Pediatric Protocols St Stephens Hospital Delhi

Department of Pediatric St Stephens Hospital, Delhi


Pediatrics Protocols

Pediatric Handbook



3rd Edition


Department of Pediatrics and Neonatology

St Stephens Hospital
Tis Hazari
Delhi 110054





Preface


This protocol was prepared by Dr Neetu Vashisht, building on the work of previous editions and the work of Dr R S Beri, Dr Nirmal Kumar, Dr Vineet Tyagi and Dr Jyotsna James.
The First Edition was published in 2003 and the Second Edition in 2004. This third edition has been a long time coming.

The 3rd edition is in the format of a web-based-protocol that allows up-dating and ever-greening. We will appreciate comments and suggestion for corrections at all times. You can send these to Puliyel@gmail.com

This book of protocols adapts some standard protocols laid out by others, but elsewhere it merely accepts them without change. Acknowledgement in each instance would by unwieldy. References are quoted mostly for controversial recommendations only.

We changed the title for this edition. It is hardly a book of protocols. It is more a handbook – a ready reckoner. We used the ‘dummy yardstick’ to decide what goes into the book and what goes out. Instructions were simplified that we could understand them ourselves. The new book of protocols is called – Pediatric Handbook



Jacob Puliyel
Feburary 2011

















Contents
Drug Infusions 3
Status Epilepticus 6
Status Asthamaticus/Ventlation 7
Ventilation and ARDS Management 9
Peritoneal dialysis 11
Septic Shock 12
Hypokalemia ( <3.5 mEq/l ) 133
Hyperkalemia (>6 mEq/l) 144
Hyponatremia (Sodium <130 mEq/l) 155
Hypernatremia 166
Hypocalcemia 177
Rapid Sequence Intubation 188
Neonatal Hypoglycemia 199
TPN 20
Dengue 21

Antibiotic Guidelines 23

Miscellaneous 24




Drugs and Infusions


DRUG

DOSE
CONCENTRATION
IN VIAL
DILUTION
INFUSION RATE
DOPAMINE

5-20
microgms/kg/min 40mg/ml (Wt × 6× 3) mg dilute in 30 ml NS 1ml/hr =10mcg/kg/min
DOBUTAMINE

5-20
microgms/kg/min 25mg/ml (Wt × 6× 3) mg dilute to 30 ml NS 1ml/hr =10mcg/kg/min
ADRENALINE

0.1-1
microgms/kg/min 1mg/ml (Wt × 0.6) mg dilute in 10 ml NS 1ml/hr =1mcg/kg/min
FENTANYL

1-4
microgms/kg/hr 50 micrograms/ml (Wt × 40) mcg dilute in 40 ml NS 1ml/hr =1mcg/kg/hr
MORPHINE

10-20
microgm/kg/hr 15 mg/ml (Wt × 0.5) mg dilute in 50 ml 5% Dextrose 1ml/hr =10mcg/kg/hr
MIDAZOLAM

1-24
microgms/kg/min 5 mg/ml (Wt × 0.6×5) mg dilute in 50 ml NS 1ml/hr =1mcg/kg/min
VECURONIUM 1.5-2.5mic/kg/min or o.09-0.12mg/kg/hr As powder, 10 and 20 mg, dilute 10 mg vial in 2 ml NS (i.e 5mg/ml) (Wt X0.6 X 5 ) mg dilute in 50 ml NS 1ml/hr = 1 mcg/kg/min
NOREPINEPHRINE


0.1-1
microgms/kg/min 1mg/ml (Wt × 0.6) mg dilute in 10 ml NS 1ml/hr =1mcg/kg/min

VASOPRESSIN 0.02 to 0.06 unit/kg/hour 20 units / ml 1 unit/kg in 50 ml 5% dextrose 1-3 ml/hour
MILRINONE Load 0.5 mcg/kg in 10 minutes follow by
0.375 to 0.75mcg/kg/min 1mg/ml Wt X 0.6 mg dilute in 10 ml NS 1ml/hr = 1 mcg/kg/min
PROSTAGLANDIN 0.05-0.1
microgms/kg/min

