DIVISION OF PEDIATRIC SURGERYHOUSE OFFICER’S MANUAL

Children’s Hospital of New York

Edited by Dr. Sam Alaish and Dr. Terry Buchmiller CrairJanuary 2002

INTRODUCTIONThe purpose of this manual is to help you get acquainted with some of the special problems in infantsand children. They are different from adults!

If you don't know the answer to something, don't be afraid to say, "I don't know." There are othershere who probably do, just ask!

Parents are worried and anxious and communication is critical. It will help to be understanding andpolite despite the late hour and often-heavy workload. Care plans should be discussed with the fellowor attending before discussion with families to avoid confusion. As a general rule: DO NOT ARGUEwith parents. Having a sick child in the hospital is a very stressful situation for most parents andprobably is at an increased level compared to that which you have experienced in most adult hospitals.Despite your medical knowledge, parents probably know their child better than you do, especiallythose children with chronic health problems when there has been frequent contact with the health caresystem. Problems that occur with parents regarding patient management, questions, etc, should bebrought to the attention of the fellows and attending. If a disagreement does occur, a safe response issay “I don’t know. I will ask Dr. Stolar” (or whoever is the child’s attending physician). In the longrun this will instill parent’s confidence in you and make for a smoother hospital stay.

The primary goal of this service is to provide excellent care for children in this region. In general,there is very little that we as a service cannot take care of. The answer to any call should be “We willbe happy to see the patient. Please send them to the ER, office, or tell them "I will be there in ____minutes". If you are unsure as to what we can provide, or where to send the patient, please ask thefellow or attending on call. Never turn anyone anyway or refer to another service without the expressinstruction by faculty.

Outside reading is strongly encouraged and textbooks are provided in the surgical library.

If you have suggestions, please share them with the editors. They may be incorporated into a futureprinting of this manual.

TABLE OF CONTENTS

I. STAFF TELEPHONE NUMBERS ............................................................................................... 5

II. DICTATION.................................................................................................................................. 8

III. RESIDENT RESPONSIBILITIES .............................................................................................. 10Protocol for New Residents........................................................................................... 15

IV. CLINICS, CONFERENCES AND ROUNDS............................................................................. 16

V. GENERAL ADMINISTRATIVE ISSUES ................................................................................. 17

VI. EMERGENCY MANAGEMENT OF THE INFANT AND CHILD ......................................... 22

VII. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD ................................... 27Fluid Management......................................................................................................... 27Central Venous Lines .................................................................................................... 28Gastrostomy................................................................................................................... 31Tracheostomy ................................................................................................................ 34 Chest tubes..................................................................................................................... 34 Nasogastric tubes........................................................................................................... 36 Infection/Antibiotic/Bowel Prep.................................................................................... 36 Apnea & Bradycardia Monitoring................................................................................. 38

VIII. COMMON PEDIATRIC SURGICAL PROBLEMS................................................................... 39 Appendicitis................................................................................................................... 39 Pyloric Stenosis ............................................................................................................. 40

Intussusception .............................................................................................................. 41 Incarcerated Inguinal Hernia ......................................................................................... 42 Unincarcerated hernias in premature and full-term infants ........................................... 42 Testicular Torsion.......................................................................................................... 43Foreign Bodies............................................................................................................... 43 Caustic Ingestions.......................................................................................................... 45 Lower GI Bleed ............................................................................................................. 47 Chest Wall Deformities-Pectus Excavatum................................................................... 48

IX.PROBLEMS OF THE SURGICAL NEONATE ............................................................................. 50 Tracheo-esophageal fistula and esophageal atresia ....................................................... 51 Intestinal obstruction ..................................................................................................... 51 Intestinal atresia............................................................................................................. 51 Hirschsprung's Disease.................................................................................................. 52 Meconium ileus ............................................................................................................. 52 Malrotation .................................................................................................................... 53 Omphalocele and gastroschisis...................................................................................... 54Special Problems of Premature Infants.......................................................................... 55 Necrotizing enterocolitis (NEC):................................................................................... 55 Recognition and Treatment of Sepsis in Newborns ...................................................... 57 Postoperative enteral feeding......................................................................................... 57 NICU Survival Guide .................................................................................................... 59 Treatment Protocol for Congenital Diaphragmatic Hernia (CDH) ............................... 61

X.Extracorporeal Membrane Oxygenation (ECMO) ............................................................................ 65

XI. PEDIATRIC TRAUMA................................................................................................................. 72 C-Spine Clearance........................................................................................................................ 78 Shock ....................................................................................................................................... 80 Spleen/Liver Trauma.................................................................................................................... 82

APPENDICES....................................................................................................................................... 84

APPENDIX 1 Modified Glascow Coma Scale for Infants and Children............................................. 84APPENDIX 2 Pediatric Trauma Score................................................................................................. 85APPENDIX 3 ETT Sizes...................................................................................................................... 86APPENDIX 4 Gastrostomy Tubes ....................................................................................................... 88APPENDIX 5 Caloric Density of Solutions......................................................................................... 89APPENDIX 6 SBE Prophylactic Regimens......................................................................................... 90APPENDIX 7 20 Commandments of Surgical Residency................................................................... 91

REFERENCES ...................................................................................................................................... 92

I. STAFF TELEPHONE NUMBERS

R. Peter Altman Surgeon-in-Chief

CH 116S 5-5804 917-271-2467

Charles J.H. Stolar Chief,Division

CH 212N 5-2305 917-271-2513

Steven Stylianos Director,Trauma

CH 206N 5-8861 917-271-2592

Jessica J. Kandel Attending CH 214N 5-5871 917-247-9107William Middlesworth Attending CH 201S 5-3325 917-271-0500

Jeffrey Zitsman Attending Westchester 914-722-6737

917-694-8141

Eric L. Lazar Attending Babies 203S 5-0641 917-271-0949Edmund Kessler Attending Long Island,

Brooklyn516-498-9000

516-337-0702

Samuel M. Alaish Attending Babies 113N 5-6110 917-271-1103

Terry L. Crair Attending NYH 746-5648 746-6700- 30800Nitsana Spigland

Carmen Ramos

Dorothy Rowe

Robert Cowles

Attending

Attending

ChiefResidentAssociateChiefResident

NYH

NYH

CH 201N

CH 201N

746-5648

746-5648

5-5875

5-5875

746-6700-16519917-205-8063917-899-2432917-899-9161

ADMINISTRATION

Sandra Bacharach DivisionAdministrator

CH 204N 5-8402 917-902-4658

NURSE PRACTITIONERS

Laura Flanigan NurseExtraordinaire

CH 215N 5-8869 917-899-6153

Jeanne Rubsam TraumaCoordinator

CH 215N 5-9911 917-899-3511

TELEPHONE NUMBERS AT CHILDREN’S HOSPITAL-COLUMBIA

(To page @ Children’s: Dial 7-5880, enter page # followed by extension)MISCELLANEOUS

Admitting Office 5-3023 Children’s ORScheduling (Add-ons)

5-2415

Engineering Office 5-5175Ambulatory Surgery 5-8069 Ophthalmology 5-5407Blood Bank 5-4440 Hospital Pharmacy 5-7180Blood DonationDirected Donor

5-4440 Page Operator 5-2323

Clinic/DPO 5-8585 Emergency Room 5-6628

Clinical Nutrition 5-4901 Trauma Stat 5-3333

LABSBacteriology 5-6276 Pathology 5-6719Chemistry 5-2761 Stat Lab 5-5696Hematology 5-6532 Virology 5-9118

OPERATING ROOM – (Front Desk) 5-2415OR A 5-9009 OR Scheduling 5-9879OR B 5-6477OR C 5-6476 Pre-op/Short stay 5-8069OR D 5-6475OR E 5-6473 Recovery Room 5-2418OR F 5-6471

X-RAYS-5-3320ER Radiology 5-6501 Nuclear Medicine 5-2721Cardiac Echo 5-6542 Ultrasound 5-9113CT 5-5879 XRAY File Room 5-3342MRI 7-1243 Angio/IR 5-5123

FLOORS5 S 5-8730/5-7630 11S CRC 5-29686 S 5-7620 12N (NICU) 5-65616S Nursery 5-7623 12 S (TN, L&D) 5-89828 S 5-5919 Pediatric Cath Lab 5-32179N (PICU) 5-32819S (PICU) 5-659110 S 5-7640

11 S 5-5945

TELEPHONE NUMBERS AT CHILDREN’S HOSPITAL-CORNELL

To page at NYH, dial 746-6700, enter page # followed by extension

Page Operator 746-5100 On-Call Ped Surgery *11836Ambulatory Surgery 6-4285 Pathology 6-2700Drug Information 6-0741 Peds Reading Room 6-2553Pediatric ER 6-3300 ER Radiology 6-2630Medical Records 6-0505MSK Page Operator 639-7900 Patient Floors:Ostomy Nurse 6-4709 NICU (6W) 6-0318Main OR 6-0338 PICU (6S) 6-0308Ambulatory OR 6-5065 Pediatric Ward (6N) 6-0309PACU 6-0336 Nursery (7C) 6-0302

II. DICTATION

Dictation Instructions at Children’s:

1. Dial 568-55302. Enter your 5 digit User ID (your Children’s Hospital ID; precede with a zero if 4 digits)3. Enter the 2-digit Work Type (01 for discharge summaries; 02 for operative reports).4. Enter the 7-digit Medical Record Number.5. Begin dictating at the tone.

A tone will sound indicating you are ready to dictate. The system is voice activated.Any silence or pause will prompt continuous beeps; dictating or speaking louder will eliminatethem. After 5 minutes of inactivity, the line will be discontinued.

Dictating Functions:

1 Pause2 Record/Dictate3 Replay Last Few Words4 Go to End of Dictation5 Disconnect from system7 Reverse to Beginning8 Start New Report

ALL INPATIENTS MUST HAVE A DISCHARGE SUMMARY. THIS IS THERESPONSIBILITY OF THE HOUSESTAFF.

Format for Discharge Dictations:Dictate in this sequence or you may be asked to repeat the dictation

Patient's Age Laboratory DataAdmit Date Hospital CourseDischarge Date Operations (with dates)Attending Physician Procedures (with dates)Admitting Diagnosis Discharge DispositionDischarge Diagnosis Prognosis

Chief Complaint Condition on DischargeHistory of Present Illness Follow-upPast Medical History InstructionsAllergies Discharge MedicationsSocial History DietFamily History Date of DictationPhysical Examination *Send copies to: (referring MDs)

To Look Up Labs at Children’s:From any computer:Type https://webcis.cpmc.columbia.eduEnter User IDEnter PasswordThen enter the patient’s medical record #, the patient’s name or a location.

III. RESIDENT RESPONSIBILITIES

1. Pediatric Surgery Fellows

a) The Chief Resident and Associate Chief Resident have independent operating privileges for life-threatening emergencies only. Neither fellow has admitting privileges. All patients must have anadmitting attending, which is determined by the Chief Resident or the Associate Chief Resident.

b) The Chief Resident oversees the care of all patients on the general surgical service. His/herbeeper is always on and he/she is always available for questions and help. He/she must beinformed of all admissions and consults. No invasive procedure or major change in thetherapeutic management of a patient should be performed without conferring with the ChiefResident or the Associate Chief Resident.

2. Residentsa) Every third night in-house call; the on-call resident’s primary responsibilities are the ER, in-

house consults, and the inpatient service.b) Emergency Room admissions. Never refer patients to other services without first asking the

Chief Resident. Testicular torsion, hematuria (possible Wilms’ tumor), ovarian pathology andaerodigestive foreign bodies are treated by the pediatric surgery service

c) See all consults as soon as possible, but respond to page immediately and indicate when patientwill be seen. Phone instructions to obtain x-rays or laboratory studies are discouraged withouthaving first examined the patient.

d) All females with abdominal/pelvic pain who may be sexually active must have a pelvic exam bya surgical resident or gynecologist and always with a female nurse present! Never be in a closedroom with a female patient without a chaperone. Parents are not chaperones. Patients will nothave surgery based solely on a pediatric/medical evaluation. [Please respond promptly when anER physician desires to perform these exams so they do not require repetition. Remember tocheck urine b -HCG for all menstruating females, even as young as 10 years, preoperatively.]

e) Trauma: The resident participates in the rapid management of all trauma patients. The ChiefResident on-call must be notified immediately. The resident will facilitate the work-up;Ordering a series of tests and then leaving is unacceptable.

f) In-house consults: Use the pink consult sheet for documentation and billing purposes and returnit to the fellow on call either at the time of consultation or the following morning. Writeattending, diagnosis, patient location, referring MD (include address and phone number) and thedate on the consult.

g) Pre-round before morning and evening rounds.h) The surgical team has responsibility for the surgical patients in the NICU and PICU, and should

work closely with the neonatologists and intensivists in a collegial manner.1. REQUIRED presentation format for ICU patients:2. Patient's name, POD # or hospital day number, and surgical problem(s).3. Maximum temperature during previous 24 hours and vital signs.4. Continuous drip medications and their rates.5. Ins and outs with a breakdown of individual fluids and caloric sources. Include drains.6. Infants: cc/kg in , Kcal/kg, and cc/kg/hr out in urine (include goals)

· Older children/adolescents: cc/24 hr in, cc/24 hr out· Pertinent physical exam · Review systems with plan · Neuro · Neuro · Respiratory · Respiratory · Cardiovascular · Cardiovascular · Abdomen · GI

· Others · Renal· Labs and studies · Metabolic/ I.D.

· Tubes, lines, and drains. Plan for the day

A daily progress note is REQUIRED on each patient. The Chief Resident will reviewand sign all ICU progress notes, including ECMO patients.

Write notes in the hospital record for all relevant inpatient events, as well aspreoperative and immediate postoperative evaluations.

REQUIRED patient presentation format for floor patients· Patient's name, POD # and surgical problem.· Maximum temperature during previous 24 hours and vital signs.· Ins and outs with a breakdown of individual fluids and caloric sources. Include

all drain output· Infants: cc/kg in , Kcal/kg, and cc/kg/hr out in urine (include goals)· Older children/adolescents: cc/24 hr in, cc/24 hr out· Pertinent physical exam by system · Neuro · Respiratory · Cardiovascular · Abdomen· Recent laboratory values· Plan for the day

The sequence for presentation on rounds is:POD, antibiotic day, weight in Kg (and amount up or down), T-max/T current, total

intake, cc’s/kg/day, kcals/kg/day, total output cc’s/kg/hr, stools, NGT, GT, drainoutput, labs, the P.E. and plan

i) Complete all discharge summaries, schedule follow-up appointments and write prescriptions forpatients being discharged at the time of discharge (or in the evening the night before for an AMdischarge.) This includes arranging home care as needed.

j) Rewrite orders weekly.k) Work up all daily elective admissions (shared responsibility - not only for the on-call residents).l) Keep current information on all consult evaluations. Consults should only be placed at the

direction of the Chief Resident or staff surgeon. Consulting another service requires a directconversation for best/prompt results. No consult is to be written as an order.

m) Ensure all laboratory and X-ray studies are completed as ordered. X-rays are personally reviewedwith the Pediatric Radiologist.

n) Provide operating room coverage as assigned. Residents should be in the O.R. by 7:15 A.M. forfirst cases. All day surgery and same day surgery patients must be evaluated and consented priorto the scheduled OR time. The Surgical Service should not be the cause of operating roomdelays. Arrange coverage for primary patients while scrubbed in OR.

o) Residents share the responsibility for work-ups in Pre-Op admissions during the day. If theresident cannot go to Admitting within 10 minutes, another resident should be designated, so thatthe patient and family need not wait an excessively long time.

p) The resident who is designated to scrub on a case must perform an independent pre-op historyand physical on that patient; however, this does not have to be the same H&P that admits thepatient to the holding area.

q) A resident should scrub on every index case. This is a major learning opportunity not to bemissed!

3. On Call Residentsa) The residents will scrub on appropriate cases at night as assigned by the Chief Resident.b) Make certain that all patients for surgery have a preoperative check (e.g., labs, consent, adequate

bowel prep, T&C, etc.). Check the add-on list in the O.R. so no patient is overlooked.c) Postoperative check on all patients operated upon that day.d) Check all ICU and other seriously ill patients again and again and again! Do NOT wait to be

called! Find problems and fix them!e) The on-call residents should have appropriate X-rays located to review with the team on

morning rounds.

f) FOR ANY PROBLEM THAT ARISES REGARDING PATIENT CARE ALWAYS ERRON THE SIDE OF TOO MUCH, RATHER THAN TOO LITTLE COMMUNICATIONWITH MORE SENIOR RESIDENTS. ALL SENIOR RESIDENTS WILL WELCOMEYOUR CALL ANY DAY AT ANY HOUR. ASKING FOR HELP IS NOT A SIGN OFWEAKNESS.

4. Medical Students

Periodically, there are medical students rotating from Columbia P & S Medical School andfrom outside medical schools as well. These medical students are an integral part of theservice and their participation is welcomed. Our responsibility as residents is to provide thestudents with a wide exposure to many topics in pediatric surgery. Participation in the care ofpatients is proportionate to their level of experience and expertise. Nevertheless, medicalstudents do not have the same obligations to the service as residents.

5. General Surgery Pediatric Nurse Practitionersa) The General Surgery Department currently has two pediatric nurse practitioners (PNP) who are

an integral part of the team.b) The PNPs 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, andparental anxiety. Please do not hesitate to call upon them. THEY KNOW A LOT AND CANBE VERY HELPFUL TO YOU IF YOU ASK. The nurse practitioners are also available toassist residents with their assigned patients when the resident is absent or in the OR.

Children’s Hospital Surgical Resident Guidelines:The following guidelines have been developed to assist surgical residents during their rotationat Children's Hospital.

1. CASE ASSIGNMENTS:The OR needs to be aware of the resident assignments. Case assignments are made by theChief Resident. Assignments may be written on the schedule at the O.R. desk.

2. PRE-OP:

Residents are expected to introduce themselves to patients and family, and identify patient vianame bracelet. At this time patient records are reviewed, history and physical is completed,surgical site is verified, and informed consent is obtained. Patients cannot be brought back tothe OR until all paperwork is completed.

3. CONSENTS:For a minor (under 18 years) parents or legal guardian must sign consent. Be aware that fosterparents are not always legal guardians, and that social services may be involved. Consents aresigned by patients 18 years and over unless legal authority has been otherwise indicated.Consents must be specific to surgical site indicating left and/or right sides. Interpreters areavailable for all non-English speaking families. Consent should be obtained in Spanish forSpanish-only-speaking families.

4. WEIGHT:Weight is documented in kilograms only. Do not estimate or round off patient weights. Useweight most recent to day of surgery.X-RAYS:Scheduled surgical x-rays should be obtained by the on-call resident the night before surgeryunless they are only located in the PAX system.BEEPERS:During cases, all beepers should be handed off to another resident outside of the OR.RESIDENT AVAILABILITY:Cases will not start without available resident or surgical attending in the OR. Residents mustbe present in the OR from the time the patient is induced until transfer to the recovery room orICU.

4. PARENT PRESENT INDUCTION:Parent present induction may be offered to patients and families by the anesthesia department.Please refrain from any unnecessary talking and noise during induction of anesthesia.

5. EYEWEAR:Residents must wear appropriate protective eyewear (side protection too) before scrubbing forall cases.

6. HAND WASHING:Hand washing is the single most effective way to prevent the spread of infection and disease.Avoid cross contamination.

7. SHARPS:“Sharps” protocol must be strictly adhered to. Many staff and environmental serviceemployees are injured by and exposed to infection by improper disposal and handling ofsharps.

8. BETADINE:The pediatric patient population is more prone to Betadine burns. When prepping, avoiddripping Betadine (especially near Bovie pad) and avoid pooling of betadine under the patient.Clean Betadine off of the patient at the end of the procedure

9. POST-OP ORDERS: Post-op orders are to be completed at the end of the case and reviewedwith either the Chief Resident or the Attending.

10. PATHOLOGY SPECIMENS: Labelling and delivery of all specimens to the correct locationis the responsibility of the resident—not the nurse.

