Ventilators 2. Risk for rapid decompensation 3. Neurovascular checks more frequent than q2h 4. Post-op cardiac neonates 5. All ECMO activations ii. Use the “IMC” designation on the appropriate floor for pts who need continuous monitoring but do not meet the above criteria i.e. continuous pulse ox monitoring.

2) Pediatric Interventional Radiology Admissions

a. Pediatric Interventional Radiology admissions are under the IR Service. b. Pediatric Surgery (GPS – General Pediatric Surgery) co-follows with IR from 5:30pm to 7am. c. Pediatric hospitalists and GPS co-follow resident follow along with all children < 2 years old. d. If IR wishes for pediatric hospitalist to co-follow on an older patient for a certain reason, they need to call the on call hospitalist at #4-HOSP (#4- 4677) to discuss. This should rarely be necessary. The pediatric hospitalist may or may not involve the pediatric house staff in the patient care, at their discretion. e. The IR fellow will be responsible for all pages on patients on IR service at 3-CVDL. This pager needs to be answered expediently (for example, by the scrub nurse when fellows are scrubbed). f. On weekends, the IR fellow on call is responsible for pages on IR service pediatric patients at 3-CVDL g. On weekdays and weekends, every day at 5:30pm, the IR fellow signs out to Senior GPS resident/fellow on pager 3-3981 for pediatric IR patients in the hospital.

10 h. Nurses may reach the on call IR fellow for routine overnight calls. GPS is co-following and can be called but are available for emergency response since they are in house overnight.

3) Clinics, Conferences And Rounds

a. General

i. Morning Rounds begin in the 7th floor Garrett Conference Room at 5:30 AM weekdays and 6:00AM on weekends and holidays. ii. Evening rounds will be held in the Garrett Conference room at 5pm or when the cases of the day are finished.

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

c. Surgery Clinic: i. Meets every Monday and Wednesday 8AM to Noon. No scrubs. ii. 1 half day per week required by all residents iii. Postoperative checks and long-term follow-up are also provided. Residents should attempt to see patients that they 1) operated on, 2) cared for in the hospital, or 3) have previously seen in the clinic.

11 V. PROBLEMS OF THE SURGICAL NEONATE

1. NICU Survival Guide

a. Respiratory Norms: i. RR 40-60 ii. O2 Sat 1. >94% in term infant 2. 88-95% in chronic preemies iii. ABG Norms 1. pH 7.35 – 7.45 2. pCO2 35 – 45 3. For every 10 of change in pCO2, pH changes 0.08 iv. VBG or Cap Norms: 1. pH 7.30 – 7.40, 40- 50 b. Pressure-Control Ventilation: i. PIP -peak inspiratory pressure ii. PEEP -positive end-inspiratory pressure iii. MAP -mean airway pressure iv. Maneuvers to Increase pO2 : 1. Increase FiO2 2. Increase PIP 3. Increase PEEP 4. Increase inspiratory time v. To decrease pCO 2 1. Increase rate 2. Increase PIP 3. Decrease PEEP c. Oscillator i. MAP: mean airway pressure ii. delta P: amplitude iii. increase MAP to increase pO2 iv. increase delta P to decrease pCO2 d. Apnea / Bradycardia of Prematurity i. Typical for <35 weeks GA ii. Usually outgrown by term iii. Treatment options: 1. Watch & wait especially if older 2. Caffeine Citrate a. Load bolus - 20mg/kg; max 40mg/kg b. Maintenance 5-10mg/kg/d; max 20mg/kg/d 3. Aminophylline a. Load Bolus 5-8 mg/kg b. Maintenance 2-6 mg/kg/dose PO/IV q8-12h

12 e. Cardiovascular Considerations i. Norms: Hr 120-160 ii. HR of 80 can be normal for term infants iii. MAP: approx 3 –5 above GA (35 weeks = MAP 40mmHg) iv. Patent Ductus Arteriosus 1. Murmur 2. Increased pulse pressure 3. Bounding pulses 4. Palmar pulses 5. Worsening respiratory parameters 6. Treatment a. Post Natal Age < 48 hours i. Indocin 0.1 mg/kg/dose IV q12-24h x 3 b. Post Natal Age 2-7 days i. Indocin 0.2 mg/kg/dose IV q12-24h x 3 c. Post Natal Age >7 days i. Indocin 0.25 mg/kg/dose IV q12-24h x 3 d. Contraindicated in renal failure, NEC, bleeding 7. Common Pressor medications: (initial; titrate to effect) a. Dopamine: 2.5 –20 mcg/kg/min b. Dobutamine: 5 – 20 mcg/kg/min c. Epinephrine: 0.05 – 1 mcg/kg/min d. Hydralazine: 0.1 – 0.2 mg/kg/dose IV q 4-6h, or 0.25 –1 mg/kg/dose PO q6-8h f. Fluids, Electrolytes and Nutrition i. Requirements increase with: 1. Decreasing gestational age 2. Increasing DOL 3. NPO Neonates Require D10 IVF if not on TPN 4. Neonate Fluid rates a. Term: i. start at 80 – 100 cc/kg/d ii. advance by 20 cc/kg/d to 120 cc/kg/d b. 1000-1500gms i. start at 80 – 100 cc/kg/d ii. advance by 20 cc/kg/d to 150 cc/kg/d c. <1000 gms i. start at 100-150 cc/kg/d, ii. use serum sodium (q6 –12h) to guide iii. may raise to 170 –300 cc/kg/d 5. Maintenance electrolytes a. Na: 2-4 mEq/kg/d b. K: 2 mEq/kg/d c. Ca Glu: 200 – 800 mg/kg/d divided q6h

13 6. TPN: a. <1500gm: i. AA/IL start at 3g/kg/d ii. Advance to 4g/kg/d b. >1500gm: i. AA/IL start at 3 ii. Advance to 3.5 7. Enteral feeds: a. Enfamil 20 for > 2 kg b. Premature Enfamil 20 for < 2 kg c. D10 = 100g/L = 100mg/cc d. D25 = 250g/L = 250 mg/cc e. Bili > 5% of body weight needs phototherapy f. Bili > 10% of body weight need exchange transfusion g. Increase daily fluids by 10 cc/kg/d with lights. g. Infectious Disease Considerations: i. Neonate Sepsis caused by: 1. Group B Strep 2. E coli 3. Listeria ii. Empiric Treatment http://insidehopkinsmedicine.org/AMP/pediatrics/downloads/nicu_sepsis_guidelines.html h. Neurological Considerations: i. Routine Head US: 1. <30 weeks a. DOL 1-2 b. DOL7-10 2. 30-34 weeks a. DOL 7-10, or if clinical suspicion b. 30 days to look for PVL 3. Eye exams should be obtained for: a. any baby <32 weeks b. 32 –34 weeks on O2 c. other suspicions d. for retinopathy of prematurity i. At corrected 35 weeks GA ii. 4-5 weeks post-natally

2. Recognition and Treatment of Sepsis in Newborns: a. Signs: (Often reported by bedside nurses) i. Hypothermia vi. Apnea, cyanosis, ii. Leukopenia desats iii. Thrombocytopenia vii. Poor feeding iv. Mottling viii. Irritability v. Lethargy

14 b. Workup: i. Blood cultures ii. Urine cultures (bagged specimens are useless) iii. Sputum cultures iv. LP v. CXR vi. PT, PTT, platelets, CBC and differential c. Treatment: i. Empiric antibiotics after workup is initiated (See sect 1.g) ii. Volume Support iii. Pressors if necessary iv. Administration of FFP if DIC is present. v. Mechanical Ventilation

3. Tracheo-Esophageal Fistula And Esophageal Atresia:

a. These anomalies are frequently not identified prenatally. The only prenatal hint is usually polyhydramnios. b. There are 5 variants of the TEF/EA anomaly i. EA with distal Fistula (85%) ii. Pure EA (7%) iii. EA with Proximal Fistula (3%) iv. EA with Proximal and Distal Fistula (<1%) v. TEF without atresia (4%) c. Inability to pass an NGT into the stomach strongly suggests EA especially when the tip fails to pass the carina. Frequently, the child will be blowing bubbles of saliva during respiration. d. Keep the infant’s head at 45 degrees and connect the NGT to continuous low suction to keep the upper esophageal pouch empty. e. Presence of gas in the stomach suggests a distal fistula. f. Ventilation using mask and bag should be avoided if there is a distal TEF to prevent gastric distention with further respiratory impairment or gastric perforation. g. If a patient with a distal fistula has a distended abdomen it is a surgical emergency. Gastric distention can cause i. Cardiac arrest due to pericardial compression ii. Gastric reflux into the trachea with acute pneumonitis iii. Gastric Rupture h. EA/TEF is frequently associated with VACTERL anomalies. Asses the patient for: i. Vertebral Anomalies (6-21%) ii. Anorectal Anomalies (10-16%) iii. Cardiac anomalies (13-34%) iv. Renal anomalies (5-14%) v. Limb Anomalies (5-19%)

15 i. An echocardiogram is required STAT in all TEF/EA patients to determine whether the child has congenital cardiac anomalies and to ascertain if there is a right or left aortic arch. This helps determine which side a thoracotomy is to be performed. Always remind the cardiology fellow that pressing firmly on the stomach with the echo probe can lead to death by aspiration thru the patent TEF.

4. Intestinal Obstruction:

a. Common causes for intestinal obstruction in infants: i. Intestinal atresias ii. Hirschsprung's Disease iii. Meconium ileus iv. Malrotation b. BILIOUS EMESIS IN AN INFANT IS A SURGICAL EMERGENCY. c. BILIOUS EMESIS IN AN INFANT DENOTES DUODENAL OSBSTRUCTION AND ISCHEMIC BOWEL FROM A MIDGUT VOLVULUS UNTIL PROVEN OTHERWISE. d. Obtain an IV and initiate NGT decompression when intestinal obstruction is suspected. e. Haustral markings are not typically present on newborn plain films. Therefore, the colon cannot be distinguished from small bowel. Contrast studies are required to make the diagnosis. f. Gastrograffin is very hyperosmolar and can cause rapid loss of fluid into the gastrointestinal tract, leading to dehydration and shock. Therefore, infants should always have an IV placed prior to a gastrografin study.

5. Intestinal Atresia:

a. Occurs in the following order of frequency: i. Jejunoileal (50%) ii. Duodenum (44%) iii. Colon (6%) iv. Pylorus (<1%) b. Atresias are commonly associated with a prenatal history of polyhydramnios. Prenatal ultrasound diagnosis of dilated stomach and/or duodenum may be indicative of duodenal atresia. c. Vomiting usually occurs within the first 48 hours of life. Emesis is bilious except in pyloric atresia and very proximal duodenal atresia. d. Plain films of the abdomen should be obtained in all cases of prenatal polyhydramnios. e. The more proximal an atresia the less severe the subsequent abdominal distention. f. Double bubble of duodenal atresia is pathognomonic and no contrast study is indicated. If no double bubble seen, inject air into NGT and repeat AXR

16 g. When multiple loops of dilated bowel are seen, suggesting a distal atresia; a UGI is mandatory. h. A contrast enema is required to identify a microcolon which is a highly reliable finding for small bowel obstruction and to ensure patency of the colon. i. 30% of children with duodenal atresia have trisomy 21. These children may have complex cardiac anomalies. All infants with duodenal atresia require an urgent cardiology evaluation and echocardiogram prior to operation.

6. Hirschsprung's Disease:

a. Hirschsprung's Disease is characterized by an absence of ganglion cells leading to ineffective conduction of peristalsis and functional obstruction. The aganglionic segment may be limited to the rectosigmoid or extend more proximally to involve the entire colon. b. Symptoms are non-specific and include episodic abdominal distension, constipation, obstipation or diarrhea. c. Any newborn that fails to pass meconium in the first 48h after birth should be evaluated for Hirschsprung’s Disease. d. A contrast enema is the initial study and should be obtained in all cases. A positive study will show a transition zone at the narrowed rectum with a dilated colon proximally. However, this finding is often absent in infants. (Specificity 60%) e. Suction rectal biopsy is used to confirm the diagnosis in neonates. A biopsy showing an absence of ganglion cells and hypertrophied nerves in the myenteric plexus of the muscularis layer is confirmatory. The presence of ganglion cells rules out Hirschsprung’s disease. f. For neonates, a pull-through procedure is commonly performed either in the first 1-3 weeks of life as a primary procedure or when the baby is thriving following a divided colostomy (ie. 6 months of age). g. Hirschsprung's may be managed with rectal irrigations in select patients with distal transition zones. Patients identified later in life typically undergo a temporary, or “leveling” colostomy above the level of the aganglionic segment.

7. Meconium Ileus:

a. 33% of all neonatal small intestinal obstructions are due to meconium ileus secondary to cystic fibrosis. b. Meconium Ileus is typically the first finding of cystic fibrosis although only about 15% of infants with cystic fibrosis will develop meconium ileus. c. The incidence of cystic fibrosis in the Caucasian community ranges up to 1 in 1150 live births. There is a known mutation prevalent in the Hispanic population, but otherwise it is extremely rare in non-caucasian communities. Males and females are equally affected.

17 d. These patients will typically present similar to other neonatal obstruction patients: i. bilious vomiting ii. generalized abdominal distention iii. failure to pass meconium in the first 24 to 48 hours e. The meconium may be palpable as a doughy substance in the dilated loops of distended bowel. f. Plain film of the abdomen demonstrates bowel loops of variable size with a soap bubble appearance of the bowel contents. Microcolon is a highly reliable finding for distal bowel obstruction that may be intraluminal from inspissated meconium or atresia due to intrauterine volvulus. g. Calcifications on the abdominal film usually indicate meconium peritonitis resulting from an intrauterine intestinal perforation. A contrast enema is contraindicated if the plain film shows calcifications. h. The initial treatment is typically nonoperative in an otherwise well- appearing child. Treatment consists of gastrografin enemas under fluoroscopic visualization. Commonly, a 50% solution of gastrografin and water is infused into the rectum and colon through a catheter. i. Gastrograffin enemas typically result in a rapid passage of semi-liquid meconium for 24 to 48 hours. Serial radiographs are taken at 12 and 24 hours to evaluate progress. Subsequent enemas may be required. j. Operative indications in meconium ileus: i. Gastrografin enema failure ii. Calcifications in the abdominal cavity iii. Ill-apperaing infants iv. If the diagnosis of meconium ileus is in doubt. k. N-acetylcysteine (mucomyst) or saline enemas can be given to complete the evacuation. Mucomyst can be given through NG tube as well l. Once the meconium ileus is relieved all these patients need a confirmatory test for CF. Options include; i. A sweat test (100% accuracy)-This test is usually not practical prior to operation since the child has to be at least 2kg or > 72 hours in age. ii. A buccal smear-only 80-90% sensitive because it looks for only common genetic mutations. m. All CF infants require vigorous pulmonary therapy. n. When enteral feedings are initiated, a pancreatic enzyme preparation is given with each feeding. Typically, one pancrease pearl per 10cc of formula

18 8. Malrotation:

a. Presentation of patients with malrotation range across a spectrum from normal well-appearing children to hemodynamically unstable. Any patient with the following must be evaluated for malrotation: i. Bilious Emesis (95%) ii. Abdominal Distention iii. Abdominal Pain iv. Inconsolability v. Bloody Emesis (due to gastritis) vi. Bloody Stools (due to necrosis) b. Time of presentation: i. 30% in first week. ii. 75% in First month iii. 90% in the first year c. Findings on plain AXR: i. Gasless abdomen ii. Dilated intestine like SBO iii. Duodenal obstruction with a double bubble d. If the child is not acutely ill, obtain an UGI to look for position of the ligament of Treitz. e. Classic Malrotation on UGI: i. Absent duodenal sweep ii. Duodenum stays to the right of midline and corkscrews down iii. Duodenum is anterior and/or lateral to the SMA iv. Cecum may be midline f. Malrotation Anatomy predisposes the bowel to volvulus following normal peristalsis and consists of: i. Ladd’s bands - fibrous attachments from the retroperitoneum to the cecum which may obstruct the duodenum ii. Absence of a ligament of Treitz iii. Midline cecum iv. Narrow vascular pedicle g. Midgut volvulus is the most serious consequence of malrotation and is a SURGICAL EMERGENCY. Delay in diagnosis can result in loss of the entire midgut, which is uniformly fatal. i. Principal Sign: Sudden onset of bilious emesis ii. An upper GI is the preferred study and should be done in almost all cases. This study may be omitted in the work-up if shock or a clear indication for exploration are present. iii. UGI should be done emergently. Hours may be the difference between a reversible condition and loss of the entire midgut. Contact the Senior Fellow immediately upon consultation for bilious emesis, so operative intervention (if needed) may be expedited.

19 iv. After diagnosis complete these Pre-op Maneuvers: 1. NGT 2. IV Hydration 3. OR 4. NO DELAYS! v. Treatment for Malrotation is the Ladd’s Procedure: 1. Supraumbilical transverse incision. 2. To decompress the volvulus, rotate the small bowel COUNTERCLOCKWISE. 3. Lyse the Ladd’s Bands 4. Place small bowel on the right side 5. Place large bowel on the left (Cecum will lie in the LLQ) 6. Perform an appendectomy 7. If bowel is dead treat as follows: a. Short segment -resect with primary anastomosis. b. Short segment w/ questionable viability-resect dead and bring out stomas. If stomas necrose in 24-48h, re- explore. c. Large segment (or multiple questionable segments) - Close and do second look in 24-48h. vi. Malrotation after the 1st year of life: 1. Symptoms may occur in childhood to adults 2. Typically vague chronic symptoms 3. 10-14% may have acute volvulus. 4. 30% may have intermittent vomiting (bilious), and colicky abdominal or recurrent partial SBO. 5. Some have malabsorption and FTT.

