DIVISION OF PEDIATRIC SURGERY HOUSE OFFICERS MANUAL

Childrens Hospital of New York

Edited by Dr. Sam Alaish and Dr. Terry Buchmiller Crair January 2002

INTRODUCTION
The purpose of this manual is to help you get acquainted with some of the special problems in infants and 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 others here who probably do, just ask! Parents are worried and anxious and communication is critical. It will help to be understanding and polite despite the late hour and often-heavy workload. Care plans should be discussed with the fellow or attending before discussion with families to avoid confusion. As a general rule: DO NOT ARGUE with parents. Having a sick child in the hospital is a very stressful situation for most parents and probably 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, especially those children with chronic health problems when there has been frequent contact with the health care system. Problems that occur with parents regarding patient management, questions, etc, should be brought to the attention of the fellows and attending. If a disagreement does occur, a safe response is say I dont know. I will ask Dr. Stolar (or whoever is the childs attending physician). In the long run this will instill parents 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 will be 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 the fellow or attending on call. Never turn anyone anyway or refer to another service without the express instruction 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 future printing of this manual.

TABLE OF CONTENTS
I. II. III. IV. V. VI. STAFF TELEPHONE NUMBERS ............................................................................................... 5 DICTATION.................................................................................................................................. 8 RESIDENT RESPONSIBILITIES .............................................................................................. 10 Protocol for New Residents........................................................................................... 15 CLINICS, CONFERENCES AND ROUNDS............................................................................. 16 GENERAL ADMINISTRATIVE ISSUES ................................................................................. 17 EMERGENCY MANAGEMENT OF THE INFANT AND CHILD ......................................... 22

VII. PERIOPERATIVE MANAGEMENT OF THE INFANT AND CHILD ................................... 27 Fluid Management......................................................................................................... 27 Central Venous Lines .................................................................................................... 28 Gastrostomy................................................................................................................... 31 Tracheostomy ................................................................................................................ 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.......................................................................................................... 43 Foreign 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...................................................................................... 54 Special 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............................................. 84 APPENDIX 2 Pediatric Trauma Score................................................................................................. 85 APPENDIX 3 ETT Sizes...................................................................................................................... 86 APPENDIX 4 Gastrostomy Tubes ....................................................................................................... 88 APPENDIX 5 Caloric Density of Solutions......................................................................................... 89 APPENDIX 6 SBE Prophylactic Regimens......................................................................................... 90 APPENDIX 7 20 Commandments of Surgical Residency................................................................... 91 REFERENCES ...................................................................................................................................... 92

I. STAFF TELEPHONE NUMBERS R. Peter Altman Charles J.H. Stolar Steven Stylianos Jessica J. Kandel William Middlesworth Jeffrey Zitsman Eric L. Lazar Edmund Kessler Samuel M. Alaish Terry L. Crair Nitsana Spigland Carmen Ramos Dorothy Rowe Robert Cowles Surgeon-inChief Chief, Division Director, Trauma Attending Attending Attending Attending Attending Attending Attending Attending Attending Chief Resident Associate Chief Resident CH 116S CH 212N CH 206N CH 214N CH 201S Westchester Babies 203S Long Island, Brooklyn Babies 113N NYH NYH NYH CH 201N CH 201N 5-5804 5-2305 5-8861 5-5871 5-3325 914-7226737 5-0641 516-4989000 5-6110 746-5648 746-5648 746-5648 5-5875 5-5875 917-271-2467 917-271-2513 917-271-2592 917-247-9107 917-271-0500 917-694-8141 917-271-0949 516-337-0702 917-271-1103 746-6700- 30800 746-6700-16519 917-205-8063 917-899-2432 917-899-9161

ADMINISTRATION Sandra Bacharach Division Administrator CH 204N 5-8402 917-902-4658

NURSE PRACTITIONERS Laura Flanigan Jeanne Rubsam Nurse Extraordinaire Trauma Coordinator CH 215N CH 215N 5-8869 5-9911 917-899-6153 917-899-3511

TELEPHONE NUMBERS AT CHILDRENS HOSPITAL-COLUMBIA (To page @ Childrens: Dial 7-5880, enter page # followed by extension) MISCELLANEOUS Admitting Office 5-3023 Childrens OR 5-2415 Scheduling (Add-ons) Engineering Office 5-5175 Ambulatory Surgery 5-8069 Ophthalmology 5-5407 Blood Bank 5-4440 Hospital Pharmacy 5-7180 Blood Donation 5-4440 Page Operator 5-2323 Directed Donor Clinic/DPO 5-8585 Emergency Room 5-6628 Clinical Nutrition 5-4901 Trauma Stat LABS Pathology Stat Lab Virology 5-3333

Bacteriology Chemistry Hematology

5-6276 5-2761 5-6532

5-6719 5-5696 5-9118

OR A OR B OR C OR D OR E OR F

OPERATING ROOM (Front Desk) 5-2415 5-9009 OR Scheduling 5-9879 5-6477 5-6476 Pre-op/Short stay 5-8069 5-6475 5-6473 Recovery Room 5-2418 5-6471

ER Radiology Cardiac Echo CT MRI

5-6501 5-6542 5-5879 7-1243

X-RAYS-5-3320 Nuclear Medicine Ultrasound XRAY File Room Angio/IR

5-2721 5-9113 5-3342 5-5123

5S 6S 6S Nursery 8S 9N (PICU) 9S (PICU) 10 S

5-8730/5-7630 5-7620 5-7623 5-5919 5-3281 5-6591 5-7640

FLOORS 11S CRC 12N (NICU) 12 S (TN, L&D) Pediatric Cath Lab

5-2968 5-6561 5-8982 5-3217

11 S

5-5945 TELEPHONE NUMBERS AT CHILDRENS HOSPITAL-CORNELL To page at NYH, dial 746-6700, enter page # followed by extension

Page Operator Ambulatory Surgery Drug Information Pediatric ER Medical Records MSK Page Operator Ostomy Nurse Main OR Ambulatory OR PACU

746-5100 6-4285 6-0741 6-3300 6-0505 639-7900 6-4709 6-0338 6-5065 6-0336

On-Call Ped Surgery Pathology Peds Reading Room ER Radiology Patient Floors: NICU (6W) PICU (6S) Pediatric Ward (6N) Nursery (7C)

*11836 6-2700 6-2553 6-2630 6-0318 6-0308 6-0309 6-0302

II. DICTATION

Dictation Instructions at Childrens: 1. 2. 3. 4. 5. Dial 568-5530 Enter your 5 digit User ID (your Childrens Hospital ID; precede with a zero if 4 digits) Enter the 2-digit Work Type (01 for discharge summaries; 02 for operative reports). Enter the 7-digit Medical Record Number. 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 eliminate them. After 5 minutes of inactivity, the line will be discontinued. Dictating Functions: 1 2 3 4 5 7 8 Pause Record/Dictate Replay Last Few Words Go to End of Dictation Disconnect from system Reverse to Beginning Start New Report

ALL INPATIENTS MUST HAVE A DISCHARGE SUMMARY. THIS IS THE RESPONSIBILITY OF THE HOUSESTAFF. Format for Discharge Dictations: Dictate in this sequence or you may be asked to repeat the dictation Patient's Age Admit Date Discharge Date Attending Physician Admitting Diagnosis Discharge Diagnosis Chief Complaint History of Present Illness Past Medical History Allergies Social History Family History Physical Examination Laboratory Data Hospital Course Operations (with dates) Procedures (with dates) Discharge Disposition Prognosis Condition on Discharge Follow-up Instructions Discharge Medications Diet Date of Dictation *Send copies to: (referring MDs)

To Look Up Labs at Childrens: From any computer: Type https://webcis.cpmc.columbia.edu Enter User ID Enter Password Then enter the patients medical record #, the patients name or a location.