May need to go up to 0.4 microgram/kg/min 0.25mg/ml or 250mcg/ml or 500mcg/ampoule
( 1 ampoule = 2ml = 0.5mg ) (Wt × 0.6 × 0.3) mg dilute in 30 ml NS
Works well for babies less than 2.5 kg.
---------------
For 5 kg child add to 15 ml NS
(Wt × 0.6 × 0.15)
----------------
For 4 kg child add to 20 ml
(Wt × 0.6 × 0.2)
------------------
For 3 kg child add to 25 ml
(Wt × 0.6 × 0.25)
1ml/hr
=0.1mcg/kg/min




NITROGLYCERINE 0.5mcg/kg/minute - 5mcg/kg/minute
Increase every 5 minutes 5mg/ml (10 ml vial = 50 mg) (Wt × 0.6) mg dilute in 10 ml dextrose 1ml/hr =1mcg/kg/min
Start at 0.5ml/hour. Increase every 5 minutes by 0.5ml/hour
NITROPRUSSIDE 0.3mcg/kg/minute to 4mcg/kg/minute 25mg/ml (Wt X 0.6 X 3) mg dilute in 30 ml 5%D 1ml/hour =1mic /kg/min
KETAMINE



Ketamine IM 5-20 mic/kg/min 50mg/ml Wt X 3 X 3 mg dil in 30 ml NS


1.5 to 2 mg/kg IM X 1 dose 1 ml/hr= 5 mic/kg/min
SILDENAFIL






Bosentan


Niedipine


Amlodipine 5-8mg/kg/day given
8 hourly

1mg/kg/dose tid
(IJP 2015: page 1131)


2mg/kg BD


2-5 mg/kg/day in 3 divided doses

2.5 – 5 mg/kg/day in BD doses Available as tablets , suspension to be made from pharmacy , as desired
Adenosine (SVT) 0.1mg/kg
(max 6 mg as first dose).

Repeat with 0.2mg/kg if needed - in absence of response (max 12 mg as repeat dose) 3mg/ml(2ml ampoule) To be administered as rapid IV push followed by NS flush.

Dilute 1ml adenosine in 2 ml normal saline as stock solution. (1mg/ml)

USE 0.1 to 0.2 ml per Kg
Amiodarone (SVT) 5mg/kg IV in 10-30 minutes.
Repeat if needed.

Followed by continuous infusion of 5 mic/kg/min upto a max of 10mic/kg/min 50mg/ml For infusion:
Wt X 3 X 3 mg dilute in 30 ml NS 1 ml/hr= 5 mic/kg/min

Lignocaine Loading dose:1mg/kg followed by continuous infusion of 20-50mic/kg/min 100mg/5 ml or 20mg/ml For infusion
Wt X 3 X 12 mg dilute in 30 ml NS 1 ml/hr= 20 mic/kg/min
Procainamide (SVT) Loading dose :10-15mg/kg max of 1g over 30 to 60 minutes.

Followed by continuous infusion of 30-80mic/kg/min 100mg/ml or 500mg/ml For infusion
Wt X 4.5 X 12 mg dilute in 30 ml NS 1 ml/hr= 30 mic/kg/min
Aropine 0.02mg/kg (min 0.1mg, max 0.5 mg in smaller children and 1mg in adolescents) 0.1mg/ml
Digoxin LOADING DOSES

Preterm neonate
IV: 15-30 mic/kg,
Oral:20-30mic/kg

Term neonate
IV: 20-30mic/kg,
Oral: 25-35mic/kg

1-2 Years
IV: 30-50 mic/kg, Oral:40-50mic/kg

2-5 Years
IV: 25-35mic/kg, oral:30-40mic/kg

5-10 Years
IV: 5-30 mic/kg,
Oral: 20-35mic/kg

Give half dose stat followed by ¼ dose twice in 8-12 hrs MAINTAINENCE DOSES

Preterm neonate
IV: 4-9- mic/kg/day Oral: 4-12mic/kg/day

Term neonate
IV: 6-8mic/kg/day Oral: 6-10mic/kg/day


1-2 Years
IV: 8-10 mic/kg/day Oral: 10-15mic/kg/day

2-5 Years
IV: 6-8mic/kg/day, Oral: 8-10mic/kg/day

5-10 Years
IV: 4-8 mic/kg/day, Oral:5-10mic/kg/day
Divide oral maintenance doses in 2 doses to 4 doses Available as

Inj:100,250mic/ml

Elixir: 50mic/ml
Carnitine 50 mg/kg as loading dose followed by 50mg/kg/day as maintenance in 4 or 6 divided doses 100mg/ml solution for oral use or 200mg/ml for IV use
Baclofen 2-7 years age oral route: 10-15 mg/day, titrate to effect and increase every 3 days by 5-15mg/day

8 years age: Titrate to effect, max dose of 60mg/day Available as tablets in strengths of 10,20 mg
Enoxaparin
(Low molecular weight Heparin) Prophylaxis in > 2 months age for DVT or pulmonary embolism: 0.5mg/kg SC
in 2 divided doses

Treatment of the same:
1mg/kg SC in 2 doses.