PROTOCOL FOR NEW RESIDENTS1. Upon Arrival:

a) Check in with Ms.Sandra Bacharach, Division Administrator, for registration information,beeper, call schedule, as well as an ID # necessary for dictating reports. (Babies 204N; Phone 5-8402)

2. Prior to Departure:a) Return beeper to Ms. Sandra Bacharach.b) Dictate all outstanding discharge summaries and operative notes. Those left undictated will be

assigned to the following resident from the same institution and you will not receive credit forthe rotation.

IV. CLINICS, CONFERENCES AND ROUNDS AT CHILDREN’S1. General

a) Morning Rounds begin PROMPTLY in the NICU at 6:30 A.M., Monday, Tuesday, Wednesdayand Friday, 6:15AM on Thursday and 8:00 A.M. on Saturdays and Sundays and holidays. Pre-rounds must be made by residents. To ensure complete exchange of information withoutdistraction and to minimize the duration of rounds, unnecessary conversation should be avoided.

b) Evening rounds begin when the cases of the day are finished. Pre-rounds must be made byresidents.

c) Conferences/Clinics (ATTENDANCE IS MANDATORY)

Day Time Scheduled Conference/ClinicMonday 5 PM Trauma Conference (CH 1S-McIntosh)(4th of month)Thursday 7 AM Morbidity and Mortality (CH 203N)

8 AM Radiology-Surgery Conference (CH 323N)9 AM Clinic (CH 106N)12 noon Basic Science Conference (CH 203N)3 PM Grand Rounds (CH 203N)4 PM Attending ward rounds (NICU)

2. Surgery Clinic: a) Meets every Thursday from 9 AM to Noon. No scrubs.b) 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 theclinic.

c) All clinic notes including a brief history, physical exam, and plan should be hand written in thechart and reviewed with a Chief Resident or Attending.

d) Write diagnosis and follow-up plan on patient encounter form, (e.g., "return to office withabdominal ultrasound in 2 months"). Send patient to front desk with encounter form andappropriate requisitions. Each patient scheduled for surgery should be entered in the logbook.

e) The Babies 1 Clinic Staff consists of:1. Georgia Campbell, Supervisor2. Carmen Rosado, Physician Aide3. Esther Rodriguez, Physician Aide4. Kirsy Grullon, Clerk

3. Ostomy Clinic /Enterostomal Therapy Programa) Skin care generally related to ostomy diversions or G-tubes, preoperative siting and

postoperative and outpatient care.b) An enterostomal therapy nurse, is available to help manage postoperative care - e.g., ostomy, G-

tube management, and pressure ulcer management.

V. GENERAL ADMINISTRATIVE ISSUES

1. Selected Policies Regarding Written Orders on Surgical Service:a) Familiarize yourself with the specific order writing policies in the specific area of the hospital.

In general, order medications in mg dosages (rather than number of pills) to avoid errors. Thedrug dosages vary depending on the age and weight of the patient. Neonatal drug doses can befound in the Neofax manual.

b) It is recommended that to decrease the chance of error and to facilitate care, that patients receivethe same solution of maintenance and NG replacement; condition permitting (i.e., D51/2 NSwith 10K+/500 @ 100 cc/hr + NG replacement (cc/cc) every 8 hours).

2. Consultations: Consults to other services require you to fill out a requisition, and then call theconsulting service. All radiographic studies including ultrasound, CT, MRI, UGI, VCUG need tobe arranged by the MD. NPO status will need to be ordered specific to the test. Includerequisition in chart. Please indicate in orders or on consultation form what specifically is beingrequested. All requests are to be made physician to physician. No orders please.

3. Discharges: Please plan discharges as early as possible!!a) Many families need varying amounts of teaching.b) All patients with new stomas/complicated wounds should be seen several days prior to DC.c) Beds are needed for admissions - Plans are made with Admitting Office by 9 a.m.d) Encourage early discharge whenever possible. If you will be in the OR in the a.m., Please do

your discharge paperwork before going into a case. The paperwork may be done the night beforedischarge, with pertinent information added on the discharge day.

e) Most cases such as hernias, pyloromyotomies, or appendectomies are seen approximately 2weeks post-op. Check with attendings prior to D/C for follow up plans.

f) Make sure you know who the attending surgeon is upon discharge. Do not simply send allpatients to "clinic" for follow up.

g) Patient Care Referrals (i.e. V.N.A.) must be completed and signed.h) Transfer to another hospital or facility will require a telephone call to the accepting M.D. You

need to dictate a stat discharge summary so it will be ready to go with patient.i) Write discharge orders / prescriptions the night before when known in advance. Pay close

attention to the need for 'triplicates'.j) Remove CVL, PICC the evening prior or morning of discharge.

4. Heparin Locks:a) An MD order is essential for heparin locks. Dose and frequency of heparin must be ordered.

Recommendations are:· CVL - 10u/cc - 2cc BID· Peripheral IV -- Use NS 1-2 cc q8° to flush

5. Medical Records - Suggestions

a) Write LEGIBLY and in ink. (No felt pens.) YOUR NAME MUST BE LEGIBLE SO YOU CANBE CONTACTED IF THERE ARE QUESTIONS REGARDING A PATIENT.

b) Sign entries with first and last name and professional designation, include beeper #.c) Record date and time of all entries.d) Record as soon after examination/assessment as possible.e) Use objective, rather than subjective language.f) State facts, not conclusions.g) Avoid judgmental statements. Politics and emotion have no place in the medical record.h) Document only clinically relevant material.i) Document what measure you took to protect the patient.j) Document what the patient did not do.k) Document the patient's response(s) to what you did do.l) Do not strike or remove erroneous entries.m) Keep records confidential.n) Release records only to those legally authorized to have access.

6. Consentsa) Provide the person with authority to consent (parent or legal guardian) with all material and

information necessary to make an informed decision. If there is any question regarding consentissues (ex. treatment of pregnancy / venereal disease / drug abuse in a minor, care of the mentallyincompetent child over 18 years) please contact the hospital's legal counsel.

b) Those obtaining consent must have full knowledge of the procedure, including pertinentpossible complications. If you do not have sufficient knowledge of the procedure and/or risks,the consent should be obtained by a more senior resident, fellow, or the attending surgeon.

c) It is necessary to inform this person of the following:1. Nature of the patient's condition in terms understandable to that person.2. Nature and probability of risks3. Benefits to be reasonably expected4. Inability of the physician to predict results5. Irreversibility of the procedure6. Likely result of no treatment7. Alternatives including risks and benefits8. Keep in mind that the more elective the treatment, the disclosure of all risks becomes

essential.

d) Obtain the agreement of the person with authority to consent. Have the person authorized toconsent sign the form.

e) It is advisable to document the 'informed consent process' in the patient's medical record.

f) State in medical record that both the patient (if age appropriate) and parents understand theproposed procedure and all risks and that they request that the procedure be performed.

THE MOST COMMON BASIS FOR JUDGEMENTS AGAINST PHYSICIANS

IS LACK OF INFORMED CONSENT!

7. Directed Donations for Blood Transfusion:a) All directed donations must be made at least 5-7 working days prior to the scheduled transfusion.

These donations must undergo the required FDA testing. No exceptions can be made.b) The parent(s) or legal guardian should be directed to call the Blood Donor Center for

information. i. Cornell Campus: Blood Bank 746-4446 ii. Columbia Campus: NY Blood Bank 305-4440

c) The patient's physician will receive a form from the Blood Donor Center regarding expected dateof transfusion (surgery) and anticipated blood usage. This should be completed and returned tothe Blood Bank Laboratory.

d) Children weighing approximately 80 lbs can qualify for autologous donation, unless medicalcontraindications exist.

8. Child Abusea) If child abuse or neglect is suspected it is MANDATORY that it be reported.b) Report abuse via Form 51A (available in the Social Service office and the ER). The completed

form goes to the Protective Service Unit at the Department of Social Service (DSS)c) Contact the Child Abuse Team upon suspicion of abuse. The team is comprised of a social

worker, lawyer, pediatrician, nurse, and psychiatric consultant. In some cases the hospitallawyer and social worker can file a Care and Protection Petition requesting temporary placementof the child, until investigation is completed.

d) Tell the ER or responsible attending after discussion with the fellow or senior surgical resident ofyour suspicion and intent to report.

e) Contact numbers: Cornell Campus: Child Abuse Center 746-6694 Columbia Campus: Contact ER for "on call" staff.

Va. GUIDELINES FOR THE PEDIATRIC SURGICAL WARDCORNELL CAMPUS, NEW YORK PRESBYTERIAN HOSPITAL

1. Orders:a) Portable X-rays: Physicians must call the Radiologist; a completed requisition must be left at the

nursing station.b) STAT orders:c) Speak DIRECTLY with the pts nurse.d) Routine: After the order is written, place the green magnet next to the pts name on the white

board at the nursing station. Nurse will check board for newly written orders.

2. D/C:a) Write prescriptions and place in front of chart.b) Review DC orders and prescriptions with the nurse.c) Multidisciplinary D/C planning q Thu at 1:15 on porch or nurse’s lounge.

3. Lab Tests:a) If ordered between 7:30 AM and 5 PM for the following day:

1. Request test by ordering in patient chart2. Write order on the IV board located at the clerk’s desk3. Clerk will fill out the lab slips and place on the IV board4. Pediatric IV Team to draw the blood the following morning

b) For test the next day, but ordered after 5:00 PM1. Request the test by ordering in the pt chart2. Write order on the IV board3. Fill out lab slips4. Stamp with patient name5. Mark tests6. Sign with MD code7. Attach lab slips to the IV board8. Pediatric IV Team will draw the blood

c) Pediatric IV Team does not draw blood culturesd) STAT labs must be drawn by the surgical resident.

4. IV Placement:a) Use EMLA cream when situation not STAT.b) Between 7:30 a.m. - 7:30 p.m. the Pediatric IV Team will insert IV’sc) Write order in the chartd) If the Pediatric IV Team is unable to obtain access, they will notify surgical housestaff.e) Between 7:30 p.m.-7:30 a.m. the surgeons are responsible for IV's.

5. Play Room and School:a) 10:30 a.m.-12:00 noon: Toddlers go to playroom; older kids go to school.b) 2:30 p.m.-4:00 p.m.: Older kids go to playroom.c) No MD visits to the playroom; it is a pain and stress-free environment.

6. Communication with the Pediatric Service The Pediatric ward senior resident (Bpr 12845) will page the chief Pediatric Surgical resident

at the completion of their morning rounds to discuss the surgical patients. If the chiefresident is scrubbed, then the intern will communicate with the Pediatric service withassistance from the attendings as needed. This will hopefully help to streamline thecommunication and eliminate intermittent paging throughout the day.

VI. EMERGENCY MANAGEMENT OF THE INFANT AND CHILD

1. Management of Respiratory Distress:a) Initial management of respiratory distress or arrest is to ventilate the child using a mask, AMBU

bag, and 100% oxygen. Most airway obstruction can be overcome with positive pressureventilation.

b) Remove any secretions or other material from the patient's mouth, nose and pharynx.c) Have a proper mask fit and a hard surface behind the patient's head.d) Make certain that the tongue is not occluding the airway, either by placing an appropriate sized

oral airway and/or by holding the mandible forward.e) Observe and listen to the chest to confirm adequate ventilation.f) Watch your maximum pressures on the "pop-off" valve as a pneumothorax may be produced in

infants and children.

2. Guidelines for Endotracheal Intubation:a) Call for help if you are not comfortable with pediatric intubation.b) Use a facemask, airway, and AMBU bag until the resuscitation is well under control. Be ready

before you attempt intubation - there is usually no rush; ventilation and oxygenation come first.It is OK to continue with effective AMBU ventilation to wait for experienced help withintubation. Ideally, you should have available suction, suction catheters (12 or 14 Fr.), propertype of bag/valve, selection of ETT, stylet, McGill forceps, airway manometer, benzoin, tape,and medications.

• Atropine 0.02 mg/kg• Succinylcholine 1-2 mg/kg• Brevital 1 mg/kg or thiopental 4 mg/kg

c) Correct Head Position - "Sniffing Position" is best for both ventilation with bag-and-mask andfor intubation - excluding a history of trauma. Otherwise, flexion of the neck and extension ofthe head is quite helpful. If there is a history of trauma, do NOT flex/extend the neck untilthe C-spine can be cleared. Use mask/AMBU bag until experienced help with "in-line"intubation can be obtained.

d) Laryngoscope:• If patient is less than 2 yrs old, use a straight blade (Miller) due to anterior location

of larynx and floppy, curved epiglottis: Size 0 (premature); 1 (infant); 2 (child).• Age 2-5 yrs, either a Miller or a MacIntosh blade.• Age >5 years, use curved MacIntosh blade.• In general, a baby's larynx is more anterior than adults, and not as far away as you

may expect. Lift up the epiglottis with the tip of the laryngoscope blade so thatyou can see the entire laryngeal vault. Do not traumatize the epiglottis. Introducethe endotracheal tube via the right corner of the mouth along the blade (but notthrough the groove of the blade) to provide an unobscured view. Note belowwhere to place the ET tube with respect to the cords.

3. Endotracheal tube:a) Cuffed tubes are not used in children, nor are tight fits desired. The correct fit should allow a

leak at 20 mm Hg inspiratory pressure. The narrowest part of the airway in a child is thesubglottis.

b) The distance from the glottis to the carina in infants is approximately 4 cm.c) "Blind" nasotracheal intubation is usually not done in older children due to the risk of bleeding

from large adenoids.d) Sizes: "Rule of Thumb" is ETT size = (Age in years + 16) / 4. Often one must use tubes 1/2 mm

smaller in ID than that calculated by this rule. Another rapid rule is that the size of the patient'slittle finger is equal to the size of the tracheal lumen.

Age ETTa) Preemie 2.5 - 3.0 mm IDb) Newborn 3.5 mmc) 13 months 4.0 mmd) 2 years 4.5 mme) > 2 years 4.5 plus age (yrs)/4 mm IDf) French size Age (yrs) plus 18

g) Tube length (cm) = 12 plus age (yrs) / 2

e) SEE THE CORDS. Don't pass the endotracheal tube blindly since this may result in esophagealor pyriform sinus perforation. Cricoid pressure may assist in cord visualization and preventionof aspiration

f) DO NOT FORCE THE TUBE - Use a smaller one if necessary. Do not push the tube too far toavoid right main stem intubation. The double line on a standard ETT is a rough guideline.

g) Examine the chest - look and listen as you ventilate. The best way to learn intubation is in theoperating room under the eye of a skilled anesthesiologist prior to an elective operation.

4. After Intubation:a) Ventilate with 100% oxygen and suction via the tube.

b) Apply benzoin to the face and tape the tube securely. The use of pink tape is stronglydiscouraged as the adhesiveness loosens in a moist environment.

c) Obtain a chest X-ray to confirm appropriate position of the tube.d) Trim the outer length of tube to an appropriate length to prevent excessive dead space.

5. Typical Ventilator Settings:a) Tidal volume 7-10 cc/kgb) PIP / PEEP 25/5 cm H2Oc) Rate=30 (titrate)d) FIO2 = 1.0 (titrate). Adjust to keep PaO2 60-80 mm (retrolental fibroplasia risk in preemies).e) PEEP at least 2-4 cm H2O ("physiologic PEEP").f) Always humidify and heat gases.

6. Emergency Drugsa) Hypoglycemia:

· 1 cc/kg of 25-50% dextrose IV push over 5 minutes b) Hypokalemia:

· Maintenance requirement of 2 mEq/kg/day· For emergency replacement: a) 1/2 mEq potassium/kg/hr x 2 hrs in IV via pump. b) Repeat serum potassium after 2-3 hrs.

c) Hyperkalemia:· Slow rate of increase, no EKG changes, K<7: Kayexalate p.o. or enema 1 gm/kg (in

sorbitol or D10W):

· Rapid rate of increase, + EKG changes, K>7 (urgent):a) Na bicarbonate 2mEq/kg IV pushb) Glucose 50% 1cc/kg IV pushc) Ca gluconate 10% 0.5cc/kg IV pushd) Insulin 0.5u/kg IV while infusing D20W

d) Metabolic acidosis (treat a base deficit greater than 5):· mEq of NaHCO3 base deficit x weight in kilograms x 0.4.· Correct half of the deficit with NaHCO3 over 8-12 hours by adding 1/2 mEq NaHCO3 to

each cc of IV fluid.

7. Supraventricular tachycardiaa) Stable: Adenosine 0.1 mg/kg IVb) Unstable: Cardioversion 0.5 - 1.0 joules/kgc) Consider digitalis once converted

8. Ventricular arrhythmias:a) Lidocaine 1 mg/kg IVP or per ET tube; then continuous infusion 20-40 micrograms/kg/min.

Quick guideline: Lidocaine 1% = 1cc / kg

9. Cardiac Arrest: Rule of One's: Medication Dose Frequency

a) NaHCO3 1 cc/kg/IV 5 minutes

b) Atropine 0.01 mg/kg 20 minutes IM/IV/Intratracheal

c) Epinephrine 1st dose - 1:10,000 dilution 5 minutes 0.1cc/kg/IV/intratracheal2nd dose –1:1000 dilution 0.1cc/kg/IV/intratracheal

d) Isoproterenol 0.1mcg/kg/min Infusion(range 0.1-1.0mcg/kg/min)

e) CaChloride 0.1-0.3cc/kg =10-30 mg/kg 10 minuteselemental Ca IV (10% soln.)

f) CaGluconate 1 cc/kg = 100mg/kg (10% solution)

g) Chloride 0.33cc/kg = 30mg/kg

h) Defibrillation 2 J / kg PRN May doubled if ineffective and repeated X 2

13. Normal Ht / Wt for Children (@50th Percentile):

AGE BOYS GIRLSYEARS Height Weight Height Weight

ft in cm lb kg ft in cm Lb kgBirth 1 8 45.7 7.5 3.4 1 8 50.8 7.5 3.4

6 months 2 2 66 17 7.7 2 2 66 16 7.21 year 2 5 73.6 21 9.5 2 5 73.6 20 9.1

2 2 9 93.8 26 11.8 2 9 83.8 25 11.33 3 0 91.4 31 14.0 3 0 91.4 30 13.64 3 3 99 34 15.4 3 3 99 33 15.05 3 6 106.0 39 17.7 3 5 104.1 38 17.26 3 9 114.2 46 20.9 3 8 111.7 45 20.47 3 11 119.3 51 23.1 3 11 119.3 49 22.28 4 2 127.0 57 25.9 4 2 127.0 56 25.49 4 4 132.0 63 28.6 4 4 132.0 62 28.1

10 4 6 137.1 69 31.3 4 6 137.1 69 31.311 4 8 142.2 77 34.9 4 8 142.2 77 34.912 4 10 147.3 83 37.7 4 10 147.3 86 39.013 5 0 152.4 92 41.7 5 0 152.4 98 45.514 5 2 157.5 107 48.5 5 2 157.5 107 48.515 5 4 162.6 116 52.6 5 3 169.0 115 52.216 5 6 167.6 128 58.0 5 4 162.6 118 53.517 5 7 170.2 134 60.8 5 4 162.6 118 53.5

14. Normal Vital Signs by Age:

Weight Heart rate Resp rate BP (Sys)Age (kg) (range/min) (range/min) (mm HG)Preemie 1 135-145 55-65 50±10Newborn 2-3 125-135 35-45 60±101 month 4 120-130 25-30 80±106months 7 120-130 25-30 90±251 year 10 110-120 20-24 96±302-3 yr 12-14 100-110 16-22 99±254-5 yr 16-18 95-105 14-20 99±206-8 yr 20-26 90-100 12-20 105±1310-12 yr 32-42 85-90 12-20 112±19>14 yr >50 75-85 10-14 120±20