III. RESIDENT RESPONSIBILITIES 1. Pediatric Surgery Fellows a) The Chief Resident and Associate Chief Resident have independent operating privileges for lifethreatening emergencies only. Neither fellow has admitting privileges. All patients must have an admitting 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/her beeper is always on and he/she is always available for questions and help. He/she must be informed of all admissions and consults. No invasive procedure or major change in the therapeutic management of a patient should be performed without conferring with the Chief Resident or the Associate Chief Resident. 2. Residents a) Every third night in-house call; the on-call residents primary responsibilities are the ER, inhouse 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 and aerodigestive 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 patient will be seen. Phone instructions to obtain x-rays or laboratory studies are discouraged without having first examined the patient. d) All females with abdominal/pelvic pain who may be sexually active must have a pelvic exam by a surgical resident or gynecologist and always with a female nurse present! Never be in a closed room with a female patient without a chaperone. Parents are not chaperones. Patients will not have surgery based solely on a pediatric/medical evaluation. [Please respond promptly when an ER physician desires to perform these exams so they do not require repetition. Remember to check 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 Chief Resident 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 return it to the fellow on call either at the time of consultation or the following morning. Write attending, diagnosis, patient location, referring MD (include address and phone number) and the date 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 Respiratory Cardiovascular Abdomen Neuro Respiratory Cardiovascular GI

Labs and studies Plan for the day

Others

Renal Metabolic/ I.D. Tubes, lines, and drains

A daily progress note is REQUIRED on each patient. The Chief Resident will review and sign all ICU progress notes, including ECMO patients. Write notes in the hospital record for all relevant inpatient events, as well as preoperative 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, ccs/kg/day, kcals/kg/day, total output ccs/kg/hr, stools, NGT, GT, drain output, labs, the P.E. and plan i) Complete all discharge summaries, schedule follow-up appointments and write prescriptions for patients being discharged at the time of discharge (or in the evening the night before for an AM discharge.) 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 direct conversation 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 reviewed with the Pediatric Radiologist. n) Provide operating room coverage as assigned. Residents should be in the O.R. by 7:15 A.M. for first cases. All day surgery and same day surgery patients must be evaluated and consented prior to the scheduled OR time. The Surgical Service should not be the cause of operating room delays. 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 the resident cannot go to Admitting within 10 minutes, another resident should be designated, so that the 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 history and physical on that patient; however, this does not have to be the same H&P that admits the patient to the holding area. q) A resident should scrub on every index case. This is a major learning opportunity not to be missed! 3. On Call Residents a) 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 ERR ON THE SIDE OF TOO MUCH, RATHER THAN TOO LITTLE COMMUNICATION WITH MORE SENIOR RESIDENTS. ALL SENIOR RESIDENTS WILL WELCOME YOUR CALL ANY DAY AT ANY HOUR. ASKING FOR HELP IS NOT A SIGN OF WEAKNESS. 4. Medical Students Periodically, there are medical students rotating from Columbia P & S Medical School and from outside medical schools as well. These medical students are an integral part of the service and their participation is welcomed. Our responsibility as residents is to provide the students with a wide exposure to many topics in pediatric surgery. Participation in the care of patients is proportionate to their level of experience and expertise. Nevertheless, medical students do not have the same obligations to the service as residents. 5. General Surgery Pediatric Nurse Practitioners a) 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, and parental anxiety. Please do not hesitate to call upon them. THEY KNOW A LOT AND CAN BE VERY HELPFUL TO YOU IF YOU ASK. The nurse practitioners are also available to assist residents with their assigned patients when the resident is absent or in the OR. Childrens Hospital Surgical Resident Guidelines: The following guidelines have been developed to assist surgical residents during their rotation at Children's Hospital. 1. CASE ASSIGNMENTS: The OR needs to be aware of the resident assignments. Case assignments are made by the Chief Resident. Assignments may be written on the schedule at the O.R. desk. 2. PRE-OP:

3.

Residents are expected to introduce themselves to patients and family, and identify patient via name 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 to the OR until all paperwork is completed. CONSENTS: For a minor (under 18 years) parents or legal guardian must sign consent. Be aware that foster parents are not always legal guardians, and that social services may be involved. Consents are signed 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 are available for all non-English speaking families. Consent should be obtained in Spanish for Spanish-only-speaking families. WEIGHT: Weight is documented in kilograms only. Do not estimate or round off patient weights. Use weight most recent to day of surgery. X-RAYS: Scheduled surgical x-rays should be obtained by the on-call resident the night before surgery unless 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 must be present in the OR from the time the patient is induced until transfer to the recovery room or ICU. 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. EYEWEAR: Residents must wear appropriate protective eyewear (side protection too) before scrubbing for all cases. HAND WASHING: Hand washing is the single most effective way to prevent the spread of infection and disease. Avoid cross contamination. SHARPS: Sharps protocol must be strictly adhered to. Many staff and environmental service employees are injured by and exposed to infection by improper disposal and handling of sharps. BETADINE: The pediatric patient population is more prone to Betadine burns. When prepping, avoid dripping 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 POST-OP ORDERS: Post-op orders are to be completed at the end of the case and reviewed with either the Chief Resident or the Attending. PATHOLOGY SPECIMENS: Labelling and delivery of all specimens to the correct location is the responsibility of the residentnot the nurse.

4.

4.

5.

6.

7.

8.

9. 10.

PROTOCOL FOR NEW RESIDENTS 1. 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 58402) 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 for the rotation.

IV. CLINICS, CONFERENCES AND ROUNDS AT CHILDRENS 1. General a) Morning Rounds begin PROMPTLY in the NICU at 6:30 A.M., Monday, Tuesday, Wednesday and Friday, 6:15AM on Thursday and 8:00 A.M. on Saturdays and Sundays and holidays. Prerounds must be made by residents. To ensure complete exchange of information without distraction 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 by residents. c) Conferences/Clinics (ATTENDANCE IS MANDATORY) Day Monday (4th of month) Thursday Time 5 PM 7 AM 8 AM 9 AM 12 noon 3 PM 4 PM Scheduled Conference/Clinic Trauma Conference Morbidity and Mortality Radiology-Surgery Conference Clinic Basic Science Conference Grand Rounds Attending ward rounds (CH 1S-McIntosh) (CH 203N) (CH 323N) (CH 106N) (CH 203N) (CH 203N) (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 the clinic. c) All clinic notes including a brief history, physical exam, and plan should be hand written in the chart and reviewed with a Chief Resident or Attending. d) Write diagnosis and follow-up plan on patient encounter form, (e.g., "return to office with abdominal ultrasound in 2 months"). Send patient to front desk with encounter form and appropriate requisitions. Each patient scheduled for surgery should be entered in the logbook. e) The Babies 1 Clinic Staff consists of: 1. Georgia Campbell, Supervisor 2. Carmen Rosado, Physician Aide 3. Esther Rodriguez, Physician Aide 4. Kirsy Grullon, Clerk 3. Ostomy Clinic /Enterostomal Therapy Program a) 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, Gtube 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. The drug dosages vary depending on the age and weight of the patient. Neonatal drug doses can be found in the Neofax manual. b) It is recommended that to decrease the chance of error and to facilitate care, that patients receive the same solution of maintenance and NG replacement; condition permitting (i.e., D51/2 NS with 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 the consulting service. All radiographic studies including ultrasound, CT, MRI, UGI, VCUG need to be arranged by the MD. NPO status will need to be ordered specific to the test. Include requisition in chart. Please indicate in orders or on consultation form what specifically is being requested. 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 before discharge, with pertinent information added on the discharge day. e) Most cases such as hernias, pyloromyotomies, or appendectomies are seen approximately 2 weeks 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 all patients 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 CAN BE 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. Consents a) 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 consent issues (ex. treatment of pregnancy / venereal disease / drug abuse in a minor, care of the mentally incompetent child over 18 years) please contact the hospital's legal counsel. b) Those obtaining consent must have full knowledge of the procedure, including pertinent possible 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 risks 3. Benefits to be reasonably expected 4. Inability of the physician to predict results 5. Irreversibility of the procedure 6. Likely result of no treatment 7. Alternatives including risks and benefits 8. 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 to consent 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 the proposed 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 date of transfusion (surgery) and anticipated blood usage. This should be completed and returned to the Blood Bank Laboratory. d) Children weighing approximately 80 lbs can qualify for autologous donation, unless medical contraindications exist. 8. Child Abuse a) 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 hospital lawyer and social worker can file a Care and Protection Petition requesting temporary placement of the child, until investigation is completed. d) Tell the ER or responsible attending after discussion with the fellow or senior surgical resident of your 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 WARD CORNELL 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 nurses 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 chart 2. Write order on the IV board located at the clerks desk 3. Clerk will fill out the lab slips and place on the IV board 4. Pediatric IV Team to draw the blood the following morning b) For test the next day, but ordered after 5:00 PM 1. Request the test by ordering in the pt chart 2. Write order on the IV board 3. Fill out lab slips 4. Stamp with patient name 5. Mark tests 6. Sign with MD code 7. Attach lab slips to the IV board 8. Pediatric IV Team will draw the blood c) Pediatric IV Team does not draw blood cultures d) 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 IVs c) Write order in the chart d) 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 chief resident is scrubbed, then the intern will communicate with the Pediatric service with assistance from the attendings as needed. This will hopefully help to streamline the communication 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 pressure ventilation. 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 with intubation. Ideally, you should have available suction, suction catheters (12 or 14 Fr.), proper type 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 and for intubation - excluding a history of trauma . Otherwise, flexion of the neck and extension of the head is quite helpful. If there is a history of trauma, do NOT flex/extend the neck until the 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 that you can see the entire laryngeal vault. Do not traumatize the epiglottis. Introduce the endotracheal tube via the right corner of the mouth along the blade (but not through the groove of the blade) to provide an unobscured view. Note below where 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 the subglottis. 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's little finger is equal to the size of the tracheal lumen. Age ETT Preemie 2.5 - 3.0 mm ID Newborn 3.5 mm 13 months 4.0 mm 2 years 4.5 mm > 2 years 4.5 plus age (yrs)/4 mm ID French size Age (yrs) plus 18 Tube length (cm) = 12 plus age (yrs) / 2

a) b) c) d) e) f) g)

e) SEE THE CORDS. Don't pass the endotracheal tube blindly since this may result in esophageal or pyriform sinus perforation. Cricoid pressure may assist in cord visualization and prevention of aspiration f) DO NOT FORCE THE TUBE - Use a smaller one if necessary. Do not push the tube too far to avoid 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 the operating 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 strongly discouraged 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/kg b) PIP / PEEP 25/5 cm H2O c) Rate=30 (titrate) d) FIO2 = 1.0 (titrate). Adjust to keep PaO 2 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 Drugs a) 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 push b) Glucose 50% 1cc/kg IV push c) Ca gluconate 10% 0.5cc/kg IV push d) 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 tachycardia a) Stable: Adenosine 0.1 mg/kg IV b) Unstable: Cardioversion 0.5 - 1.0 joules/kg c) 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 b) Atropine c) Epinephrine