Titrate to desired anti factor Xa level
(0.1-1u/ml)

Do not administer IV or IM 100mg/ml only for
Sub Cutaneous administration only
Levothyroxine 0-6 months:8-10mic/kg/day

6-12months:6-8mic/kg/day

1-5yrs:5-6mic/kg/day

6-12yrs:4-5mic/kg/day

>12yrs:2-3mic/kg/day Tablets strengths:
25, 50, 75, 100, 125, 150, 175, 200, 300 mcg
Enalapril Start with oral dose of 0.1mg/kg/day in 2 divided doses
(max 5mg)

Titrate upto 0.5mg/kg/day in 2 divided doses
(max 40mg/day) Available as tablets in strengths of 2.5, 5, 10, 20 mg.
Nifedipine 0.6-0.9mg/kg/day PO in 2 or 4 div doses

Hypertensive emergency:
0.25-0.5 mg/kg/dose PO/Sublingual
(max 10 mg)
can repeat in 4-6 hrs Available as capsules 10, 20 mg
Read “add in 30 ml NS” to mean:
Add drug to normal saline (NS) to reach desired volume of 30 ml.
Similarly for Dextrose (D).

Status Epilepticus

• Oxygen
• Dextrose infusion


0-5 Minutes IV Lorazepam in doses of 0.1 mg/kg/dose
Or Medazolam 0.2mg/kg/dose
5-10 Minutes Repeat above dose of IV Lorazepam or Medazolam
10-30 Minutes
IV Phenytoin in dose of 20mg/kg (1g max) (over 20 minutes) @ 1mg/kg/min
OR
Inj Fosphenytoin dose 20 mg/kg of Phenytoin equivalents.
(Can be infused three times faster @ 3 mg/kg/min)

35 Minutes Loading dose of Inj Valproate 30 mg/kg (1:1 dilution in NS over 10 minutes)
OR
Inj Phenobarbitone @ 20 mg/kg ( @1mg/kg/min)
OR
Inj Leveteriacetam @20-30 mg/kg (@ 5 mg/kg/min )
If Responds
45 Minutes If response is seen to Valproate:
Follow the loading dose by continuous infusion @ 5 mg/kg / hour
(till 6 hours seizure free period) and taper by 1 mg/kg/hr every 2 hrs.
Start maintenance dose of Valproate @ 10 mg/kg/dose 8 hourly when tapering Valproate.
No response
45 Minutes Consider elective intubation at this juncture.
Propofol infusion 2-5 mg/kg IV bolus followed by 1-4 mg/kg/hr
OR
Midazolam Infusion 2-24 mcg/kg/min
(after 24 hr seizure free period taper by 1 mic/kg/min every 3 hours)
OR
Thiopentone infusion Of 2-4 mg/kg bolus followed by 2-4 mg/kg/hr infusion
(Titrate with EEG, increments of 1 mg/kg/hr every 30 minutes upto max of 6 mg/kg/hr or till burst suppression pattern attained)
• Reduce Intra cranial tension
 Mannitol
 Hypertonic saline
 Diuretics
 Hyperventilate

ACTH 0.04-0.06 mg (1.6-2.4 IU)/kg/day and a total ACTH dose of 1.1-1.5 mg (44-60 IU)/kg resulted in better mental development than smaller doses of ACTH (Ito M Pediatr Neurol. 1990;6:240-4.