VII. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD

1. Fluid Management:a) NPO Orders:

• Patients should be awakened and offered fluids the night prior to surgery.(a) <2 Yrs: NPO for solids and milk/formula at midnight, offer clear liquids containing

glucose up to 4 hours prior to surgery. *(b) >2 and older: NPO for solids and milk at 8 hours, offer clear liquids up to 6 hours

prior to surgery.* Clear liquids include breast milk unless a bowel prep is done.

b) Indications for preoperative intravenous fluids:• Patients with fever, vomiting or diarrhea, or those undergoing bowel preparation should

have IVF the night prior to surgery. If surgery has been delayed more than 6 hours ininfants (0-1 years of age) and more than 8 hours in children, an IV should be started togive replacement fluids.

c) Maintenance fluids:• Newborn Day 1: 80cc/kg/d D10W

• Newborn Day 2: 100cc/kg/d D10 1/4 NS

• Older Children:a) 100 cc/kg/d or 4cc/kg/hr for first 10 kg body weightb) 50 cc/kg/d or 2cc/kg/hr for second 10 kgc) 20 cc/kg/d or 1cc/kg/hr for every kg remaining > 20kg

• Increase allowances for fever, bililights and prematurity Wt (Kg) cc/kg/Day Up to 10 100cc

10- 20 1,000cc + 50cc/kg for each kg > 10kg>20 1,500cc + 20cc/kg for each kg > 20kg

• Practical: D5 1/4 NS with 10mEq KC1/500cc is standard maintenance solution

2. Electrolytes:a) Na+ 2 - 5 mEq/kg/dayb) K+ 1 - 2.5 mEq/kg/day

3. Calories:a) Term neonate 100 - 120 kcal/kg/dayb) Preterm 120 - 130 kcal/kg/dayc) Very Low Birth Weight (< 1kg) > 150 kcal/kg/dayd) Expect weight gain of 20-30 g/day

4. Estimated blood volume:a) Newborn: 90cc/kgb) Child: 80cc/kg

c) Adult: 70cc/kgd) To estimate the volume of packed RBC's to raise HCT from A to B in a child:

• Volume = EBV x (HctB-HctA) = 80cc/kg x wt (kg) x HctB-HctA(1) HctPRBC 70

b) = 1.1 x wt x (HctB - HctA)

e) Rough rules of thumb for blood replacement:• 10cc/kg of packed RBC's - Raise Hct 3-4%• 1 unit/10 kg of platelets - Raise platelet count by 25,000• 10-15 ml/kg of FFP for coagulopathy• 1 unit/5kg of CRYO to replace Fibrinogen

f) Safe volumes to push empirically:• Packed RBC's 10cc/kg• Whole blood or 5% albumin 20cc/kg• SPA (25%) 4cc/kg (when approved by attending)

5. Deficit therapy:a) Gastric losses: D51/2NS + 20-40 mEq KCL per liter to replace measured lossb) Distal G.I. losses: D5RL to replace measured lossesc) Third space losses: D5RL + 5% albumin, empiricallyd) Body Fluid Compositions: If in doubt, send fluid for electrolytes

Source Na K Cl HCO3 pH Osm Gastric 70 10-15 120 0 1 300 Pancreas 140 5 50-100 100 9 300 Bile 130 5 100 40 8 300 Ileostomy 130 15-20 120 25-30 8 300 Diarrhea 50 35 40 50 Alk

6. Central Venous Linesa) Long-Term Central Venous Lines:

• Catheters:Single Lumen - Sizes: Cook, Broviac or Hickman 3.0, 4.0, 6.5, 9.0 Fr

Double Lumen - Sizes: Cook 5.0, 7.0, 9.0, 12.0 Fr

• Implantable Devices - 5 Fr, 6.6 Fr, 9.0 Fr• Placed in the OR under fluoroscopic guidance, usually with general anesthesia.• Cap the line with an injection port that is available in the O.R. If continuous IV

solution is not being given, instill heparin flush 10 u/cc to fill the catheter.

• Dress with Telfa & Tegaderm. Nursing staff to change Mon-Wed-Fri or as needed.Lines should be looped & taped securely to prevent inadvertent removal.

• If an implantable device is inserted, place a Huber (non-coring) right angle needle attached to extension tubing into the septum. Instill heparin flush (100 u/cc) to fill the tubing if not being used. If the device is to be used, the needle & tubing should be dressed & taped.

b) Broken or Leaking Catheter• This is considered an emergency & repair should be performed expeditiously before the

line is lost. If you have no experience with line repair, request assistance from someone who does.

• The size of the repair kit must match the size of the catheter in the patient. Ascertain the line size and type (single or double) from the label on the catheter or from the operative note. Kits are kept on each nursing unit and the Peds ER at the Columbia campus Hospital, and in Central Supply at Cornell.

• Clamp the line proximal to the break, prime the repair segment with saline flush.Squeeze the silicone glue into the barrel of a 3cc syringe and apply the blunt tip. Do Notsqueeze the glue into the needle until ready to use. Prep the line using alcohol & betadine & layon a sterile towel (use central line dressing kit). Cut with disposable scissors. Squeeze a

small amount of glue onto the metal piece of the repair segment and insert it into the proximal stump. Apply more glue and slide clear plastic sleeve over the repair site.

Inject as much glue as possible inside the sleeve. Gently try to flush the line with saline. If it flushes then follow with heparin flush. If resistant, stop. No further flushes should be attempted for 12-24 hrs. At that time tPA may be instilled if the line still cannot be flushed.

• After repair, lines should not be used for a minimum of 12 hrs, preferably 24 hrs. Stenting the repair with a tongue depressor may be helpful.

c) Line occlusion:• Make sure the clamp is open.• Inject 1-2 cc of tPA (1mg per 1 cc, from pharmacy) via 1cc syringe. If it is not possible

to instill anything into the line, then it is not reparable. If you use too much force, youwill blow a hole in the catheter, not necessarily outside the patient. Consult thefellow or attending for further instructions.

• If aspiration of clot is not possible in one hr, repeat the tPA injection and attempt aspiration.

• A volume of 0.1cc of 0.1 N HCL may be used only after consulting with the Chief Resident. This is most useful when an occlusion is secondary to a TPN precipitation.

d) Catheter insertion site infection:• Local infection of a CVL is defined as purulent drainage from the exit site. Tenderness

or erythema along the catheter tunnel also suggests an infection.• Diagnosis: Clinical examination usually establishes the diagnosis. Cultures should be

obtained from the catheter site along with peripheral and central blood cultures fromeach lumen of the CVL. Drainage should always be sent for gram stain.

• Treatment: Local wound care

Empiric antibiotic coverage through the line before cultures are backSpecific antibiotic coverage when cultures available

• Indications for catheter removal:Continued local infection after 48 to 72 hrs of specific antibioticsDevelopment of systemic infection.Fungal infection.

e) Systemic catheter infections:

· Systemic catheter infection is defined as septicemia resulting from infection of a CVL.While the definition is straightforward, the diagnosis is often difficult to make. Frequently,children with CVL’s are neutropenic or have other maladies that put them at high risk forother infections. Distinguishing catheter-related sepsis from infection elsewhere can bedifficult.1) Diagnosis: Catheter-related sepsis is a diagnosis of exclusion. When a patient with a

CVL develops a fever, all other possible causes of sepsis should be ruled out before thediagnosis of catheter sepsis is made. Candida antigen may be helpful in cases ofpersistent fever with no obvious source.

2) Blood Cultures: When catheter sepsis is suspected in a patient, at least one, andpreferably two, blood cultures should be obtained from venipuncture and from eachlumen of the line. The diagnosis of CVL infection is made if peripheral cultures arenegative and the line culture is positive.

- Make certain the aspiration site is thoroughly disinfected beforetaking cultures.

- Draw blood cultures (min. 1 cc/bottle) through CVL and one or twoperipheral sites.

- If any drainage is present at the catheter site, it should be culturedand sent for gram stain.

Indicate the exact site from which cultures were obtained on the laboratoryrequisition.

Broad spectrum antibiotics are begun after the workup is completed. Antibiotic coverage is maintained per Infectious Disease.

f) Indications for catheter removal:• Ongoing sepsis despite appropriate antibiotic coverage for 2-4 days.• Continuously positive blood cultures after 2-4 days of antibiotic coverage.• Positive culture for Candida or other fungus• Hypotension and /or pressor support.• Broviac or Hickman catheters should be removed by the Surgical service, often in the

OR. If there is resistance during the removal of a tunneled line, do not continue to pull theline as inadvertent line fracture may occur. Contact the Chief Resident as a cutdown at thesite of catheter entry may be required. An operative note is dictated with the diagnosis

prompting CVL placement as the pre- and postoperative diagnosis.

g) Implantable Port Infections:If you suspect a patient with an implantable port has a pocket abscess, culture by sterileaspiration from the pocket. NEVER I & D the area over an implantable port. Consultthe senior resident if there is any question.

8. Gastrostomy:

a) Purpose: 1. Nutritional supplementation

• Failure to thrive- wide variety of causes• Dysphagia; anatomical problems: bowel anomalies, esophogeal atresia,

• Glycogen Storage Diseases- to maintain serum glucose level

2. Medication Administration for HIV patients• Medications are extremely distasteful• Allows strict adherence to the medication regimen which has a direct bearing on course

of disease

3. Decompression postoperative GI anomalies; anti-reflux surgery; Often done during majorabdominal procedures, particularly in infants.

b) Rationale for G-tube use:

• Decompresses GI tract, especially when a lengthy ileus is expected.

• Provides a SAFE means of initially feeding the infant.

• After esophageal atresia repair, can serve as a portal for passing dilators in case of subsequent stricture.

• Is advantageous over a NG tube as:

• Babies are nose-breathers.

• One can use only a #10 French NG tube as opposed to a #12-14 Malecot in babies.

• Gastrostomy avoids erosions of the nose, nasopharynx, and esophagus occasionallyseen with NG tubes.

c) Use a Malecot tube instead of a Foley catheter for a gastrostomy tube:

• Foley has a smaller working diameter.

• Foley dependent on a balloon that can break, or, if it passes to the pylorus, can obstructthe stomach.

• There have been case reports of the Foley catheter tip causing pressure necrosis and perforation of the posterior wall of the stomach in neonates.

d) A separate stab wound from the abdominal incision is used to minimize the chance of woundinfection and is a set-up for a gastric fistula. Always suture the tube to the skin.

e) If a MIC tube is used, the tube is quite secure at the exit site. However, taping the tube to theabdominal wall is also recommended. If a Malecot / Foley is used, the tube must be securedstarting at the exit site. Pink tape is quite adherent and recommended if the patient is notLATEX ALLERGIC. See a suggested taping method below. A gastrostomy tube that comesout prior to POD 10 may be impossible to reinsert safely because a tract may not have formed.Therefore, the initial dressing should be left intact for 14 postoperative days.

f) Methods of Placement:• Open Gastrostomy (Stamm)- primary or adjunct to another open procedure• Percutaneous endoscopic gastrostomy (PEG) button in OR under general anesthesia• Laparoscopic PEG button placement

g) Appliances:• Traditional Malecot or Pezzar (mushroom) – used most commonly in infants, especially

if decompression is important. Open placement, initially sutured in place.

• Permanent Button (Microvasive)• Balloon style gastrostomy tube (MIC)• Balloon style button (MicKey, AMT, Microvasive)• Foley catheter- to be used only as a temporary measure

h) Postoperative Management• PEG for nutritional support

ß NG (if present) to suctionß NPO/NPG for 18-24 hrs. Button to gravity until following amß In am, remove “decompression” tube and cap button.ß If the abdomen remains soft for several hours, initiate Pedialyte at a low rate for

several hours. If tolerated, change to an appropriate enteral formula, advancing toward the nutritional goal. (Pediatric GI / Nutrition can help determine).

ß Children who can eat safely po may gradually resume oral feedsß Home care teaching is provided by the Pediatric Surgery PNP and / or floor nurses.ß Home care supplies and nursing support is arranged by the Social Worker.

Anticipate discharge 2nd post op morning.

• PEG for medication administrationß Resume oral feedings POD 1 and discharge when toleratedß Use of button for medications is initiated in 2 weeks as an outpatient.ß Home nursing support arranged before discharge by PNP

i) Changing G-tubes & Buttons & other GT Problems.1. Early, inadvertant removal requires consultation with Ped Surg Fellow or Attending before attempting replacement. (<4 weeks open, <8 weeks PEG, <12 weeks for immunocompromised)

2. Prompt response to calls about dislodged GT's is critica as stoma tracts may closewithin hours.

3. If called to Peds ER or inpatient floor to replace button or g tube that has come out:4. For Columbia campus M-F daytime: refer to the Pediatric Surgery PNP. All other calls

go to the senior resident.

5. If the family brings a spare button or tube.use it. If not, replace with largest size Foley you can safely get in. Non-traumatic replacement in a mature site does not require radiologic confirmation.

6. If you can not get anything into the stoma, consult the Ped Surg Fellow or Attending promptly.

7. All non emergency calls for other GT problems at Columbia such as leaking, site infections, skin problems etc., may be referred to the Pediatric Surgery PNP.

j) If the gastrostomy tube falls out early (e.g. before POD14):• The senior resident or fellow should take the infant to the X-ray Department

immediately. Remember that this tract can close completely in six hours; this must be done expeditiously. The g-tube can be repositioned under fluoroscopy.

• One can gently probe the tract with a small lacrimal duct probe to determine if stillpatent.

• Lubricate the abdominal opening and GT well.• Gently pass a smaller diameter Foley catheter rather than the previous tube. DO NOT

reinsert the same tube using a hemostat!• Once the tube is in the stomach, inflate the balloon and pull it back snugly up against the

abdominal wall and stabilize securely with tape. Then confirm the tube's intragastric position using aqueous contrast, not barium.

• If any resistance is met, STOP! You will thus avoid separating the stomach from the abdominal wall. If one cannot successfully replace the tube, it is necessary to return the child to the operating room emergently. If there is ANY question of tube placement, the patient should return to the OR.

k) Gastrostomy TubeExcessive granulation tissue or redundant gastric mucosa via the tract site can be cauterizedwith silver nitrate sticks. Protect the surrounding skin with A&D ointment or vaseline. Skinirritation around a leaking gastrostomy site can be treated with Maalox applied topically q4-6h, and the tube can be stabilized by passing it through a plastic nipple.

9. Tracheostomy:a) A tracheostomy must not be an emergency bedside procedure in an infant or child.

Tracheostomy tubes are placed in the operating room as a sterile procedure, over a bronchoscopeor an endotracheal tube. Following the placement of two prolene stay sutures, the trachea isopened longitudinally over the second cartilaginous ring. The stay sutures are labeled R and Land taped to the anterior chest wall to facilitate tube replacement, should the tube dislodgeduring the first postoperative week.

b) Cuffed tubes are rarely used because the cuff can cause serious damage to the trachea, resultingin subglottic stenosis

c) If a child with a new tracheostomy develops respiratory distress, only a moment should be spentsuctioning through the tube. If suctioning does not relieve the problem immediately, the tubeshould be immediately extracted, assuming that it has become dislodged. Pull up on the rightand left stay sutures from the OR and insert an endotracheal tube. Another tracheostomy tube oran oxygen carrying catheter can be reinserted more leisurely once the airway has been re-established.

d) Maintenance of HIGH HUMIDITY is essential, as it prevents crusting and plugging. The airwayof an infant is so small that retained secretions will quickly lead to airway obstruction and/orpulmonary collapse if good chest physical therapy and suctioning is not done night and day. Inaddition, a duplicate tracheostomy tube as well as an appropriate sized endotracheal tube shouldalways be at the bedside.

10. Chest tubes:a) Site:

• For pneumothorax, a chest tube should be placed in the anterior or anterolateral aspect ofthe chest wall.

• For pleural effusion or hemothorax, the tube should be placed posterolaterally, in the dependent position for drainage

b) Preferred sites of placement are:• Fifth to seventh intercostal space in the midaxillary line.• Third intercostal space at the lateral border of the pectoralis major muscle.• Fourth intercostal space in the anterior axillary line.• Second intercostal space in the midclavicular line, lateral to the sternal border. Avoid

this site in infants due to large thymus• Watch out for the breast bud

c) Chest Tube Sizes:• Straight, plastic intercostal catheters (e.g. Argyle chest tubes) are the best type to place

either on the ward or at operation to direct them into a specific area of the thoraciccavity.

• For an infant, a size 12 French tube is usually used. Larger tubes come in increments of4 French (e.g., 16, 20, 24, 28 Fr).

d) Insertion Technique:• The site is prepped, draped and locally anesthetized with 1% Xylocaine.• Estimate the proper intrathoracic length of the tube and mark the tube.• A small skin incision is made at a selected site over the ribs.• A curved hemostat is used to tunnel superiorly and subcutaneously over the next higher

rib and into the pleural cavity - the hemostat is then spread to enlarge the opening. TROCARS are to be avoided. It is important to displace the site of entry from the skin margin by tunneling so that pneumothorax will not recur when the chest tube is

removed, especially in babies with small amounts of subcutaneous tissue.• Introduce the tube into the chest cavity and make certain that all sideholes are

intrathoracic. A good trick in small babies is simply to cut off the distal end of the chest

tube. Connect the tube to Pleurovac suction; the amount to be determined by the indication for the tube and the size of the child.

e) Chest Tube Removal:• If there is no air leak, the tube is usually placed to water-seal and a CXR obtained.• Removal is performed with the tube clamped at the skin level and a Vaseline occlusive

dressing applied as the tube is removed. If the child is cooperative, the tube can be removed either at end inspiration or with a Valsalva maneuver. For younger children,

pull the tube while the child cries. A repeat chest X-ray is then obtained. The entry site usually seals within hours.

• Pneumothorax may occur in ventilated infants with respiratory distress syndrome. If a chest tube is required, leave instructions to "call for respiratory deterioration", as a pneumothorax may occur on the contralateral side.

f) Clotted Chest Tube Care:• Using sterile technique, open the chest tube at the connection and see if the clot can be

manually removed with a cotton applicator. Use a twirling motion to keep the clotintact. Additionally, a Fogarty catheter can be sterilely inserted and the clot removed similar to

the performance of a thrombectomy.• Check with the attending to see if they prefer tube replacement vs. thrombolysis at this

point. If manually unsuccessful, tPA can be used. Prepare the solution using 80,000 units TPA in 50cc NS. Use 60cc syringe with a 25-gauge needle. Prep 5cm

longitudinal area of connector tubing (not chest tube itself) with Betadine. Penetrate tubingwith needle at a very acute angle to make sure that an adequate tunnel through the tube willbe formed when the needle is removed. Once tPA is injected, withdraw needle and coverthe puncture site with Tegaderm. Keep tubing upright with respect to patient, but notclamped; to make sure that gravity forces the tPA through the tube. Leave in for twohours then resume suction. Repeat up to two additional times daily if necessary.

11. Nasogastric tubes:a) Nasogastric tubes are used for gastrointestinal decompression and also for gavage feedings,

particularly in neonates.b) Decompression: Use one of the small pediatric sump tubes (Salem or Replogle 10 Fr). The

Replogle tube is preferred in infants because the two holes are at the end of the tube. The airvent on the sump tube will reduce the likelihood of occlusion of the tube - a commoncomplication in small suction tubes. Check position daily, as these are easily carried into theduodenum.

c) Change the tube if it is not functioning properly. With an infant in urgent need ofgastrointestinal decompression, a large red rubber catheter can be passed through the mouth asan effective means of aspirating gastric contents.

d) Nasogastric tubes should never be clamped since the infant may vomit and aspirate around them.e) If high output is noted, check KUB and pH to see if tip of NGT is in duodenum.f) Gavage feedings in premature and newborn infants are indicated if the baby lacks a gag, is weak

from prematurity, or has a rapid respiratory rate. For feeding a newborn use a DAVOL infantfeeding tube. (Preemie-size 5 Fr; Full Term-size 8 Fr)

g) Tube placement is checked by auscultation of the stomach while injecting a small amount of airand then aspirating back into the syringe attached to the tube.

h) A measured amount of fluid is poured into the syringe and passed by gravity.i) The tube may be removed between feedings if there is evidence of nasal or oropharyngeal

irritation.