1 cc/kg/IV 0.01 mg/kg IM/IV/Intratracheal 1st dose - 1:10,000 dilution 0.1cc/kg/IV/intratracheal 2nd dose 1:1000 dilution 0.1cc/kg/IV/intratracheal 0.1mcg/kg/min (range 0.1-1.0mcg/kg/min) 0.1-0.3cc/kg =10-30 mg/kg elemental Ca IV (10% soln.)

5 minutes 20 minutes 5 minutes

d) Isoproterenol e) CaChloride f) CaGluconate g) Chloride h) Defibrillation

Infusion 10 minutes

1 cc/kg = 100mg/kg (10% solution) 0.33cc/kg = 30mg/kg 2 J / kg PRN May doubled if ineffective and repeated X 2

13.

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

AGE YEARS
Birth 6 months 1 year 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Height ft in
1 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 8 2 5 9 0 3 6 9 11 2 4 6 8 10 0 2 4 6 7

BOYS cm
45.7 66 73.6 93.8 91.4 99 106.0 114.2 119.3 127.0 132.0 137.1 142.2 147.3 152.4 157.5 162.6 167.6 170.2

Weight lb kg
7.5 17 21 26 31 34 39 46 51 57 63 69 77 83 92 107 116 128 134 3.4 7.7 9.5 11.8 14.0 15.4 17.7 20.9 23.1 25.9 28.6 31.3 34.9 37.7 41.7 48.5 52.6 58.0 60.8

Height ft in
1 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 8 2 5 9 0 3 5 8 11 2 4 6 8 10 0 2 3 4 4

GIRLS cm
50.8 66 73.6 83.8 91.4 99 104.1 111.7 119.3 127.0 132.0 137.1 142.2 147.3 152.4 157.5 169.0 162.6 162.6

Weight Lb kg
7.5 16 20 25 30 33 38 45 49 56 62 69 77 86 98 107 115 118 118 3.4 7.2 9.1 11.3 13.6 15.0 17.2 20.4 22.2 25.4 28.1 31.3 34.9 39.0 45.5 48.5 52.2 53.5 53.5

14. Normal Vital Signs by Age: Age Preemie Newborn 1 month 6months 1 year 2-3 yr 4-5 yr 6-8 yr 10-12 yr >14 yr Weight (kg) 1 2-3 4 7 10 12-14 16-18 20-26 32-42 >50 Heart rate (range/min) 135-145 125-135 120-130 120-130 110-120 100-110 95-105 90-100 85-90 75-85 Resp rate (range/min) 55-65 35-45 25-30 25-30 20-24 16-22 14-20 12-20 12-20 10-14 BP (Sys) (mm HG) 5010 6010 8010 9025 9630 9925 9920 10513 11219 12020

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 in infants (0-1 years of age) and more than 8 hours in children, an IV should be started to give replacement fluids. c) Maintenance fluids: Newborn Day 1: Newborn Day 2:

80cc/kg/d D10W 100cc/kg/d D10 1/4 NS

Older Children: a) 100 cc/kg/d or 4cc/kg/hr for first 10 kg body weight b) 50 cc/kg/d or 2cc/kg/hr for second 10 kg c) 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/day b) K+ 1 - 2.5 mEq/kg/day 3. Calories: a) Term neonate 100 - 120 kcal/kg/day b) Preterm 120 - 130 kcal/kg/day c) Very Low Birth Weight (< 1kg) > 150 kcal/kg/day d) Expect weight gain of 20-30 g/day 4. Estimated blood volume: a) Newborn: 90cc/kg b) Child: 80cc/kg

c) Adult: 70cc/kg d) 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: D5 1/2NS + 20-40 mEq KCL per liter to replace measured loss b) Distal G.I. losses: D5 RL to replace measured losses c) Third space losses: D5 RL + 5% albumin, empirically d) Body Fluid Compositions: If in doubt, send fluid for electrolytes Source Gastric Pancreas Bile Ileostomy Diarrhea Na 70 140 130 130 50 K 10-15 5 5 15-20 35 Cl 120 50-100 100 120 40 HCO3 0 100 40 25-30 50 pH 1 9 8 8 Alk Osm 300 300 300 300

6. Central Venous Lines a) 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. 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.

Lines

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 Not squeeze the glue into the needle until ready to use. Prep the line using alcohol & betadine & lay on 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, you will blow a hole in the catheter, not necessarily outside the patient. Consult the fellow 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 from each 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 back Specific antibiotic coverage when cultures available Indications for catheter removal: Continued local infection after 48 to 72 hrs of specific antibiotics Development 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 CVLs are neutropenic or have other maladies that put them at high risk for other infections. Distinguishing catheter-related sepsis from infection elsewhere can be difficult. 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 the diagnosis of catheter sepsis is made. Candida antigen may be helpful in cases of persistent fever with no obvious source. 2) Blood Cultures: When catheter sepsis is suspected in a patient, at least one, and preferably two, blood cultures should be obtained from venipuncture and from each lumen of the line. The diagnosis of CVL infection is made if peripheral cultures are negative and the line culture is positive. - Make certain the aspiration site is thoroughly disinfected before taking cultures. - Draw blood cultures (min. 1 cc/bottle) through CVL and one or two peripheral sites. - If any drainage is present at the catheter site, it should be cultured and sent for gram stain. Indicate the exact site from which cultures were obtained on the laboratory requisition. 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 the line as inadvertent line fracture may occur. Contact the Chief Resident as a cutdown at the site 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 sterile aspiration from the pocket. NEVER I & D the area over an implantable port. Consult the 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 major abdominal 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 occasionally seen 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 obstruct 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.

the

d) A separate stab wound from the abdominal incision is used to minimize the chance of wound infection 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 the abdominal wall is also recommended. If a Malecot / Foley is used, the tube must be secured starting at the exit site. Pink tape is quite adherent and recommended if the patient is not LATEX ALLERGIC. See a suggested taping method below. A gastrostomy tube that comes out 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 NG (if present) to suction NPO/NPG for 18-24 hrs. Button to gravity until following am In am, remove decompression tube and cap button. 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). Children who can eat safely po may gradually resume oral feeds Home care teaching is provided by the Pediatric Surgery PNP and / or floor nurses. Home care supplies and nursing support is arranged by the Social Worker. Anticipate discharge 2nd post op morning.

PEG for medication administration Resume oral feedings POD 1 and discharge when tolerated Use of button for medications is initiated in 2 weeks as an outpatient. 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 close within 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 still patent. 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 Tube Excessive granulation tissue or redundant gastric mucosa via the tract site can be cauterized with silver nitrate sticks. Protect the surrounding skin with A&D ointment or vaseline. Skin irritation around a leaking gastrostomy site can be treated with Maalox applied topically q46h, 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 bronchoscope or an endotracheal tube. Following the placement of two prolene stay sutures, the trachea is opened longitudinally over the second cartilaginous ring. The stay sutures are labeled R and L and taped to the anterior chest wall to facilitate tube replacement, should the tube dislodge during the first postoperative week. b) Cuffed tubes are rarely used because the cuff can cause serious damage to the trachea, resulting in subglottic stenosis