Status Asthamaticus

Oxygen + Nebulised beta agonists + IV Steroids + inhaled Ipratropium bromide

IV Hydrocort @10mg/kg loading dose followed by maintenance dose of 5mg/kg/dose Q 6 hourly
OR
IV Methylprednisolone @ 2mg/kg as loading dose followed by
maintenance dose of 0.5 – 1 mg/kg Q 6 hourly
Reassess in 1 hour

Good response
No response

PICU Transfer

IV Terbutaline in bolus dose of 10 mcg/kg in 30 minutes
followed by IV infusion of 0.1-4 mcg/kg/min
OR
SC Terbutaline 0.005mg/kg 6 hourly (max 0.3 mg)
(It is to be noted that the sc and iv preparations of terbutaline are separate and cannot be interchanged for administration )
OR
IV Salbutamol 15mcg/kg IV bolus over 10 minutes
(Reference: Ped Critical Care Med 2002)
OR
IV Magnesium Sulphate 25-75 mg/kg as infusion over 20 Minutes
Dilute to 30 ml (D5 OR N/5 )
(max dose is 2 – 2.5 g/dose )
OR
IV Aminophylline (with O2 on flow) at loading dose of 5-6 mg/kg followed by infusion @ following rates:
2 – 6 months: 0.4 mg/kg/hr
6 – 11 months: 0.7 mg/kg/hr
1 – 9 year: 1 mg/kg/hr
9 – 12 year: 0.9 mg/kg/hr
12 year & above: 0.5 mg/kg/hr
Not to exceed continuous infusion rate > 25 mg/minutes
OR
SC Adrenaline 0.01 mg/kg -0.3 mg (max dose)
(every 20 minutes for 3 doses)
Neutralize Metabolic Acidosis (Base Excess if more than 10) with NaHCO3

MgSO4 50 mg/kg (0.1ml/kg) over 30 minutes

Methylprednisolone 2 -3 mg/kg/day

Turbutaline 5-10 ug/kg loading over 10 minutes
Follow by 0.4 ug/kg/minutes
Increase by 0.2 ug/kg/minute every 10-15 minutes
Maximum 10ug/kg/min









Asthma Ventilation
Ventilation indications
• Exhaustion
• Lethargic
• Silent chest
• Worsening SpO2

Strategy
 Use ketamine
 Low PIP (low volume)
 Slow rate
 Low PEEP
 Allow permissive hypercarbia.


Ventilation and ARDS Management

Definition ARDS = PaO2 / FiO2 < 200.
(ALI = PaO2 / FiO2 < 300)
ARDS = Saturation less than 100% (PaO2 less than 100) in 50% O2
-----------------------------------------
• Acute onset respiratory distress
• Radiographic infiltrates (bilateral patchy, diffuse or homogenous consistent with pulmonary edema like in CCF)
• Normal heart size suggesting absence of CCF

o






.


Reference NIH NHLBI ARDS Clinical Network



Volume ventilation
Broad target guidelines
Start with 8 ml / kg
Safe volume is 6 ml / kg

Minute Ventilation is 200 ml/kg/minute in newborns

Going down to 100 ml/kg in adults



Peritoneal dialysis

Monitor Vitals
Sedate with Benzodiazepines
Empty bladder, prepare abdomen
Pre-warm PD fluid to body temperature
Add Heparin (1000 u/l) to PD fluid
Inject PD fluid through 14 g needle into peritoneal cavity initial infusion is 20 ml/kg
Pass stylet through needle and remove needle, to thread 14 gauge canula over stylet
Initial infusion volume of 15-30 ml/kg, Increase upto 50-70 ml/kg as tolerated.
(usual amount is 40-50 ml/kg )
Stop Heparin after 2 cycles if returns are clear
No Potassium to be added to PD fluid unless Serum k < 5 meq/l
Dwell time of 30-45 mins
Outflow time of 15-20 mins
1 Cycle/hr
Remove PD Catheter after 3-5 days
Monitoring:
• Monitor Vitals
• Monitor Urine output
• Renal function and electrolytes at the end of 3 rd , 10 th and 20 th cycles
• Blood Gas at the end of 3rd, 10th and 20th cycles
• 4 Hourly Blood Glucose
• Blood Counts, Gram staining, Cultures of drained PD fluid once or twice a day
• Blood cultures at the end of PD
• PD catheter tip for fungal smear and culture




Septic Shock

The following should be achieved in the first hour of management:
1. Airway
2. Breathing (Oxygen)
3. Circulation
Fluid Bolus 20 ml/kg with Isotonic Crystalloids, going up to 60 ml/kg
(may use Colloids instead of Crystalloids)
4. Correct Hypoglycemia and Hypocalcemia
5. Start Antibiotics
6 Stress dose hydrocortisone @ 2mg/kg iv stat, followed by 2 mg/kg/day for 48 hours, as continuous infusion