9. Omphalocele & Gastroschisis:

a. Omphalocele – a central abdominal wall defect at the site of the umbilical ring. The abdominal contents are covered by a sac composed of peritoneum, Wharton’s jelly and amnion. b. Gastroschisis - a smooth-edged abdominal wall defect adjacent to a normal umbilical cord, typically on the right. The abdominal contents are eviscerated and uncovered. i. The bowel must be covered promptly to prevent hypothermia. Options include: 1. Warm saline soaked sponges 2. Plastic Bowel bag ii. Note: Gauze bandages tend to stick to the bowels – Do not use them

20 c. These anomalies require lateral support to prevent the mesenteric vessels from becoming kinked. Support them initially as follows: i. Gastroschsis: 1. place the child in the decubitus position with the defect down (typically right lateral decub) 2. The bowel should be supported by towels ii. Omphalocele: 1. Cover the defect with Xerofrom Gauze 2. Place an unwrapped Kerlex roll bilateral to the defect 3. Wrap the entire child with an additional Kerlex ventral to dorsal 4. Place child in supine position d. Treatment maneuvers: i. GI decompression with an NG tube ii. Rectal exam to evacuate and decompress colon iii. Foley catheter placement to monitor urine output iv. Empiric intravenous antibiotics v. IV Fluid support vi. These patients typically require NS boluses to initiate urine e. Rule out associated anomalies, i. Omphalocele: 1. Cardiac 2. Renal 3. Chromosomal (trisomy 13, 18, 21) 4. Beckwith-Wiedemann (large tongue, gigantism, hypoglycemia) 5. Imperforate anus ii. Gastroschisis 1. Intestinal Atresia. f. For gastroschisis, a silo is often used to protect the viscera prior to definitive repair. The silo must be supported to prevent it from falling to the side of the baby, which would kink the blood supply to the intestine. g. Nutrition-when ready start feeds low calorie and slowly, daily wgts, strict I/O, any vomiting and # of stools/day.

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

a. Modern treatment protocol for CDH: i. Delayed surgical repair until resolution of fetal circulation ii. Minimize iatrogenic barotrauma from excessive ventilation. iii. ECMO if mechanical ventilation is insufficient iv. Note: Timing of surgical repair is dictated by clinical course. Do not make treatment changes without discussion with the Senior Fellow or the attending. b. Initial NICU Management: i. Neurological

21 1. Head ultrasound 2. Minimize Sedation 3. Respiratory: Order of Advancing Ventilator Support: a. Supplemental Oxygen b. SIMV (neonatal pressure support) c. High frequency ventilation (oscillator) d. ECMO 4. Vent Settings a. Maintain spontaneous respirations b. Peak inspiratory pressure <25 cm H2O (if possible) c. Rate: Initial settings of 25-35 breaths per minute d. FiO2=1.0 5. Goals: a. Mean airway pressure: i. <12-13 cm H2O ii. Barotrauma kills CDH babies b. Preductal oxygenation: Cerebral Perfusion i. pO2>60 ii. O2 Sat >90%. c. Postductal Oxygenation: Distal Perfusion i. pO2/O2 Sat's will often be <60 /90% ii. Do not use these postductal values to adjust ventilator settings. d. Permissive hypercapnia: i. Maintain pH > 7.25 ii. Maintain pCO2 <60 e. Note: Allow pCO2 to rise >60 and use small amounts of NaHCO3 to maintain pH >7.25. Increasing ventilator settings will elevate mean airway pressures and cause barotrauma. ii. Cardiovascular: 1. Cardiology consult 2. Echocardiogram on admission 3. Conserve IJ and EJ for possible ECMO Cannulation 4. Right radial (preductal) 5. UA, PT, or DP (postductal) iii. Drugs: 1. Fentanyl 1-2 mcg/kg PRN for agitation 2. Empiric systemic antibiotics a. Zosyn b. Amp/Gent 3. Pressors a. Dopamine b. Dobutamine

22 iv. Lab studies: 1. Pre- and postductal ABG's q 1 hour 2. Hematocrit, lytes, ionized Ca q 6 hours 3. PT, PTT q AM 4. CBC, Chem 20 q AM 5. Type and Screen

11. Necrotizing Enterocolitis (NEC):

a. NEC is a disease of low birth weight newborn infants characterized by ischemic necrosis of the gastrointestinal tract secondary to stress, followed by bacterial invasion of damaged tissue. Typically seen between the second and fifth day of life and usually after the initiation of feeds. b. Commonly seen associated with: i. RDS ii. Apneic spells iii. Low Apgars iv. Premature rupture of the membranes v. Breech delivery vi. Exchange transfusions vii. Cesarean section viii. Umbilical artery catheter. c. Clinical findings: i. Bloody diarrhea ii. Abdominal distention iii. Poor feeding iv. Increased apneic spells v. Lethargy vi. Prolonged gastric emptying (read as: Increased aspirates) vii. Bilious emesis d. NEC is frequently evaluated with serial radiographs. The main findings are: i. Dilated bowel –earliest sign ii. Intramural gas (pneumatosis) 1. Not indicative of severity 2. May disappear without actual improvement iii. Portal venous gas 1. Usually indicates increased severity 2. May disappear without actual improvement iv. Pneumoperitoneum. e. Tissue damage is typically focused on the ileum, cecum, and right colon. Findings of increasing severity include: i. Mucosal ulceration ii. Submucosal hemorrhage iii. Necrosis of the entire bowel wall. f. Pneumatosis is found in the submucosa and subserosa.

23 g. Treatment: i. NPO ii. NG suction iii. Broad-spectrum antibiotics for 7-10 days empirically. iv. Serial Radiographs v. Serial CBC, platelet count, blood pH, electrolytes. vi. Contact precautions vii. Slowly increase feeds then increase calories h. Surgical Indications: i. Absolute 1. Pneumoperitoneum - most sensitive film is lateral decubitus ii. Relative 1. Abdominal wall cellulitis 2. Palpable mass on abdominal exam 3. Persisting isolated dilated loop of bowel 4. Failure to respond to medical therapy a. Thrombocytopenia b. Acidosis c. Severe hemodynamic instability i. Pre-Op Preparation: i. Check CBC, PT/PTT, Electrolytes, and ionized Calcium ii. If platelets < 100K, order 2 units of platelets. iii. Move promptly to OR

12. Postoperative Enteral Feeding:

a. Initiation of feeds i. Term newborns: 1. 150 cc/kg/day of 20-kcal/30cc formula q3-4h 2. Goal: Weight gain of 20-30 grams/day ii. Premature infants 1. Higher volume because of evaporative losses 2. More frequent feeding 3. Gavage may be necessary 4. Continuous feeds may be easiest iii. Postoperatively 1. After passage of flatus and stool 2. Begin with D5W or Pedialyte. 3. Examine frequently for abdominal distention b. Gastroesophageal Reflux i. Common in infants and is temporary. ii. Medical management 1. Feeding upright in a chair 2. Leaving infant in chair at least one hour after feeding 3. Thickening feeds with cereal.

24 4. Medications a. Ranitidine PO 2-4mg/kg/day Q12 b. Lansoprazole i. <10 wks old: 0.2-0.3 mg/kg/day ii. >10 wks old: 0.5-1 mg/kg/day c. Gastric Residuals: i. For bolus feeds 1. Hold for residual >1/2 of previous feed ii. For continuous feeds 1. Check residuals every 4 hours 2. Hold feeds if residual exceeds half the amount infused in 4 hours. iii. Infants usually tolerate increasing volume more readily than increasing concentration of feedings. iv. Increasing osmolarity leads to diarrhea v. Increasing volumes leads to gastric residual and/or vomiting. d. Infant formulas: i. Term Infant 1. First Year of Life a. Breast milk i. Ideal for infants ii. Well tolerated iii. Easily digested b. Formula i. Standard - Similac/Enfamil/SMA 1. Lactose is carbohydrate 2. Casein/Whey is protein 2. After Year One a. Cow's milk b. Training Foods ii. Special Cases 1. Lactose Intolerance and Allergy a. Soy Formulas - Isomil/Prosobee i. Sucrose & starches are Carbohydrate ii. Soy is the protein source 2. Malabsorption, short bowel, gastroschisis, CF a. Hydrolyzed Formulas - i. Nutramigen, Pregestimil,, Neocate ii. Sucrose & starches are Carbohydrate iii. Pre-digested proteins (hydrolyzed casein) b. Free-Amino Acid Based Formulas i. Elecare; Neocate (Infant & Jr) ii. Corn Syrup are solids iii. Protein is free amino acids

25 VI. COMMON PEDIATRIC SURGICAL PROBLEMS

1) Appendicitis

a. Basics i. The most frequent surgical consultation in the emergency department ii. The most common abdominal surgical problem in childhood. iii. Early appendectomy for non-perforated appendicitis typically results in hospital discharge within two days. iv. Children less than 2 years of age typically present with a perforated appendix v. Do NOT start antibiotics for “appy rule out” overnight admissions when presentation is equivocal b. Presentation: i. Abdominal pain begins as periumbilical visceral pain ii. Typically migrates to the right lower quadrant – focal peritonitis iii. Perforation typically occurs at around 36 hours (± 10 hours) after pain begins iv. Abdominal pain usually precedes vomiting. v. Associated symptoms: 1. Anorexia 2. Nausea 3. Vomiting c. Examination i. Fever and leukocytosis tend to be minimal in early appendicitis ii. Consistent, localized point tenderness is the cardinal sign iii. Psoas and Rovsing signs are variable iv. Rectal examination may reveal 1. Retrocecal appendicitis 2. Pelvic mass 3. Phlegmon 4. Abscess v. Use a pelvic exam to rule out GYN pathology in sexually-active young women d. Labs i. BMP and CBC ii. Pregnancy test if >10 years old e. Imaging i. No imaging is needed if the history and physical examination strongly suggest appendicitis. ii. A calcified fecalith on KUB is strong evidence for appendicitis 1. Found in only 10-15% of cases iii. Ultrasound is the most common imaging strategy used in children 1. Typically used for all females 2. Used in males for non-classic presentation iv. CT’s are rarely obtained in children

26 v. MRI A/P appendicitis protocol if further imaging needed vi. Antibiotics -The Johns Hopkins Guidelines for the Management of Appendicitis in Children is found in APPENDIX 1 f. Perforated Appendicitis: i. Patients with prolonged symptoms (>5 days) prior to presentation may have perforated appendicitis with phlegmon or abscess seen on imaging ii. Non-operative management may be appropriate iii. IR consultation for drainage/aspiration of abscesses iv. Broad spectrum antibiotics, IVFs v. Consider Interval appendectomy in 6-8 weeks esp if + fecalith

2) Pyloric Stenosis

a. Basics i. Typically occurs in the first 3-6 weeks of life ii. Extremely rare prior to week of life 3 iii. Male predominance 4:1 b. Presentation i. Classic: worsening vomiting over several days leading to projectile NON-BILIOUS vomiting after EVERY feed. ii. Lack of vomiting after every feed should prompt a search for other causes iii. If vomiting has lasted several days the pt may appear toxic c. Examination: i. Classic: a palpable ”olive” in the RUQ ii. If present no further diagnostic tests are necessary iii. To palpate: 1. Give the infant a pacifier 2. Elevate the baby's feet 3. Palpate over the spine at the midline 4. Palpated by rocking superiorly and inferiorly d. Imaging i. Ultrasound is imaging study of choice 1. Positive US findings a. Wall thickness > 3mm AND b. Channel Length >16mm ii. UGI if diagnosis is in question

27 e. Pre-operative maneuvers i. Note: pyloric stenosis is NOT a surgical emergency ii. Electrolytes must be corrected prior to induction of anesthesia iii. Long-term vomiting leads to hypokalemic hypochloremic metabolic alkalosis iv. This MUST be corrected like so: 1. Make sure the vomiting is NOT bilious a. If it is get an UGI ordered and contact the Senior Fellow 2. If vomiting is non- bilious, check UOP if low then “3.” 3. Use NS blouses of 20 cc/kg to induce UOP a. If no urine in 1 hr; repeat NS Bolus 4. Obtain labs or review OSH labs a. If electrolytes come back with HCO3 > 30 give D5 1/2NS at 1.5 x maint b. Add 20 mEq of KCl/L to fluids after good UOP has been established. 5. Check labs every 6 hours. 6. Pre-op Goals: (Anesthesia will not put the pt to sleep otherwise) a. Cl> 90 AND b. HCO3 < 30 AND c. Normal K 7. No need to repeat labs once: a. D5 1/2 NS w/ 20MEq of KCl/l is running b. Goal lytes are obtained c. UOP is good v. Postoperative management: 1. Note: Warn parents that post-op pyloric pts frequently vomit 2. Feeding may resume 6 hrs post-op and are spaced out Q3hrs 3. The first feed is 15 ml of Pedialyte 4. If tolerated the next feed is 30 ml Pedialyte 5. If tolerated switch feeds to 30 ml of formula 6. If tolerated advance to goal volume formula feed 7. Pt may d/c home once tolerating two consecutive ad lib goal feeds 8. If a pt vomits, repeat the vomited feed/volume at the next feeding time until tolerated then continue to advance feeds as indicated. 9. If the bowel lumen is injured intra-op a. NGT suction x 2 days b. IV ABX

28 3) Intussusception

a. Basics i. An invagination of a portion of the intestine into the lumen of an immediately adjoining part. ii. Typical age range: 4 months to 2 years iii. Peak incidence at age 8 months iv. Outside this age range consider a lead point for the intussusception: 1. Meckel's diverticulum 2. Intestinal polyp v. Typical location - ileocecal valve b. Presentation and Examination i. Classic triad: (rarely are all found) 1. Intermittent colicky abdominal pain 2. Abdominal "sausage-like" mass 3. Currant jelly stools. c. Imaging i. Ultrasound is the diagnostic test of choice 1. Positive tests yield a target sign 2. If found a therapeutic air contrast enema is needed. d. Treatment i. Air contrast enema 1. Should not be performed if the child has peritoneal signs 2. Both confirmatory and therapeutic 3. If successful, enemas can be repeated 2 more times if the pain returns 4. Surgery is not needed if reduction is complete. 5. General principles a. A functioning IV must be in place b. Give prophylactic ABX (cefoxitin) x 1 for concern of translocation c. Reduction is successful when there is free reflux of air or contrast into the ileum d. Repeat attempts can be made if the baby's condition will permit. ii. Surgery 1. Required for all children with peritoneal signs 2. Mandatory if reduction cannot be accomplished 3. A sick child should go to the OR after a. IVF b. IV ABX c. NGT placement 4. Resection may be required

29 e. Post Reduction Care i. Admitted GPS for 24 hours observation even after non-operative reduction ii. NPO for the first 8 hours; then gradually advance the diet iii. High temperatures typically follow reduction iv. If symptoms recur, enema reduction should be repeated again v. The recurrence rate after enema or surgical reduction is ~ 5%.

4) Incarcerated Inguinal Hernia

a. Basics i. Typically found in infants during the first year of life (F>M) ii. Girls typically have sliding hernia w ovary/tube in canal iii. Most can be reduced manually which obviates the need for emergency surgery b. Reduction techniques: i. Infant needs to be calm- sweety dipped pacifier ii. ED can provide conscious sedation. iii. Very steep Trendelenburg position assists in reducing the hernia. iv. Have an assistant hold the infant above the knees in a frog leg position to relax the abdominal wall. v. Technique: 1. Use one hand to put traction on external ring, apply steady even pressure to hernia into the canal 2. A considerable length of steady pressure (5 minutes) may be required to produce the desired reduction 3. Should feel the hernia “pop” into the abdomen on reduction 4. Try to milk the bowel contents out of the incarceration, until it is less edematous and can be put back into the abdomen. vi. Some hernias reduce easily; others require several attempts. vii. If successful, the patient is always admitted 1. Repair is performed electively within the next 24-48 hours after the edema has resolved 2. The infant should have serial examinations to rule out re- incarceration viii. Emergency surgical intervention is required if the hernia cannot be reduced, or if there is post reduction evidence of intestinal obstruction, or nonviable bowel c. Hydrocele i. It is imperative to differentiate an incarcerated hernia from a hydrocoele of the cord 1. Hydrocoele of the cord is often tense 2. Hydrocoele in the first year rarely requires operative intervention. 3. Clues to distinguish a hydrocoele from a hernia: a. Transillumination - hydroceles are filled with clear fluid

30 b. Non-tender c. Swelling discontinuous with inguinal ring ii. These infants can be sent home & booked for elective surgery d. Complications i. Infarction of the testicle 1. Reduction will usually reinstitute blood flow to the testis. e. Incarcerated inguinal hernias in girls invariably are sliding hernias containing ovary and tube i. If asymptomatic, these can be repaired on a semi-elective basis ii. The blood supply to the ovary is usually not impaired, and the vessels are small in comparison.

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

a. If consulted on an inpatient preemie with multiple problems either: i. Repair within 4 days prior to discharge home b. Babies < 52 weeks post-conceptual age or with a history of prematurity (gestational age < 38 wks at birth) must be admitted overnight after hernia repair for cardio-respiratory monitoring

6) Foreign Bodies

a. Basics: i. Requires a high index of suspicion and a low threshold for endoscopic examination if there is any question of aspiration of a foreign body ii. Excessive morbidity and mortality results from unaddressed foreign body aspirations iii. Most common in the toddler age group iv. First get AP & lateral CXR to determine the location of the object 1. Radiopaque will show location 2. Radiolucent FBs (wood, plastic, food) will not be seen on CXR a. Esophageal: Obtain esophagram if high index of suspicion b. Airway: often presents as hyperinflation on CXR of affected side- Ball valve effect in bronchus i. Inspiration/expiration CXR ii. Lateral decubitus CXR 1. Affected (down) side will have absence of mediastinal shift from gravity

b. Laryngeal foreign bodies i. A foreign body lodged in the oropharynx or glottis may warrant immediate attention to clear the airway: 1. Heimlich maneuver 2. Direct laryngoscopy 3. Bronchoscopy

31 ii. If possible, a mask airway should be maintained and more controlled laryngoscopy performed in the operating room. iii. If the patient is ventilating adequately when seen, no maneuvers should be performed until the patient is in the O.R. where conditions and equipment are ideal c. Tracheobronchial foreign bodies i. Less than 10% of foreign bodies are located above the carina ii. Majority located in the right main stem bronchus iii. History alone may be sufficient to warrant admission and endoscopy, even in the absence of physical and X-ray findings iv. Plain chest X-ray will reveal the foreign body if it is radio-opaque. However, most foreign bodies such as wood, plastic objects, or peanuts are not radio-opaque and may only manifest as hyper- or hypo-inflation. 1. Obtain Insp/Exp films or lateral decub CXR v. Management 1. The Storz rigid bronchoscope or optical forceps greatly facilitate foreign body removal from the tracheobronchial tree 2. A fine Fogarty arterial embolectomy balloon passed beyond the object can aid in its removal, particularly if the object is fragile (e.g., peanuts), and will not withstand the pressure of forceps vi. The consequences of the neglected foreign body are quite serious and include: 1. Atelectasis 2. Recurrent pneumonia 3. Eventual destruction of the segment or lobe vii. Since there is minimal morbidity using the miniaturized bronchoscope, an aggressive approach is warranted viii. All patients should have a postoperative CXR d. Esophageal foreign bodies i. An esophageal foreign body can cause respiratory distress in small children ii. Objects tend to lodge just below the cricopharyngeus muscle, usually behind the larynx or cervical trachea, thereby obstructing the airway. Other locations include aortic arch, left main bronchus, diaphragm iii. Diagnostic tests 1. CXR will locate the object if it is radio-opaque a. PA and lateral to determine position and possibility of 2 objects i. Disk batteries have step off on lateral projections 2. Abdominal film will determine if the object has slipped through to the stomach 3. Esophagram is occasionally required

32 iv. Management: 1. Endoscopic (rigid or flexible) under general anesthesia typically during business hours a. Overnight presentations should be admitted to floor NPO 2. Sometimes a long laryngoscope will be sufficient to allow removal with either foreign body forceps or a Fogarty catheter 3. Passage of the scope beyond the site of impaction is generally not necessary and can increase the risk of esophageal perforation 4. Consider a postoperative CXR to check for pneumomediastinum if multiple passes of the scope v. Disk batteries require emergent endoscopic retrieval 1. Can cause caustic injury and full thickness lesion 2. Require level 1 to OR

e. Gastrointestinal foreign bodies i. Once in the stomach, most ingested foreign bodies will safely traverse the GI tract, usually within 4-5 days ii. One exception is magnets - Multiple magnets should be removed aggressively iii. The problem sites are: 1. Pylorus 2. Ligament of Treitz 3. Ileocecal valve iv. If the object is radio-opaque, it can be followed with serial X-ray films v. The child should be followed for abdominal pain, vomiting, or blood in the stool . Once the object has passed the ileocecal valve the patient can typically be discharged with appropriate follow-up vi. If after 4-6 weeks the object is still in the stomach, it can be retrieved by EGD

7) Caustic Ingestions

a. Basics i. All patients with suspected caustic ingestion are admitted for esophagoscopy under general anesthesia in 12-18 hr from injury ii. Although most patients with esophageal injury show burns of the oropharynx as well, this is not a completely reliable guideline iii. Upper airway injury as well as face and hands should be assessed iv. Pharyngeal burns may be so severe as to require tracheostomy v. Symptoms can occur between 1-5h after ingestion b. Types i. Acids: Toilet bowl cleaners, rust removers (HF1). 1. These cause coagulation necrosis. 2. Tend to injure the stomach.