c) If a child with a new tracheostomy develops respiratory distress, only a moment should be spent suctioning through the tube. If suctioning does not relieve the problem immediately, the tube should be immediately extracted, assuming that it has become dislodged. Pull up on the right and left stay sutures from the OR and insert an endotracheal tube. Another tracheostomy tube or an oxygen carrying catheter can be reinserted more leisurely once the airway has been reestablished. d) Maintenance of HIGH HUMIDITY is essential, as it prevents crusting and plugging. The airway of an infant is so small that retained secretions will quickly lead to airway obstruction and/or pulmonary collapse if good chest physical therapy and suctioning is not done night and day. In addition, a duplicate tracheostomy tube as well as an appropriate sized endotracheal tube should always be at the bedside. 10. Chest tubes: a) Site: For pneumothorax, a chest tube should be placed in the anterior or anterolateral aspect of the 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 thoracic cavity. For an infant, a size 12 French tube is usually used. Larger tubes come in increments of 4 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 clot intact. 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 tubing with needle at a very acute angle to make sure that an adequate tunnel through the tube will be formed when the needle is removed. Once tPA is injected, withdraw needle and cover the puncture site with Tegaderm. Keep tubing upright with respect to patient, but not clamped; to make sure that gravity forces the tPA through the tube. Leave in for two hours 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 air vent on the sump tube will reduce the likelihood of occlusion of the tube - a common complication in small suction tubes. Check position daily, as these are easily carried into the duodenum. c) Change the tube if it is not functioning properly. With an infant in urgent need of gastrointestinal decompression, a large red rubber catheter can be passed through the mouth as an 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 infant feeding 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 air and 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 interventional radiology. 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 with congenital 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 divided q2-3 hours x 3 doses, and perioperative administration of parenteral antibiotics. Check with the attending surgeon to verify their preference. b) Golytely: The product is an isotonic solution of polyethylene glycol and electrolytes. It contains high molecular weight polyethylene glycol which is not absorbed. Golytely is used for colon cleaning preoperatively. The entire infusion of Golytely must be completed before midnight. In comparison to conventional colon cleaning methods (magnesium citrate and clear liquid 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 7.6-10kg 10-20kg 20-30kg 30-40kg 40-50kg >50kg (approx. surface area) 0.5 M2 0.75 M2 1.0 M2 1.3 M2 1.5 M2 1.5M2 Golytely Dosage 80 ml every 10 minutes 100 ml every 10 minutes 140 ml every 10 minutes 180 ml every 10 minutes 200 ml every 10 minutes 240 ml every 10 minutes Total Dose ('up to') 1,100 ml 1,600 ml 2,200 ml 2,900 ml 3,200 ml 4,000 ml

Note: For those children <7.5kg, follow the protocol: Golytely Dosage Weight 7.5 kg Dose 12.5 mL/kg/hr x 4 hrs Total Dose 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 and bradycardia 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 points to 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 in childhood. If an appendectomy is appropriately performed soon after the onset of symptoms, the child 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 a exclusion 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 1015% 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 antibiotic therapy (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 the patient is crying. Be patient. Re-examine. Elevate the baby's feet to relax the abdominal wall and palpate over the spine at the midline. 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 in experienced 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 IVF can 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 may vomit postoperatively as part of the normal postoperative course. d) Postoperative pyloric regimen (to be determined by attending) Sample regimen below: NPO for 6 hrs 15cc Pedialyte PO; if no vomiting then in 2 hrs, start 30 cc Pedialyte PO; if no vomiting then in 2 hrs, start 30 cc 0.5 strength formula PO q 3 hrs x 2; if no vomiting, start 45 cc 0.5 strength formula PO q 3 hrs x 2; if no vomiting, start 45 cc full-strength formula PO q 3 hrs x 2; if no vomiting, start 60 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 immediately adjoining part. a) The common age range is 4 months to 3 years with the highest incidence at age 8 months. If the patient is younger or older, one should be suspicious of a lead point for the intussusception such as a Meckel's diverticulum, or an intestinal polyp. b) The typical triad of colicky abdominal pain, abdominal "sausage-like" mass, and currant jelly stools 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/stool throughout the colon rules out intussusception. If the films cannot rule out intussusception, then an ultrasound is performed. This is followed by an air contrast enema that is diagnostic and in most cases also therapeutic. This must be performed by one of the pediatric radiologists. The following guidelines must be observed: The fellow should see the patient and the usual preoperative preparations should be made 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 IV in 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 into the 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-in of 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.

c) d) e)

f) g)

Fingers of one hand should attempt to fix the hernia while the other hand should press 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 a comfortable position. Try to milk the bowel contents out of the incarcerated bowel, until it "pops" back with the abdomen. Some hernias reduce easily, others require several attempts. 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 to rule out reincarceration. Emergency surgical intervention is required if the hernia cannot be reduced, or if there is postreduction evidence of persistent intestinal obstruction, or nonviable bowel. This is a rare, but possible event. It is imperative to differentiate an incarcerated hernia from a hydrocoele of the cord. Hydrocoele of 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. If unsure, compare palpation on the other side. An unfortunate complication of an incarcerated hernia is hemorrhagic infarction of the testicle. Reduction will usually reinstitute blood flow to the testis. Incarcerated inguinal hernias in girls invariably are sliding hernias containing ovary and tube. If asymptomatic, these can usually be repaired on a semi-elective basis. The blood supply to the ovary is usually not impaired, and the vessels are small in comparison.

the

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 the undescended 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, is essential 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 be performed 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 the toddler 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 performed until 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 "poptops" 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 and mediastinal shift away from the side of the foreign body. The Storz bronchoscope or optical forceps greatly facilitate foreign body removal from the tracheobronchial tree. A complete set of foreign body instruments is available in the O.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 scope beyond 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, the ligament 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 show burns 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 so severe as to require tracheostomy. Symptoms can occur between 1-5h after ingestion. c) Bases (alkali): Include NaOH, KOH, ammonia, electric dishwasher soaps, some denture cleaners, non-phosphate detergents, hair straighteners. These chemicals cause liquefaction necrosis 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; 2-4hmuscularis; 8-12h-perforation. g) PILLS: Can get stuck, adhere, prolonged contact. NSAIDS-hemorrhage and stricture. Potassium Chloride-strictures, hemorrhage, death. Quinidine-strictures. h) Most ingestions occur at home in the kitchen. 85% of esophageal injuries are due to bases; acids tend to injure stomach. Caustic flakes or powder tend to stick and cause localized oropharynx and upper esophagus injury, lead to segmental strictures. Always think about battered child syndrome, Munchausens by proxy (8%). 78% of poisonings occur with pt near parent. Get Social 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. Wait a 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 injurybetween 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 dose steroids. Circumferential burns are more likely to cause strictures. Repeat esophagoscopy is usually performed in 14 days, at which time a dilatation may be performed 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 or hospital Rx. Amount ingested is poor predictor. ? vomit. ? dilution. Establish the need for airway management and consider CXR and KUB if physical exam suggests. 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 over 6 weeks) to decrease infection, exuberant granulation tissue and scar formation. If the burn 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: cautious NGT 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: Swallowed maternal blood Hemorrhagic disease of the newborn Vit K deficiency Thrombocytopenia from multiple causes Anal fissure NEC Malrotation and volvulus Allergic colitis from formula INFANTS 3-18mo: Anal fissure Intussusception Intestinal volvulus Duplication Ectopic gastric mucosa Gastroenteritis TODDLERS and PRESCHOOL: Anal fissure Rectal prolapse Gastroenteritis Meckel`s diverticulum Juvenile polyp Trauma OLDER CHILDREN and TEENS 6-18y Polypoid diseases Ulcerative colitis Hemorrhoids Meckel`s WORKUP Apt test Coags NGT UGI Anal exam KUB, cross table lateral UGI Eosinophilia WORKUP Anal exam Colon study-air or contrast KUB, lat Colonoscopy Meckel's scan for ectopic gastric mucosa Coags NGT WORKUP Coags, NGT Anorectal exam KUB Meckel`s scan Upper and lower endoscopy RBC scan WORKUP Coags, KUB, NGT Upper and lower endoscopy Anorectal exam 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 Marfans Syndrome, scoliosis. Indications for Repair: Severity, psychological & social issues. b) Management Preop: may have any of following: MRI, PFTs, 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 Repair 1. 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 close observation. 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 at waist. 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.

24

5. Clears to diet as tolerated. 6. Drain removed on POD 3 7. Activity: Less restrictive. May bend & turn. Ambulate POD 1. Must wear custom fitted protective vest prior to discharge then continue to wear 18hours/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 the PICU. The Surgical Service is consulted prior to transfer of patients with surgical problems; we accept all transfers of stable patients. It is important to give proper instructions for the safety of the transport. The Chief Resident on-call must be aware of and involved in all transport communication. 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 and sump 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 surgeon of 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 disastrous bleeding and is sometimes overlooked during a difficult delivery of an infant with a congenital problem.