Fluid Responsive: (responding to 2-3 fluid boluses)
• Capillary filling time improves to< 2 seconds
• Peripheral core temperature difference becomes < 3 degrees C Heart rate normalizes
• Urine output improves to > 1 ml/kg/hr
• Consciousness improves
• Serum lactates decrease
• Base deficit decreases
• B P normalises

NON FLUID RESPONSIVE

NORMOTENSIVE
ScVO2 <70% HYPOTENSIVE
VASODILATED
ScVO2>70%
Warm Shock
Sepsis (High pulse volume) HYPOTENSIVE
VASOCONSTRICTED
ScVO2 <70%
Cold Shock
(Low pulse volume)
DOPAMINE
5- 20mcg/kg/min
DOBUTAMINE
5- 20mcg/kg/min DOPAMINE
5- 20mcg/kg/min
DOBUTAMINE
5- 20mcg/kg/min DOPAMINE
5- 20mcg/kg/min
DOBUTAMINE
5- 20mcg/kg/min
HYDROCORTISONE
Dilute 1mg in 1ml dextrose
Give 1mg/kg over 5 minutes follow by 1mg/kg Q8H over 30 minutes (Day 1)
0.5mg/kg Q12H (Day 2)
0.25mg/kg Q12H (Day 3)
0.125mg/kg Q12H (Day 4)

Nelson suggests giving
Stress dose 50 mg/kg
Max dose 300mg
HYDROCORTISONE
Dilute 1mg in 1ml dextrose
Give 1mg/kg over 5 minutes follow by 1mg/kg Q8H over 30 minutes (Day 1)
0.5mg/kg Q12H (Day 2)
0.25mg/kg Q12H (Day 3)
0.125mg/kg Q12H (Day 4)

Nelson suggests giving
Stress dose 50 mg/kg
Max dose 300mg
HYDROCORTISONE
Dilute 1mg in 1ml dextrose
Give 1mg/kg over 5 minutes follow by 1mg/kg Q8H over 30 minutes (Day 1)
0.5mg/kg Q12H (Day 2)
0.25mg/kg Q12H (Day 3)
0.125mg/kg Q12H (Day 4)

Nelson suggests giving
Stress dose 50 mg/kg
Max dose 300mg

NOREPINEPHRINE
0.05 to 1.5 mcg/kg/min EPINEPHRINE
0.1 to 3 mcg/kg/min
MILRINONE
50 mcg/kg (0.05mg/kg)]
Preparation: 1mg/ml (Sufficient for 20 kg)

Follow by
0.5 to 1mcg/kg/minute
(Wt X 0.6)mg dilute in 20ml NS Run at 1ml/hr= 0.5mcg/kg/min

NITROPRUSSIDE
0.5 to 4 mcg/kg/min
(can be used only in normotensive cold shock and not in hypotensive VASOPRESSIN
0.02 to 0.06 u/kg/hour
Prepare 20 units / ml
Add 1 unit per kg in 50 ml of 5% dextrose

Dose 1-3 ml/hour
Hypokalemia ( <3.5 mEq/l )

ECG changes in severe Hypokalemia: Prominent u waves, diphasic T waves, ST segment depression, apparent QTC prolongation, PR interval prolongation, sino-atrial block.

Serum Potassium
Infusion Rates


2.5-3.5


Add IV Potassium 40 mEq/l to 60 mEq/l

1 ml KCl provides 2O mEq/L if added to 100 ml of Potassium free fluid.


< 2.5 OR Severe Symptomatic Hypokalemia



Speak to Consultant
Rapid correction
0.3-0.5 mEq/kg
Run in 1 hour and STOP.

Remember this is nearly 200mEq/L (Central vein)

Wt × 0.5/2 ml KCl dilute
in 5%Dextrose
Add this to 50 ml in child less than 10 kg
Add to 100 ml in 10 to 20 kg child
Add to 150 ml in 20-30 kg child
Add to 200 ml if more than 30 kg
Run in 1 hour








Hyperkalemia (>6 mEq/l)


Normal ECG ( Potassium = 6 - 7 mEq/l)



Abnormal ECG ( Potassium >7 mEq/l )
(peaked T waves, loss of p waves, widened QRS complex, sine waves, AV blocks, bradycardia, ventricular arrhythmias )