33 ii. Bases (alkali): 1. NaOH, KOH, ammonia, electric dishwasher soaps, some denture cleaners, non-phosphate detergents, hair strengtheners. 2. These cause liquefaction necrosis. 3. May involve full thickness injury. 4. Tend to injure the esophagus. iii. Caustic flakes or powder tend to stick and cause localized oropharyngeal and upper esophageal injury. 1. Lead to segmental strictures. iv. Bleaches: Clorox (Na Hypochlorite). 1. Experimentally causes superficial burns and ulceration, no strictures. v. Disk batteries: 1. Experimental model – 1 hour = mucosal injury, 2-4 hours = muscularis injury, 8-12 hours = perforation. vi. Pills: Can get stuck and adhere to mucosa. 1. NSAIDS – hemorrhage and stricture. 2. Potassium Chloride – strictures, hemorrhage, death. 3. Quinidine – strictures. c. Always think about battered child syndrome, Munchausen’s by proxy (8%). i. 78% of poisonings occur with patient near parent. ii. Get social services involved if story is incongruous with injuries. d. Management – i. Acute: 1. DO NOT INDUCE VOMITING, DO NOT LAVAGE 2. NPO and IVF. 3. Wash skin and eyes; wash out mouth with water or milk. 4. CXR and KUB for sx of respiratory distress, odynophagia, drooling, abdominal pain. 5. Esophagoscopy 24-48 hours post injury. a. Do not evaluate distal to lesion. b. Avoid in patients with severe oropharygneal burns or laryngeal edema c. Repeat evaluation in ~2weeks 6. Barium swallow in 2-3 weeks. ii. In patient: 1. Moderate burns – Inpatient 2 weeks, abx and steroids 2. Severe or full thickness – as above, omit steroid administration. 3. Consider esophageal silastic stent with distal penrose to prevent GER or NGT for 6 weeks as sole treatment. 4. If full thickness stomach injury gastrectomy/esophagectomy. 5. Esophageal stricture: develops in 7-15%. Long term risk of cancer.

8) Lower GI Bleed:

a. NEONATES: Condition - Workup i. Swallowed maternal blood - Apt test ii. Hemorrhagic disease of the newborn – Coags, Vit K deficiency NGT, Thrombocytopenia from multiple causes, UGI iii. Anal fissure - Anal exam iv. NEC - KUB, cross table lateral v. Malrotation and volvulus – UGI vi. Allergic colitis from formula – Eosinophilia b. INFANTS 3-18mo: Condition – Workup i. Anal fissure - Anal exam ii. Intussusception - Colon study-air or contrast iii. Intestinal volvulus - KUB, Small Bowel Follow Through iv. Ectopic gastric mucosa - Meckel's scan for ectopic gastric mucosa v. Gastroenteritis – Coags, NGT c. TODDLERS and PRESCHOOL: Condition – Workup i. Anal fissure – Anal Exam, Coags, NGT ii. Rectal prolapse - Anorectal exam iii. Gastroenteritis – KUB iv. Meckel`s diverticulum - Meckel`s scan v. Juvenile polyp - Upper and lower endoscopy vi. Trauma - RBC scan d. OLDER CHILDREN and TEENS 6-18y: Condition – Workup i. Polypoid diseases - Coags, KUB, NGT ii. Ulcerative colitis - Upper and lower endoscopy iii. Hemorrhoids - Anorectal exam iv. Meckel`s - Meckel`s scan

9) Biliary Atresia a. Background– rare 1:18 K infants, non-hereditary, leading cause of liver transplants in infants/toddlers i. Cause- unknown b. Symptoms-persistent hyperbilirubinemia > 2 wks of age Acholic stools Poor weight gain Poor feeding Sleepy Dark urine c. Differential Diagnosis- Hereditary disorders (Alagilles, Wilsons, Primary Sclerosing cholangitis) Viral hepatitis Autoimmune hepatitis Toxicity d/t exposure ie: acetaminophen OD d. Work up-- Blood test screening for genetic disorders

35 Hepatic duplex HIDA scan- NPO & no narcotics x 4 hrs prior Liver biopsy Intraoperative cholangiogram e. Treatment - Kasai f. Post-op Kasai Management: i. Medications 1. Actigall: Oral - 10mg/kg/dose – BID (helps absorb bile acids decrease pruritis) 2. Bactrim: Oral - 5mg/kg - Daily (cholangitis prophylaxis) 3. ADEK: Oral - 2mL - Daily 4. Ranitidine: Oral - 2mg/kg – BID 5. Tylenol: Oral - 12.5mg/kg/dose - q 12 hours PRN Additional Medications: depending on clinical picture/lab values 6. K : oral 2.5mg MWF (only with abnormal coags) 1. In INRis hight (>1.2) then they will start it here and stay on until GI f/u apt 7. Spironolactone: start 1mg/kg BID to 2mg/kg/BID a. Can be TID based on clinical exam, may increase frequency if clinically needed b. Initiate after POD4 if pt is edematous and having increase abdominal girth post op iii. Strict I/O-monitor for ascites, edema, color of urine, strict I&Os 1. monitor stools for color, hematochezia iv. Monitor BP/persistent portal hypertension, varacies v. acetaminophen Q 12 hrs, narcotics & other meds given at longer intervals ie:Q6+ hrs d/t poor clearance r/t liver failure vi. Enteral feeds after bowel function returns: 1. Breast milk , BM with MTC oil (per nutrition)/ Pregestimil (short chain fatty acid formula- best tolerated and absorbed) vii. Things to be aware of while on floor: 1. Abdominal distention 2. Nausea 3. Vomiting 4. Clay/gray color stools 5. Bilious emesis 6. Tea color urine 7. Itchy/yellow skin

13. Chest Wall Deformities-Pectus Excavatum

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

36 posteriorly toward spine ii. Male to female ratio 3:1. iii. Etiology unknown but ~ 30% incidence in relatives iv. Often apparent at birth but may increase in severity with growth v. Associated Anomalies: 1. Marfan’s Syndrome 2. Scoliosis vi. Indications for Repair 1. Severity and symptoms 2. Psychosocial issues b. Management i. Preop: may have any of following: 1. CT with Haller index 2. PFT’s 3. Echocardiogram ii. Intraop: Nuss Procedure 1. Prep with chlorhexidine hand scrub 2. Small bilateral intercostal incisions 3. Large clamp passed across mediastinum from left to right 4. Stainless steel bar custom shaped to desired contour passed across mediastinum concave side up 5. Bar then flipped to elevate chest wall 6. Bar secured with stabilizers & wire to remain in 3 years iii. Postop: Nuss Procedure 1. CXR (AP, possible lateral) in PACU to check bar position 2. PCA for 2-3 days managed by the Pediatric Pain Team 3. Convert to oral pain meds on 2nd or 3rd POD 4. Will need narcotic Rx for home pain management 5. Post-op clears, then advance diet as tolerated 6. OOB and early ambulation, incentive spirometer 7. If urinary retention, place foley for 24 hours iv. Bar removal 1. Typically 3 years after placement 2. Outpatient procedure 3. Minimal pain meds (No narcs typically) 4. NO POST-OP CXR unless symptomatic a. Desats b. Major Chest pain

14. Gastrostomy tube a. Indications i. Nutritional supplementation: 1. Failure to thrive 2. Oral Aversion 3. Oromotor Dysfunction & Dysphagia ii. Medication administration

37 b. Work-Up i. Many of these children require a concomitant Nissen ii. Work up must determine 1. Normal Rotation 2. Gastric Feeding tolerance by NGT 3. Bolus NGT feeding Tolerance iii. UGI – REQUIRED to rule out Malrotation (not to determine reflux) iv. pH probe to prove reflux in symptomatic child w/ bolus tolerance v. Malro get’s a Ladd’s vi. Reflux or Bolus intolerance gets a Nissen c. Placement methods i. Open – Cardiac Infants ii. Percutaneous (PEG) - > 1y/o iii. Laparoscopic – Neonates and Infants d. Types of gastrostomy tubes i. Malencot or Pezzar: used if decompression is necessary ii. Balloon gastrostomy tube (MIC) iii. Balloon gastrostomy button (MIC-Key) e. Post Operative Management i. NPO following the placement of the G-tube ii. Continue peri-operative antibiotics x 24 hours (Cefotetan) iii. Ask attending if toradol OK iv. Feeds may initiate on POD#1 1. For smaller children a. Pedialyte @ 5ml/hr x 4 hours then; b. Switch to pre-op formula at 10ml/hr; c. Increase feeds by 5ml q4hrs until at goal 2. For older children (>1 year) a. Start with Pedialyte @ 10ml/hr x 4 hours then; b. Switch to pre-op formula at 20ml/hr c. Increase feeds by 10ml q4hrs until at goal 3. Gtube must be a continuous rate for 24 hours before changing to bolus feeds and Nissen/Gtube must be on continuous feeds for 3 days then can change to bolus feeds. Stitches can be removed day 3-5 based on the attending v. Tubes are changed electively in clinic at 6-8weeks f. Complications i. Leak: Refer to Wound and Ostomy nurses ii. Accidental dislodging 1. Early inadvertent removal- notify Fellow or Attending before attempting replacement 2. Within 2 weeks of insertion: a. Re-insert tube or foley immediately b. Obtain a g-tube study with contrast c. Do not force the tube in

38 d. If a foley was used and the contrast study shows access to the stomach, re-insert a g-tube e. If the tube cannot be inserted without difficulty, dilate the tract serially with 8Fr, 10Fr and 12Fr Cook dilators and then attempt to reinsert. This often requires sedation and possibly OR 3. Radiologic confirmation is not necessary for accident dislodgement in a tube that has a matured tract 4. Prompt response to calls about dislodged GTs are critical as tract may close within hours iii. Excessive granulation tissue or redundant gastric mucosa 1. Can be cauterized w silver nitrate sticks

15. Empyema a. Causes i. Pneumonia- most common ii. Extension of mediastinal, retropharyngeal, paravertebral infections iii. Thoracic surgery or trauma b. Stages Stage Time after onset Fluid characteristics Treatment Exudative 24-72hrs Thin fluid, few cells Drainage (CT or needle) Fibrino- 5-10 days Fibrinous debris, many Fibrinolysis +/- purulent PMNs, loculated septations thoracoscopy Organizing 2-4 weeks Thickened pleura Pleurectomy c. Organisms i. Staph aureus – most common ii. Strep pneumoniae iii. Haemophilus influenza iv. Pseudomonas aeruginosa d. Presentation i. Hx of URI w fever and cough ii. Pleuritic chest pain and resp distress iii. Lethargy, tachycardia iv. Diminished breath sounds and dullness to percussion on exam e. Work up i. CXR ii. US 1. Usually adequate for diagnosis 2. ID locuated fluid collections iii. CT Chest for special circumstances iv. Thoracentesis 1. Complicated pleural effusion a. pH <7.2 b. glucose < 60mg/dL

39 c. LDH >1000 un/L f. Treatment i. IV ABX, may require PICC for home ii. Early- chest tube drainage alone iii. Advanced (loculations)- 1. Chest tube drainage and fibrinolysis w tPA 2. VATS w drainage and decortication a. Dr Lukish uses tPA post op iv. See appendix for tPA procedure guidelines

16. Spontaneous Pneumothorax Most common in tall, lean adolescent males, Family history Recurrence rate 50% after one, 62% w/second, 83% if third incident No history of trauma or recent illness a. Causes i. Blebs ii. Unknown iii. Infectious iv. CPAM

b. Symptoms i. Ipsilateral chest pain ii. Dyspnea iii. Diminished breath sounds iv. Tracheal shift c. Diagnosis i. CXR d. Management i. < 20% lung volume and asymptomatic 100% O2 & observe ii. > 20% or symptomatic small pneumo - Place chest tube or pigtail catheter and wall suction - Place to suction for 48 hours if no air leak, then place to water seal prior to removal -If persistent air leak, troubleshoot system and then consider CT iii. Recurrent spontaneous pneumo Place chest tube/Pigtail and obtain CT iv. VATS for blebectomy and pleurodesis if CT + blebs on ipsilateral side, blebs on contralateral size just observe

VII. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD

Many pediatric surgery patients do not require preoperative lab work.

40 As a rule same day surgery patients do not require lab work or diagnostic studies unless there is an underlying diagnosis that places the child at increased risk related to surgery or anesthesia. Pre-op labs are not routinely ordered on pediatric surgery patients. a. Outpatient Surgery Guidelines

i. Please refer to Appendix 10 for broad coverage of outpatient surgery guidelines ii. NPO Guidelines 1. Patients should be awakened and offered fluids the night prior to surgery 2. <2 Years Old: a. NPO for solids at midnight b. NPO for milk/formula 4 hours prior to surgery c. NPO for clear liquids 2 hours prior to surgery 3. >2 years old and older a. NPO for solids and milk at 8 hours b. May have clear liquids up to 2 hours prior to surgery 4. Clear liquids include breast milk unless a bowel prep is required 5. Patients should be sent home on pain medications: a. Tylenol only for child < 6 months of age b. Oxycodone for older children when extent of operation warrants 6. Follow-up: Return to clinic in 2 weeks unless it is a line removal b. In-Patient guidelines i. ERAS Protocol 1. Start IVF D5 ½ c 20k 2. Clear liquid diet until midnight then NPO 3. Neomycin 23mg/kg/dose x 2 given at 1hr & 4 hrs after admission 4. Neomycin 500mg/ml in syringe to be sent to OR w/pt day of surgery 5. Erythromycin 30mg/kg/dose x 2 given at 1 & 4 hrs after admission 6. Bisacodyl 30 mg x 1 dose given at 3 hrs after admission (for pts 12yr >) 7. Miralax 238 gms given with 32 oz of Gatorade on admission, (pts 10 yr+) To be finished within one hour 8. Miralax 3mg/kg (max 238 gms ) given with 8 -24 oz of pedialyte or Gatorade on admission for pts (0-9 yr) to be finished within one hour. 9. Gabapentin 5mg/kg QHS x1 for patients 2yrs and up 10. Wash pt with chlorhexidine wipes the night before and morning of surgery ii. ERAS protocol for Neonates (pre-term to 37) 1. Neomycin 23mg/kg/dose x 2 given at 1hr & 4 hrs after admission 2. Neomycin 500mg/ml in syringe to be sent to OR w/pt day of surgery 3. Erythromycin 30mg/kg/dose x 2 given at 1 & 4 hrs after admission 4. Miralax 3mg/kg (max 238 gms ) given with 8 -24 oz of pedialyte or Gatorade on admission for pts (0-9 yr) to be finished within one hour.