12. Tube feedings in older infants:a) When a feeding tube is to be used in an infant for continuous slow delivery of formula, one can

use either type of enteral feeding tube (8-10Fr): Entriflex or Corflo NG (Corpak).b) When gastroesophageal reflux is a problem, the tube should be advanced into the third position

of the duodenum or upper jejunum, and the patient should be fed in the upright position.c) The Nutritional Support Service also has appropriate sized Dobbhoff, soft Keofeed tube or

Entriflex feeding tubes available (6-8 Fr). NJ placement is by pH guidance or interventionalradiology.

13. Infection/Antibiotic/Bowel Prep:a) Principles of antibiotic use:

• Obtain cultures before starting antibiotics.• Monitor serum levels of aminoglycosides (pre- and post- dose) and adjust accordingly.• Alter antibiotic regimen as dictated by cultures.• Avoid overuse of broad-spectrum drugs to avoid selecting out resistant strains.• Make appropriate use of Infectious Disease consultants.

14. Prophylactic Antibiotics:a) Newborns are relatively immunodeficient and hence, prophylactic antibiotics are used for all

major surgical procedures, whether clean or not. The usual choice is Ampicillin(150mg/kg/dose) + gentamicin (2.5mg/kg/dose) with appropriate dosing intervals.

b) See Appendix 8 for the guidelines on prophylactic antibiotic coverage for children withcongenital heart disease.

15. Bowel Preparation:a) Elective bowel surgery is commonly managed with preoperative mechanical bowel preparation

(Golytely), oral administration of erythromycin base 50!mg/kg + neomycin 50 mg/kg day dividedq2-3 hours x 3 doses, and perioperative administration of parenteral antibiotics. Check with theattending surgeon to verify their preference.

b) Golytely: The product is an isotonic solution of polyethylene glycol and electrolytes. It containshigh molecular weight polyethylene glycol which is not absorbed. Golytely is used for coloncleaning preoperatively. The entire infusion of Golytely must be completed before midnight.

• In comparison to conventional colon cleaning methods (magnesium citrate and clearliquid diet), Golytely is faster and more complete. Colon evacuation can be accomplished in as

little as four hours. Because it is isotonic, patients do not exhibit the fluid and electrolyte changes associated with magnesium citrate. If the rectal effluent is not “clear” in 4-6 hours, the same Golytely dose can be repeated. If the effluent is still not clear, alert the Chief Resident for assistance.

• Best results are obtained when the solution is consumed quickly (every 10 minutes),rather than sipped slowly. Usually, this requires insertion of a nasogastric tube for all age

groups. A soft feeding tube is preferable for patient comfort. May give Reglan to help empty stomach at start of Golytely infusion.

• After Golytely, give Neomycin and Erythromycin bases: Dose: 50mg/kg/day q2-3˚ x 3 doses PO/PG. Give after Golytely prep.

• Follow with normal saline enemas per rectum and/or per stoma until clear.• Neomycin 0.5% enemas after NS enema per rectum and per stoma.• Diet: Clears until midnight, then NPO (Clears DOES NOT include breast milk)

c) All children weighing <10 kg should receive maintenance IVF during bowel preparation.

Weight (approx. surface area) Golytely Dosage Total Dose ('up to')7.6-10kg 0.5 M2 80 ml every 10 minutes 1,100 ml

10-20kg 0.75 M2 100 ml every 10 minutes 1,600 ml

20-30kg 1.0 M2 140 ml every 10 minutes 2,200 ml

30-40kg 1.3 M2 180 ml every 10 minutes 2,900 ml

40-50kg 1.5 M2 200 ml every 10 minutes 3,200 ml>50kg 1.5M2 240 ml every 10 minutes 4,000 ml

Note: For those children <7.5kg, follow the protocol:

Golytely‚ Dosage Weight Dose Total Dose £ 7.5 kg 12.5 mL/kg/hr x 4 hrs 50 mL/kg =_________mL

Infuse continuously via an enteral infusion pump over 4 hr.

16. Apnea & Bradycardia Monitoring:Expreemie infants (<37 wks) up to 60 wks postconceptual age require overnight apnea andbradycardia monitoring for recovery from anesthesia with narcotics.

VIII. COMMON PEDIATRIC SURGICAL PROBLEMS

This section focuses on the pediatric surgical problems commonly seen in the emergency ward setting.A complete diagnosis and therapeutic review of each entity is not attempted, but rather pertinent pointsto facilitate initial patient management are stressed.1. Appendicitis:

a) The most frequent surgical problem in the emergency ward will be to evaluate "abdominal pain,rule out appendicitis". Appendicitis is by far the most common abdominal surgical problem inchildhood. If an appendectomy is appropriately performed soon after the onset of symptoms, thechild is usually discharged from the hospital within two days.

b) Guidelines:• Abdominal pain begins in the periumbilical area and usually (but not invariably) shifts to

the right lower quadrant. Remember that the peritoneal cavity is six-sided and localized pain will reflect where the appendix or its inflammatory fluid resides (e.g. retrocecal or pelvic appendix). Perforation commonly occurs at approximately 36 hours (± 10 hours) after the pain begins.

• Abdominal pain usually PRECEDES vomiting.• Appendicitis is at times accompanied by anorexia, nausea, and vomiting, but these are

not discriminating signs. Diarrhea is common with gastroenteritis but can also be due to irritation of the rectum by pus, abscess or phlegmon. Diarrhea is therefore not aexclusion criteria for appendicitis.

• Consistent, localized point tenderness is the cardinal reliable sign of appendicitis, whereas other physical findings tend to be variable.

• Fever and leukocytosis tend to be minimal in early appendicitis.• Rectal examination should be done in all cases of abdominal pain of unclear etiology

since this may be the only way to detect the tenderness associated with the retrocecal appendix, or to feel a pelvic mass, phlegmon, or abscess. Rectal exam by the

Emergency Room physician is not sufficient.• For suspected GYN pathology in sexually-active young women, a pelvic exam should be

done by the most senior surgical resident available with a chaperone.• A calcified fecalith on KUB is strong evidence for appendicitis, but is found in only 10-

15% of the cases. If a fecalith is present, always err on the side of early operation.Neither a KUB nor a CT scan is needed if the history and physical examination strongly suggest

appendicitis.• In the child less than 2 years of age, the appendix is usually perforated by the time the

infant is brought to the emergency ward. Fortunately, appendicitis in this age group is infrequent (approximately 2% of all cases).

• An abdominal CT scan may be useful in cases where there is an equivocal history and physical exam and further information is needed in order to establish a diagnosis. A CT scan is not a substitute for an accurate history and physical or a timely response. Few CT's should be needed.

c) Antibiotics:• Traditionally, appendicitis has been managed with Cefoxitin (30 mg/kg) preoperatively

and for 24 hours postoperatively (for cases without perforation) or with broad-spectrum, antibiotics for 5-10 days (in cases with perforation).

d) Perforated Appendicitis Protocol

• Administer fluids, control hyperthermia, and administer broad-spectrum antibiotictherapy (ie. Ampicillin 50 mg/kg/dose Q 6 hrs , Gentamicin 2.5 mg/kg/dose Q 8hrs and Flagyl

15mg/kg as loading dose followed by 7.5 mg/kg/dose Q 6hrs). Use Gentamicin and Clindamycin for PCN allergy.)

• Explore peritoneal cavity via right lower quadrant incision or laparoscopically. Perform appendectomy in all cases. Interval appendectomy in 6-8 weeks may be chosen plan in patients presenting late in their course (ie. > 5 days of symptoms).

• If tolerating full PO diet by Day 5 then switch to PO antibiotics (ie. Bactrim and Flagyl) for additional 5 days of antibiotic therapy; the child may be discharged once on PO therapy and afebrile for 24 hours.

2. Pyloric Stenosis:a) Pyloric stenosis is extremely rare in the first week of life. It usually occurs in the first 3-6 weeks

of life.b) If the pyloric olive can be felt, no further diagnostic tests are necessary. Give the infant a

pacifier to suck or a small amount of Pedialyte, because the olive is impossible to feel if thepatient is crying. Be patient. Re-examine.

• Elevate the baby's feet to relax the abdominal wall and palpate over the spine at themidline. The olive can be palpated by rocking it superiorly and inferiorly.

• If the story is good, but a mass is not palpable, an ultrasound is a good diagnostic test inexperienced hands. Infants referred from other hospitals will often come with a barium study that may reveal a typical "string" or "double track" sign. If pyloric stenosis is not the cause of vomiting in this scenario, gastroesophageal reflux should be considered. All outside films need to be reviewed by the attending radiologists here! If inadequate, repeat studies.

• A clinical assessment of the patient's hydration should be made, and serum electrolytes should be checked immediately upon admission to rule out a serious hypokalemic hypochloremic metabolic alkalosis. This MUST be corrected (so CL >90 and CO2

<30) with boluses of intravenous Normal Saline until urine output is established. Then IVFcan be changed to D5 0.5 NS with 20 meq KCl at 1-1.5 X maintenance prior to elective

pyloromyotomy. Urine volume and specific gravity should be measured to follow the status. Electrolytes must be normal prior to general anethesia and surgical correction.

c) Postoperative management:• Diluted formula or sugar water can usually begin 4-6 hours postoperatively. Infants

must be fed initially under nursing supervision. Parents should be informed that the baby mayvomit postoperatively as part of the normal postoperative course.

d) Postoperative pyloric regimen (to be determined by attending)Sample regimen below:

NPO for 6 hrs15cc Pedialyte PO; if no vomiting then in 2 hrs, start30 cc Pedialyte PO; if no vomiting then in 2 hrs, start30 cc 0.5 strength formula PO q 3 hrs x 2; if no vomiting, start45 cc 0.5 strength formula PO q 3 hrs x 2; if no vomiting, start45 cc full-strength formula PO q 3 hrs x 2; if no vomiting, start60 cc full-strength formula PO q 3 hrs x 2; if no vomiting, start

75 cc full-strength formula PO q 3 hrs or ad-lib feeds.If vomiting occurs, retry previous step.

• If the duodenum is inadvertently entered during the pyloromyotomy, the infant should remain on both nasogastric suction via the tube placed in the OR and intravenous antibiotics postoperatively for a minimum of 2 days.

3. Intussusception: An invagination of a portion of the intestine into the lumen of an immediatelyadjoining part.

a) The common age range is 4 months to 3 years with the highest incidence at age 8 months. If thepatient is younger or older, one should be suspicious of a lead point for the intussusception suchas a Meckel's diverticulum, or an intestinal polyp.

b) The typical triad of colicky abdominal pain, abdominal "sausage-like" mass, and currant jellystools is well known, but all these components are late findings and are not invariably present.The most common location is the ileocecal valve.

c) Diagnostic studies typically begin with plain films (3 views) of the abdomen. Air/stoolthroughout the colon rules out intussusception. If the films cannot rule out intussusception, thenan ultrasound is performed. This is followed by an air contrast enema that is diagnostic and inmost cases also therapeutic. This must be performed by one of the pediatric radiologists. Thefollowing guidelines must be observed:

• The fellow should see the patient and the usual preoperative preparations should bemade before any attempt at reduction is made. Place an IV, hydrate the patient and give one

dose of Cefoxitin in the Emergency Room. The patient must have a functioning IVin place at the time of the enema.

• Enema reduction should not be performed if the child is sick with peritoneal signs. This child should be fluid resuscitated, placed on intravenous antibiotics, have a nasogastric tube passed, and be taken to the O.R. expeditiously.

• Reduction is not considered successful unless there is free reflux of air or contrast intothe ileum. A repeat attempt can be made if the baby's condition will permit.

• The patient is always admitted for 24 hours observation after reduction. Keep NPO for the first 8 hours; then gradually advance the diet. Warn parents and staff that high temperatures can follow reduction. If symptoms recur, enema reduction should be performed again. Operation is mandatory if reduction cannot be accomplished. The recurrence rate after either enema reduction or surgical reduction is approximately 5%.

• Intussusception is known to occur postoperatively. For example, if a pursestring turn-inof too large a segment of cecal wall is performed during appendectomy, this can serve as a

lead point. A small bowel-to-small bowel intussusception can be particularly difficult to diagnose in the postoperative period after intra-abdominal procedures.

4. Incarcerated Inguinal Hernia:a) This condition is age-related occurring most often in infants during the first year of life. Most, if

not all, can be reduced manually, which obviates the need for emergency surgery.b) Reduction techniques:

• If sedation is necessary, obtain assistance from Emergency Room Attending for their conscious sedation protocol in the E.R. Occasionally, simply holding the baby in very steep Trendelenburg position reduces the hernia, due to the pull of the mesentery.

• Have an assistant hold the infant above the knees in a frog leg position to relax the abdominal wall.

• Fingers of one hand should attempt to fix the hernia while the other hand should pressthe incarcerated mass upward toward the canal. A considerable length of steady pressure (5

minutes) may be required to produce the desired reduction, so the surgeon should be in acomfortable position. Try to milk the bowel contents out of the incarcerated bowel, untilit "pops" back with the abdomen.

• Some hernias reduce easily, others require several attempts.c) If successful, the patient is always admitted, and the repair is performed electively within the

next 24-48 hours after the edema has resolved. The infant should have serial examinations torule out reincarceration.

d) Emergency surgical intervention is required if the hernia cannot be reduced, or if there ispostreduction evidence of persistent intestinal obstruction, or nonviable bowel. This is a rare,but possible event.

e) It is imperative to differentiate an incarcerated hernia from a hydrocoele of the cord. Hydrocoeleof the cord is often tense. Hydrocoele in the first year rarely requires operative intervention.

• One can often distinguish the end of the hydrocoele from the testes itself and can also appreciate the proximal end of the cord using transillumination. These infants can be

sent home and booked for elective surgery. A rectal exam can also be helpful to distinguish the two. One can palpate the inside of the abdominal wall at the level of the internal

ring, and if the wall and ring are easily palpable, an incarceration cannot be present. Ifunsure, compare palpation on the other side.

f) An unfortunate complication of an incarcerated hernia is hemorrhagic infarction of the testicle.Reduction will usually reinstitute blood flow to the testis.

g) Incarcerated inguinal hernias in girls invariably are sliding hernias containing ovary and tube. Ifasymptomatic, these can usually be repaired on a semi-elective basis. The blood supply to theovary is usually not impaired, and the vessels are small in comparison.

5. Unincarcerated hernias in premature and full-term infants:a) If consulted on an inpatient preemie with multiple problems, it can be repaired just prior to

discharge home.b) Babies < 60 weeks postconceptual age with a history of prematurity (gestational age < 38

wks at birth) must be admitted overnight after hernia repair for apnea monitoring.

6. Testicular Torsion:a) The peak age group for this condition is adolescent boys ages 12-18 with an annual incidence of

1/4,000 males below the age of 25. Torsion also can occur in the infant particularly in theundescended testis.

b) Major considerations:• Early operative intervention if diagnosis is suspected in orders to save the testicle (6 hour

golden-period).• The patient may reveal a high riding and swollen testicle.• The differential diagnosis includes primarily torsion of the appendix testis or

epididymitis.• Duplex US can usually assist in diagnosis.

c) Torsion of the appendix testis:• Symptoms are very similar to testicular torsion, but the child is often pre-teen.• Examination may reveal localization of the pain to the upper pole of the testis, and

transillumination may reveal the "blue dot" sign.

• Later presentation may reveal erythema, diffuse tenderness, and reactive hydrocele, making differentiation impossible. Testicular scan is often helpful, but may be misleading.

• If one is certain of diagnosis, this condition can be treated with analgesia and scrotal support. Symptoms usually subside after 5-12 days. If uncertain, err on the side of operation.

d) Epididymitis:• It is rare in children <14 years, except in association with mumps. If present in the

younger child without mumps, a urinary tract evaluation with IVP and VCUG, isessential to rule out ectopic ureter to vas, or other urologic conditions.

• Examination should include a rectal examination to rule out associated prostatitis, and urinalysis to rule out a urinary tract infection.

• Elevation of the testis sometimes gives relief with epididymitis, but usually not with torsion.

e) After a thorough, but expeditious evaluation, if any doubt exists, exploration should beperformed as a safe, practical and accurate method of diagnosis and treatment.

7. Foreign Bodies:a) The clinician must have a high index of suspicion and a very low threshold to recommend

endoscopic examination if there is any question of aspiration of a foreign body. Otherwise,excessive morbidity and mortality results. Foreign body problems occur most commonly in thetoddler age group, but may be seen in older children (or infants) as well.

b) Laryngeal foreign bodies:• A foreign body lodged in the oropharynx or glottis may warrant immediate attention to

clear the airway, the Heimlich maneuver, direct laryngoscopy, or bronchoscopy. If possible, a mask airway should be maintained and more controlled laryngoscopy performed in the operating room.

• If the patient is ventilating adequately when seen, no maneuvers should be performeduntil the patient is in the O.R. where conditions and equipment are ideal.

c) Tracheobronchial foreign bodies:• Less than 10% of foreign bodies are located above the carina. Most slip into the

bronchus with the majority located in the right main stem bronchus.• History alone may be sufficient to warrant admission and endoscopy, even in the

absence of physical and X-ray findings.• Plain chest X-ray will reveal the foreign body if it is radio-opaque. However, most

foreign bodies such as wood, plastic objects, peanuts, carrots, celery, or aluminum "pop-tops" are not radio-opaque and may only manifest as hyper- or hypo-inflation.

• Fluoroscopy can detect subtle mediastinal shifts during expiration and inspiration, but cannot necessarily pinpoint the site of the foreign body. A foreign body which totally obstructs the bronchus leads to slow lung collapse and slow mediastinal shift toward the side of the offending object. Partial occlusion of the lumen causes the more common

ball- valve effect, with subsequent air trapping and hyperinflation on the side of the lesion andmediastinal shift away from the side of the foreign body.

• The Storz bronchoscope or optical forceps greatly facilitate foreign body removal fromthe tracheobronchial tree. A complete set of foreign body instruments is available in theO.R. Of note, 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.

• The consequences of the neglected foreign body are quite serious and include atelectasis,recurrent pneumonia, and eventual destruction of the segment or lobe. Since there is minimal morbidity using the miniaturized bronchoscope, an aggressive approach is warranted. All patients should have a postoperative CXR.

d) Esophageal foreign bodies:• An esophageal foreign body can cause respiratory distress in small children. Objects

tend to lodge just below the cricopharyngeus muscle, usually behind the larynx or cervical trachea, thereby impinging or obstructing the airway.

• Diagnostic tests: -A CXR will locate the object if it is radio-opaque; a PA and lateral view is essential to determine position and the possibility of two superimposed objects. An abdominal film will determine if the object has slipped through to the stomach.-Barium swallow is occasionally required, but must be done by a skilled pediatric radiologist to avoid aspiration.

• Esophageal foreign bodies should be removed endoscopically, under general anesthesia.Sometimes a long laryngoscope will be sufficient to allow removal with either foreign body forceps or a Fogarty catheter. Otherwise, the endoscope will be required. After the object has been removed, the esophagoscope should be reintroduced to assess the status

of the esophageal wall at the site of impaction and manipulation. Passage of the rigid scopebeyond the site of impaction is generally not necessary and can increase the risk of esophageal perforation. All of these patients should have a postoperative CXR to check for pneumomediastinum.

• Special consideration should be given to batteries which can burn the esophagus and should be considered a caustic ingestion and require emergent endoscopy.

e) Gastrointestinal foreign bodies:• Once in the stomach, most ingested foreign bodies will safely traverse the

gastrointestinal tract, usually within 4-5 days. The problem sites are usually the pylorus, theligament of Treitz, and the ileocecal valve.

• If the object is radio-opaque, it can be followed with serial X-ray films. The stools should be checked for appearance of the object. The child should be followed for abdominal pain, vomiting, or blood in the stool.