1. Stop all Enteral AND Parenteral Potassium





2. Sodium polysterene resin 0.25 to 1gm/kg orally or rectally one to 4 times daily













1. IV Calcium Gluconate in dose of 1 ml/kg/dose over 3-5 minutes. Repeat the second dose after 10 minutes if required.


2. IV Sodium Bicarbonate
1-2 mEq/kg over 5- 10 minutes


3. Subcut Crystalline Insulin
in doses of 0.1 u/kg
WITH 2 ml/kg of 25% Dextrose
(0.5 g/kg ) in 30 minutes.
Repeat dose in 30-60 minutes
OR
begin a continuous infusion of Insulin at 0.1u/kg/hr + 1-2 ml/kg/hr of 25 % dextrose


4. Salbutamol inhaled
OR
IV Salbutamol of 4 Microgram/kg in 20 minutes

5. Sodium polysterene resin 1gm/kg orally or rectally

6. Dialysis



Hyponatremia (Serum Sodium <130 mEq/l)




GI loss And Dehydration



Water Intoxication


SIADH


Renal Salt Wasting

High BUN

High Urine Osmolarity

Oliguria



• Fe Na >1 %

• Low Urine Osmolarity

• Polyuria
• Fe Na >1%

• High Urine Osmolarity > 100 mOsm/l

• Oliguria

• Fe Na >1%

• High Urine Osmolarity

• Polyuria

Replace deficit with 0.9% NaCl over
48 Hours



Restrict Water
+
Replace Urine Sodium Losses
Restrict Water to 2/3

Maintenance using 0.9% NaCl
Replace Urine Sodium Losses
+
Replace Water Deficit as 0.9% NaCl
Treatment of Hyponatraemia
SYMPTOMATIC (seizures, deeply comatose, depressed respiration)
Consider intubation and ventilation
3% NS through central vein (don’t delay while administering anticonvulsants simultaneously): to be given as 2 ml/kg over 15-30 minutes (1ml/kg of 3% NS raises serum sodium by 1 mEq/l).
Repeat infusion if symptoms persists up to 3 times.
Aim is to raise the plasma sodium till CNS symptoms resolve and/or change in plasma sodium <12 mmol/l/24hrs or plasma sodium becomes 125 mmol/l.
• Risk of Central Pontine Myelinolysis if rapidly corrected especially in long standing hyponatraemia.
• Acute hyponatraemia is more symptomatic and is also safer to treat with hypertonic saline.

ASYMPTOMATIC
Treatment with half normal saline is often all that is needed.
• Restrict fluids to 60% of maintenance ( IVF or enteral feeds )
• 3% NS to achieve change in plasma sodium by 1-2 meq/l/over 30 minutes
• Lasix if edematous


Hypernatremia



Free water deficit estimation (FWD) = 0.6 × Wt × (1 – 145/current sodium)

(As total body water is 60% of the body weight)

STRATEGY
Use Maintenance fluid +additional 30% of maintenance
(for correction of hypernatraemic dehydration slowly)


Choice of fluids In Hypernatremia:

• Replacement fluid in absence of complicating factors: Half Normal Saline

• If with shock: NS OR 5% Albumin

• If due to Sodium overload: add Sodium free fluid like 5% dextrose in addition to loop diuretic

• If associated with Hyperglycemia: use 2.5 % dextrose.


• Do not use Insulin for hyperglycemia as that can cause precipitous fall in Plasma Glucose/Osmolarity with subsequent cerebral edema.


 Monitor Serum Sodium 4 hourly

 Correct concomitant Hypocalcemia

 Add 40mEq/l of KCl if patient passes urine well.



 If Sodium > 200mEq/l: Peritoneal Dialysis

 If associated with Diabetes Insipidus: use DDAVP, Diuretics, VASOPRESSIN.














Hypocalcemia


ECG changes in Hypocalcemia: prolonged QTc interval



Asymptomatic Symptomatic
No Bolus.
10% Ca Gluconate 8ml/Kg/Day
OR
80 mg/Kg/Day Elemental Calcium PO for 2 Days
10% Cal Gluconate as Bolus of 2ml/kg diluted in 1:1 dilution using 5%DEXTROSE. CAN RUN IN 10 TO 20 MINUTES

Repeat Serum Calcium
Repeat Bolus if no response occurs

If normal,taper to 4ml/kg/day of IV Calcium
OR
40 mg/kg/day elemental Calcium PO for 1 Day
Follow it with IV infusion of 8ml/kg/day for 48 hrs of Ca Gluconate

Taper to 4ml/Kg/day of Cal Gluconate OR 40 mg/kg/day of elemental Calcium for 1 Day



Hypocalcaemia in an Older Child



• 1-2 ml/kg of 10% calcium gluconate (100-200 mg/kg) IV stat in 15-20 minutes under cardiac monitoring

• Followed by 20-50mg/kg/hr (0.2-0.5 ml/kg/hr )

Run this for 4 hours only.