41 5. Wash pt with chlorhexidine wipes the night before and morning of surgery c. NPO Guidelines

i. Medications: Can be given with a sip of water except for the following which should not be given within 8 hours of surgery: 1. White liquid antacids (Mylanta, Maalox) 2. Stool softeners (carafate, senna, miralax) 3. ACE inhibitors (captopril, lisinopril, enalapril) 4. ARBs (losartan, valsartan, irbesartan) ii. Solid foods, milk, meat-8 hours (or after midnight) before arrival at the hospital iii. Infant formula - 6 hours prior to arrival at the hospital/ first case start iv. Breast milk - 4 hours prior to arrival at the hospital/ first case start v. Clear liquids - 2 hours prior to arrival at the hospital/ first case start2 d. Fluid Management

i. Indications for pre-operative IV fluids 1. Vomiting, diarrhea, fever or preoperative bowel preparation 2. Delay of surgery more than 6 hours in infants or 8 hours in children ii. Maintenance IV fluids 1. Newborn a. Day of Life #1: 80ml/kg/d of D10W b. Day #2: 100ml/kg/d of D10 1/4NS c. Glucose infusion rate (GIR) 4-6mg/kg/min (term) or 5-8 mg/kg/min (preterm) = [IVF rate (ml/hr) x dextrose conc (g/dL) x 0.167]/wt (kg) 2. Older children a. 100ml/kg/day or 4 ml/kg/hr for first 10kg b. 50ml/kg/day or 2 ml/kg/hr for second 10kg c. 20ml/kg/day or 1 ml/kg/hr for every kg over 20 d. Remember “4-2-1” Rule (When wt> 20 kg add 40 to wt in kg for maint rate) e. Standard maintenance IV fluid: D5 1/2NS with 20mEq/L KCl 3. Electrolytes a. Daily sodium: 2-5mEq/kg/day b. Daily potassium: 1-2.5mEq/kg/day 4. Blood products a. Estimated blood volume i. Newborn 90cc/kg ii. Child 80cc/kg iii. Adult 70cc/kg b. PRBCs 10cc/kg will raise Hct by 3-4% c. Platelets 1 unit/10 kg will raise count by 25,000 d. FFP 10-15 ml/kg for coagulopathy

42 e. CRYO 1 unit/5kg to replace Fibrinogen 5. GI losses: Replace all with cc per cc. a. Gastric: i. Infants: D5 1/2NS with 20mEq/L KCl ii. Older: NS w 20mEq/L KCl iii. Distal GI losses: D5LR e. Immunization status -See Appendix 7 for immunization schedule1 f. Nutritional basics i. Growth parameters 1. Measure weight daily 2. Measure length weekly (in NICU) 3. Follow growth parameters closely in making decisions on nutrition 4. Average weight gain a. Premie <2kg: 15-20 g/day b. Premie >2 kg: 20-30 g/day c. 0-3 months: 25-35 g/day d. 3-6 months: 20 g/day e. 6-12 months: 12 g/day f. 12-18 months: 8 g/day ii. Calories 1. Term neonate 100-120 kcal/kg/day 2. Preterm 120-130 kcal/kg/day 3. Very low birth weight (<1kg)>150kcal/kg/day g. Parenteral Nutrition

i. Indications: 1. Prolonged period of fasting (> 5 days) 2. Malnutrition ii. Can be initiated using peripheral or central venous access 1. If peripheral access is used, the PN solution must be diluted to avoid phlebitis and sclerosis –osmolality <1000 2. If PN is to provided for >3days; recommend central access to optimize nutritional provision without osmolality limits 3. Full CPN requires that central line be at the junction of the SVC and right atrium iii. Daily fluid requirements for pediatric population 1. 0-10kg  100ml/kg 2. 10-20kg  1000ml + 50ml/kg >10kg 3. 20+kg  1500ml + 20ml/kg > 20kg iv. Main components 1. Lipids a. Initiated at 1g/kg/day b. slowly increased with maximum dose of 3g/kg/day c. Check weekly triglycerides and adjust lipids PRN 2. Dextrose

43 a. Preterm infants started at a rate of 5mg/kg/min; advance by 1-2 mg/kg/min pending blood glucose< 110 to max of D12.5 in peripheral lines; D20-25% in central lines; or GIR of 18mg/kg/min b. Term infants start at 2.5% higher than their normal fluids. If BS<110advance to a max of 12.5% in peripheral lines and D20-25% in central lines 3. Protein a. <1kg – start at 1.5 g/kg advance by 1g/kg to goal of 3.5-4 g/kg b. 1-2kg start at 2 g/kg/day advance by 1g/kg to goal of 3-3.5 g/kg c. >2 kg and term infants start at 2g/kg and go up 2-3 g/kg to goal of 2.5-3.5 g/kg d. Adolescents start at goal of 0.8-2.5 g/kg 4. CPN should also contain water and fat-soluble vitamins as well as trace elements 5. All patients on TPN should get daily electrolytes in the initiation phase 6 6. All TPN orders must be entered into POE and on Hopkins Pediatric CPN portal 7. Completed forms are faxed to the pharmacy daily at 5-0283 8. Guidelines for advancement and calorie, fluid, and protein recommendations for parenteral nutrition can be found in Nutrition Assessment note in POE h. Central Venous Lines i. Access points usually include: 1. internal jugular 2. subclavian 3. femoral ii. If access is obtained from an upper vein, the goal is to ensure that the line is at the cavoatrial junction on chest x-ray iii. Non-tunneled central lines: 1. Used for short or medium-term access 2. Include Arrow and Cook iv. Tunneled central lines: 1. Usually placed in the operating room under fluoroscopy 2. Brands: Cook, Broviac, Hickman 3. Instill heparin flush to fill catheter if not in use v. Totally implanted central venous lines (Ports) 1. Used for long-term, intermittent access such as for patients with malignancies, hematologic illnesses or renal failure 2. These are accessed with special non-coring (Huber) needles. 3 3. Per Hopkins policy, nurses are not allowed to access until POD#5 after placement 4. Be sure to ask team if they will need it accessed in the operating room 5. Instill heparin flush (final flush dosing) to fill tube if not in being used 6. GPS requires ANC >= 500 to place a port vi. Complications 1. Line break: Call the GPS senior or fellow to discuss – Repair kits exist a. Contact fellow prior to repairing line

44 b. This is considered an urgent procedure and repair should be performed expeditiously before the line is lost c. Repairing and salvaging lines is especially important for patients on long term TPN (ie short gut) and have had multiple repeated line placements d. Repair kits are located in Peds ED or Interventional radiology e. Know the size and type of catheter in patient, repair kit must match size f. Technique i. Clamp the line proximal to the break, ii. Prime the repair segment with saline flush. iii. Squeeze the silicone glue into the barrel of a 3cc syringe and apply the blunt tip. 1. Do not squeeze the glue into the needle until ready to use. iv. Prep the line sterilely and lay on a sterile towel. v. Cut with disposable scissors. vi. Partially insert the metal piece of the repair segment into proximal stump and apply glue to metal segment circumferentially before fully inserting. vii. Apply more glue around connection and slide clear plastic sleeve over the repair site. viii. Inject as much glue as possible inside the sleeve. ix. Gently try to flush the line with saline. 1. If it flushes then follow with heparin flush. 2. If resistant, stop. x. No further flushes should be attempted for 12-24 hours. xi. At that time tpa may be instilled if the line still cannot be flushed. g. After repair, lines should not be used for a minimum of 12 hours, preferably 24 hours. Stenting the repair with a tongue depressor may be helpful. Administer fluids via peripheral IV until cvl is safe to use again. 2. Line occlusion: a. Make sure that the line is unclamped b. Test the line yourself c. Call VAT to declot with tPA i. TPA should be applied for 2-4 hours, at least 2 attempts, if still not resolved, consider leaving TPA in overnight 3. Catheter site infection a. Erythema or drainage from the insertion site b. Send peripheral and central blood cultures c. Treat with local wound care and empiric antibiotics until cultures result then de-escalate d. Remove if: i. Continued local infection despite 48-72hr abx ii. Developing systemic infection iii. Fungal infection

45 iv. Ongoing sepsis v. Persistent + cultures on appropriate ABX 4. Central line associated blood stream infection (CLABSI) a. See guidelines in Appendix 12 and 13 b. Obtain peripheral and central line blood cultures c. Treat with empiric antibiotics d. Tunneled catheters are treated with intent to sterilize e. Cultures are drawn daily f. Antibiotic locks g. Hydrochloric Acid may be required by protocol to clear line i. Antibiotic prophylaxis

i. Most important method of preventing surgical site infections is proper hand scrubbing ii. Clipping, if necessary, should be done just prior to surgery iii. Systemic prophylaxis should be given only when risk of wound infection and benefits of prophylaxis outweigh risks of adverse drug reactions 1. Clean cases: Respiratory, GI, or GU tract or oropharygeal cavity is not entered a. Risk of infection is low at 1-2% therefore prophylaxis is NOT needed b. Exceptions include implantation of prosthesis, open-heart surgery, exploration of body cavity in neonates or neurosurgical cases 2. Clean-contaminated: Respiratory, GI or GU tract is entered in a controlled setting. a. Risk of infection is approximately 3-15% 3. Contaminated: Include open wounds, cases in which there has been a break in sterile technique, exposed viscera at birth, congenital anomalies a. Risk of infection is approximately 15% 4. Dirty: Included penetrating trauma >4hrs, devitalized tissue, wound with infection/ perforated viscus. 4 iv. Antibiotic should be administered within 60 minutes of incision v. Antibiotic should be re-dosed if 1. case >4hrs 2. >30% blood volume loss 3. >1500ml if >50kg and normal renal function vi. See Appendix 14 for specific prophylaxis guidlines5 j. Tracheostomy

i. Usually performed in the operating room as an elective case on a child who is already intubated ii. The operation 1. Transverse incision in the lower neck and dissecting down to the trachea 2. The trachea is incised a. just below the isthmus of the thyroid b. no higher than the second tracheal ring 3. A stay suture on each side of the tracheostomy with polypropylene sutures and labels for “right” and “left”5

46 4. The ETT is withdrawn under direct vision 5. Use a cuffless tube iii. Respiratory distress in a patient with new tracheostomy 1. Suction first but only for a moment 2. Pull up on the stay sutures and remove the trach tube 3. Re-insert endotracheal tube and replace tracheostomy when airway is well- established k. Chest tubes

i. Indications: 1. Pneumothorax 2. Hemothorax 3. Pleural effusion ii. Insertion site: 1. Pneumothorax: place on the anterolateral aspect of the chest wall 2. Hemothorax/ pleural effusion: Place posterolaterally iii. Insertion Technique 1. Prep and drape the skin and anesthetize with local anesthetic 2. Make a small incision in the mid-axillary line at the level of the nipple 3. Use a curved hemostat to tunnel superiorly and above the higher rib into the pleural cavity 4. Once in the pleural cavity spread the hemostat to create a tract 5. Insert the chest tube into the pleural cavity and ensure that all holes are intrathoracic iv. Obtain a post-insertion chest x-ray to confirm the position v. Chest tube removal 1. Chest tubes should be removed after: a. being placed on water seal b. CXR evidence of post-seal resolution of hemo/ pneumothorax 2. NOTE: Lukish wants ALL his Chest tubes removed ON Suction a. Take off water seal two hours prior to pull b. He only wants symptomatic post-pull CXR 3. Chest tubes should be removed at the end of inspiration or with a vasalva maneuver 4. If the patient, is cooperative, you can ask them to blow like they are blowing on a birthday cake 5. Once the tube is removed, cover with xeroform and an occlusive dressing such as a Tegaderm 6. Obtain a post-pull CXR an hour afterwards l. Nasogastric tubes

i. Used for gastric decompression and enteral feeds ii. Use sump tubes for decompression

47 iii. Confirm the position of the tube by instilling a small amount of air while auscultating over the stomach iv. If the NG tube output is high, get an abdominal xray to confirm its placement v. Gavage feeds in neonates and infants for: 1. lack of gag 2. weakness 3. rapid respiratory rate vi. Requires 1:1 replacement when volumes are high m. Apnea and Bradycardia monitoring

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

i. Indicated in the setting of post-operative surgical site infection or abscess. ii. Wound infection: signs include erthyema, leukocytosis iii. Treat with oral or IV antibiotics depending on severity iv. Abscess 1. Definitive treatment is incision and drainage 2. Once the wound is opened, pack with aquacel or wet-to-dry saline solution and let it heal with secondary intention4 o. Pediatric Pain Tips i. PCA’s can only be ordered by the Pediatric Pain Team ii. You cannot order a narcotic and sedative together as it is considered conscious sedation (ie oxy and valium) iii. If the Pain team is involved, no other narcotics, sedatives, analgesics can be ordered by our service. iv. Place order for pain team consult with transfer orders from OR to PACU, for patients except lap appy, lap chole, umbo/inguin hernia, GC fistula repair, lap nissen/GTube v. Order ketorolac ATC for lap chole/appy, hernia, GC fistulas. May also order morphine prn and acetaminophen for breakthrough pain vi. NSAIDs not ordered for onc , hemophiliac, chronic renal disease, ICH, liver/spleen/kidney lacs. vii. No acetaminophen for liver failure patients viii. Procedures- 1. Bedside procedures- removal of chest tubes/drains/TPA instillation/wound VACs/wound exploration 2. Discuss time of procedure with patient and nurse. 3. If patient has PCA instruct pt/nurse to give bolus doses as allowed starting 30 min prior to procedure 4. If PO meds instruct nurse to give oral pain meds/anxiolytics one hour prior to procedure 5. Central lines cannot be removed at the bedside

48 VII. PEDIATRIC TRAUMA

I. Pediatric Trauma at Johns Hopkins A. Policy: Care of the Pediatric Trauma Patient PAT092. B. “Pediatric” is defined as patients aged < 15y arriving directly from the scene of injury; patients > 15y are adult patients. Patients < 17y may be transferred in from OSHs. C. Three categories of pediatric trauma activation: a. Alpha trauma: highest priority; unstable patients or injuries that may quickly result in instability. b. Bravo trauma: high priority; stable patients with a significant mechanism of injury or specific types of injuries. c. Critical trauma transfers: high priority; essentially a stabilized Alpha trauma arriving to the trauma bay for primary & secondary survey; then, expeditious admission to the PICU. d. PED Trauma Activation Criteria 1. Mechanisms not meeting above criteria e. GPS Consult Criteria 1. NAT work up f. PED trauma requiring chest or abdominal CT

D. Team members who respond to pediatric trauma activations include: a. GPS attending (required for Alpha traumas only) b. GPS fellow/senior resident-team leader c. GPS intern/NP d. PICU fellow and attending for airway management (Alpha traumas only) e. ED attendings: 1. on odd days- pediatric emergency medicine attending 2. on even days- adult emergency medicine attending f. PED resident and AED resident g. PED Nursing h. PICU Nursing (Alpha traumas only) i. Respiratory Therapy (Alpha traumas only) j. Pharmacy (not available 24/ 7) ); If needed during off shifts can activate an RRT k. Radiology l. Additional ancillary services, i.e., Social Work, Chaplain, Security. E. All team members require yellow gown and role name tag upon entering room. F. Establish roles early prior to patient arrival. G. Pediatric/ adult ED resident enters orders (labs, imaging) while the patient is in the ED; paper requisitions for imaging are also acceptable and can be filled out by the GPS team, if necessary. H. Complete the trauma-specific H&P note in the patient’s electronic medical record (eMR) for all Alphas, Bravos, critical & non-critical trauma transfers & trauma consults. Fill in all information and be accurate: it becomes part of the patient record, and data is submitted to the National Trauma Data Bank.

49 I. Use the pediatric trauma-specific order sets for all trauma admissions. J. Consult other services as needed through PING. K. Procedures, e.g., central lines, chest tubes, etc.: document a procedure note in eMR. L. All patients admitted following a pediatric trauma activation are admitted to the GPS service for at least 24 hours; transfer to another service can be considered later if the patient has only single-system injuries. Exceptions include isolated injuries taken to OR by specialty service with remainder of trauma work up completed and negative.

II. Evaluation of the Pediatric Trauma Patient A. Pre-arrival: obtain as much information as possible regarding the mechanism of injury and potential injuries, prepare a game plan based on this information, and obtain equipment that may be required for emergent procedures. B. Primary Survey a. EMS provides their report as the patient is moved to the ED stretcher. Do NOT delay initiation of the patient evaluation to hear details from EMS that can be provided after the patient is stabilized. , (30 second time out). b. The ED attending or fellow (or GPS attending or fellow, if present) serves as team leader, looking at the “big picture” of the resuscitation. The primary survey is performed by the GPS intern/NP/ fellow/ senior resident. The GPS senior/intern/NP documents the trauma history and physical and assists with procedures, as needed c. Perform ABCDE evaluation per ATLS protocol. d. Airway i. Indications for rapid-sequence intubation: 1. GCS8 2. Significant facial trauma with poor airway control 3. Airway obstruction 4. Shock unresponsive to fluid resuscitation 5. Failure to adequately oxygenate 6. Paralysis secondary to high spinal cord injury 7. Blunt chest trauma compromising ventilation ii. Endotracheal tube size can be estimated by: 1. The size of the child's little finger or nares 2. According to the following formula for children 1-10 years old: (Age in years/4) + 4. iii. A surgical airway is indicated when orotracheal intubation is unsuccessful or contraindicated. 1. Surgical cricothyroidotomy is rarely indicated in children. 2. A needle cricothyroidotomy is instead preferred. a. Can support patients for 30-45 minutes with transtracheal jet ventilation. b. With patient supine and the neck prepped: i. Palpate the cricothyroid membrane. ii. Assemble a 12- or 14-gauge catheter over a needle.

50 iii. Connect it to a small syringe. iv. Puncture the skin midline over the cricothyroid membrane. v. Direct the needle at 45 degree angles caudally. vi. Insert the needle through the lower half of the membrane while aspirating. vii. After aspiration of air, advance the catheter inferiorly while withdrawing the stylet/ needle. viii. Attach the catheter to oxygen tubing and secure it to the neck. e. Breathing i. Listen for bilateral breath sounds. ii. Emergent needle decompression of tension pneumothorax & chest tube placement, as needed iii. Operative indications: 1. Initial chest tube output > approximately 15-20 mL/kg 2. Ongoing output of > approximately 5 mL/kg f. Circulation i. Confirm the presence of a pulse and begin compressions if not present. ii. Obtain non-invasive blood pressure. iii. Obtain two large-bore IVs. iv. Use intraosseous access or place a central line if adequate peripheral IV access cannot be obtained quickly (within 2-3 attempts). v. Control any external hemorrhage. vi. Give 2 boluses of 20 mL/kg of isotonic crystalloid (NS or LR) for hypotension, followed by 10 mL/kg of PRBC if still hypotensive and there is concern for ongoing hemorrhage. Discuss activation of the pediatric massive transfusion protocol (MTP), if needed. vii. Children can maintain nearly normal vital signs even with severe hemorrhage. 1. The primary response to hypovolemia in children is tachycardia. 2. Hypotension is a LATE sign of shock in children (may not occur until after 40% of blood volume is lost). viii. Indications for an ED thoracotomy: 1. Penetrating injury with loss of vital signs en route/ within 5 minutes of arrival to ED. 2. Blunt or penetrating injury with loss of vital signs in the ED. g. Deformity & Disability: i. Perform a brief neurologic exam, e.g., GCS, pupils, etc. ii. Check pelvis stability and look for long bone fractures. h. Exposure: i. Remove all clothing. ii. Try to keep patient warm thereafter, e.g., warm blankets, warmed IV fluids, level one warmer, bear-hugger, etc.

51 iii. Ensure there are no chemicals on the patient.

C. Obtain an AMPLE History a. Allergies b. Medications c. Past medical history d. Last meal e. Events leading to injury and environment of injury

D. Initial Data Collection a. Trauma Lab Panel b. CXR (if mechanism warrants) i. Advanced tip: place a CXR plate on stretcher prior to patient arrival c. Pelvic XR d. FAST

E. Secondary Survey a. Perform a complete head-to-toe examination. b. Log-roll the patient with the C-spine stabilized to examine. i. The back for spinal tenderness/deformity. ii. Perform a rectal examination. iii. Remove the hard board before rolling the patient back. Leaving patients on the hard board can quickly lead to skin breakdown. c. Additional procedures (NG/OG, Foley catheter, change to padded rigid cervical collar (Aspen of Miami J/ Jr.), additional IV access, etc.) are performed as needed i. Do not place an NG if there is concern for naso/oropharyngeal trauma or skull fracture. ii. do not place a Foley catheter if urethral injury is suspected

F. Transport/Additional Studies a. Head CT should be used selectively to avoid the long-term risks of cancer associated with radiation. b. Add CT of the face if facial fractures are suspected based on the physical exam. c. Utilize the PECARN algorithm to identify which pediatric trauma patients should undergo head CT.