• If after 4-6 weeks the object is still in the stomach, it can be retrieved by gastroscopy

9. Caustic Ingestions:a) All patients with suspected ingestion of a caustic material are admitted for esophagoscopy under

general anesthesia in 12-18 hr from injury. Although most patients with esophageal injury showburns of the oropharynx as well, this is not a completely reliable guideline.

b) Upper airway injury as well as face and hands should be assessed. Pharyngeal burns may be sosevere as to require tracheostomy. Symptoms can occur between 1-5h after ingestion.

c) Bases (alkali): Include NaOH, KOH, ammonia, electric dishwasher soaps, some denturecleaners, non-phosphate detergents, hair straighteners. These chemicals cause liquefactionnecrosis and may involve full thickness injury.

d) Acids: Includes toilet bowl cleaners, rust removers (HF1). These cause coagulation necrosis.e) Bleaches: Clorox (Na Hypochlorite) Experimentally causes superficial burns and ulceration, no

strictures.

f) DISK BATTERY ingestion: NaOH, KOH, Hg. Experimental: 1h-mucosa injured; 2-4h-muscularis; 8-12h-perforation.

g) PILLS: Can get stuck, adhere, prolonged contact. NSAIDS-hemorrhage and stricture. PotassiumChloride-strictures, hemorrhage, death. Quinidine-strictures.

h) Most ingestions occur at home in the kitchen. 85% of esophageal injuries are due to bases; acidstend to injure stomach. Caustic flakes or powder tend to stick and cause localized oropharynxand upper esophagus injury, lead to segmental strictures. Always think about battered childsyndrome, Munchausens by proxy (8%). 78% of poisonings occur with pt near parent. GetSocial Services involved.

i) Management:• DO NOT INDUCE VOMITING. The child should be kept NPO and placed on

intravenous fluids. Wash skin & eyes; wash out mouth with water or milk. Contraindicated: gastric lavage, vomiting.

• Barium swallow does not adequately determine if the esophagus has been injured, but should be obtained as a baseline sometime during the first 2-3 weeks after injury. If it shows atonic dilated esophagus, serious injury is implied.

• Esophagoscopy is done under general anesthesia within 24-48 hours of admission. Waita minimum of 15h for full extent of injury to be seen. Esophagoscopy is done only to the

point of injury and then stopped once the diagnosis is made. If the injury is severe, a gastrostomy may be indicated for feeding and a string can then be passed through the nares, down the esophagus, into the stomach, and out the gastrostomy. This string will insure a lumen in the strictured area and aid in future dilatations. Absence of oropharyngeal lesions does not exclude esophageal or gastric injury—between 8-20% of patients without oropharyngeal lesions have esophageal injury. Do not scope in

presence of severe burn with laryngeal edema, or if the patient has been on high dosesteroids. Circumferential burns are more likely to cause strictures. Repeatesophagoscopy is usually performed in 14 days, at which time a dilatation may beperformed if a stricture is present. These children demand close follow-up.

• PATHOLOGY: Acute necrosis 1-4d, granulation 4-15d, Scarring begins 21d-worst in second month. Bases cause liquefaction necrosis, solubilize proteins, saponify fat, and

are progressive. Acids cause coagulation necrosis, leaving supporting structures intact.j) Caustic Ingestion Protocol:

• Determine extent of injury-type, amount, brand, and container. Previous home orhospital Rx. Amount ingested is poor predictor. ? vomit. ? dilution.

• Establish the need for airway management and consider CXR and KUB if physical examsuggests.

• Symptoms: Airway-stridor, dyspnea, hoarseness. If oropharyngeal erythema is present, generally the child is admitted with a planned endoscopy to occur 12 to 14 hours post ingestion to study the lining. Digestive-odynophagia, drooling, refusal of food. Other: substernal chest pain, abd pain/rigidity

• There is a paucity of data to plan therapy. If 1st or 2nd degree moderate burns,hospitalize for 2 weeks with antibiotics (Ampicillin 50mg/kg/d divided q6h) and steroids

(Methylprednisolone 4mg/kg/d IV for 2-4d, then Prednisone 5mg/kg/d po and taper over6 weeks) to decrease infection, exuberant granulation tissue and scar formation. If theburn is severe, or full thickness, omit steroid administration. For full thickness burns,

hospitalize with antibiotics, but no steroids. To decrease scar formation, use for moderately severe lye burns only. NOT for severe burns. Full thickness burns: Hospitalize, antibiotics. No steroids. Consider esophageal silastic stent with distal

penrose to prevent GER or NGT for 6 weeks as sole treatment. Severe lye ingestion: cautiousNGT insertion to aspirate stomach: if alkaline that does not neutralize with irrigation,

laparotomy. If full thickness stomach injury gastrectomy/esophagectomy. Severe acid ingestion: may cause massive gastric injury. Pyloric stenosis is a late consequence.

• Esophageal stricture: develops in 7-15%. Long-term cancer risk.

10. Lower GI Bleed:

NEONATES: WORKUP Swallowed maternal blood Apt test Hemorrhagic disease of the newborn

Coags

Vit K deficiency NGT Thrombocytopenia from multiple causes

UGI

Anal fissure Anal exam NEC KUB, cross table lateral Malrotation and volvulus UGI Allergic colitis from formula Eosinophilia

INFANTS 3-18mo: WORKUP Anal fissure Anal exam Intussusception Colon study-air or contrast Intestinal volvulus KUB, lat Duplication Colonoscopy Ectopic gastric mucosa Meckel's scan for ectopic

gastric mucosa Gastroenteritis Coags

NGT

TODDLERS andPRESCHOOL:

WORKUP

Anal fissure Coags, NGT Rectal prolapse Anorectal exam Gastroenteritis KUB Meckel`s diverticulum Meckel`s scan Juvenile polyp Upper and lower endoscopy Trauma RBC scan

OLDER CHILDREN andTEENS 6-18y

WORKUP

Polypoid diseases Coags, KUB, NGT Ulcerative colitis Upper and lower endoscopy Hemorrhoids Anorectal exam Meckel`s Meckel`s scan

11. Chest Wall Deformities-Pectus Excavatum:

a) Background• Chest wall deformity with overgrowth of costal cartilages causing sternum to angle

posteriorly toward spine.• Male to female ration 3:1.• Etiology unknown but ~ 30% incidence in relatives.• Often apparent at birth but may increase in severity with growth.• Associated Anomalies: Most severe with Marfan’s Syndrome, scoliosis.• Indications for Repair: Severity, psychological & social issues.

b) Management• Preop: may have any of following: MRI, PFT’s, Echocardiogram• Intraop: Nuss Procedure or Video Assisted Repair

1. Small bilateral intercostal incisions.2. Telescope introduced slightly below right incision.3. Large clamp passed across mediastinum to opposite incision.4. Stainless steel bar custom shaped to desired contour passed across

mediastinum convex side up; bar then flipped to elevate chest wall.5. Bar secured with stabilizers & suture to remain in x 2-3 years.6. Epidural for pain management, Foley, IV antibiotics x ?? days

• Postop: Nuss Procedure or Video Assisted Repair1. CXR (AP, possible lateral) in Recovery Room to check size of pneumothorax &

bar position.2. Epidural for 2-3 days managed by the Pediatric Pain Team. Epidural warrants

PICU for 1 day then stepdown (ex. BH 8S Rm 808) for closeobservation. If epidural not successful, manage with IV narcotics.

3. Convert to IV or oral pain meds on 2nd or 3rd POD. Will need narcotic Rx for home pain management.

4. Foley stays until the epidural has been out 4-6 hours.5. Activity: Position important to prevent bar from slipping: When supine, may

have HOB elevated 30-40 degrees, may not roll on side, no twisting atwaist. Begin OOB to chair POD 1.

6. Clears, then advance diet as tolerated.7. Bar removed in 2-3 years as outpatient.

• Intraop: Open procedure (Ravitch or modification)1. Most widely used procedure until Nuss procedure developed.2. Transverse incision below the nipple line across central defect.3. Abnormal costal cartilages (~5-6) on each side removed leaving pericondrium.4. Sternum mobilized.5. Anterior wedge osteotomy done above highest cartilage resected.6. Substernal & subcutaneous drains placed.

• Postop: Open procedure (Ravitch or modification)1. CXR in Recovery Room to check for pneumothorax.2. Pain managed by Pediatric Pain Team with IV narcotics using PCA for ~2-3 days.3. Pain generally less intense & of shorter duration than with Nuss procedure.4. No Foley.

5. Clears to diet as tolerated.6. Drain removed on POD 37. Activity: Less restrictive. May bend & turn. Ambulate POD 1. Must wear

custom fitted protective vest prior to discharge then continue to wear 18-24 hours/day for ~4-8 weeks until cartilage regenerates.

IX. PROBLEMS OF THE SURGICAL NEONATE

1. Transportation of a Surgical Neonate:a) Outside referrals can be transported by a team from the referring hospital or by the Transport

Team in-house. The transportation of older children is provided by the Transport Team from thePICU. The Surgical Service is consulted prior to transfer of patients with surgical problems; weaccept all transfers of stable patients. It is important to give proper instructions for the safety ofthe transport. The Chief Resident on-call must be aware of and involved in all transportcommunication.

b) Basic information exchange:• Define the patient's specific problem(s).• Specific instructions regarding suctioning and positioning should be given to the

referring physician and the transport team, such as elevation of the head 45 degrees andsump drainage of the proximal esophageal pouch in a baby with esophageal atresia and

tracheoesophageal fistula.• It is essential that appropriate records and X-rays accompany the patient.• The anticipated time of arrival should be estimated.• The Chief Resident should be informed as soon as possible by the surgical resident. If

the referring doctor specifies that the patient is being referred to a particular staff surgeon,the patient should be admitted to his service. Otherwise, admit the baby to the staff surgeonof the day. The attending must be notified.

• The NICU should be informed of the baby's expected problems and needs.• All other physicians who will be participating in the baby's care (e.g. the neonatologist,

radiologist, and anesthesiologist) should be informed with regard to problems and the anticipated arrival time.

• If it seems likely that the baby will require urgent operative intervention, the operating room should be informed by the Chief Resident.

2. Preoperative preparation for newborns:a) Type and Screen (Cord blood alone is inadequate.)b) IV antibiotics (Ampicillin 50mg/kg/dose and gentamicin 2.5 mg/kg/dose q 12 hrs)c) Consents for surgery and anesthesia (done by anesthesia housestaff).d) Babies with possible cardiac anomalies need an EKG, CXR, and 4 limb pressures prior to

cardiology evaluation.e) It is very important to remember to give a newborn Vitamin K 1 mg. IM if this has not already

been done in the delivery room. This must be done to prevent possible subsequent disastrousbleeding and is sometimes overlooked during a difficult delivery of an infant with a congenitalproblem.

SPECIFIC NEONATAL SURGICAL CONDITIONS1. Tracheo-esophageal fistula and esophageal atresia:

a) This infant should be kept head up at 45 degrees and a sump tube should be passed via the noseor the mouth to keep the upper pouch empty with continuous low suction.

b) Ventilation using mask and bag should be avoided if there is a distal TEF to prevent gastricdistention with further respiratory impairment or gastric perforation.

c) Look for VACTERL anomalies. Frequent association with imperforate anus, renal anomalies,and cardiac anomalies.

d) If patient’s abdomen is distended, it is a surgical emergency. Gastric distention can cause 1)cardiac arrest due to pericardial compression and 2) reflux into the trachea with acute life-threatening pneumonitis.

e) An echocardiogram is required urgently (STAT) in all patients to determine whether the childhas congenital cardiac anomalies and to ascertain if there is a right or left aortic arch. This helpsdetermine which side a thoracotomy is to be performed. Always remind the cardiology fellowthat pressing firmly on the stomach with the echo probe can lead to death by aspiration thru thepatent TEF.

2. Intestinal obstruction:a) Causes for intestinal obstruction in infants differ from those in older children. The common

causes of obstruction are intestinal atresias, Hirschsprung's Disease, meconium ileus, andmalrotation. There are several points to emphasize which are common to all infants withintestinal obstruction.

b) BILIOUS EMESIS IN AN INFANT DENOTES DUODENAL OSBSTRUCTION ANDISCHEMIC BOWEL FROM A MIDGUT VOLVULUS UNTIL PROVEN OTHERWISE.BILIOUS EMESIS IN AN INFANT IS A SURGICAL EMERGENCY.

c) All infants require an adequate IV and a nasogastric tube when intestinal obstruction issuspected.

d) On plain films, the newborn colon cannot be distinguished from small bowel because haustralmarkings are not yet detectable. Only by filling the colon with contrast agent can the dilatedloops be accurately identified as colon or small bowel.

e) Gastrografin 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 agastrografin study.

3. Intestinal atresia:a) Occurs in the following order of frequency:

• jejunoileal• duodenum• colon• pylorus

b) A careful antenatal history usually reveals polyhydramnios. Prenatal ultrasound diagnosis ofdilated stomach and/or duodenum may be indicative of duodenal atresia.

c) Abdominal distention is seen in most newborns with bowel atresia, although it may be minimalor absent with the more proximal atresias. Vomiting usually occurs within the first 48 hours oflife. Emesis is bilious except in pyloric atresia and very proximal duodenal atresia.

d) Plain films of the abdomen should be obtained in all cases. The double bubble of duodenalatresia is pathognomonic and no contrast study is indicated. When multiple loops of dilatedbowel are seen, suggesting a distal atresia; a contrast study is mandatory.

e) A contrast enema is helpful to identify a microcolon which is a highly reliable finding for smallbowel obstruction and to ensure patency of the colon.

f) Up to 1/3 of children with duodenal atresia have trisomy 21. These children may have complexcardiac anomalies. Therefore, all infants with duodenal atresia require a cardiology evaluationprior to operation.

4. Hirschsprung's Disease:a) Hirschsprung's Disease (congenital aganglionic megacolon) is a frequent cause of neonatal

intestinal obstruction. In this disease there is an absence of ganglion cells that leads toineffective conduction of peristalsis resulting in a functional obstruction. The aganglionicsegment may be limited to the rectosigmoid or extend more proximally to involve the entirecolon.

b) Symptoms are non-specific and include episodic abdominal distension, constipation, obstipationor diarrhea. Symptoms specific to the newborn are the failure to pass meconium in the first 48hafter birth.

c) A contrast enema, which should be obtained in all cases, may show a transition zone at thenarrowed rectum with a dilated colon proximally. However, this finding is often absent ininfants.

d) The diagnosis is confirmed by suction mucosal rectal biopsy or full thickness rectal biopsyshowing an absence of ganglion cells and hypertrophied nerves in the myenteric plexus of themuscularis layer. There is increased acetyl cholinesterase in the aganglionic rectum. Thepresence of ganglion cells rules out Hirschsprung’s disease.

e) Hirschsprung's may be managed with rectal irrigations (some patients with distal transistionzones) or a temporary colostomy above the aganglionic segment. The colostomy is usually madeat the transitional zone between the normal and aganglionic bowel. Some surgeons prefer a righttransverse colostomy if a competent pathologist is not available.

f) A pull-through procedure is usuallly performed either in the first 1-3 weeks of life as a primaryprocedure or when the baby is thriving following a colostomy (ie. 6 months of age).

5. Meconium Ileus:a) Meconium ileus accounts for almost 1/3 of all neonatal small intestinal obstructions. It occurs in

about 15% of infants with cystic fibrosis. The incidence of cystic fibrosis in the Caucasiancommunity ranges from 1 in 1150 to 1 in 2500 live births. It is extremely rare in non-caucasiancommunities, except for a known mutation prevalent in our Hispanic population. Males andfemales are equally affected.

b) The diagnosis is suspected in the infant who develops generalized abdominal distention, biliousvomiting, and failure to pass meconium in the first 24 to 48 hours. A family history of cysticfibrosis is not uncommon, and there is a maternal history of polyhydramnios in 20% of patients.

c) The meconium may be palpable as a doughy substance in the dilated loops of distended bowel.The anus and rectum are typically narrow.

d) Plain film of the abdomen demonstrates bowel loops of variable size with a soap bubbleappearance of the bowel contents. Calcifications on the abdominal film usually indicatemeconium peritonitis resulting from an intrauterine intestinal perforation. Microcolon is a highlyreliable finding for distal bowel obstruction which may be intraluminal from inspissatedmeconium or atresia due to uterine volvulus. A contrast enema demonstrates a microcolon withinspissated meconium proximally. A contrast enema is contraindicated if the plain film showscalcifications.

e) The initial treatment is nonoperative - gastrografin enemas. Under fluoroscopic control, a 50%solution of gastrografin and water is infused into the rectum and colon through a catheter. Thisusually results in a rapid passage of semi-liquid meconium which continues during the next 24 to

48 hours. Follow up KUB’s are taken at 12 and 24 hours to evaluate progress. Multiplegastrografin enemas are frequently required.

f) Operation is indicated in meconium ileus if the gastrografin enema fails to relieve theobstruction, if there are calcifications in the abdominal cavity, if the infant appears too ill todelay operation, or if the diagnosis of meconium ileus is in doubt.

g) All infants diagnosed with meconium ileus require the gold standard, a sweat test (100%accuracy) to confirm the diagnosis of cystic fibrosis. This test is usually not practical prior tooperation since the child has to be at least 2kg or > 72 hours in age. Pilocarpine is a cholinergicdrug that stimulates sweat production. This is applied to the skin and a small electrical current isapplied for five minutes. The sweat is then collected over the next hour and analyzed.Concentrations of sodium and chloride above 60 mEq/L are diagnostic providing a minimum of100 milligrams of sweat is collected. A buccal smear can confirm CF, but is only 80-90%sensitive because it looks for only the most common genetic mutations.

h) Postoperatively all infants require vigorous pulmonary therapy. When oral feedings are begun apancreatic enzyme preparation is given with each feeding, starting at 1 capsule every 4 hours.

6. Malrotation:

a) Malrotation is an important cause of intestinal obstruction in infants and must be considered inevery infant with bilious emesis. In classic malrotation, the duodenal sweep is not present;rather, the duodenum stays to the right of midline and corkscrews down; the cecum may bemidline; the duodenum is anterior and/or lateral to the SMA. Ladd’s bands are fibrousattachments from the retroperitoneum to the cecum which may obstruct the duodenum. Theabsence of a ligament of Treitz coupled with a midline cecum results in a narrow vascularpedicle which predisposes the bowel to volvulus following normal peristalsis.

b) Clinical Findings: Most present in first month of life (>50%), 30% present in first week. 95%have vomiting which becomes bilious (i.e., green). Bloody emesis is due to gastritis. Bloodystools are due to necrosis. 28% have bloody stools. Infants often are acutely ill. Plain x-raysmay reveal either a gasless abdomen, dilated intestine suggesting SBO, or duodenal obstructionwith a double bubble or normal findings. If uncertain, get UGI to look for position of theligament of Treitz.

c) Midgut volvulus is one of the most serious emergencies seen in the neonate or infant, anddelay in diagnosis can result in loss of the entire midgut, which is uniformly fatal.

• Sudden onset of bilious emesis is the primary presenting sign. Abdominal distention is common, but may be absent. Abdominal tenderness varies. On rectal examination, stoolif present, is usually guaiac positive.

• Plain films of the abdomen are variable, and a definitive diagnosis requires a contrast study. An upper GI is the preferred study and should be done in almost all cases. With shock or a clear indication for exploration, these contrast studies may be dispensed with.If obtained, these studies should be done emergently, because a few hours may be the difference between a reversible condition and loss of the entire midgut. Contact the

Chief Resident immediately upon consultation for bilious emesis, so operative intervention (if needed) may be expedited.

• OPERATION: NGT, IV Hydration, OR. NO DELAYS. Ladd’s Procedure: Supraumbilical transverse incision. To decompress the volvulus, rotate the small bowel COUNTERCLOCKWISE. The duodenum and cecum lie next to each other, with SMA and SMV posterior. Lyse the adhesions including those medial to the duodenum on the mesentery. Place small bowel on the right side and the large bowel on the left; the

cecum will lie in the LLQ. Perform an appendectomy. Recurrent volvulus is low (0-2%)• 3 SITUATIONS:

a) Short segment dead bowel-resect with primary anastomosis.

b) Short segment dead bowel with proximal and distal questionable viability-resect dead and bring out stomas. If stomas necrose in 24-48h, re-explore.

c) Large segment of dead bowel, or multiple segments questionable bowel. Closeand do second look in 24-48h. Goal is to minimize short gut syndrome.