SPECIFIC NEONATAL SURGICAL CONDITIONS 1. 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 nose or 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 gastric distention with further respiratory impairment or gastric perforation. c) Look for VACTERL anomalies. Frequent association with imperforate anus, renal anomalies, and cardiac anomalies. d) If patients 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 lifethreatening pneumonitis. e) An echocardiogram is required urgently (STAT) in all patients to determine whether the child has congenital cardiac anomalies and to ascertain if there is a right or left aortic arch. This helps determine which side a thoracotomy is to be performed. Always remind the cardiology fellow that pressing firmly on the stomach with the echo probe can lead to death by aspiration thru the patent TEF. 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, and malrotation. There are several points to emphasize which are common to all infants with intestinal obstruction. b) BILIOUS EMESIS IN AN INFANT DENOTES DUODENAL OSBSTRUCTION AND ISCHEMIC 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 is suspected. d) On plain films, the newborn colon cannot be distinguished from small bowel because haustral markings are not yet detectable. Only by filling the colon with contrast agent can the dilated loops 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 a gastrografin 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 of dilated 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 minimal or absent with the more proximal atresias. Vomiting usually occurs within the first 48 hours of life. Emesis is bilious except in pyloric atresia and very proximal duodenal atresia. d) Plain films of the abdomen should be obtained in all cases. The double bubble of duodenal atresia is pathognomonic and no contrast study is indicated. When multiple loops of dilated bowel 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 small bowel 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 complex cardiac anomalies. Therefore, all infants with duodenal atresia require a cardiology evaluation prior 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 to ineffective conduction of peristalsis resulting in a functional obstruction. The aganglionic segment may be limited to the rectosigmoid or extend more proximally to involve the entire colon. b) Symptoms are non-specific and include episodic abdominal distension, constipation, obstipation or diarrhea. Symptoms specific to the newborn are the failure to pass meconium in the first 48h after birth. c) A contrast enema, which should be obtained in all cases, may show a transition zone at the narrowed rectum with a dilated colon proximally. However, this finding is often absent in infants. d) The diagnosis is confirmed by suction mucosal rectal biopsy or full thickness rectal biopsy showing an absence of ganglion cells and hypertrophied nerves in the myenteric plexus of the muscularis layer. There is increased acetyl cholinesterase in the aganglionic rectum. The presence of ganglion cells rules out Hirschsprungs disease. e) Hirschsprung's may be managed with rectal irrigations (some patients with distal transistion zones) or a temporary colostomy above the aganglionic segment. The colostomy is usually made at the transitional zone between the normal and aganglionic bowel. Some surgeons prefer a right transverse 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 primary procedure 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 Caucasian community ranges from 1 in 1150 to 1 in 2500 live births. It is extremely rare in non-caucasian communities, except for a known mutation prevalent in our Hispanic population. Males and females are equally affected. b) The diagnosis is suspected in the infant who develops generalized abdominal distention, bilious vomiting, and failure to pass meconium in the first 24 to 48 hours. A family history of cystic fibrosis 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 bubble appearance of the bowel contents. Calcifications on the abdominal film usually indicate meconium peritonitis resulting from an intrauterine intestinal perforation. Microcolon is a highly reliable finding for distal bowel obstruction which may be intraluminal from inspissated meconium or atresia due to uterine volvulus. A contrast enema demonstrates a microcolon with inspissated meconium proximally. A contrast enema is contraindicated if the plain film shows calcifications. 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. This usually results in a rapid passage of semi-liquid meconium which continues during the next 24 to

48 hours. Follow up KUBs are taken at 12 and 24 hours to evaluate progress. Multiple gastrografin enemas are frequently required. f) Operation is indicated in meconium ileus if the gastrografin enema fails to relieve the obstruction, if there are calcifications in the abdominal cavity, if the infant appears too ill to delay 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 to operation since the child has to be at least 2kg or > 72 hours in age. Pilocarpine is a cholinergic drug that stimulates sweat production. This is applied to the skin and a small electrical current is applied 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 of 100 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 a pancreatic 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 in every 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 be midline; the duodenum is anterior and/or lateral to the SMA. Ladds bands are fibrous attachments from the retroperitoneum to the cecum which may obstruct the duodenum. The absence of a ligament of Treitz coupled with a midline cecum results in a narrow vascular pedicle 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. Bloody stools are due to necrosis. 28% have bloody stools. Infants often are acutely ill. Plain x-rays may reveal either a gasless abdomen, dilated intestine suggesting SBO, or duodenal obstruction with a double bubble or normal findings. If uncertain, get UGI to look for position of the ligament of Treitz. c) Midgut volvulus is one of the most serious emergencies seen in the neonate or infant, and delay 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, stool if 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. Ladds 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.

and

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. Close 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 of peritoneum, Whartons jelly and amnion. Gastroschisis is a smooth-edged abdominal wall defect located adjacent to (usually to the right of) a normal umbilical cord. The eviscerated contents are uncovered. b) Hypothermia is usually the immediate life-threatening problem. The sac or exposed intestines should be covered with warm saline soaked sponges, followed by a barrier-type dressing. This can be Steri-drape, Lahey or Linton bag, or Saran wrap to decrease evaporative loss from the moist dressing. A large circumferential dressing is used last. Gauze bandages tend to stick to the bowels and dbride the bowels when removed. c) With gastroschisis in particular, it is essential that the bowel be supported, usually with the baby on its side with the bowel supported by towels, to prevent angulation of the bowel and its mesentery with consequent bowel ischemia. d) Gastrointestinal decompression with an NG tube is imperative to minimize further gastrointestinal distention and prevent the aspiration of gastric contents. A urinary catheter should be placed to decompress the bladder and monitor urine output. A rectal exam should be done with supervision to dilate the anus, helping to evacuate meconium. e) Systemic intravenous antibiotics (Ampicillin/gentamicin) are given to protect contaminated amnion 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 approximately 150 ml/kg/d. g) Rule out associated anomalies, particularly in neonates with omphalocele. Omphalocele is associated with midline anomalies such as cardiac (get ECHO), renal (get renal U/S postoperatively), chromosomal (trisomy 13, 18, 21), Beckwith-Wiedemann (large tongue, gigantism, hypoglycemia), and Downs. Look for imperforate anus. Gastroschisis is associated with 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 kink the 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 the infants will have been fed prior to onset of the disease. The most outstanding clinical feature is bloody diarrhea. Poor feeding, apneic spells, lethargy, abdominal distention, prolonged gastric emptying and bile-stained emesis characterize the disease. d) Etiology: The basic mechanism appears to be circulatory ischemia which results from a stressinduced reflex causing redistribution of blood away from the mesenteric, renal, and peripheral vasculature and towards the heart or the brain. Subsequently, there is invasion of the damaged tissue by bacteria. Prior feeding appears to be a significant factor. It appears that injury to the mucosa, 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. The bowel becomes dilated, hemorrhagic and necrotic. Microscopically, the earliest finding is coagulation necrosis. With increasing severity there is mucosal ulceration, submucosal hemorrhage, 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 and veins is not present. Small blood vessels may be thrombosed, compatible with the intravascular coagulation and hemorrhagic state (frequently seen terminally). f) Radiology: Since the clinical presentation is often nonspecific, radiography is important in early diagnosis, 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 and pneumoperitoneum. 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 it may 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 and therapeutic regimens are directed toward the control of microbiologic agents. NPO, NG suction, broad-spectrum antibiotics (i.e. Ampicillin and Gentamicin) for 10 days 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 2448 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 stoolreducing substances and free water are checked to be sure that the carbohydrate load is tolerated. 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 concentration of feedings. Inability to tolerate increasing osmolarity leads to diarrhea, whereas inability to 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,

milk

no matter what the diagnosis (including CF). Mothers can use breast pumps to obtain 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 pO2 : To decrease pCO2 : 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 older 2. Aminophylline 5mg/kg bolus, 2 mg/kg/dose PO/IV q8h 3. 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 of micropreemie in 1st week of life on large amounts of fluids Treatment includes Indocin 0.2 mg/kg/dose IV q12h x 3 contraindicated in renal failure, NEC, bleeding disorders Other medications: Dopamine: 2.5 20 mcg/kg/min Dobutamine: 5 20 mcg/kg/min Epinephrine: 0.05 1.0 mcg/kg/min Hydralazine: 0.1 0.5 mg/kg/dose IV q 6-8h, or 0.25 1.0 mg/kg/dose PO q6-8h 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 electrolytes Na: 2-4 mEq/kg/d K: 2 mEq/kg/d Ca 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 kg D10 = 100g/L = 100mg/cc D25 = 250g/L = 250 mg/cc

Bili > 5% of body weight needs phototherapy Bili > 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 total PE 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 d Q8h If 30-35 weeks, >14 d if 36-42 weeks, >7d

Gentamicin: for <37 weeks gestation 3mg/kg/q24 For >37 weeks gestation 4mg/kg/q24 Levels: pre <2, post 4-8