The PECARN Algorithm

Suggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores of 14–15 after head trauma*GCS=Glasgow Coma Scale. ciTBI = clinically-important traumatic brain injury. LOC=loss of consciousness. *Data are from the combined derivation and validation populations. †Other signs of altered mental status: agitation, somnolence, repetitive questioning, or slow response to verbal communication. ‡Severe mechanism of injury: motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 0.9 m (3 feet) (or more than 1.5 m [5 feet] for panel B); or head struck by a high-impact object. §Patients with certain isolated findings (i.e., with no other findings suggestive of traumatic brain injury), such as isolated LOC, isolated headache, isolated vomiting, and certain types of isolated scalp hematomas in infants older than 3 months have a risk of ciTBI substantially lower than 1%. ¶Risk of ciTBI exceedingly low, generally lower than risk of CT-induced malignancies. Therefore, CT scans are not indicated for most patients in this group. From: Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3; 374(9696):1160-70. d. Obtain plain films of the cervical spine rather than CT to avoid thyroid radiation, even if CT is performed of the head or chest. e. Get CT of the abdomen/pelvis as needed based on physical exam findings and mechanism. f. Get plain films for any significant findings on examination of the extremities: i. One joint above.

53 ii. One joint below. g. FAST exam can be considered but should never delay care. Although appealing to minimize radiation, FAST is relatively insensitive in children because of the frequency of solid-organ injury that is seen without associated hemoperitoneum. h. Labs i. Consider CMP/amylase/lipase/urinalysis to screen for abdominal injury. ii. Get CBC, coagulation profile, and type and screen if any concern for bleeding. i. Transport the patient directly to the PICU or OR as necessary or to the pediatric ED for observation until discharge or admission to a general care unit.

G. Tertiary Survey a. To be completed when the patient is alert and no distracting injuries remain. b. C-spine can be “cleared” during this examination. i. C-spine clearance consists of both a negative clinical examination (no mid-line spinal tenderness and no pain with flexion, extension, lateral flexion, or rotation) and negative radiographic examination (plain films or CT). ii. If there are no fractures on CT or plain films but tenderness or pain with movement remains, continue spinal precautions and obtain an MRI of the spine.

54 III.

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

55 Other Important Points A. Spleen/Liver a. SEE APPENDIX 17 for management algorithm. b. Commonly injured in blunt trauma. c. Most isolated spleen/liver injuries in children can be treated NON- operatively. d. Operative management of spleen/liver injuries is indicated for ongoing hemorrhage and/or refractory hemodynamic instability. e. Grading for splenic injury i. Grade I: subcapsular hematoma  10% of surface area, capsular laceration  1 cm depth. ii. Grade II: subcapsular hematoma 10–50% of surface area, intraparenchymal hematoma  5 cm in diameter, laceration 1-3 cm depth not involving trabecular vessels. iii. Grade III: subcapsular hematoma > 50% of surface area or expanding, intraparenchymal hematoma > 5 cm or expanding, laceration > 3 cm in depth or involving trabecular vessels, ruptured subcapsular or parenchymal hematoma. iv. Grade IV: laceration involving segmental or hilar vessels with major devascularization (> 25% of spleen) v. Grade V: shattered spleen, hilar vascular injury with devascularized spleen f. Grading for liver injury i. Grade I: subcapsular hematoma  10% of surface area, capsular laceration  1 cm depth. ii. Grade II: subcapsular hematoma 10-50% of surface area, laceration 1- 3 cm in depth. iii. Grade III: subcapsular hematoma > 50% of surface area or expanding or ruptured, laceration > 3 cm in depth. iv. Grade IV: parenchymal disruption of 25-75% of hepatic lobe, 1-3 cm laceration of Couinaud’s segments in a single lobe. v. Grade V: parenchymal disruption of > 75% of hepatic lobe, > 3 cm laceration of Couinaud’s segment in a single lobe, juxtahepatic venous injuries. vi. Grade VI: hepatic avulsion. B. Child Abuse a. Pay attention for suspicious injuries, signs on physical examination, and conflicting stories or inconsistencies in the history that raise concern for child abuse. b. Document all noted injuries in detail. c. Work-up for abuse generally consists of a skeletal survey with addition of head CT, brain MRI, and/or abdominal CT, as indicated. d. If the patient has a significant finding on neuroimaging, consider an ophthalmologic evaluation with a dilated fundoscopic exam to look for retinal hemorrhages. If the patient has negative neuroimaging, there is a low

56 probability for retinal hemorrhages! Therefore, an ophthalmic exam is not necessary. e. Social work/CPT consult. Any concern for child abuse MUST be reported to CPS for investigation.

C. Head Trauma a. Surgical decompression is indicated in the presence of a rapidly expanding epidural or subdural hematoma that causes an increase in ICP and/or focal compression: done immediately if signs of increased ICP, altered mentation, focal neurologic signs, pupillary changes, or midline shift are present. b. Conservative management with close monitoring in the PICU is acceptable if no focal neurologic signs, altered mentation, or midline shift are present and the hematoma is relatively small (<2 cm). c. ICP monitor may be required with loss of neurologic exam in setting of head trauma. d. Skull fractures i. Categorized as: 1. Open or closed, based upon the presence or absence of an overlying scalp laceration in continuity with the fracture site. 2. Depressed or non-depressed, based upon the relationship of the bone fragments to each other. ii. Depressed skull fractures often cause injury to the underlying brain and are often open. iii. Depressed skull fractures are treated surgically with debridement and elevation when any of the following indications are present: 1. The depression is greater than the thickness of the skull (approximately 8-10 mm). 2. A focal neurologic deficit results from compression of the brain parenchyma. 3. A significant underlying intracranial hematoma is present. 4. Pneumocephalus is seen. 5. The frontal sinus is involved. 6. Gross cosmetic deformity exists. 7. Gross wound contamination is present. 8. Intraparenchymal bone fragments are seen, indicating laceration of the dura mater and an increased risk of infection. iv. Non-operative management is appropriate for patients with depressed skull fractures (even if open) that possess none of the above findings. v. A "ping-pong fracture” is a type of greenstick fracture typically seen in newborns (because of the plasticity of their skull) that appears as a local concavity of the skill without sharp edges: unless the depression is deeper than the thickness of the skull (or another indication for surgery is present), these fractures usually do not require surgical intervention because the skill will remodel and smooth out the defect during growth.

57 IX. PEDIATRIC BURNS

1. Policy: Care of the Pediatric Burn Patient PAT095. 2. All burns > 20% TBSA are activated as Alpha traumas and should have an expeditious admission to the PICU or OR. 3. See Appendix 12 for documentation requirements for pediatric burn patients. 4. Types of burns a. Superficial [1st degree] i. Damage limit: epidermis ii. Appearance: red and dry iii. Sensation: pain or tingling at site iv. Typical Causes: 1. Sunburn 2. Hot liquid splashes 3. Flash burns. v. Natural healing time: 5-7 days vi. Treatment: oral analgesics and topical moisturizers b. Superficial & Deep Partial Thickness [2nd degree] i. Damage Limit: Dermis; Portion of hair follicle remains ii. Appearance: red, white or tan, possibly mottled with blisters iii. Sensation: Extreme pain; sensitive to cold air iv. Typical Causes: 1. Contact 2. Severe heat flashes 3. Immersion v. Natural healing time: 1. Superficial partial thickness: 1-2 weeks 2. Deep partial thickness: 2-3 weeks vi. Treatment: debridement & dressing; possible grafting for deep partial thickness. c. Full thickness [3rd degree] i. Damage Limit: Sub-dermal tissue; No hair follicle remains ii. Appearance: Skin white, brown, deep red; dry and leathery iii. Sensation: Little to no pain at site iv. Typical Causes: 1. Flame 2. Grease 3. Chemical 4. Electrical – usually associated with internal burns v. Natural healing time: never vi. Treatment: Excision and grafting

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

58 1. Entire palmar surface and fingers of CHILD’s hand = 1% 2. Fast but crude estimation ii. Lund and Browder chart*

Lund and Browder Chart Superficial Deep/ Full Partial Age (years) Thickness Thickness Area (%) 0-1 1-4 5-9 10-15 >15 Head 19 17 13 10 7 Neck 2 2 2 2 2 Trunk Ant. 13 17 13 13 13 Trunk Post. 13 13 13 13 13 Right Buttocks 2.5 2.5 2.5 2.5 2.5 Left Buttocks 2.5 2.5 2.5 2.5 2.5 Genitalia 1 1 1 1 1 Upper Right arm 4 4 4 4 4 Lower Right arm 4 4 4 4 4 Upper Left arm 3 3 3 3 3 Lower Left arm 3 3 3 3 3 Right hand 2.5 2.5 2.5 2.5 2.5 Left hand 2.5 2.5 2.5 2.5 2.5 Right thigh 5.5 6.5 8.5 8.5 9.5 Left thigh 5.5 6.5 8.5 8.5 9.5 Right leg 5 5 5.5 6 7 Left leg 5 5 5.5 6 7 Right foot 3.5 3.5 3.5 3.5 3.5 Left foot 3.5 3.5 3.5 3.5 3.5 TOTAL:

6. Primary Survey: a. History: i. Mechanism and source of injury ii. Time of injury b. Airway and breathing i. Airway patency ii. Respiratory rate iii. Respiratory effort iv. Singed nasal/ facial hair v. Carbonaceous sputum vi. Monitor pulse oximetry vii. Administer oxygen if necessary viii. Have a LOW THRESHOLD FOR INTUBATION

59 c. Circulation and cardiac status i. Inspect heart rate and blood pressure for hypovolemic shock ii. Monitor for dysrhythmias iii. Check pulses in all extremities iv. Monitor urine output with Foley catheter d. STOP THE BURNING PROCESS e. Examine body surface i. Remove clothing. ii. Calculate body surface area percentage and determine depth. iii. Cover and dress wounds properly. See APPENDIX 16: BURN WOUND CARE: ED PROCEDURE. iv. Elevate burned extremities and check hourly, especially for circumferential burns. v. Assess for compartment syndrome.

7. Secondary Survey a. Neurologic evaluation b. Check for concurrent injury c. Pain management d. Obtain labs i. CBC ii. CMP iii. Arterial blood gas e. Obtain a CXR and c-spine and pelvic films, if applicable.

8. Fluid Resuscitation a. Fluid resuscitation is required for all burns > 20% TBSA. b. Avoid boluses if possible. c. The goal is to initiate fluid resuscitation upon admission to the PICU. See also, Fluid Resuscitation for the PICU Burn Patient MDU042. i. If transport from the PED trauma bay to PICU is expected to be < 60 minutes, 1. For patients < 40kg and hemodynamically stable, initiate D5LR at maintenance rate in the PED trauma bay and initiate fluid resuscitation upon admission to the PICU. 2. For patients > 40kg and hemodynamically stable, defer fluid resuscitation in the PED trauma bay and initiate fluid resuscitation upon admission to the PICU. ii. If transport from the PED trauma bay to PICU is expected to be > 60 minutes, or the patient is hemodynamically unstable, fluid resuscitation shall be initiated in the PED trauma bay and managed by the PICU nurse. d. PICU nurse manages the hourly fluid titrations based on urine output.

9. Burn Management in the Peds ED

60 a. An Alpha trauma will be activated for: i. Burns with signs of inhalation injury. ii. Burn injuries > 20% TBSA. b. Criteria for GPS consult/Burn center referral: i. Partial thickness (2nd˚) burns ≥ 10% TBSA ii. Partial thickness burns that involve face (>1%), hands or feet (when a joint is crossed), genitalia, perineum or major joints iii. Full thickness burns of any size iv. Electrical burns including lightening injury 1. Obtain EKG & CK level v. Chemical burns 1. Contact Poison Control 1-800-222-1222 for recommendations (alkali vs. acidic) vi. Circumferential partial – full thickness injury vii. Burn injury of any size in patients with pre-existing medical conditions that could complicate management, prolong recovery or effect mortality viii. SW concerns cannot be resolved or there is a concern for non- accidental trauma (NAT) ix. Home caregiver is unable to demonstrate ability to provide effective wound care x. Other injuries at the discretion of the PED provider. c. ED policies for burn debridement i. Ask for the PED Burn Nurse when you arrive for consultation. ii. Administer tetanus prophylaxis, if necessary. iii. Most burns can be debrided in ED except: 1. Burns requiring > 30 minutes of sedation with 2 providers (i.e., GPS and PED burn nurse) debriding. 2. Unstable or intubated patients requiring PICU. 3. Patients requiring escarotomies. 4. ED attending does not feel can provide adequate sedation, e.g., patients ≤ 3mon of age or cardiac comorbidities. iv. PED burn nurse program 1. Trained RNs perform debridement & dressings. 2. Will help facilitate procedural sedation. 3. Will complete L&B for burns they debride. 4. Require assistance from GPS for debridement/ dressings taking > 30min with one provider. 5. Bedside RN will complete wound photography. Photos are available under the MEDIA tab in EPIC. d. DEBRIDEMENT & DRESSINGS SEE APPENDIX 16: BURN WOUND CARE: ED PROCEDURE

10. Inpatient management a. PED, PICU, OR: Non-debrided burns SHOULD NOT be admitted to 10S unless a plan is discussed & agreed on by PED, GPS & 10S. This is a RARE occurrence (i.e., PED Purple Alert). If this occurs, GPS has agreed to take the patient to the OR for initial debridement. b. Burn Management on 10 South i. DRESSING CHANGES 1. Pre-medication for dressing changes begins at 08:00. 2. Dressing changes begin at 09:00 in the treatment room. 3. If there is a preference for dressing change order, please call the 10 South Charge RN BEFORE 08:00 with preferred patient order. c. Burn Management in the PICU i. Multidisciplinary burn rounds occur at 09:30. ii. DRESSING CHANGES 1. There is not a set time for dressing changes. Time should be coordinated with AM bedside nurse ASAP. 2. Occur in the patient’s room or OR. iii. PAIN 1. Pediatric Pain Team should be consulted on all burns. 2. Work collaboratively with the Pain Team and PICU to develop the best plan for the patient. 3. Patient needs to tolerate dressing change without sedation to be transferred to floor. iv. Fluid resuscitation 1. See Section IX.8. 2. Avoid boluses if possible. v. Nutrition 1. Enteral/ oral feeds should be started within 24h of injury, when possible. 2. Patients with ND tubes DO NOT need to be NPO for procedures; however, this is at the discretion of the Anesthesiologist. 3. If patient is on vasopressors, enteral feeds may not be an option. Define acceptable vasopressor levels for feeding with the PICU team. vi. Pharmacology >30% burn 1. Oxandrolone 0.1mg/kg/dose BID (max dose of 10mg) to be started 24-48 post resuscitation 2. Propranolol 2mg/kg/day Q4-6 hours initially and may increase to 4mg/kg/day as a goal of reducing tachycardia by 15%

11. Common burn dressings and treatments

62 a. Silvadene (silver sulfadiazine): white cream, painless administration, antibacterial, poor penetration of eschar, widely used for burns, not on face or genital area. Can turn a yellow color. Side effects: methhemoglobinemia, leucopenia. b. Sulfamylon (mafenide): white cream, Painful Administration, bacteriostatic, good penetration of eschar. Used commonly on ear burns. Side effects: metabolic acidosis due to carbonic anhydrase inhibition c. Bacitracin- clear ointment, painless administration, poor penetration of eschar. Commonly used on face. Often used with overlying Adaptic or Xeroform. Side effects: Rash d. Silver Nitrate- often used as a sheet or as a solution (0.5%), painless administration antibacterial and antifungal. Good penetration of eschar. Note: stains everything it comes into contact with brown. Side effects: leeching of electrolytes (Na, Cl) e. Mepilex AG – Silver impregnated dressing, self-adhesive silver containing foam dressing. f. Adaptic – Petrolatum covered synthetic mesh. g. Biobrane- synthetic mesh with silicone (transcyte without fibroblasts on the one side) h. Scarlet red- fine mesh, semi-occlusive gauze dyed red. Apply to graft donor sites. Promotes wound healing i. Alloderm- artificial dermal replacement used under split thickness skin grafts on full thickness burns. Allows for thinner grafts and better cosmetic outcome. j. Autograft- grafting of a full thickness burn with the patient’s own skin. May be split thickness or full thickness. k. Allograft- coverage of a full thickness burn with human skin. Not of the patient’s own skin. Used when not enough of the patient’s skin is available. Usually lasts for 2-4 weeks before autolysing. l. Xenograft- typically pig skin is used. In the same manner as allograft

12. Nutrition:

a. All burn patients get a nutrition consult. b. Burn patients typically have much higher protein needs. c. Burns > 8% TBSA: weekly/biweekly labs of transferrin & pre-albumin d. Supplements to be given to all pediatric burn patients:

AGE < 3 years of age > 3 years of age TBSA < 20% > 20% < 20% > 20% Supplementation Optional:  MVI with Optional:  MVI with Multivitamin minerals daily Multivitamin minerals daily (MVI) with  Ascorbic acid (MVI) with  Ascorbic acid minerals 250 mg BID minerals 500 mg BID  AquADEK 1 mL  AquADEK 2 mL daily (1 mL – daily (1 mL – 5751 IU 5751 IU Vitamin A) Vitamin A)  Zinc sulfate  Zinc sulfate 100 mg BID 220 mg BID  Elemental Zinc  Elemental Zinc enteral liquid enteral liquid 20 mg BID 50 mg BID

e. For ages below 1 year: i. protein should not exceed 4gm/kg/day

Size of Caloric Protein Age Feeds burn % requirements goals 0-12 0-10% 0-6 months: 20-25%  Between 0 and 4-6 months only use months 98 kcal/kg/day total standard infant formula caloric goal  >4-6 months use formula plus high 6-12 months: with calorie, high protein solids. No Juice 102 maximum  Nutrition consult if poor p.o. during 2nd kcal/kg/day of 4 day of admission. If unable to meet gm/kg/day nutritional goals by 3rd day use tube feeding  Initiate tube feeding if patient consumes <90% of caloric goal (begin at 2cc/kg/hr) 11-25% >14% TBSA burn warrants nutrition consult  If unable to meet nutritional goals by 3rd day use tube feeding.  Concentrate formula to between 24 and 27 kcal/kg

64  Tube feeding continues until patient reaches 90% caloric goal  If 12 hour tube feeds overnight, protein content should equal 75% of total protein goal >25% Nutrition consult  Order indirect calorimetry  Concentrate formula to 24 - 27 kcal/kg  Use continuous tube feedings (1- 2cc/kg/hour) until patient able to meet 90% needs  Initiate tube feeding if patient consumes <90% of caloric goal (begin at 2cc/kg/hr)

65 f. 1-6 years of age i. Pediasure can be used.