• LATE MALROTATION: Symptoms may occur in childhood to adults. Most have vague chronic symptoms, but 10-14% may have acute volvulus. Up to 30% may have intermittent vomiting (bilious), and colicky abdominal or recurrent partial SBO. Some have malabsorption and FTT.

7. Omphalocele and gastroschisis:a) Omphalocele is a central abdominal wall defect at the site of the umbilical ring. The eviscerated

contents are covered by a sac consisting of a translucent avascular membrane composed ofperitoneum, Wharton’s jelly and amnion. Gastroschisis is a smooth-edged abdominal walldefect located adjacent to (usually to the right of) a normal umbilical cord. The evisceratedcontents are uncovered.

b) Hypothermia is usually the immediate life-threatening problem. The sac or exposed intestinesshould be covered with warm saline soaked sponges, followed by a barrier-type dressing. Thiscan be Steri-drape, Lahey or Linton bag, or Saran wrap to decrease evaporative loss from themoist dressing. A large circumferential dressing is used last. Gauze bandages tend to stick tothe bowels and débride the bowels when removed.

c) With gastroschisis in particular, it is essential that the bowel be supported, usually with the babyon its side with the bowel supported by towels, to prevent angulation of the bowel and itsmesentery with consequent bowel ischemia.

d) Gastrointestinal decompression with an NG tube is imperative to minimize furthergastrointestinal distention and prevent the aspiration of gastric contents. A urinary cathetershould be placed to decompress the bladder and monitor urine output. A rectal exam should bedone with supervision to dilate the anus, helping to evacuate meconium.

e) Systemic intravenous antibiotics (Ampicillin/gentamicin) are given to protect contaminatedamnion and/or viscera. Infection can be a devastating problem if a mesh closure is necessary.

f) Intravenous hydration with balanced salt solution is essential. Initial volume is approximately150 ml/kg/d.

g) Rule out associated anomalies, particularly in neonates with omphalocele. Omphalocele isassociated with midline anomalies such as cardiac (get ECHO), renal (get renal U/Spostoperatively), chromosomal (trisomy 13, 18, 21), Beckwith-Wiedemann (large tongue,gigantism, hypoglycemia), and Down’s. Look for imperforate anus. Gastroschisis is associatedwith intestinal atresia.

h) If a silo is necessary to accommodate viscera, then it is imperative that the silo be supported(attached to isolette above) to prevent it from falling to the side of the baby, which would kinkthe blood supply to the intestine.

8. Special Problems of Premature Infants:a) Thermal instability:

• Heat loss can be very rapid and fatal and requires a number of precautions. Isolette or Radiant-heated table for patient care. Heat lamp during procedures outside isolette or during prepping and draping in O.R. Temperature monitor and thermostatic warming blanket in O.R. Warming IV solutions (for massive infusion); warming prep solutions, intraperitoneal irrigant solutions.

b) Hypoglycemia:

• This is a particular risk in the infant of a diabetic mother or a small-for-gestational-age baby. Symptoms can include jitteriness, seizures, apathy, hypotonia, apnea, or hypothermia; but it can be asymptomatic.

• Aim is to keep glucose > 40 mg/100 ml. Prophylactically, one should give 4-8mg glucose/kg/min. (e.g. 100 ml/kg/24 hours of D10W). For acute hypoglycemia, STAT, push of D25W, 1-2 ml/kg.

c) Hypocalcemia:• This is likely in low birth weight or stressed infants, and in infants of diabetic mothers.

Symptoms can include jitteriness, convulsions, and other nonspecific symptoms.• Critical level is that of ionized calcium, which depends on serum total protein. For acute

symptomatic hypocalcemia start 10% Ca gluconate at 1 ml/min to maximum dose of 3 ml/kg. Stop when clinical response is obtained. Monitor ECG continuously. Follow

with Ca infusion up to 50-60!mg!Ca/kg/24 hours.

9. Necrotizing enterocolitis (NEC):a) Highly lethal disease primarily seen in low birth weight newborn infants. Characterized by

ischemic necrosis of the gastrointestinal tract.b) Clinical: Mostly seen in premature and/or low birth weight infants. The incidence of prenatal

complications is high: RDS, apneic spells, low Apgars, premature rupture of the membranes,breech delivery, exchange transfusions, Cesarean section, umbilical artery catheter.

c) The time of onset is usually between the second and fifth day of life. The great majority of theinfants will have been fed prior to onset of the disease. The most outstanding clinical feature isbloody diarrhea. Poor feeding, apneic spells, lethargy, abdominal distention, prolonged gastricemptying and bile-stained emesis characterize the disease.

d) Etiology: The basic mechanism appears to be circulatory ischemia which results from a stress-induced reflex causing redistribution of blood away from the mesenteric, renal, and peripheralvasculature and towards the heart or the brain. Subsequently, there is invasion of the damagedtissue by bacteria. Prior feeding appears to be a significant factor. It appears that injury to themucosa, bacteria, and feedings are three important factors in the development of the disease.

e) Pathology: The ileum, cecum, and right colon are the most common sites of involvement. Thebowel becomes dilated, hemorrhagic and necrotic. Microscopically, the earliest finding iscoagulation necrosis. With increasing severity there is mucosal ulceration, submucosalhemorrhage, and eventual necrosis of the entire bowel wall. A mononuclear infiltrate is present.Gas is found in the submucosa and subserosa. Thrombosis of major mesenteric arteries andveins is not present. Small blood vessels may be thrombosed, compatible with the intravascularcoagulation and hemorrhagic state (frequently seen terminally).

f) Radiology: Since the clinical presentation is often nonspecific, radiography is important in earlydiagnosis, in addition to evaluation of progress and detection of early and late complications.The main findings are dilated bowel, intramural gas (pneumatosis), portal venous gas andpneumoperitoneum.

• Dilatation: This is the earliest and most common sign.• Intramural gas (Pneumatosis): In the proper clinical setting, this finding confirms the

diagnosis. However, the amount of gas is not related to the severity of the disease, and itmay disappear within 12 hours. Disappearance is not necessarily related to

improvement.• Portal venous gas: Not as early a sign as intramural gas. Those infants with portal vein

gas are usually, but not always, more severely affected. As with pneumatosis, it may appear and disappear rapidly and its disappearance is not always associated with clinical improvement.

g) Treatment: Because there is evidence NEC is infectious in nature, both prevention andtherapeutic regimens are directed toward the control of microbiologic agents.

• NPO, NG suction, broad-spectrum antibiotics (i.e. Ampicillin and Gentamicin) for 10days empirically.

• Obtain KUB and lateral decubitus films q6-8h and review with the radiologist.• Serial CBC, platelet count, blood pH, electrolytes.• Routine ID control measures, such as gown-glove, isolation, and good hand washing.

h) Surgical Indications:• Pneumoperitoneum - most sensitive film is lateral decubitus• Abdominal wall cellulitis - on exam• Mass palpated on abdominal exam• Persisting isolated dilated loop of bowel. Failure to respond to medical therapy:

Thrombocytopenia, acidosis, severe hemodynamic instability.• Once surgical indications exist, it is imperative to move to the OR without delay.

Resuscitation of a critically ill infant can be best accomplished in the operating room.

i) Pre-Op Preparation:• Check CBC, PT/PTT, Electrolytes, and ionized Calcium.• If platelets < 100K, order 2 units of platelets.

10. Recognition and Treatment of Sepsis in Newborns:a) Signs: Most are reported by the bedside nurses

• Hypothermia• Thrombocytopenia• Leukopenia• Mottling• Lethargy• Apnea• Poor feeding• Irritability

b) Workup:• Blood cultures• Urine cultures (bladder tap or straight cath - bagged specimens are useless & delay dx)• Sputum cultures• LP• CXR• PT, PTT, platelets, CBC and differential

c) Treatment:• Empiric antibiotics after workup is initiated• Support of circulation with colloid and/or pressors, if necessary.• Administration of FFP if DIC is present.• Respiratory support, if necessary

11. Postoperative enteral feeding:a) Initiation of feeds

• Term newborns can be fed 150 cc/kg/day of 20-kcal/30cc formula on a q3-4h schedule. Caloric requirements may vary from 110-160 kcal/kg/day. Consistent weight gain of approximately 20-30 grams/day is usually the best indicator of adequate caloric intake. The feeding interval will be shorter for premature infants, who may have a higher

volume requirement because of evaporative losses. Gavage feedings may be necessary and constant infusion may be the easiest method. Fluid requirements are lower in the first

24- 48 hours of life (1/2 maintenance).• Postoperatively, feedings are commenced when passage of flatus and stool confirm that

ileus has resolved. In general, feeding is started with D5W or Pedialyte.• Volume may be advanced to maintenance level and then formula may be substituted in

increasing strength.• Careful physical examination to monitor abdominal distention and bowel function

dictate advance of feedings.• Gastric aspirates are measured if feeding is by gavage or gastrostomy, and stool-

reducing substances and free water are checked to be sure that the carbohydrate load istolerated.

• The caloric density of a feeding preparation can be increased by:1. Increasing the amount of formula base (concentrate powder).2. Adding carbohydrate (e.g. Polycose, dextrose, fructose, Karo syrup).3. Adding fat (e.g., corn oil, MCT oil, lipomul).

b) Gastroesophageal Reflux:• Is common in infants and is often outgrown with time.• Medical management includes feeding upright in a chair and leaving infant in the chair

at least one hour after feeding, and thickening feeds with cereal.• Medications include Zantac, Prevacid and Reglan.

c) Gastric Residuals:• For bolus feeds, hold for residual >1/2 of previous feed.• For continuous feeds, check residuals every 4 hours. Hold feeds if residual exceeds half

the amount infused in 4 hours. e.g., If rate is 10cc/h, hold feeds for a 4 hour residual of >20cc.

• Infants usually tolerate increasing volume more readily than increasing concentrationof feedings. Inability to tolerate increasing osmolarity leads to diarrhea, whereas inabilityto tolerate increasing volumes leads to increased gastric residual and/or vomiting.

d) Choosing the proper infant formula:• Breast milk or infant formulas are used for the first year of life.• Introduction of cow's milk earlier than one year may result in iron-deficiency anemia,

which can cause cognitive and developmental delays. When milk is introduced, whole milk should be used (not low-fat or skim) until age two.

• Choosing infant formulas should be done carefully. Breast milk continues to be best for infants. It is well tolerated, easily digested and can be attempted for any infant initially,

no matter what the diagnosis (including CF). Mothers can use breast pumps to obtainmilk that can be frozen for later use for infants unable to feed initially. Breast milk can be

diluted as necessary, or calories increased by addition of supplements.

e) Categories of infant formulas and their indications:• Standard Formulas (Similac/Enfamil/SMA): Lactose is CHO source, casein/whey is

protein source• Soy Formulas (Isomil/Nursoy/Prosobee): Lactose-free, variation of sucrose and other

starches as the CHO source, soy is the protein source.• Semi-Elemental Formulas (Nutramigen, Pregestimil, Portagen, Neocate): All are

lactose- free and have pre-digested proteins (hydrolyzed casein) except for Portagen:.Commonly used for infants with malabsorption, short bowel, gastroschisis, CF.

12. NICU Survival Guide

a) Respiratory Norms:• RR 40-60• O2 Sat >94% in term infant• O2 Sat 88-95% in chronic preemies• ABG: For every 10 of change in pCO2, pH changes 0.08• ABG Norms: pH 7.35 – 7.45, pCO2 35 – 45• VBG or Cap 7.30 – 7.40, 40- 50

b) Ventilatory parameters:SIMV: PIP/PEEP at rate and FiO2

• Ex: 25/5 at 20 and 50%• PIP: peak inspiratory pressure• PEEP: positive end-inspiratory pressure• MAP: mean airway pressure• To increase pO 2 : To decrease pCO 2 :

Increase FiO2 Increase rate Increase PIP Increase PIP Increase PEEP Decrease PEEP Increase inspiratory time

HIFI:• MAP: mean airway pressure• delta P: amplitude• increase MAP to increase pO2

• increase delta P to decrease pCO2

c) Apnea / Bradycardia of Prematurity• Typical for <35 weeks, usually outgrown by term• Treatment options:

1. Watch & wait especially if older2. Aminophylline 5mg/kg bolus, 2 mg/kg/dose PO/IV q8h3. Aminophylline “Bump & Bolus” increasing 1 mg/kg to increase by 2 or give an

extra dose then increase maintenance by 10%4. Caffeine 10mg/kg bolus, then 2.5mg/kg/d (No need to check levels)

d) Cardiovascular• Norms: Hr 120-160, but as low as 80 resting HR for term infants• Mean BP 3 –5 above gestational age• Patent Ductus Arteriosus:

Diagnosis suggested by murmur, increased pulse pressure, bounding pulses,palmar pulses, worsening respiratory parameters especially in setting ofmicropreemie in 1st week of life on large amounts of fluidsTreatment includes Indocin 0.2 mg/kg/dose IV q12h x 3 – contraindicated inrenal failure, NEC, bleeding disorders

• Other medications:Dopamine: 2.5 –20 mcg/kg/minDobutamine: 5 – 20 mcg/kg/minEpinephrine: 0.05 – 1.0 mcg/kg/minHydralazine: 0.1 – 0.5 mg/kg/dose IV q 6-8h, or 0.25 –1.0 mg/kg/dose POq6-8h

e) FEN• Fluid requirements in general increase with decreasing gestational age, and increasing

DOL, if on IVF start D10, adjust based on glucose• Term: start at 80 – 100 cc/kg/d advancing by 20 cc/kg/d to 100 – 120 cc/kg/d• 1000-1500gms: start at 80 – 100 cc/kg/d, advancing by 20 cc/kg/d to 150 cc/kg/d• <1000 gms: start at 100-150 cc/kg/d, use serum sodium (check q6 –12h) to guide, may

need to increase to 170 –300 cc/kg/d, aim eventually to decrease to 150 cc/kg/d, calories increase eventually to 30 cal/oz.

• Maintenance electrolytesNa: 2-4 mEq/kg/dK: 2 mEq/kg/dCa Glu: 200 – 400 mg/kg/d

• TPN:<1500gm: AA/IL start at 0.5g/kg/d advancing by 0.5 g/kg/d to 3.0>1500gm: AA/IL start at 1.0, advancing by 1 to 3

• Enteral feeds:Enfamil 20 for > 2 kg or Premature Enfamil 20 for < 2 kgD10 = 100g/L = 100mg/cc

D25 = 250g/L = 250 mg/cc

Bili > 5% of body weight needs phototherapyBili > 10% of body weight need exchange transfusion

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

f) Heme:• Ferisol Drops: 15 mcg/0.6cc (25mg/cc)

Premature babies need 4 mg/kg/d totalPE contains 2 mg/kg/d

g) ID:• Sepsis caused by Group B Strep, E coli, Listeria, and therefore treat with amp/gent• Ampicillin: 150 mg/kg/dose IV q12h

if <30 weeks, >28 dQ8h If 30-35 weeks, >14 dif 36-42 weeks, >7d

• Gentamicin: for <37 weeks gestation 3mg/kg/q24For >37 weeks gestation 4mg/kg/q24Levels: pre <2, post 4-8

• Norms for LP Fluid:Term—WBC 0-22, Protein 20-170, Glucose 34-119Preterm—WBC 0-25, Protein 65-150, Glucose 22-63

h) Neuro:• Head US is obtained on any baby <30 weeks at DOL 1-2, and 7-10, 30-34 weeks at DOL

7-10, or if clinical suspicion then again at 30 days to look for PVL• Eye exams should be obtained for any baby <32 weeks, 32 –34 weeks on O2, other suspicions,

are usually done for retinopathy of prematurity at correct 35 weeks or 4-5 weeks post-natally• Meds: Phenobarbital 10–20mg/kg load, then 2-5mg/kg/d IV/PO div. q12h

Dilantin: same as aboveAtivan 0.1mg/kg/doseFentanyl 1-4mcg/kg/dose IV q1-2h or /h continuous gttMSO4 0.1mg/kg/dose q 3-4h

13. Treatment Protocol for Congenital Diaphragmatic Hernia (CDH):a) Overview:

• The incidence of congenital diaphragmatic hernia is estimated to be between 1 in 2000and 1 in 4000 live births.

• Despite intensive therapies including ECMO (extracorporeal membrane oxygenation) mortality continues to be high with improper NICU care.

• The treatment protocol for congenital diaphragmatic hernia has recently undergoneseveral changes designed to favor delayed surgical repair of the defect and to minimizeiatrogenic barotrauma from excessive ventilation. During the initial stabilization periodthe child receives moderate levels of ventilatory support. If the child cannot be stabilizedwithout excessive ventilation, then the child is placed on ECMO prior to surgery.

b) Transport:

• Respiratory: Intubation, FI02=100%, PIP enough to move chest but in general < 30 cmH20, PEEP=0-3 cm H20, IMV 30-40.

• Tubes/Lines: UA line is placed to monitor postductal ABG's and right radial line or pulse oximetry is placed to monitor preductal ABG's or O2 saturation. NG tube is essential to prevent gaseous distention of the intestinal contents in the chest and must be functioning properly. IV: D10W plus electolytes at maintenance.

• ABGs: Preductal pO2>60-90 or preductal SaO2 > 90%, pH>7.25. Ideally, aim for preductal pO2 > 60 and pH >7.25. However, watch for metabolic acidosis particularly

in the setting of a mismatched preductal and postductal O2, since this situationdemonstrates that O2 delivery is poor. If there is no preductal ABG, then O2 sat >90% isacceptable, since a pO2 > 60 corresponds to O2 sats > 90%. Give NaHCO3 1-2mEQ/kg formetabolic acidosis only.

• Drugs: Fentanyl 10mcg/kg/dose only if necessary for performing procedures.• Other: Maintain temperature, check calcium, check blood glucose, and transport to

Children's Hospital as soon as possible.

c) ICU Management - First 24 hours:• Respiratory: Initial ventilator setting - VIP bird ventilator in flow synch mode (Neonatal

Pressure Support). Maintain spontaneous respirations.1. Peak inspiratory pressure <25 cm H2O (if possible)2. Rate: Initial settings of 25-35 breaths per minute3. FiO2=1.04. Goals:

1) Preductal oxygenation: Try to maintain preductal pO2>60/preductal O2 Sat >90%. Remember that preductal values indicate flow to the brain via carotid arteries and therefore are critical. The post ductal pO2/O2 Sat's will often be <60 /90%. Do not use these postductal values to adjust ventilator settings, since postductal Sat's indicate less critical, non-cerebral perfusion.

2) Permissive hypercapnia:Liberalize pCO2 to maintain pH > 7.25.Try to maintain pCO2 <60 and pH >7.25.It is preferable to accept pCO2 >60 and use small amounts ofNaHCO3 to maintain pH >7.25 (see below), than to increaseventilator settings which elevate mean airway pressures andcause barotrauma. Try to maintain mean airway pressure <12-13cm H2O

Remember, barotrauma kills CDH babies. Refer all ventilator ?'s directly to the Chief Resident.• All CDH infants need a head ultrasound and cardiology consult including

echocardiogram on admission.• ABG's: FIO2 at 1.0 until the patient is absolutely stable. Maintain pH at >7.25,

pCO2<60 using ventilator adjustments.

d) Cardiovascular:

• Avoid internal and external jugular lines in case ECMO is required.• Right radial (preductal) and UA, PT, or DP (postductal) are essential. Follow

preductal ABG's for ventilator changes.• Pre- and post-ductal oximetry to follow oxygenation trends.

e) Drugs: Minimize sedation• Fentanyl 1-2 mcg/kg given by IVP or by continuous infusion only if patient is agitated.• Systemic antibiotics begun.• Dopamine or Dobutamine necessary for blood pressure support. If epinephrine becomes

necessary the situation must be re-evaluated.f) Lab studies:

• Pre- and postductal ABG's q 1 hour and PRN• Hematocrit, lytes, ionized Ca q 6 hours and PRN• PT, PTT q AM• CBC, Chem 20 q AM• Clot to blood bank needs to be continuously updated. Notify the Blood Bank

immediately if use of ECMO likely. Type and cross 2 units PRBC's and platelets.g) Stress Precautions: Activity and lights should be kept to a minimum, (rounds conducted outside

the room, etc.). CDH patients respond to stimuli by increasing pulmonary artery pressure, whichmakes shunting more problematic.

h) CDH Protocol:• Conventional mechanical ventilation (CMV) on SIMV (neonatal pressure support) with

minimal sedation. As previously mentioned, attention towards avoiding barotrauma bylimiting peak airway pressures to 25-30 is essential.