Norms for LP Fluid: TermWBC 0-22, Protein 20-170, Glucose 34-119 PretermWBC 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, usually done for retinopathy of prematurity at correct 35 weeks or 4-5 weeks post-natally Meds: Phenobarbital 1020mg/kg load, then 2-5mg/kg/d IV/PO div. q12h Dilantin: same as above Ativan 0.1mg/kg/dose Fentanyl 1-4mcg/kg/dose IV q1-2h or /h continuous gtt MSO4 0.1mg/kg/dose q 3-4h

are

13. Treatment Protocol for Congenital Diaphragmatic Hernia (CDH): a) Overview: The incidence of congenital diaphragmatic hernia is estimated to be between 1 in 2000 and 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 undergone several changes designed to favor delayed surgical repair of the defect and to minimize iatrogenic barotrauma from excessive ventilation. During the initial stabilization period the child receives moderate levels of ventilatory support. If the child cannot be stabilized without 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 O 2 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 situation demonstrates that O2 delivery is poor. If there is no preductal ABG, then O2 sat >90% is acceptable, since a pO2 > 60 corresponds to O2 sats > 90%. Give NaHCO3 1-2mEQ/kg for metabolic 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 minute 3. FiO2=1.0 4. 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, noncerebral perfusion. 2) Permissive hypercapnia: Liberalize pCO2 to maintain pH > 7.25. Try to maintain pCO 2 <60 and pH >7.25. It is preferable to accept pCO2 >60 and use small amounts of NaHCO3 to maintain pH >7.25 (see below), than to increase ventilator settings which elevate mean airway pressures and cause barotrauma. Try to maintain mean airway pressure <12-13 cm 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, which makes 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 by limiting 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, medically refractory respiratory or cardiac failure. At our institution, we focus on respiratory failure in the newborn; however, older pediatric patients and those needing cardiac support are considered candidates under certain circumstances. Indications: A. Neonatal Respiratory Failure 1. Meconium aspiration 2. Persistent Pulmonary Hypertension 3. Congenital Diaphragmatic Hernia a. Pre-ductal saturations near >90%; pO2 < 50 torr b. Pre-op support c. Post-op support B. Pediatric Respiratory Failure C. Sepsis D. Cardiac support 1. Cardiac stun after congenital repair 2. Cardiomyopathy as a bridge to transplant Extracorporeal support can be used for cold water drowning, on an immediate basis for cardiac arrest, and for other, unusual, isolated conditions. We use clinical criteria to place a patient on ECMOusually focused on continued poor respiratory performance while on optimal (not maximal) ventilator support. The Oxygenation Index > 40, prolonged A-a gradient > 600, four hours of pO2 <60 are all used as criteria but there are important caveats beyond the scope of this outline. Contraindications: A. Grade II or greater intracranial hemorrhage B. Congenital/genetic abnormalities incompatible with good outcome a. Downs is no longer considered, a priori, a contraindication C. Prolonged or sustained cardiac arrest D. CDH with severe pulmonary hypoplasia as seen with depressed pre-ductal saturations E. 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 with the ECMO fellow and neonatal staff. The key feature is careful informed consent of the parents who are understandably anxious and fatigued but whose cooperative support is central 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 the NICU at Childrens requesting an evaluation. If the history is that of a rapidly declining respiratory status in the setting of rapidly escalating respiratory therapy strategies, our neonatologist or neonatal fellow 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 and must be ascertained during the phone call with the neonatologist at the referring institution: Demographics: Pertinent History: -Date, time, and location of birth -Parents address, location now, phone numbers (home, cell, pager) -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 lethal defect) -When did symptoms start? -What respiratory therapies were tried? Results? -What data was gathered to initiate or change therapy? ABG's Pre- 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 concentrations and the responsethis data is vital in the overall assessment. Cardiac: -Record type and dose of drips (commonly dopamine and dobutamine as well as epinepherine) -ECHO results (exclude significant cardiac lesions) -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 now floppy is quite worrisome for significant anoxic encephalopathy) Hematologic: Evidence of bleeding (head, see above)

Resuscitation:

Neurologic:

Misc:

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

Once all of the data is gathered, inform the referring nursery that you will return their call after reviewing this data. In conjunction with the ECMO fellow and attending, the above information is assessed in view of the overall respiratory problem. The ideal ECMO candidate has a known, resolvable respiratory problem who has not been ventilated for a prolonged period of time and who has no evidence of anoxic encephalopathy. The more difficult assessments involve children in whom the respiratory problem is not 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 and may be hard to get on the phone but every effort should be made to speak with the mother and the father. In most cases the parents are just learning how sick their baby is and you are now an unfamiliar face from a distant hospital on the phone talking about risks, anticoagulation, and bypass. For the new parent 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 bond that will help guide the parents through this experience. Done well, it is the launch pad to a successful end, even if there is a bad outcome. Start by identifying yourself and state that you represent a team of doctors, naming the attending surgeon and neonatologist. Acknowledge that this is a frightening time but you need to tell them what is going to happen when their child arrives. State that the transport is considered high risk but necessary. Also tell them that sometimes children do get into trouble in the ambulance but that a team of 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 a period of observation may be indicated. State that some babies come here for ECMO but many do not need it. If the child does not meet the criteria for ECMO, we will simply continue with the same types of 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 child on ECMO and this has some risks (stroke, bleeding, arrest). The child is then connected to the circuit which is a set of life support organs that will sustain the baby while the lungs improve. We discuss heparinization and its risks and that the ECMO course may be stopped when the child is improving or sooner 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 the baby 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 the rate-limiting step. Ask the referring center to get both patient and maternal blood in a plain tube for crossmatch. Though the blood can be drawn on arrival, it is faster if it can be sent to the bloodbank the minute the child arrives. Inform the blood bank that they will need three units, stat, for an ECMO circuit. Label the blood with CPMC labels and requisitions and follow all labeling rules to minimize delays. Perfusion: Alert the on call team that an ECMO is in the works. Setting up a circuit depends on the childs history. OR: Inform the OR that a transfer is coming and they may be needed. Keep in touch with the referring physicianonce you have parental permission, the transport team can go and get the babythis is arranged by the NICU upon your advisement. Technique: Cannulation is done at the bedside with an OR team. The patients position on the bed and the placement of the pump must be planned. For example, the side of the bed where the pump is to be located must be the patients rightthis may require turning the patient. The neck is extended (roll under shoulders) and the head turned to the left. The chest and neck are prepped. The patient is given 25-50 mg kg heparin before the vessels are ligated; paralytic is given prior to venotomy. A. Veno-venous 1. One double lumen cannula, usually placed in the RA via an IJ cutdown a. Usual size is 12 French b. Usual depth is RA c. Echo helpful during placement 2. No cardiac support needed 3. Excellent coronary perfusion 4. Flows range 100 to 150 cc/kg/min 5. Recirculation may limit needed flow a. Recirculation increases with increasing heart failure b. Increases with increasing flow 6. Cannula position and cannula characteristics somewhat more finicky 7. Technique of choice in neonates 8. Conversion to VA indicated when perfusion inadequate or cardiac support needed B. Veno-arterial 1. Two cannulas: arterial (carotid) and venous (IJ) a. Usual size is 12 Fr venous, 10 Fr arterial b. Usual depth is 10 cm venous, 7 cm arterial 2. Excellent cardiac support 3. Coronary perfusion is retrograde from arch 4. Carotid ligated (not usually repaired) 5. Technique of choice in most post-op cardiac patients and septic patients

For both of these, percutaneous techniques are available. ECMO Circuit: A. Polyvinylchloride tubing B. "Better bladder" C. Bubble detector D. Pump E. Silicone membrane oxygenator F. Warmer (countercurrent heat exchanger) G. In-line ABG assessment devices The circuit is primed with plasmanate (a balanced electrolyte solution), albumin (pacifies the circuit so that blood products dont 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 kept anticoagulated. Coagulation is assessed by the activated clotting time (ACT) that is measured at 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 conventional 2. 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, etc 2. No other heparin in drips, lines F. Ancef is sufficient antibiotic coverage absent sepsis G. Sedation without paralysis (one dose of paralytic is used during cannulation); goal is spontaneous breathing on low vent settings H. TPN is started on the second day of ECMO; 1. Fat emulsion is safe but is given post oxygenator I. 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 needed K. Volume expansion is achieved by blood first, then LR L. 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 not met. M. Complications:

1. Generalized bleeding. DIC may supervene. Cryoprecipitate and FFP may rarely be needed and should be given post oxygenator. ACT may be kept tighter (closer to 180 than 220). Sepsis should be suspected. 2. Intracranial hemorrhage. May be part of generalized or bleeding or as a result of hypertension. 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 echo b. Recirculation may be too high a fraction of flow c. 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 but if pressures are above 20, rates above 40, and FiO2 > .40 are needed consideration should be given to remaining on ECMO. Certain clinical scenarios may dictate accepting higher than ideal vent settings or lower than ideal saturations. If the patient is bleeding or if there is a worsening neurologic exam, the benefits 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 place b. Cannulae are flushed and clamped; the bypass bridge is opened. c. If child fails trial, the cannulae are unclamped (venous first in VA ECMO) and the bridge clamped. d. If trial is successful, the circuit is discarded Decannulation requires the OR team. The cannulae are removed. Key features of this procedure are: a. Paralysis will be needed to prevent air embolus from spontaneous respiration during vein 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. B. C. D. E.