Size of Caloric Protein Age Feeds burn % requirements goals 1-6 0-10% 1-3 years: 20-25%  Supplement with Pediasure (1-10 years 102 kcal/kg/day total caloric years) or boost (>10 years) if patient goal consumes less than 75% high protein 4-6 years: high calorie meals 90 kcal/kg/day  Initiate tube feeding if patient consumes <90% caloric goal 11-25% 1-3 years:  >14% TBSA requires nutrition consult 102 kcal/kg/day  Supplement with Pediasure (1-10 years) or boost (>10 years) if patient 4-6 years: consumes less than 75% high protein 90 kcal/kg/day high calorie meals  Initiate tube feeding if patient consumes <90% caloric goal at half caloric goal rate. Advance by 5cc q4-6 hours  If 12 hour tube feeds overnight, protein content should equal 75% of total protein goal >25% WHO equation x 1.2-  Nutrition consult 1,3  Initiate tube feeding if patient consumes <90% caloric goal  If 12 hour tube feeds overnight, protein content should equal 75% of total protein goal.

66 g. >6 years age i. adult formula to be used 1. Pediasure: 1 kcal/cc. 7.7 gm protein in 240cc 2. Boost: 1 kcal/cc, 10 gm/240cc 3. Boost Plus: 1.5 kcal/cc 14gms/240cc

Size of Caloric Protein Age Feeds burn % requirements goals >6 0-10% 7-10 years: 20-25%  High calorie, high protein diet years 70 kcal/kg/day total caloric  Supplement with Pediasure (1-10 years) or goal boost (>10 years) if patient consumes less 11-14 years (M): than 75% high protein high calorie meals 55 kcal/kg/day  Initiate tube feeding if patient consumes 11-14 years (F): <90% caloric goal 47 kcal/kg/day  If 12 hour tube feeds overnight, protein content should equal 75% of total protein 15-18 years (M): goal 45 kcal/kg/day 15-18 years (F): 40 kcal/kg/day 11-25% 7-10 years:  Supplement with Pediasure (1-10 years) or 70 kcal/kg/day boost (>10 years) if patient consumes less than 75% high protein high calorie meals 11-14 years (M):  Initiate tube feeding if patient consumes 55 kcal/kg/day <90% caloric goal 11-14 years (F):  If 12 hour tube feeds overnight, protein 47 kcal/kg/day content should equal 75% of total protein goal 15-18 years (M): 45 kcal/kg/day 15-18 years (F): 40 kcal/kg/day >25% Indirect  Initiate tube feeding of Promote (1 kcal/cc) calorimetry or or boost plus (1.5 kcal/cc) or Novasource WHO equation x 2.0 (2 kcal/cc) day #1 half goal rate, day#2 1.2-1,3 goal

67 X. EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) a. General Information

i. ECMO is a cardiopulmonary bypass system employed to support the patient in severe, medically refractory respiratory or cardiac failure ii. Used in neonates primarily for respiratory failure iii. In older pediatric patients ECMO is also used for those needing cardiac support iv. There are two types of ECMO: 1. Veno-Arterial – allows for cardiac AND Respiratory support 2. Veno-Venous – supports only the respiratory system v. The ideal ECMO candidate has: 1. A known, resolvable respiratory or cardiac problem 2. Has not been ventilated for a prolonged period of time 3. Has no evidence of anoxic encephalopathy b. Indications:

i. Neonatal Respiratory Failure 1. Meconium aspiration 2. Persistent Pulmonary Hypertension 3. Congenital Diaphragmatic Hernia a. Pre-ductal saturations near >90%; pO2 < 50 torr b. Pre-op support c. Post-op support ii. Pediatric Respiratory Failure iii. Sepsis iv. Cardiac support 1. Cardiac stun after congenital repair 2. Cardiomyopathy as a bridge to transplant v. Uncommon Indications 1. Cold water drowning 2. Cardiac arrest of unclear etiology 3. Other, unusual, isolated conditions vi. Clinical criteria indicating ECMO may be of benefit 1. Continued poor respiratory performance while on optimal (not maximal) ventilator support: 2. Oxygenation Index > 40 3. Prolonged A-a gradient > 600,f 4. Four hours of pO2 <60 c. Contraindications:

i. Grade II or greater intracranial hemorrhage ii. Congenital/genetic abnormalities incompatible with good outcome 1. Down’s is no longer considered, a priori, a contraindication

68 iii. Prolonged or sustained cardiac arrest iv. CDH with severe pulmonary hypoplasia as seen with depressed pre-ductal saturations v. Prematurity (less than 36 weeks) vi. Relative contraindication - weight < 2kg d. Logistics of an ECMO Activation

i. The decision to place a child on ECMO is made by the NICU or PICU attending in concert with GPS Fellow and GPS call Attending ii. In preparation for ECMO, the child will be transferred to a PICU ECMO room iii. The PICU will obtain informed consent iv. Once ECMO has been decided upon: 1. The GPS Senior/Fellow should: a. Notify GPS Fellow and Attending immediately b. Post the case: i. Procedure: “ECMO Cannulation” ii. Post as Level 1 c. Speak Directly with the OR Charge Nurse at time of posting 2. The PICU will notify respiratory a. Respiratory will prime the ECMO circuit 3. The PICU will notify Blood bank e. Technique:

i. Cannulation is done at the bedside with an OR team ii. The patient is positioned on the bed based on the child’s size and the type of ECMO planned iii. VA ECMO positioning 1. Neonates - head towards the door and at the foot of the incubator 2. Children – towards the door in PICU bed 3. ECMO pump on patient’s right 4. Neck is extended with a shoulder roll 5. Head turned to the left 6. Chest and neck are prepped iv. VV ECMO positioning 1. Venous access site towards the door 2. ECMO pump on side of access site v. Veno-arterial Cannulation 1. Two cannulas: arterial (carotid) and venous (IJ) a. Usual size is 12 Fr venous, 10 Fr arterial b. Usual depth is 10 cm venous, 7 cm arterial 2. Excellent cardiac support 3. Coronary perfusion is retrograde from arch 4. Carotid ligated (not usually repaired) 5. Technique of choice in post-op cardiac patients and septic patients vi. Veno-venous Cannulation

69 1. One double lumen cannula, usually placed in the RA via an IJ cutdown a. Usual size is 12 French b. Usual depth is RA c. Echo helpful during placement 2. Requires that no cardiac support is needed 3. Excellent coronary perfusion 4. Flows range 100 to 150 cc/kg/min 5. Recirculation may limit needed flow d. Recirculation increases with increasing heart failure e. Increases with increasing flow 6. Cannula position and cannula characteristics somewhat more finicky 7. Technique of choice in neonates 8. Conversion to VA indicated when perfusion inadequate or cardiac support needed f. ECMO Circuit:

i. Polyvinylchloride tubing ii. "Better bladder” iii. Bubble detector iv. Pump v. Silicone membrane oxygenator vi. Warmer (countercurrent heat exchanger) vii. In-line ABG assessment devices viii. The circuit is primed with: a. Plasmanate (a balanced electrolyte solution) b. Albumin (pacifies the circuit so that blood products don’t react to the foreign surface) c. Heparin d. New washed packed cells that displace the plasmanate ix. The circuit is: a. Matched to patient serum K levels, pH (bicarbonate added) b. Kept anticoagulated i. activated clotting time (ACT) is kept prolonged at 1.5-2.0 times normal g. Management of the Patient on ECMO

i. Initial flow established for: a. Saturations > 90% b. Decreased shunt fraction c. Normal blood pressure ii. Pressors may be weaned iii. Ventilator settings, which may have been maximized, are reduced a. Ventilator switched from oscillator or jet to conventional b. Settings lowered to ideal settings (PIP 18, rate 20, 25% O2) iv. Subsequently, flows may be weaned against PaO2 (VV) or SVO2 (VA) v. Heparin is administered by drip and adjusted for goal ACT ~ 200

70 a. No IM meds, heel sticks, etc b. No other heparin in drips, lines vi. Ancef is sufficient antibiotic coverage absent sepsis vii. Sedation without paralysis (one dose of paralytic is used during cannulation) 1. Goal is spontaneous breathing on low vent settings viii. TPN is started on the second day of ECMO 1. Fat emulsion is safe but is given post oxygenator ix. Platelet count must be kept near 100K x. Hematocrit is kept 35-40% by transfusion as needed xi. Volume expansion is achieved by blood first, then LR xii. Neurologic examination and head US are routine daily in order to detect ICH early 1. ICH may force an abrupt end to the ECMO run despite poor respiratory function xiii. Complications 1. Generalized bleeding a. DIC may supervene b. Cryoprecipitate and FFP may rarely be needed c. Products should be given post oxygenator d. ACT goal drop to ~180 e. Sepsis should be suspected 2. Intracranial hemorrhage a. May be due to: i. Generalized bleeding ii. Hypertension 1. Hypertension - Aggressively treated with Nitroprusside 3. VV ECMO may not provide adequate support requiring conversion to VA ECMO a. Check cannula position with echo b. Recirculation may be too high a fraction of flow c. Heart may be failing 4. Surgery may be required while on ECMO (usually to correct CDH) a. Amicar is used (100 mg/kg bolus and drip of 30mg/kg/hr h. Completion of the ECMO Run

i. Conditions for a decannulation trial 1. Flows of 20-25cc/kg/min 2. Saturations in the mid or higher 90s 3. Euvolemia 4. Minimal vent settings 5. Off pressor ii. The circuit is diverted iii. ECMO is Re-instituted if: i. Vent pressures are above 20 ii. Respiratory rates above 40 iii. FiO2 > .40 iv. Key features of trial off ECMO a. Heparin must be given to the patient to ensure anticoagulation with the cannulae in

71 place b. Cannulae are flushed and clamped; the bypass bridge is opened c. If child fails trial, the cannulae are unclamped (venous first in VA ECMO) and the bridge clamped. d. If trial is successful, the circuit is discarded v. Decannulation a. Requires the OR team b. The cannulae are removed c. Key features of this procedure i. Paralysis will be needed to prevent air embolus from spontaneous respiration during vein manipulation ii. Artery is ligated iii. The vessels may be fragile after a long run and rapid hemorrhage can result from cannula removal iv. The wound is drained

72 APPENDIX 1. Guidelines for the Management of Appendicitis in Children I. Simple Appendicitis . Definition: Appendicitis without visible perforation of the appendix and/or the presence of stool in the abdomen or pelvis . Pre-operative antibiotics: o Previously healthy: Ceftriaxone and IV metronidazole (see Table for dosing); penicillin allergy: Ertapenem o Healthcare-associated (e.g., recently hospitalized, notable underlying medical conditions, or known to be colonized with Pseudomonas aeruginosa): Piperacillin-tazobactam; penicillin allergy: IV ciprofloxacin and IV metronidazole . Post-operative antibiotics: o Post-operative antibiotics are not recommended for simple appendicitis without concern for umbilical wound contamination (in which case 24 hours of IV antibiotics (see above) can be considered) . Cultures: Routine cultures are not recommended for simple appendicitis, unless it is healthcare-associated II. Gangrenous Appendicitis . Definition: Appendicitis that does not meet criteria for perforated appendicitis, but with visible necrosis of appendiceal tissue . Reasonable to consider 24-48 hours of IV antibiotics as outlined under “Simple Appendicitis” III. Perforated Appendicitis . Definition: Appendicitis with visible perforation of the appendix and/or stool in the abdomen or pelvis . Pre-operative antibiotics: o Previously healthy: Ceftriaxone and IV metronidazole (see Table for dosing); penicillin allergy: Ertapenem o Healthcare-associated: Piperacillin-tazobactam; penicillin allergy: IV ciprofloxacin and IV metronidazole . Post-operative antibiotics: o Patients should receive a minimum of 24 hours of the same pre-operative IV antibiotics following appendectomy o Patients who are afebrile for 24 hours and able to tolerate enteral therapy should be converted to PO amoxicillin/clavulanate for a total treatment duration of 5 days after the date of surgery  Although amoxicillin/clavulanate has activity against only approximately 43% of Escherichia coli, initial IV therapy in combination with source control will significantly reduce the bacterial burden by the time this drug is administered  Patients with a confirmed penicillin allergy or with healthcare-associated appendicitis should receive PO ciprofloxacin and PO metronidazole o Patients who do not meet above criteria should remain on IV antibiotic therapy until clinical improvement is observed o Patients who remain febrile or who fail to show clinical improvement (i.e. continued pain, nausea, vomiting, etc.) by post-operative day #6 should undergo an ultrasound or CT scan with IV contrast to rule out abscess o If no intra-abdominal abscess is observed, please consider consulting pediatric infectious diseases for possible changes to the antibiotic regimen . Cultures: o Routine cultures are NOT recommended for perforated appendicitis, unless it is healthcare-associated IV. Intra-abdominal Abscess . Drainage is always preferred when intra-abdominal abscesses are present . If the abscess is unable to be drained percutaneously, enteral therapy can still be considered as a valid treatment option . Studies have demonstrated similar efficacy rates when comparing enteral vs. IV therapy in adult patients with intra-abdominal abscesses . Treatment: o Patients presenting initially with abscess should receive at least 24 hours of IV antibiotic therapy as outlined under “Simple Appendicitis”  Patients who are afebrile for at least 24 hours and are able to tolerate enteral therapy may be converted to PO ciprofloxacin and PO metronidazole for a total treatment duration of 7-10 days  Because of the increased activity of ciprofloxacin compared to amoxicillin-clavulanate against E. coli, this agent (in combination with metronidazole) is recommended for ALL age groups with undrained abscesses o For patients who return with an abscess following operative or non-operative appendicitis management, piperacillin/tazobactam is recommended as initial IV therapy and after meeting the above criteria, conversion to PO ciprofloxacin and PO metronidazole is recommended . Cultures: o Intra-abdominal fluid cultures are always recommended for patients who return with an abscess following operative or non-operative management of appendicitis V. Non-operative management (NOM): . Non-operative management of simple appendicitis has been shown to be effective in some patients . Factors that may increase risk of failure for NOM include: symptoms >48 hours or presence of appendicolith or abscess . NOM can be an effective option, but recurrence may occur in approximately 10-30% of patients in 1 year . Treatment: o Patients should receive at least 24 hours of IV antibiotic therapy as outlined under “Simple Appendicitis” o After a minimum of 24 hours, patients without a documented penicillin allergy who are afebrile for 24 hours and are able to tolerate enteral therapy should be converted to PO amoxicillin/clavulanate for 7 days  Patients with a documented penicillin allergy or healthcare-associated infection should receive PO ciprofloxacin and PO metronidazole for the same duration o Patients with signs of worsening clinical status or who fail to show clinical improvement within 24 hours of initiation of treatment should be considered as failures of NOM VI. Dosing and Activity of Select Antibiotics for the Treatment of Appendicitis Antibiotic Dosing Activity at JHH in (assuming normal renal function) Children (% Susceptible)

coli

Pseu

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Amoxicillin/ 45 mg/kg/day PO divided q8h; max 500 mg/dose 43 0 clavulanate Ceftriaxone 50 mg/kg/dose IV IV/IM q24h, max 2 g/dose 90 0 Ciprofloxacin 10 mg/kg/dose IV q8h, max 400 mg/dose IV 79 83

20 mg/kg/dose PO q12h, max 750 mg/dose PO Ertapenem 3 mo to 12 yr: 15 mg/kg/dose IV q12h; max 500 mg/dose 97 0

>12 yr: 1 g IV q24h Metronidazole 10 mg/kg/dose IV/PO q8h, max: 500 mg/dose - -

Piperacillin/ 100 mg/kg/dose of piperacillin component IV q6h, 92 86 Tazobactam max: 4000 mg of piperacillin/dose

Selected References: 1. Minneci PC et al. JAMA Surg 2016: 151(5): 408-15. [Effectiveness of Patient Choice in Non-operative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis] 2. Talishinskiy et al. J Pediatr Surg 2016: 51(7), 1174-6. [Factors associated with failure of nonoperative treatment of complicated appendicitis in children] 3. McCutcheon et al. J Am Coll Surg 2014; 218(5): 905-13. [Long-term outcomes of patients with nonsurgically managed uncomplicated appendicitis] 4. Mahida JB et al. J Pediatr Surg 2016 51(6): 908-11. [High failure rate of nonoperative management of acute appendicitis with an appendicolith in children] 5. Park HC et al. World J Surg 2011: 35(5), 1118-22. [Oral antibiotics for intra-abdominal abscesses]

73 APPENDIX 2. PEDIATRIC GLASCOW COMA SCALE

Patients > 1 year Patients < 1 year Score Spontaneously Spontaneously 4 EYE To verbal command To shout 3 OPENING To pain To pain 2 No response No response 1 Obeys Spontaneous 6 Localizes pain Localizes pain 5 MOTOR Flexion- withdrawal Flexion- withdrawal 4 RESPONSE Flexion-abnormal (decorticate rigidity) Flexion-abnormal (decorticate rigidity) 3 Extension (decerebrate rigidity) Extension (decerebrate rigidity) 2 No response No response 1 > 5 years 2-5 years 0-23 months Oriented Appropriate Smiles and coos appropriately 5 words/ phrases Disoriented/ Inappropriate Cries and is consolable 4 confused words VERBAL Inappropriate Persistent cries & Persistent inappropriate crying and/ or RESPONSE 3 words screams screaming Incomprehensible Grunts Grunts, agitated and restless 2 sounds No response No response No response 1 Total Pediatric Glasgow Coma Scale (3 – 15)

74 APPENDIX 3. ENDOTRACHEAL TUBE SIZES

From: http://www.docstoc.com/docs/29667541/Size-and-length-of-endotracheal-tube-%28ETT%29-Pre-pubertal-children accessed 6/4/2013.

75 APPENDIX 4. EMERGENCY AIRWAY MANAGEMENT OF THE INFANT & CHILD

1. Respiratory Distress:

a. The first step in the management of respiratory distress is to ventilate the child using a bag valve mask and 100% oxygen. b. Prepare for success by placing the child’s head in the “sniffing position;” with the neck in extension and chin up to the ceiling. Note: Do not use this maneuver in a child on C-Spine precautions. c. Suction all secretions and other material from the patient's nose and oropharynx. d. Using the proper size mask, form a seal by holding the mask in place with your non-dominant hand. i. Thumb and index finger around the base of the mask ii. Fifth digit hooked under the angle of the mandible iii. Flex your arm at the elbow to maintain a jaw thrust e. An oral airway can be used to ensure that the tongue is not occluding the airway. f. Observe the chest rise and listen to breath sounds to confirm adequate ventilation. g. Note: Over pressurization can cause a pneumothorax more easily in infants and children than adults.