• High frequency ventilation (oscillator) if patient fails CMV. If the patient can maintain adequate ABG, they may avoid ECMO.

• Timing of surgical repair is dictated by clinical course. These infants require frequent physical exams. Do not make treatment changes without discussion with chief resident

or the attending.

X. Extracorporeal Membrane Oxygenation (ECMO)

ECMO is a cardiopulmonary bypass system employed to support the patient in severe, medicallyrefractory respiratory or cardiac failure. At our institution, we focus on respiratory failure in thenewborn; however, older pediatric patients and those needing cardiac support are consideredcandidates under certain circumstances.

Indications:A. Neonatal Respiratory Failure

1. Meconium aspiration2. Persistent Pulmonary Hypertension3. Congenital Diaphragmatic Hernia

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

B. Pediatric Respiratory FailureC. SepsisD. Cardiac support

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

Extracorporeal support can be used for cold water drowning, on an immediate basis for cardiacarrest, and for other, unusual, isolated conditions.

We use clinical criteria to place a patient on ECMO—usually focused on continued poorrespiratory performance while on optimal (not maximal) ventilator support. The OxygenationIndex > 40, prolonged A-a gradient > 600, four hours of pO2 <60 are all used as criteria but thereare important caveats beyond the scope of this outline.

Contraindications:A. Grade II or greater intracranial hemorrhageB. Congenital/genetic abnormalities incompatible with good outcome

a. Down’s is no longer considered, a priori, a contraindicationC. Prolonged or sustained cardiac arrestD. CDH with severe pulmonary hypoplasia as seen with depressed pre-ductal saturationsE. Prematurity (less than 36 weeks)F. Relative contraindication may be weight < <2000 gm as the smaller patient size makes

cannula size small and thus flows lower)

The decision to place a child on ECMO is made by the ECMO attending in concert withthe ECMO fellow and neonatal staff. The key feature is careful informed consent of theparents who are understandably anxious and fatigued but whose cooperative support iscentral to a successful outcome.

Handling the ECMO Referral Call:

Usually, an ECMO referral is from a neonatologist at an outlying nursery who will have called theNICU at Children’s requesting an evaluation. If the history is that of a rapidly declining respiratorystatus in the setting of rapidly escalating respiratory therapy strategies, our neonatologist or neonatalfellow will refer the call to the surgery service for consideration of ECMO.

The following items are important in considering whether or not a patient is an ECMO candidate andmust be ascertained during the phone call with the neonatologist at the referring institution:

Demographics: -Date, time, and location of birth-Parents address, location now, phone numbers (home, cell, pager)

Pertinent History: -Method of Birth (vaginal, section)-Prenatal history (antenatal diagnoses, maternal infection)-Results of prenatal tests (sonogram, amniocentesis)-Perinatal events (Apgars, feeding, infections)-Suspicion of genetic disease (Trisomy 21 is not in and of itself

exclusionary, but Trisomy 13 and 18 are as well as any other lethaldefect)

Resuscitation: -When did symptoms start?-What respiratory therapies were tried? Results?-What data was gathered to initiate or change therapy?

ABG'sPre- and post-ductal oxygen saturations

-What is the current regimen? (Type of ventilator [jet, conventional, oscillator], settings, ABG's, vital signs)

-Chest radiograph: Current and progression from initial

You need to accurately record all known gases and ventilator/02 concentrationsand the response—this data is vital in the overall assessment.

Cardiac: -Record type and dose of drips (commonly dopamine and dobutamine as well asepinepherine)-ECHO results (exclude significant cardiac lesions)

Neurologic: -Often (unfortunately) paralyzed-Seizure activity-Prolonged anoxia-Wakefulness-Tone-Head sonogram (>Grade II hemorrhage precludes ECMO)

-Note: the history of an arrest with CPR in a baby with low Apgars who is nowfloppy is quite worrisome for significant anoxic encephalopathy)

Hematologic: Evidence of bleeding (head, see above)

Misc: The remainder of the physical findings, location of all existing lines, results ofother tests (ex. abdominal sonogram--? 2 kidneys)

Once all of the data is gathered, inform the referring nursery that you will return their call afterreviewing this data.

In conjunction with the ECMO fellow and attending, the above information is assessed in view of theoverall respiratory problem. The ideal ECMO candidate has a known, resolvable respiratory problemwho has not been ventilated for a prolonged period of time and who has no evidence of anoxicencephalopathy. The more difficult assessments involve children in whom the respiratory problem isnot precisely worked out or is due to sepsis. In these patients, the prognosis is worse.

If the baby is a candidate, then transfer procedures are enacted.

Transfer of an ECMO Candidate:

Transfer begins with a call to the parents. In most cases, the mother is recovering from delivery andmay be hard to get on the phone but every effort should be made to speak with the mother and thefather.

In most cases the parents are just learning how sick their baby is and you are now an unfamiliar facefrom a distant hospital on the phone talking about risks, anticoagulation, and bypass. For the newparent with a sick baby, this is a dizzying prospect and requires clarity and patience on your part.While time is of the essence, this phone call is the single most important event in establishing a bondthat will help guide the parents through this experience. Done well, it is the launch pad to a successfulend, even if there is a bad outcome.

Start by identifying yourself and state that you represent a team of doctors, naming the attendingsurgeon and neonatologist. Acknowledge that this is a frightening time but you need to tell them whatis going to happen when their child arrives. State that the transport is considered high risk butnecessary. Also tell them that sometimes children do get into trouble in the ambulance but that a teamof doctors and nurses will be traveling with the child.

Upon arrival, indicate that a determination as to whether or not bypass is needed will be made and aperiod of observation may be indicated. State that some babies come here for ECMO but many do notneed it. If the child does not meet the criteria for ECMO, we will simply continue with the same typesof care that were being used at the first hospital.

Indicate that if the baby is a candidate, a surgical operation on the neck is required to place the childon ECMO and this has some risks (stroke, bleeding, arrest). The child is then connected to the circuitwhich is a set of life support organs that will sustain the baby while the lungs improve. We discussheparinization and its risks and that the ECMO course may be stopped when the child is improving orsooner if the risk and dangers of bleeding are outweighed by the continuation of ECMO.

Answer all questions, but do not make predictions about likely outcomes. Promise to phone after thebaby arrives and the initial assessment has been made.

Blood Bank: While the phone call to the parents is the most important, the blood bank is often therate-limiting step. Ask the referring center to get both patient and maternal blood in a plain tube forcrossmatch. Though the blood can be drawn on arrival, it is faster if it can be sent to the bloodbankthe minute the child arrives. Inform the blood bank that they will need three units, stat, for an ECMOcircuit. Label the blood with CPMC labels and requisitions and follow all labeling rules to minimizedelays.

Perfusion: Alert the on call team that an ECMO is in the works. Setting up a circuit depends on thechild’s history.

OR: Inform the OR that a transfer is coming and they may be needed.

Keep in touch with the referring physician—once you have parental permission, the transport team cango and get the baby—this is arranged by the NICU upon your advisement.

Technique:Cannulation is done at the bedside with an OR team. The patient’s position on the bed and theplacement of the pump must be planned. For example, the side of the bed where the pump is tobe located must be the patient’s right—this may require turning the patient. The neck isextended (roll under shoulders) and the head turned to the left. The chest and neck areprepped. The patient is given 25-50 mg kg heparin before the vessels are ligated; paralytic isgiven prior to venotomy.

A. Veno-venous1. One double lumen cannula, usually placed in the RA via an IJ cutdown

a. Usual size is 12 Frenchb. Usual depth is RAc. Echo helpful during placement

2. No cardiac support needed3. Excellent coronary perfusion4. Flows range 100 to 150 cc/kg/min5. Recirculation may limit needed flow

a. Recirculation increases with increasing heart failureb. Increases with increasing flow

6. Cannula position and cannula characteristics somewhat more finicky7. Technique of choice in neonates8. Conversion to VA indicated when perfusion inadequate or cardiac support needed

B. Veno-arterial1. Two cannulas: arterial (carotid) and venous (IJ)

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

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

For both of these, percutaneous techniques are available.

ECMO Circuit:A. Polyvinylchloride tubingB. "Better bladder"C. Bubble detectorD. PumpE. Silicone membrane oxygenatorF. Warmer (countercurrent heat exchanger)G. In-line ABG assessment devices

The circuit is primed with plasmanate (a balanced electrolyte solution), albumin (pacifies thecircuit so that blood products don’t react to the foreign surface), heparin, and @ 400 cc of new,washed packed cells that displace the plasmanate.

The circuit is matched to patient serum K levels, pH (bicarbonate added) and is keptanticoagulated. Coagulation is assessed by the activated clotting time (ACT) that is measuredat the bedside and is kept prolonged about 1.5-2.0 times normal.

Management of the Patient on ECMO:A. Initial flow established so as to provide saturations > 90%, decreased shunt fraction, and

normal blood pressure.B. Pressors may be weaned.C. Ventilator settings, which may have been maximized, are reduced

1. Ventilator switched from oscillator or jet to conventional2. Settings lowered to ideal settings (PIP 18, rate 20, 25% O2)

D. Subsequently, flows may be weaned against PaO2 (VV) or SVO2 (VA)E. Heparin is administered by drip and adjusted as dictated by ACT (normal ACT 90-120 sec;

goal ACT on ECMO is @ 200)1. No IM meds, heel sticks, etc2. No other heparin in drips, lines

F. Ancef is sufficient antibiotic coverage absent sepsisG. Sedation without paralysis (one dose of paralytic is used during cannulation); goal is

spontaneous breathing on low vent settingsH. TPN is started on the second day of ECMO;

1. Fat emulsion is safe but is given post oxygenatorI. Platelet count (which steadily falls during run) must be kept near 100K. Transfusion, often

daily, may be accompanied by need for increased flow because of thromboxane release by“bruised” platelets

J. Hematocrit is kept 35-40% by transfusion as neededK. Volume expansion is achieved by blood first, then LRL. Neurologic examination and head sonograms are routine daily in order to detect ICH early.

This event may force an abrupt end to the ECMO run even if the pulmonary goals are notmet.

M. Complications:

1. Generalized bleeding. DIC may supervene. Cryoprecipitate and FFP may rarely beneeded and should be given post oxygenator. ACT may be kept tighter (closer to 180than 220). Sepsis should be suspected.

2. Intracranial hemorrhage. May be part of generalized or bleeding or as a result ofhypertension. As noted, this event may herald the end of the run.

3. Hypertension. Aggressively treated with Nitroprusside.4. VV ECMO may not provide adequate support requiring conversion to VA ECMO

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

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

Completion of the ECMO Run:As the flow approaches 20-25cc/kg/min with saturations in the mid or higher 90s,decannulation may be considered. The patient should be euvolemic, on minimal vent settings,and off pressors. When these conditions are met, the circuit is diverted, the cannulae flushed,and the patient trialed off ECMO. Modest increases in ventilator support may be required butif pressures are above 20, rates above 40, and FiO2 > .40 are needed consideration should begiven to remaining on ECMO.

Certain clinical scenarios may dictate accepting higher than ideal vent settings or lower thanideal saturations. If the patient is bleeding or if there is a worsening neurologic exam, thebenefits of continued bypass are outweighed by the risks of coming off bypass.

Key features of trial off bypass:a. Heparin must be given to the patient to ensure anticoagulation with the cannulae in

placeb. 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

Decannulation requires the OR team. The cannulae are removed. Key features of thisprocedure are:

a. Paralysis will be needed to prevent air embolus from spontaneous respiration duringvein manipulation.

b. Artery is ligated. There are no data to support the need to reconstruct.c. The vessels may be fragile after a long run and rapid hemorrhage can result from

cannula removal.d. The wound is drained.

Aftercare:Patients are weaned from the ventilator to CPAP over a period of 24 hours to several days.

After patient is free from supplemental respiratory care:

A. Head CTB. VAER's and BAER'sC. EEG if indicatedD. Renal scan if persistent hypertensionE. Appropriate consultation follow-up plans established

1. Neurology2. Pulmonary3. Cardiology

F. Outpatient care through High-risk neonatal clinic1. Early intervention as needed

G. Feeding may be problematic in CDH patients1. H2 blockers2. Motility agents3. Postural maneuvers during feeds4. Continuous feeds condensed and transitioned to bolus over time.5. GI consultation when appropriate

XI. Pediatric Trauma

Overview:The Columbia campus of the Children’s Hospital of New York is a designated Regional PediatricTrauma Center, also known as a Level 1 Pediatric Trauma Center. The Cornell campus is a Level 1Trauma Center. Children may be admitted to the Trauma Service in one of the following ways:

1. Brought to the Pediatric Emergency Department (ED) by EMS or the Transport Team.2. As a direct transfer to the PICU/surgical floor from an outside institution.

Columbia Campus:The Pediatric Trauma Team will be alerted to incoming patients by activation of the pediatric

trauma beepers. Initial notification will originate from either the Pediatric ED for EMS transports and“walk-ins” or by the Pediatric ICU charge nurse for inter-hospital transfers. Automatic activation ofthe pediatric trauma beepers requires dialing the page operator at #6-3333. The operator should beinstructed to page the Pediatric Trauma Team to the ED or the Pediatric ICU. The pediatric traumabeepers are voice-activated beepers that direct staff where to report. After receiving a trauma page youshould proceed immediately (within 5 minutes) to the Pediatric ED or Pediatric ICU. Phone numbersof these locations are clearly marked on the beepers. Beepers should be on 24 hours day/ 7 days week.Batteries need to be replaced every two weeks.

Composition of the Pediatric Trauma Team:

Pediatric Trauma DirectorPediatric Surgery AttendingPediatric Surgery FellowGeneral Surgery PGY 5*Pediatric Surgery Junior ResidentPediatric Intensive Care Unit Charge NurseAnesthesia Resident/ Babies Hospital*Anesthesia Team Captain/ Milstein Hospital *Radiology Supervisor/TechnicianTrauma Nurse Coordinator/ Nursing Supervisor

*During the evening/night/weekend hours the following changes occur:

*General Surgery PGY 5When the Pediatric Surgery Fellow or Attending is not in the hospital, the in-house PGY 5 generalsurgery resident will carry the pediatric trauma beeper. They will respond to pediatric trauma teamactivations and provide senior surgical support until the Pediatric Surgery Fellow or Pediatric SurgeryAttending arrives.

*Anesthesia

From 8:00 pm-4:00 pm the pediatric trauma beeper will be carried by the anesthesia resident assignedto the Babies Hospital operating room. From 4:00 pm- 8:00 am the pediatric trauma beeper will becarried by the Anesthesia Team Captain in Milstein Hospital.

Criteria for Notification of the Pediatric Trauma Response Team:

The Pediatric Trauma Team will be activated when an injured child arrives in the hospital and meetsthe following criteria:

Mechanism of Injury

• Motor vehicle crash with ejection• Motor vehicle crash with death at the scene of other occupants• Motor vehicle crash with need for extrication• Pedestrian or cyclist hit by a vehicle moving > 15 mph• Fall > 15 feet• All transfers within 24 hours of injury• Significant blood loss at scene• All injured infants (Age < 6 mos)• All penetrating injuries

Physiology

• Cyanosis, retractions, shallow breathing• Systolic BP < 90 mmHG (> 1 yr. of age)• Capillary refill > 2 seconds• Pulse > 130 BPM or < 50 BPM• Dilated or unreactive pupils• Depressed LOC

Specific Injury

• Amputation or crush injury of an extremity• Burns > 20% BSA• Injury to two or more body regions• Two or more long bone fractures

The Pediatric Surgery Service will be consulted on injured children who do not meet the abovecriteria. Any time an injured patient’s condition changes, the Pediatric Trauma Team can be activatedby calling the page operator at 6-3333.

Roles and Responsibilities:

Emergency Department Team - Directs the initial management of pediatric patients until the surgicalTeam Leader arrives. A child with multiple or serious injuries must be managed by one identifiablesurgeon-in-charge, usually the senior surgical resident. This individual is responsible to supervise thetotal management of the patient and coordinates the activation of various specialty services consultingon the patient’s care.

Team Leader- General Surgery PGY 5/Pediatric Surgery Fellow or Pediatric SurgeryAttending

Note: The Pediatric Emergency Department Attending Physician will assume the role of team leaderuntil the arrival of one of the above.

• Goes directly to the Pediatric ED when the pediatric trauma team beeper is activated.• The pediatric trauma team leader will stand at the foot of the patient’s bed and assume

complete responsibility for the coordination and direction of the entire trauma team. The teamleader will establish the priority of diagnosis and define the order of therapy.

• Performs or supervises the primary survey including immobilization of the C-spine duringtransfer of the patient onto the ED stretcher.

• Directs resuscitation and performs surgical interventions as needed.• Directs and helps to perform the secondary survey once the initial resuscitation is completed.• Responsible for direct orders to physicians and nurses during the resuscitation. May also

reassign personnel roles as needed.• Conveys all anticipated plans to the team.• Requests additional physicians/service consults.• Orders diagnostic tests, procedures and medications.• Speaks with the family of the patient following the resuscitation.

Documentation Responsibilities• Documents course of resuscitation on the Physician Trauma Assessment Form.

Surgical Resident - Pediatric Surgery Junior Resident

• Goes directly to the Pediatric ED when pediatric trauma team beeper is activated.• Obtains vascular access as directed by the team leader.• Performs surgical procedures, places chest tubes as needed.• Controls hemostasis.• Assures placement of NG tube, foley catheter if needed.• Administers resuscitation fluids.• Accompany patient to OR, radiology, Pediatric ICU or other destinations throughout transport

until admitted to the receiving unit.• May document resuscitation on the Physician Trauma Assessment Form (If not done by Team

Leader). This includes Adult/Pediatric Glasgow Coma Score and Pediatric Trauma Score uponadmission and one hour after the injury.

• Writes trauma admission orders.• Calls admissions office to book bed.• Obtains parental signatures on all operative permits.

Patients with multiple injuries must be admitted to the Pediatric Trauma service. Subsequent transferto surgical or medical subspeciality services is at the discretion of the Pediatric Trauma Attending.

* All patients in the Pediatric Intensive Care Unit are on the Pediatric Trauma service.

Pediatric Neurotrauma Response:

The Pediatric Neurology and Pediatric Neurosurgery services will be consulted on all injured childrenwith possible neurotrauma at the request of the Trauma Team leader.

The Pediatric Neurosurgery service will be the primary consultation service expected to respondimmediately to the following specific clinical situations at the discretion of the Trauma team leader:

• Penetrating cranial wounds• Open skull fractures• Acute or progressive deterioration of neurologic exam• Focal or unilateral deficit• Suspected spinal cord lesions

Management of the Pediatric Trauma Patient

Primary Survey:

AIRWAY Follow algorithm A

BREATHING Follow algorithm B

CIRCULATION Follow algorithm C

DISABILITY Brief neurologic exam

EXPOSURE Remove all clothingKeep in mind thermoregulationMay use heat lamps and warm IV fluids

IV Access

• Two large bore IV’s if possible.• Use NS or LR for all trauma patients.• May insert intraosseous needle into tibia or femur if unable to place peripheral or central IV’s.• See chart below for PIV size.