Head CT VAER's and BAER's EEG if indicated Renal scan if persistent hypertension Appropriate consultation follow-up plans established 1. Neurology 2. Pulmonary 3. Cardiology F. Outpatient care through High-risk neonatal clinic 1. Early intervention as needed G. Feeding may be problematic in CDH patients 1. H2 blockers 2. Motility agents 3. Postural maneuvers during feeds 4. Continuous feeds condensed and transitioned to bolus over time. 5. GI consultation when appropriate

XI. Pediatric Trauma Overview: The Columbia campus of the Childrens Hospital of New York is a designated Regional Pediatric Trauma Center, also known as a Level 1 Pediatric Trauma Center. The Cornell campus is a Level 1 Trauma 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 of the pediatric trauma beepers requires dialing the page operator at #6-3333. The operator should be instructed to page the Pediatric Trauma Team to the ED or the Pediatric ICU. The pediatric trauma beepers are voice-activated beepers that direct staff where to report. After receiving a trauma page you should proceed immediately (within 5 minutes) to the Pediatric ED or Pediatric ICU. Phone numbers of 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 Director Pediatric Surgery Attending Pediatric Surgery Fellow General Surgery PGY 5* Pediatric Surgery Junior Resident Pediatric Intensive Care Unit Charge Nurse Anesthesia Resident/ Babies Hospital* Anesthesia Team Captain/ Milstein Hospital * Radiology Supervisor/Technician Trauma Nurse Coordinator/ Nursing Supervisor *During the evening/night/weekend hours the following changes occur: *General Surgery PGY 5 When the Pediatric Surgery Fellow or Attending is not in the hospital, the in-house PGY 5 general surgery resident will carry the pediatric trauma beeper. They will respond to pediatric trauma team activations and provide senior surgical support until the Pediatric Surgery Fellow or Pediatric Surgery Attending arrives. *Anesthesia From 8:00 pm-4:00 pm the pediatric trauma beeper will be carried by the anesthesia resident assigned to the Babies Hospital operating room. From 4:00 pm- 8:00 am the pediatric trauma beeper will be carried 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 meets the 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 above criteria. Any time an injured patients condition changes, the Pediatric Trauma Team can be activated by calling the page operator at 6-3333. Roles and Responsibilities: Emergency Department Team - Directs the initial management of pediatric patients until the surgical Team Leader arrives. A child with multiple or serious injuries must be managed by one identifiable surgeon-in-charge, usually the senior surgical resident. This individual is responsible to supervise the total management of the patient and coordinates the activation of various specialty services consulting on the patients care. Team Leader- General Surgery PGY 5/Pediatric Surgery Fellow or Pediatric Surgery Attending

Note: The Pediatric Emergency Department Attending Physician will assume the role of team leader until 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 patients bed and assume complete responsibility for the coordination and direction of the entire trauma team. The team leader will establish the priority of diagnosis and define the order of therapy. Performs or supervises the primary survey including immobilization of the C-spine during transfer 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 upon admission 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 transfer to 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 children with possible neurotrauma at the request of the Trauma Team leader. The Pediatric Neurosurgery service will be the primary consultation service expected to respond immediately 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 BREATHING CIRCULATION DISABILITY EXPOSURE Follow algorithm A Follow algorithm B Follow algorithm C Brief neurologic exam Remove all clothing Keep in mind thermoregulation May use heat lamps and warm IV fluids

IV Access Two large bore IVs 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 IVs. 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 PRBCs (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 of potential GU injury. DO NOT insert a foley catheter if urethral injury suspected. See chart below for foley catheter size.

Tube Sizes: IV Catheter Infant Young Child Older Child NG / Foley Infant Child Adolescent Thoracostomy Tube Neonate 6 m-18 m. 1-3 yr. 4-7 yr. 8 12 yr. Adolescent

20-22 g. 18-20 g. 16-18 g. 8 Fr. 10 Fr. 14 Fr. 10-12 Fr. 12-14 Fr. 16-20 Fr. 20-24 Fr. 28-32 Fr. 28-40 Fr.

Approximate Measurements: Weight: Age (years) x 2 + 8 = # in kgs Blood 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 scan o IVP, cystogram, urethrogram o Arteriogram A cross table C-spine will be obtained (with appropriate stabilization precautions) at the request of the Trauma 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-ray need not be cleared prior to obtaining urgent films. The trauma team members will position all patients without C-spine clearance for subsequent X-rays. The final decision to discontinue C-spine immobilization will be made by the Trauma team leader. It is expected that all patients return from radiology with immobilization in place. Children with obvious extremity fractures may require fracture X-rays within the resuscitation area if not stable for transport. Otherwise extremity and facial films should be obtained only after resuscitation and stabilization. These films should be obtained in the Radiology Department whenever possible. Only patients with abdominal crush mechanisms such as handlebar injuries or lap belt injuries should receive 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 tenderness or paresthesia? YES Go to UNRELIABLE algorithm

NO Is there pain or paresthesia with collar off during passive range of motion? Yes Replace collar No

Obtain lateral C spine xray Lateral films (x2) not adequate as per Radiology Swimmers view for Clearance C6-T1

Films adequate as per Radiology C-Spine cleared Neurosurgery consult Flexion/Extension films Remove collar

Injury noted? YES

NO Injury noted? YES Treatment per Neurosurgery

Neurosurgery consult

NO

C- Spine cleared Remove 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 distraction 2. 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 scan

Injury noted?

YES

NO

Neurosurgery consult

Collar remains in place HOB not to be elevated > 45 degrees Is child awake/ alert within 24 hours?

YES Go to reliable algorithm

NO 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 Volume Loss 25%-45% Blood Volume Loss Weak thready pulse; tachycardia Change in level of consciousness, dulled response to pain Cyanotic, decreased capillary refill, cold extremities Minimal urine output >45% Blood Volume Loss Hypotension; bradycardia Comatose

Cardiac

Increased heart rate Lethargic, irritable, confused Cool, clammy

CNS

Skin

Pale, cold

Kidneys

Decreased urinary output;increased specific gravity

No urinary output

Algorithm for Management of Shock in Children:

Signs of Shock? NO Exit algorithm YES Initial LR bolus 20 ml/kg External hemostasis if open laceration

Are there continued signs of shock? NO Moderate to severe head injury?? NO Maintenance fluid YES 2/3 maintenance fluid Are there continued signs of shock? NO Exit algorithm YES Type specific or O neg blood 10 ml/kg PRBC or 20 ml/kg whole blood Is there ongoing blood loss?? NO Thorax / Abdomen If arrest: Open thoracotomy in ED If stable: Thoracotomy or laparotomy in OR YES Pelvic Arteriography or External Fixation in OR YES Repeat 20ml/kg LR

Child Abuse: The suspicion of child abuse must always be kept in mind when caring for injured children. Suspected abuse 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 for assistance: Monday-Friday 8:00am- 4:00pm Child Abuse Supervisor Columbia-Beeper 5002 Cornell-61306 24 hours day/ 7 days week Child Protection Beeper Columbia -Beeper 3935 Cornell-Beeper 30644 Social Work Administrator on call Columbia-Beeper 2812 Cornell-Call page operator Spleen/Liver Trauma Most isolated spleen/liver injuries are treated nonoperatively. Spleen/liver injuries are graded by the radiologist following an abdominal CT scan using the following Abdominal Injury Grading Scale: Spleen Injury Scale
Grade I. Hematoma Laceration II.Hematoma Laceration Injury Description Subscapsular <10% surface area Capsular tear, <1 cm parenchymal depth Subscapsular, 10-50% surface area;intraparenchymal,<5cm in diameter 1-3 cm parenchymal depth which does not involve a trabecular vessel I.

Liver Injury Scale

Grade Hemaotoma Laceration Hematoma Laceration Injury Description Subscapsular <10% surface area Capsular tear, < 1cm parenchymal depth Subscapsular, 10-50% surface area;intraparenchymal, <10 cm in diameter 1-3 cm parenchymal depth, <10 cm in length Subscapsular,>50% surface area or expanding; ruptured subscapsular or parenchymal hematoma Intraparenchymal hematoma >10 cm or expanding > 3cm parenchymal depth Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Couinauds segments within a single lobe Parenchymal disruption involving >75 % of hepatic lobe or > 3 Couinauds segments within a single lobe Juxtahecatic venous injuries:ie. retrohepatic vena cava/central major hepatic veins

II.

III .Hematoma Subscapsular,>50% surface area or expanding; ruptured subscapsular or parenchymal hematoma Intraparenchymal hematoma>5 cm or expanding Laceration > 3 cm parenchymal depth or involving trabecular vessels

III.

Hematoma

Laceration Laceration

IV. Laceration Laceration involving segmental or IV. hilar vessels producing major devascularization(>25% of spleen) V. Laceration Completely shattered spleen V.

Laceration

Vascular

Hilar vascular injury which devascularizes spleen

Vascular

VI.