2. Endotracheal Intubation:

On the Hopkins GPS service, endotracheal intubation is only to be performed by a resident or fellow under supervision of an anesthesiologist.

Pediatric intubation is similar to an adult intubation however several anatomic differences must be accounted for: 1) a child’s larynx is more anterior than adults; 2) the trachea narrows below the epiglottis in children < 8 yrs old. Therefore, when you lift the epiglottis with the tip of the laryngoscope the cords will not be not as distal as you may expect. Passing the endotracheal tube (ETT) via the right corner of the mouth along the blade will provide an unobstructed view. For younger children the use of a cuffed ETT is usually not necessary. A properly fitted tube should allow a leak at 20 mm Hg inspiratory pressure.

a. If you are concerned that a child will need long-term positive pressure ventilation - Call for help. Anesthesia, PICU staff and the Difficult Airway Response Team (DART) are available to help you. b. As long as a patient can be adequately ventilated using bag valve mask ventilation there is no rush to intubate.

76 c. Prepare for intubation by acquiring the following items: i. Suction ii. An ETT stylet iii. An end-tidal CO2 Indicator iv. An ETT tube clamp or; benzoin and tape v. Medications 1. Propofol 2.5-3.5 mg/kg IV over 20 seconds 2. Succinylcholine 1 mg/kg 3. Ketamine 1-3 mg/kg IV if hemodynamically unstable vi. Laryngoscope: 1. < 2 yrs old, use a Miller blade (Straight) a. Size 0 – Premature b. Size 1 – Infant c. Size 2 - Child 2. Age 2-5 yrs, either a Miller or a MacIntosh blade. 3. Age >5 years, use curved MacIntosh blade. vii. The appropriate size ETT and one smaller 1. Size can be determined in the following ways: a. For preemies use 2.5 - 3.0 mm ID b. ETT size (mm) = [(Age in years + 16) / 4] - 0.5 c. ETT diameter = patient’s little finger diameter

Once all the supplies above have been collected, an endotracheal intubation may be undertaken using the following steps:

1) Assemble the laryngoscope – TEST THE LIGHT 2) Assemble the suction 3) Place the sytlet in the ETT 4) Ask an assistant to apply cricoid pressure 5) Administer Propofol of Ketamine 6) Administer Succinylcholine 7) Scissor the teeth apart with your right hand 8) Use the laryngoscope to VISUALIZE THE CHORDS. NO BLIND INTUBATIONS 9) Place the tube through the chords to a length of: Tube length (cm) = 12 plus age (yrs) / 2 The tube should pass easily. DO NOT APPLY FORCE Use a smaller ETT if your initial attempt met resistance 10) Look, Listen, Test a. Look for chest rise b. Listen for breath sounds c. Test for End-tidal CO2 11) Secure the tube with an ETT Clamp

77 3. Managing the Intubated Patient: a. Request a stat portable chest x-ray to confirm tube placement above the carina b. Provide 100% oxygen and wean O2 for sats >92% c. Initiate a maintenance sedative: i. Propfol 125 to 300 mcg/kg/min IV ii. Ketamine 0.01 to 0.03 mg/kg/min IV 4. Initial Ventilator Settings: a. Tidal volume 7-10 cc/kg b. Peak Inspiratory Pressure (PIP) - 25 cm H2O c. Post-End Expiratory Pressure (PEEP) - 5 cm H2O d. Rate – 30 breaths per minute e. FIO2 – 100% f. PEEP at least 2-4 cm H2O ("physiologic PEEP"). g. Always humidify and heat gases.

APPENDIX 5. GASTROSTOMY TUBES

APPENDIX 6: PEDIATRIC SURGERY FELLOWSHIP CONFERENCES & TRAINING

Johns Hopkins Hospital Monday Tuesday Department of Surgery M&M, 6:30a-7:30a, Chevy Chase Auditorium Pediatric Surgery Teleconference Lecture, 7:30a-8:30a, Garrett Room Division M&M, 830-930a, Garrett Room Tumor Board, 12-1p, 11N Conference Room Once a month there is radiology conference in place of division M&M

Wednesday 1st Wed of Month: Trauma and Burn M&M, 7-8a, Garrett Room

Thursday Department of Surgery Grand Rounds, 6:30a-7:30a, Chevy Chase Auditorium

APPENDIX 7. CDC IMMUNIZATION SCHEDULE

APPENDIX 8. EMERGENCY DRUGS

1. Emergency Drugs a. Hypoglycemia i. 1 cc/kg of 25-50% dextrose IV push over 5 minutes b. Hypokalemia: i. Maintenance requirement of 2 mEq/kg/day ii. For emergency replacement: 1. 1/2 mEq potassium/kg/hr x 2 hrs in IV via pump. iii. Repeat serum potassium after 2-3 hrs. c. Hyperkalemia: i. Slow rate of increase, no EKG changes, K<7: Kayexalate p.o. or enema 1 gm/kg (in sorbitol or D10W): ii. Rapid rate of increase, + EKG changes, K>7 (urgent): 1. Na bicarbonate 2mEq/kg IV push 2. Glucose 50% 1cc/kg IV push 3. Ca gluconate 10% 0.5cc/kg IV push 4. Insulin 0.5u/kg IV while infusing D20W iii. Metabolic acidosis (treat a base deficit greater than 5): 1. mEq of NaHCO3 base deficit x weight in kilograms x 0.4. 2. Correct half of the deficit with NaHCO3 over 8-12 hours by adding 1/2 mEq NaHCO3 to each cc of IV fluid.

Normal Vital Signs by Age: Age Weight (kg) Heart rate Resp rate BP (Sys)

Preemie 1 135-145 55-65 50±10 Newborn 2-3 125-135 35-45 60±10 1 month 4-6 120-130 25-30 80±10 6months 7-9 120-130 25-30 90±25 1 year 10-11 110-120 20-24 96±30 2-3 yrs 12-15 100-110 16-22 99±25 4-5 yrs 16-18 95-105 14-20 99±20 6-8 yrs 19-26 90-100 12-20 105±13 10-12 yrs 27-42 85-90 12-20 112±19 >14 yrs >50 75-85 10-14 120±20

APPENDIX 9. A USER’S GUIDE TO SURGICAL PROCEDURES FOR ONCOLOGY

Safety

Line requests by the oncology service REQUIRE documentation regarding type of line, how many lumens, if a port, whether to leave accessed. This documentation should be found in POE or EPIC. If not found, then oncology service needs to be contacted to avoid an incorrect procedure for the patient.

Scheduling

The number one complaint in the OR about oncology procedures is the last minute addition of LPs, BM, echo, eye exams, and other ‘minor’ add-ons that significantly increase the length of time of a scheduled procedure. This has an enormous impact on our ability to complete our OR list in a timely fashion and disrupts the flow of emergent add-on cases.

It is imperative that as soon as you know an additional procedure is indicated, you adjust the posting and/or notify the OR front desk 56520 so that additional time can be allotted.

Outpatients: For patients requiring outpatient line placement or removal,

1) Please contact the office directly at 52717 to schedule. 2) The EPR note must be in the chart for line placement. Please 3) Provide the following information: a. Type of line needed b. If an LP/BM is to be posted as part of the procedure (with onc attdg name) c. If the patient is to be a same day admission to oncology 4) If there is anything unusual or special about the patient or procedure requested please send an email to the fellow.

As a general rule we would like to see outpatient lymph node biopsies in our clinic prior to scheduling them to ensure there is a surgically accessible node. Call 52717 to schedule an appointment. For more exotic outpatient biopsy requests, please email the fellow to facilitate discussion and scheduling.

Inpatients: The GPS senior pager (33982) is the first contact for new consults

1) An EPR note is required for lines. 2) We need to know if an LP/BM is to be performed at the same sitting. 3) We will do our best to schedule these lines as soon as possible

We do not usually have open block time sitting available to fill with oncology patients. If there is no open time for the next business day, lines are scheduled into the urgent/emergent or work-in OR rooms and are at the mercy of every other service who

posts emergency cases. Therefore, if we post a line for the next day, it is not likely that we will be able to give you a precise time even on the morning of the case.

CONSENTS FOR LP/BM MUST BE ON THE PATIENT’S CHART BY 7AM ON THE DAY OF THE PROCEDURE. IF THERE IS NO ONCOLOGY CONSENT, THE PATIENT WILL NOT BE BROUGHT TO THE PREOP AREA AND MAY LOSE THEIR OR TIME.

Preparation for OR

ANC: There is no lower limit for ANC for Hickman catheters. Based on published data, we prefer to avoid placing ports in patients with an ANC < 500 due to high risk of wound complications. Call to discuss in specific cases.

Platelet count >50 is acceptable for line placement. All patients with platelets <50 should have a unit of platelets available for transfusion at the time of the procedure. Please clarify plan for additional transfusions with GPS for patients with platelets <30.

APPENDIX 10. GUIDELINES FOR PEDIATRIC PREOPERATIVE EVALUATION

Phone Contacts Pediatric Anesthesia Office 410-955-7610 Bloomberg 6321 Pediatric Anesthesia In-Patient Consults 410-955-7610 Preoperative Evaluation Center Appts 410-955-6495 JHOC Basement Wilmer Preoperative Evaluation 410-955-5730 Wilmer 340 Pediatric Anesthesia Remote Posting 410-502-2637 Department of Social Services 410-361-2235

Fax Numbers Pediatric Anesthesia Office Fax 410-502-5312 Bloomberg 6321 Preoperative Evaluation Center Fax 410-614-8204; 866-341-2834 Wilmer Preoperative Evaluation Fax 410-614-0316 Wilmer 340

Pediatric Anesthesiology Attending Pagers Ivor Berkowitz 3-2099 Sapna Kudchadkar 4-2637 Sally Bitzer 3-6959 Benjamin Lee 4-0421 Anna Brown 4-3224 Jenny Lee 3-9812 Nick Dalesio 3-3875 Jackie Martin 3-2072 Richard Elliot 4-2214 Connie Monitto 3-2058 Jim Fackler 3-3758 Nina Nami 3-6437 Allison Fernandez 3-5043 Dolores Njoku 3-2109 Jessica George 3-7723 Shivani Patel 3-7755 Robert Greenberg 3-2044 Deborah Schwengel 3-2062 Richard Hardart 3-5439 Hal Shaffner 3-2112 Eric Jackson 3-4579 Joanne Shay 3-2303 Rahul Koka 4-0945 Monica Williams 3-3163 Sabine Kost-Byerly 3-8837 Myron Yaster 3-2064

These guidelines apply to all pediatric patients who are scheduled to receive anesthesia or sedation by the Department of Anesthesiology and Critical Care Medicine for any type of surgery, treatment or diagnostic procedure.

I. Preoperative History, Physical and Anesthesia Assessment

The surgical preoperative history and physical must be performed within 30 days of the scheduled procedure. (This is a Joint Commission regulation.)

The preoperative history and physical examination may be done by the staff of the Johns Hopkins Preoperative Evaluation Center (PEC) or by the surgical/procedural staff prior to the procedure. Alternatively, the patient’s primary care physician may complete a full history and physical examination (not a clearance note).

For more complicated cases or in situations involving specific anesthesia- related questions and concerns, an anesthesia consult should be specifically requested. These patients will be seen by anesthesia residents and the case will be discussed with a pediatric anesthesia attending in order to address preoperative concerns in an optimal fashion (See Section VI).

 PEC appointments may be scheduled by calling 410-955-1147. Secretaries can make appointments via the EPIC system. o Preoperative Evaluation Center (JHOC) Fax: 410-614-3230

 Pediatric Anesthesia INPATIENT Consults may be scheduled by phone at 410-955- 7610; or by contacting the Pediatric Anesthesia OR coordinator 410-955-6520.

Preoperative screening paperwork from a primary care provider must be forwarded to the Preoperative Evaluation Center prior to scheduled procedure for review. Pre-surgical laboratory tests must be done by an accredited laboratory facility and the results must be forwarded to the PEC prior to scheduled procedure.

All Blood Bank specimens must be drawn at Johns Hopkins or an approved Johns Hopkins facility.

Updates of current medical records, without a visit to the PEC or primary care provider, may be done if there has not been any significant change in the patient’s overall medical conditions and if:  The most recent evaluation was performed < 30 days prior to the scheduled surgery,  The procedure was postponed for a non-medical reason  The patient undergoes a scheduled series of procedures (e.g. radiation oncology).

II. Criteria for Having a Procedure as an Outpatient

1. Full term infants (defined as > 37 weeks post-conception at birth) without significant medical problems who are at least 48 weeks post-conception at the time of scheduled procedure.

2. Premature infants (defined as < 37 weeks post-conception at birth) with no medical problems who are at least 52 weeks post-conception.

3. Premature infants with medical problems may need to be at least 60 weeks post- conception, at the discretion of the anesthesiologist.

4. Infants who have required supplemental oxygen or apnea monitoring must be symptom- free and have not required any supplemental oxygen or monitoring for at least six months and be > 60 weeks post-conception at the time of scheduled procedure

Older children with significant medical problems should be evaluated as candidates for outpatient surgery on a case-by-case basis. Patients with central sleep apnea or severe obstructive sleep apnea must be cleared by an anesthesiologist as candidates for outpatient surgery.

III. Scheduling

Patients should be scheduled so that the cases move from youngest to oldest child when possible.

Patients with a family or personal history of malignant hyperthermia (MH) or conditions associated with increased risk of malignant hyperthermia, should be scheduled as the first case of the day.

Patients scheduled for MRI who have risk of post-anesthetic problems (e.g. those with hypotonia, apnea, and possible recurrence of brain tumor) should be scheduled to start as early as possible to allow sufficient time for extended post-anesthetic observation prior to discharging home.

Diabetics should be scheduled as the first case of the day whenever possible.

IV. Guidelines for Preoperative Testing

See Appendix E for Specific Diagnoses

No tests are required for healthy children expected to have minimal loss of blood with the procedure.

Hemoglobin for premature infants < 60 weeks post-conception having outpatient procedures.

Type and Screen or Type and Cross  Per surgeon’s posting.  Pediatric cardiac surgery patients who weigh < 20 kg need 1 unit RBC and 1 unit FFP (thawed) for the pump prime in addition to the needs for the case.  Outpatients coming for surgery may have a Blood Bank sample sent that won’t expire for 30 days if they meet the following requirements:  Have not been transfused during the past 3 months  Have not been pregnant during the past 3 months  Have no history of antibodies  Have the sample drawn while they are outpatients  In order for a Blood Bank sample to be good for 30 days, the Blood Bank Requisition MUST have the following information about the patient written on the requisition:  No transfusions or pregnancy for the past three months  Seen in Outpatient Clinic 290, 291 or 292  If the above info is not specifically written on the requisition, the blood sample is only good for three days (just like an inpatient). If the patient is found to have an antibody, the sample will be good for only 3 days.

Pregnancy testing: All females who have begun their menstrual periods should have a preoperative pregnancy test.

V. Anesthesia Consults Anesthesia consults are indicated for children who have significant medical conditions that can impact the safe delivery of anesthesia that include, but are not limited to:

 Abnormal airway anatomy or syndromes with known difficulty airway (e.g. Treacher- Collins, Goldenhar, Pierre-Robin, Cornelia deLange, Hurler’s, Hunter’s)  History of difficult airway or significant life threatening intraoperative or perioperative complications in the past.  Cystic fibrosis  Diabetes  Heart disease that is symptomatic, presence of cyanosis or heart failure  Hypoxemia  Liver failure or liver transplant  Malignant hyperthermia (patient or family history)  Oxygen-dependent, BIPAP, or home ventilator therapy  Organ transplant patients (patients who have had or will have organ transplant)  Renal failure  Sickle cell (SS, SC or S-thal) disease  Scoliosis (non idiopathic or curve > 60 degrees)  Severe central or obstructive sleep apnea coming for surgery other than tonsillectomy  Skeletal dysplasia  Neuromuscular disorders  Metabolic disorders  Former premature infant with ongoing oxygen requirement or severe chronic lung disease

Consultations should be scheduled with the PEC no less than one week or no more than 30 days prior to surgery to allow time for further testing/consultation if indicated. Prior to date of consultation, parent questionnaire should be forwarded to the PEC with the patient’s date of surgery and name of surgeon. For patients followed elsewhere, all available medical records should be forwarded to the PEC in advance of the date of the visit to the PEC, or brought by the patient.

Cardiology Consults Refer patients with an unevaluated or new heart murmur to a cardiologist.

Guidelines for patients with known congenital heart disease:  If the patient’s diagnosis is an asymptomatic ASD or VSD, the evaluation should be within one year unless recent cardiologist’s note states otherwise.  If the patient is s/p cardiac surgery, and is totally asymptomatic with respect to heart disease, routine follow-up diagnostic studies should occur prior to the scheduled procedure.  The cardiologist should see patients with symptomatic heart disease within 30 days of surgery and the cardiologist should know when the patient is having surgery.  The cardiology service should be informed of any child with symptomatic or complex congenital heart disease who is to be admitted to the hospital after surgery.

VI. Fasting Guidelines

From the time the patient is told to arrive at the hospital, make patient NPO:  Two (2) hours for clear liquids  four (4) hours for breast milk  six (6) hours for infant formula (for infants < 1 year of age)  eight (8) hours (or NPO post midnight for first case starts) for solids and milk.

See Appendix C for NPO Instruction handout in English, French, Spanish and Arabic.

Please note: although guidelines allow infant formula six hours prior to anesthesia in patients less than one year of age with normal gastric emptying, the parent/guardian handout does not include these instructions for infant formula because parents/guardians have misinterpreted the instructions in the past. This misinterpretation has resulted in cancellations.

VII. Possible Reasons for Cancellation

Decisions for cancellation on the day of surgery are always at the discretion of the attending anesthesiologist and attending surgeon.

For patients seen in PEC, the PEC staff shall contact attending anesthesiologists and attending surgeons of the following conditions, which may indicate the need to delay or reschedule the surgery at a later date:

 Upper respiratory infection (URI) that involves purulent (yellow or green) nasal discharge, productive cough, fever, rhonchi or wheezing. Patients coming for elective procedures should ideally have no URI symptoms for at least 2 weeks prior to anesthesia.