Fluids

• 20 ml/kg of NS or LR (warmed fluid if possible)• May repeat if necessary• If no response to second bolus may transfuse with blood• Transfusion- 10 ml/kg PRBC’s (Type specific or O negative)

Blood

• All patients have a CBC, amylase, and Type & Hold.• Additional blood tests can be ordered as necessary.

NG Tubes

• NG tubes are placed in all patients with thoracic or abdominal injury.• DO NOT place an NG tube if there is a possibility of oropharnygeal trauma or skull fracture.• An OG tube is placed if facial fractures or a basilar skull fracture is suspected.• See chart below for NG tube size.

Foley Catheter

• Allow hemodynamically stable patients to void if awake and alert with no clinical indication ofpotential GU injury.

• DO NOT insert a foley catheter if urethral injury suspected.• See chart below for foley catheter size.

Tube Sizes:

IV Catheter• Infant 20-22 g.• Young Child 18-20 g.• Older Child 16-18 g.

NG / Foley• Infant 8 Fr.• Child 10 Fr.• Adolescent 14 Fr.

Thoracostomy Tube• Neonate 10-12 Fr.• 6 m-18 m. 12-14 Fr.• 1-3 yr. 16-20 Fr.• 4-7 yr. 20-24 Fr.• 8 12 yr. 28-32 Fr.• Adolescent 28-40 Fr.

Approximate Measurements:

Weight: Age (years) x 2 + 8 = # in kgsBlood Pressure: Systolic = 80 + (2 x age in yrs)

Secondary Survey:Head-to-Toe Exam: See Algorithm D

Radiology Sequence:

• Lateral C-spine (view C1-C7), CXR (AP), & AP pelvis in all patients• Special studies (as indicated):

o CT scano IVP, cystogram, urethrogramo Arteriogram

A cross table C-spine will be obtained (with appropriate stabilization precautions) at the request of theTrauma team leader. Additional X-rays in the trauma resuscitation area should be limited to chest &pelvis and are obtained at the discretion of the Trauma team leader. The cross-table C-spine X-rayneed not be “cleared” prior to obtaining urgent films. The trauma team members will position allpatients without C-spine clearance for subsequent X-rays. The final decision to discontinue C-spineimmobilization will be made by the Trauma team leader. It is expected that all patients return fromradiology with immobilization in place.

Children with obvious extremity fractures may require fracture X-rays within the resuscitation area ifnot stable for transport. Otherwise extremity and facial films should be obtained only afterresuscitation and stabilization. These films should be obtained in the Radiology Department wheneverpossible.

Only patients with abdominal crush mechanisms such as handlebar injuries or lap belt injuries shouldreceive oral contrast prior to abdominal CT scan.

C-Spine Clearance:The following algorithms are used to guide the C-spine clearance of Pediatric trauma patients:

C-Spine Clearance: Reliable Patient

C-Collar to remain in place until diagnostic workup complete

1. Is there altered sensorium or other painful injury causing distraction?2. Is there an inability to communicate or localize pain?

/ /NO YES

Child complaining of neck pain Go to UNRELIABLE algorithm tenderness or paresthesia?

NO YES Is there pain or paresthesia with collar off during passive

range of motion?

YesObtain lateral C spine xray Replace collar

No

Lateral films (x2) not Films adequate asadequate as per Radiology per Radiology

C-Spine clearedSwimmers view for Clearance C6-T1

Neurosurgery consult Remove collarFlexion/Extension films

Injury noted? NOInjury noted? YES Treatment per

Neurosurgery YES

Neurosurgery consult NO

C- Spine clearedRemove collar

C-Spine Clearance: Unreliable Patient

C-Collar to remain in place until diagnostic workup complete

1. Is there altered sensorium or other painful injury causing distraction2. Is there an inability to communicate or localize pain?

YES NO

Lateral C spine Go to RELIABLE algorithm

Film adequate per radiology?

YES NO

Films (x2) not adequate per Radiology

Obtain CT scanInjury noted?YES NO

Neurosurgery Collar remains in place consult HOB not to be elevated > 45 degrees

Is child awake/ alert within 24 hours?

YES NO Go to reliable algorithm Flexion/extension within 24 hours

Plain films

Injury noted? YES NO

Treatment per Neurosurgery Remove collar

Shock• Children may maintain nearly normal vital signs even with severe hemorrhage.• The primary response to hypovolemic shock in children is tachycardia.• Hypotension is a LATE sign of shock in the injured child.• Children may lose up to 40% of their total blood volume before becoming hypotensive.• Signs & symptoms of shock in children

<25% Blood 25%-45% Blood >45% BloodVolume Loss Volume Loss Volume Loss

Cardiac Increased Weak thready Hypotension;heart rate pulse; tachycardia bradycardia

CNS Lethargic, Change in level of Comatoseirritable, consciousness, dulledconfused response to pain

Skin Cool, clammy Cyanotic, decreased Pale, coldcapillary refill,cold extremities

Kidneys Decreased urinary Minimal urine output No urinaryoutput;increased outputspecific gravity

Algorithm for Management of Shock in Children:

Signs of Shock?

NO YES Exit algorithm Initial LR bolus 20 ml/kg

External hemostasis if open laceration

Are there continued signs of shock?

NO YESModerate to severe head injury?? Repeat 20ml/kg LR

NO YESMaintenance fluid 2/3 maintenance fluid

Are there continued signs of shock?

NO YESExit algorithm Type specific or O neg blood 10 ml/kg PRBC

or 20 ml/kg whole blood

Is there ongoing blood loss??

NO YES

Thorax / Abdomen PelvicIf arrest: Open thoracotomy in ED Arteriography or

If stable: Thoracotomy or laparotomy in OR External Fixation in OR

Child Abuse:The suspicion of child abuse must always be kept in mind when caring for injured children. Suspectedabuse must be reported.

The following “red flags” will alert suspicion of child abuse:• Failure to thrive• Delay in obtaining care• Previous injuries• Uninterested/absent caretaker• Conflicting stories between parents/guardians• History not consistent with injuries

If there is suspicion of intentional injury please call the following in-house staff members forassistance:Monday-Friday 8:00am- 4:00pm Child Abuse Supervisor

Columbia-Beeper 5002Cornell-61306

24 hours day/ 7 days week Child Protection BeeperColumbia -Beeper 3935Cornell-Beeper 30644

Social Work Administrator on callColumbia-Beeper 2812Cornell-Call page operator

Spleen/Liver TraumaMost isolated spleen/liver injuries are treated nonoperatively. Spleen/liver injuries are graded by theradiologist following an abdominal CT scan using the following Abdominal Injury Grading Scale:

Spleen Injury Scale Liver Injury Scale

Grade Injury Description Grade Injury Description

I. Hematoma Subscapsular <10% surface area I. Hemaotoma Subscapsular <10% surface area Laceration Capsular tear, <1 cm Laceration Capsular tear, < 1cm

parenchymal depth parenchymal depth

II.Hematoma Subscapsular, 10-50% surface II. Hematoma Subscapsular, 10-50% surface area;intraparenchymal,<5cm area;intraparenchymal, <10 cm

in diameter in diameter Laceration 1-3 cm parenchymal depth Laceration 1-3 cm parenchymal depth, <10 cm

which does not involve a in lengthtrabecular vessel

III .Hematoma Subscapsular,>50% surface area III. Hematoma Subscapsular,>50% surface areaor expanding; ruptured or expanding; rupturedsubscapsular or parenchymal subscapsular or parenchymalhematoma hematoma

Intraparenchymal hematoma>5 Intraparenchymal hematoma >10 cm or expanding cm or expanding

Laceration > 3 cm parenchymal depth or Laceration > 3cm parenchymal depthinvolving trabecular vessels

IV. Laceration Laceration involving segmental or IV. Laceration Parenchymal disruption involving hilar vessels producing major 25-75% of hepatic lobe or 1-3devascularization(>25% of Couinaud’s segments within aspleen) single lobe

V. Laceration Completely shattered spleen V. Laceration Parenchymal disruption involving>75 % of hepatic lobe or > 3Couinaud’s segments within asingle lobe

Vascular Hilar vascular injury which Vascular Juxtahecatic venous injuries:ie.devascularizes spleen retrohepatic vena cava/central

major hepatic veins

VI. Vascular Hepatic avulsionOnce an isolated injury has been graded, the following algorithm of care is used:

CT Grade I II III IV

ICU LOS None None None 24 hrs

Hospital LOS 2 days 3 days 4 days 5 days

Pre-discharge imaging None None None None

Post-discharge imaging None None None None

Time of restricted 3 weeks 4 weeks 5 weeks 6 weeksactivity / post-injuryvisit

Operative management of spleen/liver injuries is indicated for:• Ongoing hemorrhage• Refractory hemodynamic instability

Following total splenectomy patients are at risk for fulminant bacteremia from Streptococcuspneumoniae and Haemophilus influenzae type b. Patients must be started on antimicrobial prophylaxisupon discharge. The current recommendation is:

Oral Penicillin V 125 mg PO BID Children less than 5 years250 mg PO BID Children 5 years old and older

Some experts also recommend Amoxicillin (20 mg/kg/day).

It is also recommended that asplenic children > 2 yrs receive the pneumococcal and meningococcalvaccine. Parents should be instructed to follow-up with their pediatrician for vaccine administration.

APPENDIX 1

Modified Glascow Coma Scale for Infants and Children

Child Infant Score

Eye Opening Spontaneous Spontaneous 4To verbal stimuli To verbal stimuli 3To pain only To pain only 2No response No response 1

Verbal response Oriented, appropriate Coos and babbles 5Confused Irritable cries 4Inappropriate words Cries to pain 3Incomprehensible/nonspecific Moans to pain 2 Words/soundsNo response No response 1

Motor response Obeys commands Moves spontaneously and 6 purposefully

Localizes painful stimulus Withdraw to touch 5Withdraws in response to pain Withdraws in response to pain 4Flexion in response to pain Decorticate posturing (abnormal 3

flexion) in response to painExtension in response to pain Decerebrate posturing (abnormal 2

extension) in response to painNo response No response 1

APPENDIX 2

Pediatric Trauma Score

PTS Component +2 +1 -1

Size >/= 20 kg 10-20 kg < 10 kg

Airway Normal Maintainable Unmaintainable

Systolic BP > 90 mm Hg 90-50 mm Hg < 50 mmHg

CNS Awake Obtunded/ Hx LOC Coma/decerebrate

Open Wound None Minor Major/penetrating

Skeletal fxs None Closed Open/multiple

APPENDIX 3

ETT SizesShiley

ETT Jackson mmOD Fr Holinger NT PT SCT

3.0 00 4.3 13 00 00x30mm 00x39mm --3.5 0 5.0 15 0 0x32mm 0x40mm --4.0 1 5.5 16.5 1 1x34mm 1x41mm --4.5 2 6.0 18 2 2 2x42mm --5.0 3 7 21 3 3 3x44mm 5x58mm5.5 4 8 24 4 4 4x46mm 6x67mm6.0 5 9 27 5 -- -- --6.5 6 10 30 6 -- -- 7x80mm7.0 7 11 33 7 -- -- 8x89mm 8.0 8 12 36 8 -- -- 9x99mm-- - 13.3 39.9 - -- -- 10x105mm

Bivona makes a line of adjustable trach tubes that look like reinforced ETT tubes with a sliding flange.

Trachestomy Sizes

TYPE SIZE ID OD LENGTHShileyNeo 00 3.1 4.5 30 mm

0 3.4 5.0 321 3.7 5.5 34

Ped 00 3.1 4.5 39 mm0 3.4 5.0 401 3.7 5.5 412 4.1 6.0 423 4.8 7.0 444 5.5 8.0 46

Adult 4 5.0 8.5 67 mm6 7.0 10.0 788 8.5 12.0 8410 9.0 13.0 84

ARGYLE 000 2.5 4.0 31 mm00 3.0 4.7 320 3.5 5.4 341 4.0 6.0 362 4.5 6.6 403 5.0 7.3 464 5.5 7.8 505 6.0 8.5 54

PORTEX 3.5 3.5 5.8 40 mm4.0 4.0 6.5 444.5 4.5 7.1 485.0 5.0 7.7 505.5 5.5 8.3 55

Tracheostomy Sizes

TYPE SIZE ID OD LENGTHShileyCuff 6.0 6.0 8.3 55 mm

7.0 7.0 9.7 758.0 8.0 11.0 829.0 9.0 12.0 87

Special 3.0 3.0 5.2 36 mm6.0 6.0 8.0 36

Talking 6.0 6.0 8.37.0 7.0 9.7

METAL 000 2.1 33 mm00 2.4 4.5 330 2.9 5.0 33,401 3.0 5.5 33,402 3.3 6.0 33,403 4.4 7.0 33,50,554 5.3 8.0 555 6.1 9.0 686 7.1 10.0 68

HEALY- 2 3.3 46COTTON 3 4.4 50

4 5.3 505 6.1 63

Bronchoscope SizesStorz

SIZE/ID OD LENGTH2.5 4.0 20 cm3.0 5.0 203.5 5.7 203.5 6.0 303.7 6.1 264.0 7.1 30

APPENDIX 4

GASTROSTOMY TUBES

MIC TUBES (clear plastic tubes that extend out from abdominal wall 6" and have an access port toinflate balloon with H20 or NS and 1 or 2 ports for gastric and/or jejunal feeds.

GS # SIZE

8431 12 Fr.8432 14 Fr.8427 16 Fr.8428 18 Fr.8429 20 Fr.8430 24 Fr.

MIC-KEY TUBES (skin level device that has a round clear plastic flange that anchors onto the skinwith a side access port to inflate the balloon with H20 or NS.

GS # SIZE

8419 14 fr. X 1.2 cm shaft length8420 14 fr. x 1.7 cm8421 14 fr. x 2.0 cm8422 16 fr. x 1.7 cm8423 16 fr. x 2.0 cm8424 18 fr. x 1.7 cm8425 18 fr. x 2.0 cm8426 18 fr. x 2.5 cm

BARD BUTTONS (skin level device that has a firm mushroom-shaped end (not a balloon) anchoringit on the stomach wall. A metal obturator or stylet is needed to stretch out the mushroom end toreplace and/or remove.

GS # SIZE

8400 18 fr. x 1.7 cm shaft length8401 18 fr. x 2.4 cm8402 18 fr. x 3.4 cm8413 24 fr. x 1.7 cm8403 24 fr. x 2.4 cm8404 24 fr. x 3.4 cm

APPENDIX 5

Caloric Density of Parenteral Nutrition, Dextrose and Lipid Solutions

SOLUTION KCAL/mL SOLUTION KCAL/mL(% Dextrose/ %amino acids) (% Dextrose)

10/1 .38 D5 .1710/2 .42 D10 .3410/3 .46 D12.5 .4310/4 .50 D15 .51

D20 .6815/1 .55 D25 .8515/2 .59 D30 1.0215/3 .63 D35 1.1915/4 .67 D40 1.3615/5 .71

20/1 .72 (Lipids)20/2 .76 10% 1.120/3 .80 20% 2.020/4 .8420/5 .88

25/1 .8925/2 .9325/3 .9725/4 1.0125/5 1.05

30/1 1.0630/2 1.1030/3 1.1430/4 1.1830/5 1.22

35/1 1.2335/2 1.2735/3 1.3135/4 1.3535/5 1.39

40/1 1.4340/2 1.4740/3 1.4840/4 1.5240/5 1.56

APPENDIX 6

Table 4 –Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures Situation Agent Regimen*______________________________________________________________________________________________________________________________________Standard general prophylaxis Amoxicillin Adults: 2.0 g:

Children: 50 mg/kg orally1 h before procedure_____________________________________________________________________________________________________________________________________Unable to take oral medications Ampicillin Adults: 2.0 g intramuscularly (IM) or Intravenously (IV):

Children: 50 mg/kg IM or IV within 30 min. before procedure______________________________________________________________________________________________________________________________________Allergic to Penicillin Clindamycin Adults: 600 mg:

Children: 20 mg/kg orally 1 hours before procedure

_____________________________________________________________________________________________Cephalexin† or Adults: 2.0 g: Cefadroxil† Children: 50 mg/kg orally 1 h before procedure Or

____________________________________________________________________________________________Azithromycin or Adults: 500 mg:

clarithromycin Children: 15 mg/kg orally 1 h before procedure____________________________________________________________________________________________________________________________________Allergic to penicillin and unable to Clindamycin Adults: 500 mg:Take oral medications or Children: 20 mg/kg IV < 30 min before procedure

___________________________________________________________________________________________Cefazolin† Adults: 1.0 g:

Children: 25 mg/kg IM/ IV < 30 min pre-procedure

*Total children’s dose should not exceed adult dose†Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticana, angioedema, or anaphylaxis) to penicillins

Table 5 – Prophylactic regiments for Genitourinary Gastrointestinal (Excluding Esophageal) ProceduresSituation Agents* Regimen†

High-risk patients Ampicillin/Gent Adults: Ampicillin 2.0 g intramuscularly (IM) plus gentamicin1.5 mg/kg (not to exceed 120 mg) within 30 min of starting procedure:

6 h later: ampicillin 1 g IM/IV or amoxicillin 1 g orally

Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 g) plus gentamicin 1.5 mg/kg within 30 min of starting procedure:

6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kgorally________________________________________________________________________________________________________High-risk patients allergic to Vancomycin plus Adults: Vancomycin 1.0 g IV over 1-2 h plus gentamicinampicillin/amoxicillin Gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete

injection/infusion within 30 min of starting procedure_________________________________________________________________________________________________________

Moderate-risk patients: Amoxicillin or Adults: amoxicillin 2.0 orally 1 h before procedure, orAmpicillin ampicillin 2.0 g IM/IV within 30 min of starting procedure

Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within 30 min of starting procedure

_________________________________________________________________________________________________________Moderate-risk patients allergic Vancomycin Adults: Vancomycin 1.0 g IV over 1-2 h: complete infusionTo ampicillin/amoxicillin within 30 min of starting procedure

Children: Vancomycin 20 mg/kg IV over 1-2 h: complete infusion 30 min of starting

APPENDIX 7

20 Commandments of Surgical Residency

1. Honesty first.2. See it yourself.3. Do it now.4. Do it yourselfif you know how.5. Do it right the first time.6. Be complete, double check.7. Write it down.8. Don’t trust anyone.9. Don’t complain, fix it.10. Don’t argue with idiots.11. Delegate with discretionyou are still responsible.12. Ask if you don’t know.13. Read about it .14. Anticipate disasters.15. Cover your gluteus.16. Sleep comes last.17. Always be prepared for early or stealth rounds.18. Once on a task, finish it.19. Wash, wash, wash your hands.20. Chew your food.

REFERENCES

A. Textbooks

1. Welch KH, et al. Pediatric Surgery, 4th ed. Chicago: Year Book Medical Publishers, 1986Two volumes, 1547.

2. Holder T and Ashcraft K, eds. Pediatric Surgery, 2nd ed. Philadelphia: Saunders Co., 1993.

3. Raffensperger JE, ed. Swenson's Pediatric Surgery, 5th ed. New York: Appleton-Century-Crofts, 1980.

4. Koop CE. Visible and Palpable Lesions in Children. New York: Grune and Stratton, 1976.

5. Welch KJ, et al. Complications of Pediatric Surgery. Philadelphia: Saunders Co., 1982.

6. Gross RE. The Surgery of Infancy and Childhood. Philadelphia: Saunders Co., 1953.

B. Manuals

1. Leape LL. Patient Care in Pediatric Surgery. Boston: Little, Brown & Co., 1987.

2. Ternberg JL, et al. A Handbook for Pediatric Surgery. Baltimore: Williams and Wilkins, 1980.

3. The Harriet Lane Handbook, 12th ed. Chicago: Year Book Medical Publishers, 1991.

4. Benitz W. The Pediatric Drug Handbook, 2nd ed. St. Louis: MosbyYearbook, 1988.

5. Department of Surgery House Officer’s Manual, Children’s Hospital, Boston, 12th Ed., 2000.