Vascular

Hepatic avulsion

Once an isolated injury has been graded, the following algorithm of care is used: CT Grade ICU LOS Hospital LOS Pre-discharge imaging Post-discharge imaging Time of restricted activity / post-injury visit I None 2 days None None 3 weeks II None 3 days None None 4 weeks III None 4 days None None 5 weeks IV 24 hrs 5 days None None 6 weeks

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 Streptococcus pneumoniae and Haemophilus influenzae type b. Patients must be started on antimicrobial prophylaxis upon discharge. The current recommendation is: Oral Penicillin V 125 mg PO BID 250 mg PO BID Children less than 5 years 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 meningococcal vaccine. Parents should be instructed to follow-up with their pediatrician for vaccine administration.

APPENDIX 1 Modified Glascow Coma Scale for Infants and Children

Child Eye Opening Spontaneous To verbal stimuli To pain only No response Oriented, appropriate Confused Inappropriate words Incomprehensible/nonspecific Words/sounds No response Obeys commands Localizes painful stimulus Withdraws in response to pain Flexion in response to pain Extension in response to pain No response Infant Spontaneous To verbal stimuli To pain only No response Coos and babbles Irritable cries Cries to pain Moans to pain No response Moves spontaneously and purposefully Withdraw to touch Withdraws in response to pain Decorticate posturing (abnormal flexion) in response to pain Decerebrate posturing (abnormal extension) in response to pain No response Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Verbal response

Motor response

APPENDIX 2 Pediatric Trauma Score

PTS Component Size Airway Systolic BP CNS Open Wound Skeletal fxs +2 >/= 20 kg Normal > 90 mm Hg Awake None None +1 10-20 kg Maintainable 90-50 mm Hg Obtunded/ Hx LOC Minor Closed < 10 kg Unmaintainable < 50 mmHg Coma/decerebrate Major/penetrating Open/multiple -1

APPENDIX 3 ETT Sizes ETT Jackson 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 8.0 -00 0 1 2 3 4 5 6 7 8 mmOD 4.3 5.0 5.5 6.0 7 8 9 10 11 12 13.3 Fr 13 15 16.5 18 21 24 27 30 33 36 39.9 Holinger 00 0 1 2 3 4 5 6 7 8 Shiley NT 00x30mm 0x32mm 1x34mm 2 3 4 -----PT 00x39mm 0x40mm 1x41mm 2x42mm 3x44mm 4x46mm -----SCT ----5x58mm 6x67mm -7x80mm 8x89mm 9x99mm 10x105mm

Bivona makes a line of adjustable trach tubes that look like reinforced ETT tubes with a sliding flange. Trachestomy Sizes TYPE Shiley Neo SIZE 00 0 1 00 0 1 2 3 4 4 6 8 10 000 00 0 1 2 3 4 5 ID 3.1 3.4 3.7 3.1 3.4 3.7 4.1 4.8 5.5 5.0 7.0 8.5 9.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 OD 4.5 5.0 5.5 4.5 5.0 5.5 6.0 7.0 8.0 8.5 10.0 12.0 13.0 4.0 4.7 5.4 6.0 6.6 7.3 7.8 8.5 LENGTH 30 mm 32 34 39 mm 40 41 42 44 46 67 mm 78 84 84 31 mm 32 34 36 40 46 50 54

Ped

Adult

ARGYLE

PORTEX

3.5 4.0 4.5 5.0 5.5

3.5 4.0 4.5 5.0 5.5

5.8 6.5 7.1 7.7 8.3

40 mm 44 48 50 55

Tracheostomy Sizes TYPE Shiley Cuff SIZE 6.0 7.0 8.0 9.0 3.0 6.0 6.0 7.0 000 00 0 1 2 3 4 5 6 2 3 4 5 ID 6.0 7.0 8.0 9.0 3.0 6.0 6.0 7.0 2.1 2.4 2.9 3.0 3.3 4.4 5.3 6.1 7.1 3.3 4.4 5.3 6.1 OD 8.3 9.7 11.0 12.0 5.2 8.0 8.3 9.7 4.5 5.0 5.5 6.0 7.0 8.0 9.0 10.0 LENGTH 55 mm 75 82 87 36 mm 36

Special Talking METAL

33 mm 33 33,40 33,40 33,40 33,50,55 55 68 68 46 50 50 63

HEALYCOTTON

Bronchoscope Sizes Storz SIZE/ID 2.5 3.0 3.5 3.5 3.7 4.0

OD 4.0 5.0 5.7 6.0 6.1 7.1

LENGTH 20 cm 20 20 30 26 30

APPENDIX 4 GASTROSTOMY TUBES MIC TUBES (clear plastic tubes that extend out from abdominal wall 6" and have an access port to inflate balloon with H20 or NS and 1 or 2 ports for gastric and/or jejunal feeds. GS # 8431 8432 8427 8428 8429 8430 SIZE 12 Fr. 14 Fr. 16 Fr. 18 Fr. 20 Fr. 24 Fr.

MIC-KEY TUBES (skin level device that has a round clear plastic flange that anchors onto the skin with a side access port to inflate the balloon with H20 or NS. GS # 8419 8420 8421 8422 8423 8424 8425 8426 SIZE 14 fr. X 1.2 cm shaft length 14 fr. x 1.7 cm 14 fr. x 2.0 cm 16 fr. x 1.7 cm 16 fr. x 2.0 cm 18 fr. x 1.7 cm 18 fr. x 2.0 cm 18 fr. x 2.5 cm

BARD BUTTONS (skin level device that has a firm mushroom-shaped end (not a balloon) anchoring it on the stomach wall. A metal obturator or stylet is needed to stretch out the mushroom end to replace and/or remove. GS # 8400 8401 8402 8413 8403 8404 SIZE 18 fr. x 1.7 cm shaft length 18 fr. x 2.4 cm 18 fr. x 3.4 cm 24 fr. x 1.7 cm 24 fr. x 2.4 cm 24 fr. x 3.4 cm

APPENDIX 5 Caloric Density of Parenteral Nutrition, Dextrose and Lipid Solutions SOLUTION KCAL/mL (% Dextrose/ %amino acids) 10/1 10/2 10/3 10/4 15/1 15/2 15/3 15/4 15/5 20/1 20/2 20/3 20/4 20/5 25/1 25/2 25/3 25/4 25/5 30/1 30/2 30/3 30/4 30/5 35/1 35/2 35/3 35/4 35/5 40/1 40/2 40/3 40/4 40/5 .38 .42 .46 .50 .55 .59 .63 .67 .71 .72 .76 .80 .84 .88 .89 .93 .97 1.01 1.05 1.06 1.10 1.14 1.18 1.22 1.23 1.27 1.31 1.35 1.39 1.43 1.47 1.48 1.52 1.56 SOLUTION KCAL/mL (% Dextrose) D5 D10 D12.5 D15 D20 D25 D30 D35 D40 (Lipids) 10% 20% .17 .34 .43 .51 .68 .85 1.02 1.19 1.36

1.1 2.0

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 childrens 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) Procedures Situation Agents* High-risk patients Ampicillin/Gent

Regimen

Adults: Ampicillin 2.0 g intramuscularly (IM) plus gentamicin 1.5 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/kg

orally ________________________________________________________________________________________________________ High-risk patients allergic to Vancomycin plus Adults: Vancomycin 1.0 g IV over 1-2 h plus gentamicin ampicillin/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, or Ampicillin 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 infusion To 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. Dont trust anyone. 9. Dont complain, fix it. 10. Dont argue with idiots. 11. Delegate with discretionyou are still responsible. 12. Ask if you dont 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. 2. 3. 4. 5. 6. Welch KH, et al. Pediatric Surgery, 4th ed. Chicago: Year Book Medical Publishers, 1986 Two volumes, 1547. Holder T and Ashcraft K, eds. Pediatric Surgery, 2nd ed. Philadelphia: Saunders Co., 1993. Raffensperger JE, ed. Swenson's Pediatric Surgery, 5th ed. New York: Appleton-CenturyCrofts, 1980. Koop CE. Visible and Palpable Lesions in Children. New York: Grune and Stratton, 1976. Welch KJ, et al. Complications of Pediatric Surgery. Philadelphia: Saunders Co., 1982. Gross RE. The Surgery of Infancy and Childhood. Philadelphia: Saunders Co., 1953.

B. Manuals 1. 2. 3. 4. 5. Leape LL. Patient Care in Pediatric Surgery. Boston: Little, Brown & Co., 1987. Ternberg JL, et al. A Handbook for Pediatric Surgery. Baltimore: Williams and Wilkins, 1980. The Harriet Lane Handbook, 12th ed. Chicago: Year Book Medical Publishers, 1991. Benitz W. The Pediatric Drug Handbook, 2nd ed. St. Louis: MosbyYearbook, 1988. Department of Surgery House Officers Manual, Childrens Hospital, Boston, 12th Ed., 2000.