 Asthmatic patients who have had an asthma exacerbation during the past week may need to have elective procedures postponed. Patients who have poorly controlled asthma should be referred to their primary care provider for further medical treatment and delayed until asthma is thought to be as well-controlled as possible, unless a pediatric anesthesia attending overrides this.

 Chicken pox exposure: Any child with exposure within the past 21 days must be postponed until the 21 day incubation period has passed. A child with recent chicken pox may have surgery after all lesions are crusted over. Children with chicken pox or an exposure in the past 21 days should not come into the Hospital at all, even for the preoperative evaluation.

 NPO violations

VIII. Parental Refusal of Blood Products

Inform attending anesthesiologist and surgeon of situation as soon as possible.

Advise parents that many measures will be utilized to avoid the need for a blood transfusion; if the anesthesiologist believes it is needed to preserve the life of the child they will administer blood. No child (minor) will be allowed to die due to the desire of the parent/guardian not to have the child transfused. (See Interdisciplinary Clinical Practice Manual Policy #MEL003 “Refusal of Transfusion of Blood or Blood Products” section on Minors.)

IX. Guardianship Documentation

Inform Pediatric Anesthesiology Office (5-7610) of patients requiring Department of Social Services (DSS) consent as soon as possible. Patients requiring DSS consent should be seen in the Preoperative Evaluation Center several days prior to the procedure so that anesthesia consent forms are signed and available prior to the day of the procedure.

Foster Care: Children in foster care or in the care of relatives/friends must have informed consent signed by a legal guardian or by authority of the court. The legal guardian must have guardianship papers when the child is brought to the hospital for treatment. A copy of the papers shall be placed in the patient’s medical record. (See Interdisciplinary Clinical Practice Manual #MEL002: V. Treatment of a Minor.) A fax cover letter to obtain DSS signed consent is attached as Appendix D. DSS phone contact for consents: 410-361-2235.

X. Contacting an Anesthesiology Attending

For a patient issue on the day of surgery, contact the Pediatric Anesthesia Coordinator via the OR desk (5-8075).

To speak directly with a pediatric anesthesiologist regarding a future patient, you may call 5- 7610 during regular business hours to identify an anesthesiologist assigned on a particular date.

APPENDIX 11: Procedure: Intrapleural Alteplase (tPA) for Loculated Pleural Effusion, Pediatric Patients Only

1) OBJECTIVES a) To induce localized fibrinolysis of a loculated pleural effusion in order to achieve one of the following therapeutic objectives: i) Promote drainage of chest tube or pleural catheter (e.g. Cook pigtail or Teleflex ) leading to reduction of the pleural effusion ii) Decrease the potential need for a surgical or invasive treatment approach

2) INDICATIONS FOR USE a) Loculated pleural effusions resulting in a non-draining chest tube or pleural catheter

3) RESTRICTIONS a) Intrapleural administration requires approval from Pediatric Intensive Care Unit attending, or General Pediatric Surgery attending.

4) CONTRAINDICATIONS FOR USE a) Positive air leak in patient’s chest tube or pleural catheter.

5) WARNINGS/PRECAUTIONS a) All major and relative contraindications for thrombolytic therapy as outlined in “Thrombolytic agents (intravenous), management of a patient receiving continuous GEN388”.

6) DEFINITIONS tPA (tissue A serine protease enzyme the catalyzes the conversion of plasminogen activator) plasminogen to plasmin, the enzyme responsible for clot breakdown Loculated pleural A pleural effusion in which pleural fluid has become walled- effusion off or encapsulated between visceral layers of the pleural prohibiting drainage and access to antibiotic therapy Dwell time The period post administration of tPA in which the chest tube or pleural catheter is clamped 7) RESPONSIBILITY a) Authorized Prescriber i) Evaluate response to therapy (e.g., chest tube or pleural catheter drainage output, improvement of signs/symptoms, evaluation of chest CT or radiograph) ii) Evaluate and treat side effects of therapy (e.g., tension pneumothorax during administration, signs/symptoms of hemorrhage post administration) iii) Order every 12 hr hematocrit during tPA therapy. b) Registered Nurse i) Assess and monitor patient status and parameters including: (1) Air leak in chest tube or pleural catheter

(2) Vital signs at baseline and post administration (3) Signs/symptoms of tension pneumothorax during dwell time (dyspnea, deviated trachea, asymmetrical chest movement) (4) Signs/symptoms of hemorrhage c) Pharmacy i) Prepare and dispense the tPA (alteplase) in the appropriate syringe as requested. ii) When requested, provide drug information including, but not limited to, dosing, side effects, adverse events, drug interactions, monitoring and compatibilities.

8) PROCEDURE a) Administration in Pediatrics i) Administration should be performed by either a Pediatric Intensive Care Unit (PICU) or General Pediatric Surgery (GPS) attending physician, a fellow under the supervision of the attending physician, or a resident under the supervision of the attending physician, familiar with chest tubes. Prior to administration, the nurse and physician will check for the presence of any air leak in the chest tube or pleural catheter as this is a contraindication to the protocol. ii) RN will obtain baseline vital signs at the time of administration and every 15 minutes during the dwell time. iii) Administering Physician will be available during the dwell time. iv) The Pharmacy will dispense a standardized tPA concentration of 0.1mg/ml in Normal Saline (NS 0.9%NaCl) in a slip tip syringe. (1) Children < 1 year of age (a) Dose: 2 mg tPA/ 20ml in NS (2) Children > 1 year of age (a) Dose: 4 mg tPA/40 ml in NS v) The administrating physician will: (1) disconnect the chest tube or pleural catheter at the connection closest to the patient’s chest after the suction has been turned off. (2) inject the tPA dilution aseptically directly into the lumen of the chest tube or pleural catheter. The end of the chest tube or pleural catheter will be raised above the level of the patient to promote gravitational flow of the solution into the chest. (3) place a clamp on the chest tube or pleural catheter closest to the chest, to prevent backflow of the solution. After clamping the chest tube the pleural catheter can be reconnected. vi) The clamp will remain in place for a dwell time of 1 hour, after which the clamp will be removed by the administering physician and the suction of -20cm H2O will be re-started to allow for drainage. vii) Intrapleural tPA may be administered, in an aseptic manner, at the time of chest tube or pleural catheter placement with 2 additional doses each given 24 hours apart. A patient may receive a maximum of 3 doses during a 48 hour treatment period at the discretion of the authorizing prescriber. If administered to a previously placed chest tube or pleural catheter then physician can administer 3

doses, in an aseptic manner, each dose separated by 24 hours at the discretion of the authorizing prescriber. viii) On day 3, the patient should undergo repeat ap/lat CXR to assess radiographic response. Transthoracic ultrasound may be ordered to assess for residual localized effusion at the discretion of the authorizing prescriber. b) Assessment i) RN will check vital signs 15 minutes after administration and every 1 hour while tube is clamped. ii) RN will monitor for signs of tension pneumothorax while clamp is in place every 15 minutes. iii) RN will monitor for signs and symptoms of hemorrhage throughout the entire course of treatment. c) Interventions i) RN shall turn and reposition the patient every 15 minutes to promote an even distribution of tPA within the pleural space as tolerated. ii) RN shall notify physician of any adverse events or reactions as described under “Reportable Conditions”. iii) RN shall measure amount of drainage from the chest tube or pleural catheter throughout the course of treatment.

9) Reportable Conditions to Physician a) Positive air leak of chest tube or pleural catheter b) Signs or symptoms of hemorrhage c) Drop in hematocrit d) Vital sign abnormalities e) Chest discomfort or pain f) Signs or symptoms of tension pneumothorax including respiratory distress g) Absence of drainage once chest tube or pleural catheter is unclamped

APPENDIX 12: Guidelines for Central Line Related Blood Stream Infections

APPENDIX 13: Central Line Lock Therapy for Treatment of CRBSI

APPENDIX 14: Perioperative Antibiotic Prophylaxis

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APPENDIX 15: BURN DOCUMENTATION REQUIREMENTS 1) H&P AND LUND & BROWDER A) REQUIRED for all burn patients seen in the PED. The L&B is completed by whoever debrides the burn (PED Burn RN vs. GPS); then, scanned into EPIC. 2) BURN ORDER SET A) REQUIRED for all burn admissions: Burn Injury Admission PED. This order set lists required & recommended consults/ interventions for burn patients. 3) DAILY NOTES A) REQUIRED for all burn patients and should include specifics on: . % TBSA . IVF/ Parkland Resuscitation . UOP i.e. during Parkland – is the patient meeting the goal? . Nutrition . Pain plan . ID, if necessary . Specific dressing instructions for each wound . Plan for next 24 hours . Plan discussed with bedside RN and PICU Provider (if in the PICU). 4) PROCEDURE NOTES A) REQUIRED for all burn dressing changes. Use the Procedure Note – Burn Dressing Change TEMPLATE. This will ensure you cover all documentation requirements. Be specific when describing burn appearance & dressings used on each wound. 5) OPERATIVE NOTES A) All OR procedures REQUIRE a narrative operative note. B) A brief operative note can be documented in POE; however, a narrative op note is still required. 6) BURN CLINIC A) Open most Mondays, Wednesdays & Fridays mornings. I) Patient must call to make an appointment! 888-KID-BURN II) Discharge instructions should advise families to pre-medicate patient with OTC or Rx medication 30 minutes before appointment.

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APPENDIX 16: BURN WOUND CARE: ED PROCEDURE

Indications Interventions Suspected or reported . Don personal protective equipment, including gloves, chemical burns without non-permeable gown and mask with face shield. powder for patients < 2 . Remove all of the patient’s clothing. years old, or patients ≥ 2 . Irrigate with saline copiously until GPS makes years with <10% TBSA recommendations to PED prescriber. involvement Suspected or reported . Don personal protective equipment, including gloves, chemical burns without non-permeable gown and mask with face shield. powder for patients ≥ 2 . Remove all of the patient’s clothing. years and patients with ≥ . Irrigate with running water copiously until GPS makes 10% TBSA involvement recommendations to PED prescriber. Suspected or reported . Don personal protective equipment, including gloves, chemical burn with powder non-permeable gown and mask with face shield. . Remove all of the patient’s clothing. . Brush off all visible powder off skin using gloved hands. . Await GPS attending or fellow recommendations. Suspected or reported . Await GPS recommendations for wound care. electrical burns Suspected or reported . Wash burned area with warm normal saline and mild thermal burns with no loose soap. tissue or blisters (superficial) . Obtain order for moisturizing cream. . Apply moisturizing cream. Suspected or reported . Pre-debridement: thermal burns with loose . Discuss pain plan with prescriber and obtain orders. tissue and blisters, . Complete pre-debridement wound photography. determined to be admitted . Wash burned area with warm normal saline and mild by GPS soap. . Debride loose tissue and blisters. . Single blisters < 2 cm may be left intact. . Complete post-debridement wound photography. . Apply thin layer of bacitracin to non-adherent mesh dressing, then apply to burned areas and secure with several layers of gauze roll and elasticized net dressing. . Complete Lund & Browder diagram and obtain attending co-signature.

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Suspected or reported . Pre-debridement thermal burns with loose . Discuss pain plan with prescriber and obtain orders. tissue and blisters, with no . Complete pre-debridement wound photography. GPS consult or GPS . Wash burned area with warm normal saline and mild determined patient will be soap. discharged . Debride loose tissue and blisters. . Single blisters < 2 cm may be left intact. . Complete post-debridement wound photography . Apply silver-impregnated foam dressing to moist, well- debrided areas. Do not apply silver-impregnated foam dressing to face, genitalia, palmar surface of the hands or soles of feet. Dressing should overlap the surrounding unburned skin by a minimum of 2 cm. . Secure with several layers of gauze roll and elasticized net dressing. . Complete Lund & Browder diagram and obtain attending co-signature. Suspected or reported burn . Obtain order for moisturizing cream. injuries with signs of . Wash area with warm normal saline and mild soap. spontaneous healing, . Apply moisturizing cream to area using massage. including scabbing, presence of epithelial islands, blanching, pink and dry ANATOMICAL CONSIDERATIONS Burns of the face . Pre-debridement . Discuss pain plan with prescriber and obtain orders. . Complete pre-debridement wound photography. . Wash burned area with warm normal saline and mild soap. . Debride loose tissue and blisters. . Single blisters < 2 cm may be left intact. . Complete post-debridement wound photography . After debridement, apply thin layer of bacitracin. . NOSE and EARS: Instead of bacitracin, apply thin layer of mafenide acetate cream. . EYES: Instead of bacitracin, apply ophthalmic erythromycin to burns within an inch perimeter of the globe.

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Burns of the hands and feet . Pre-debridement . Discuss pain plan with prescriber and obtain orders. . Complete pre-debridement wound photography. . Wash burned area with warm normal saline and mild soap. . Debride loose tissue and blisters. . Single blisters < 2 cm may be left intact. . Sterile scissors and tweezers may be used to de-roof blisters and remove sloughing skin. . Complete post-debridement wound photography. . Apply thin layer of bacitracin to non-adherent mesh dressing. Wrap fingers and toes individually and apply roll gauze and elasticized net dressing. . Maintain neutral to extended anatomical position with access to fingertips and toes for circulation assessment. Burns of the genitalia . Pre-debridement . Discuss pain plan with prescriber and obtain orders. . Complete pre-debridement wound photography. . Wash burned area with warm normal saline and mild soap. . Debride loose tissue and blisters. . Single blisters < 2cm may be left intact. . Complete post-debridement wound photography. . Apply thin layer of bacitracin to non-adherent mesh dressing and place on burned areas. . For continent patients, apply gauze wrap and secure with elasticized net dressing. . For incontinent patients, apply diaper; dressing change should be completed after each bowel movement. . If concerned for urinary obstruction secondary to genital edema, discuss with GPS attending or fellow prior to inserting a Foley catheter.

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APPENDIX 17: Non-operative management of liver & spleen injuries

SPECIFIC DIAGNOSIS GUIDELINES Clinical CBC Basic Compreh PT T&S ECG CXR Notes Diagnosis or Metabolic ensive PTT Procedure Chemistry Chemistr y Cong. Adrenal Preop endocrine consultation for corticosteroid / mineralocorticoid replacement Hyperplasia, or X Adrenal Insuff. Anemia history X CBC if untreated, or not followed by PMD, or if recent Hgb is not documented Asthma If patient has asthma exacerbation associated with URI, then surgery should be See postponed for 4 weeks and the patient should receive nebs and steroids (prednisone 1 notes mg/kg qd) for 3 days preop.

If a patient has asthma exacerbation with no URI symptoms and the patient's asthma is well-controlled otherwise, then surgery should be postponed for one week and the patient should receive nebs and steroids (prednisone 1 mg/kg qd) for 3 days preop.

Prednisone 1 mg/kg qd starting 3 days before procedure and given the day of procedure if:  Oral or IV steroids have been prescribed in the past 6 months  Pt is on continuous meds for asthma or had active wheezing in past 2 months.

If patient's asthma is not well-controlled, obtain pulmonary consult. Pulmonary or PMD evaluation if pt:  Wheezes daily  Had 3 acute episodes in past 6 months requiring physician-directed treatment If pt is wheezing during preop visit – may need CXR; check with attending. Cardiac surgery X X X X X X X Coagulopathies X X May require factor levels or Hematology Consult for perioperative management Craniosynostosi X X X s Cystic Fibrosis CXR only if significant pulmonary compromise exists; consult attending anesthesiologist Diabetes X Consult attending anesthesiologist re: perioperative vasopressin insipidus Diabetes X Determine if endocrinologist has made plans for perioperative care with insulin infusion mellitus or insulin pump use.

Consult attending anesthesiologist, try to schedule as first case or as early AM case Down Thyroid function and C-spine films if not previously done Syndrome (Trisomy 21)

SPECIFIC DIAGNOSIS GUIDELINES Clinical CBC Basic Compreh PT T&S ECG CXR Notes Diagnosis or Metabolic ensive PTT Procedure Chemistry Chemistr y Failure to thrive X X X If not already done as part of workup Heart Failure or X X X X If on ACE inhibitor or diuretic, discuss with attending whether to hold AM dose on day of Hypertension surgery. Liver disease Consult attending anesthesiologist Neuromuscular Consult attending anesthesiologist dis Renal disease X X Determine if nephrologist has plans for perioperative care. Scoliosis repair  Chemistries only if indicated by medication or associated illness. X See note See note See X See See  PT/PTT only if there is a history of bleeding in patient or family, or if taking valproic note note note acid (Depakene) or carbamazepine (Tegretol)  CXR in past 12 months unless asymptomatic, totally healthy & only idiopathic scoliosis  Echo if pt has cardiac, neuromuscular or metabolic disease; and for heart size and function if curve > 60 degrees with associated co-morbidities such as MRCP or spina bifida  PFT per anesthesia attending if curve > 60 degrees and age > 6 years and mentally capable; also may be requested by surgeon for muscular dystrophy patients Seizure history X X X X May need these labs if on tegretol, depakote or zarontin and If receiving carbamazepine, phenobarbital or phenytoin, may need drug levels Ketogenic diet All patients with sickle SS, SC, or S-thal disease must have Hematology consult. Sickle Cell X X X X X See  After pt’s final preop transfusion ,obtain hematology studies and %Hgb S Disease note  CXR if history of cardiac or pulmonary involvement Sleep Apnea, Generally needs monitored bed postop (all CMSC beds have monitoring capability); Severe: defined Hb decision for ICU, if not ordered by surgeon, should be made by attending as either RDI or in anesthesiologist consult or attending assigned to case. AHI > 10 or som  If sleep study has been done, obtain report. oxygen sat e  Review case with attending anesthesiologist nadir < 70% case during sleep. s

REFERENCES

Sources 1. “Recommended immunization schedule for persons aged 0 through 18 years – 2013” http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-schedule.pdf 2. “Pediatric Fasting Guidelines for Surgery”. www.hopkinschildren.org , n.p. Web 2. Oct. 2012 3. Vegunta, Ravindra. “Vascular Access.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 110-116 4. Slater, J; Krummel TM. “Surgical Infectious Disease.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 5. “Pediatric Perioperative Antibiotic Prophylaxis to Prevent Surgical Site Infection” http://www.insidehopkinsmedicine.org/amp/pediatrics/downloads/PeriOp_AbxProphylaxis_Prevent_SSI.pdf n.p Web 5 May 2013 6. Othersen Jr, BH; Hebra, A. “ Tracheal Obstruction and Repair.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 272-273 7. Mehta, N; Jaksic T. “Nutritonal Support of the Pediatric Patient.” Ashcraft’s Pediatric Surgery. 5. Holcomb, GW and Murphy, JP. Philadelphia, 2010. 19-31