Check serum levels before starting infusion for next 4 hours.
Stop infusion when calcium levels reach 8mg%

May need to supplement with magnesium also







Rapid Sequence Intubation





























Neonatal Hypoglycemia (below 45mg/dl)

Glucose Delivery Rate (GDR) (mg/kg/min) = % dextrose X Volume (ml/kg/day)
-------------------------------------------
144

ASYMPTOMATIC SYMPTOMATIC
TPN Made Simple




Glucose 10% or 12.5%
Isolyte P for maintainance electrolytes
Heparin 1 unit/ml of above
MVI add 1 ml to days fluid


Aminoacid
From day 1 if enteral feeding not anticipated for 5 days
Add 15 ml to 85 ml AA to Isolyte P
Day 3 add 20 ml AA to 80 ml Isolyte P
Day 5 add 25 ml AA to 75 ml Isolyte P
Day 7 add 30 ml AA to 70 ml Isolyte P
Run through long line
Don’t break the line for another infusion

After 1 days lipids may be added
Infuse 2.5ml/kg of 20% Intralipid

Day 3 run 5 ml/kg (0.2ml/kg/hour)
Day 5 run 7.5 ml/kg (0.3ml/kg/hour)
Day 7 run 10 ml/kg (0.4 ml/kg/hour)
Day 9 run 12.5 ml /kg (0.5ml/kg/hour)
Day 11 onwards run 15 ml/kg (0.6 ml/kg/hour)
This is the maximum of 3 gm/kg/day
Run lipid through a peripheral line

Dengue
Danger signs
• Persistent vomiting, not drinking.
• Severe abdominal pain.
• Lethargy and/or restlessness, sudden behavioral changes.
• Bleeding: Epistaxis, black stool, haematemesis, excessive menstrual bleeding, dark colored urine (haemoglobinuria) or haematuria.
• Pale, cold and clammy hands and feet.

WHO Protocol for fluid management on next page

PICU Antibiotic guide


A child being shifted to PICU for worsening sepsis may need up gradation of antibiotics after discussion with the consultant. Following system may be used.
GRADE 1:
Cefotaxime / Ceftriaxone with or without Amikacin / Gentamycin
Amoxycillin with or without Clavulinic acid
Ampicillin with or without Gentamycin

GRADE II
Piperacillin tazobactam (poor CSF penetration) + Amikacin
Cefoperazone /sulbactam (Magnex) + Amikacin
Ceftazidim (Fortum) with or without vancomycin / Linizolid (compromised CSF Penetration)

GRADE III
Meropenem / Imipenam cilastatin + Vancomycin / Linizolid
Empirical addition of disease/ system specific antibiotic (ATT/ septran / clindamycin / acyclovir / fluconazole / amphotericin)

GRADE IV (Must be avoided in the absence of sensitivity evidence / avoid as single agent)
Colistin
Polymyxin B
Phosphomycin

Other supportive care / agent: only after multidisciplinary or departmental meeting
Exchange transfusion for sepsis
IVIG for sepsis

Miscellaneous

PEF (5 Height in cm) - 400(+/-50)
Systolic BP 70 + (Age X 2)
Diastolic BP 55 + Age
Endotracheal tube size For Child over 1 year = (Age [Y] divided by 4 ) + 4
Preterm 2.5
Term 3
1 year 4
Endotracheal tube length (Age[Y] divided by 2) + 12
ET size X 3
Cricothyroid needle 14 gauge needle with 3 mm ET adapter
Drug infusion calculation (Weight 0.6 mg) Add to 10 ml
Run 1 ml/hour = 1 microgram/kg/minute
Empyema Streptokinase 2.5 to 3 lakh units in 100 ml saline.
Retain 4 hours (Cost Rs 1500)
SaO2 between 90 and 60% SaO2 – 30 = PaO2
Weight in <12 months of age Age(in months) +9/2
Weight ( 1-6 yr age) (Age X2)+ 8
Weight(> 6 yrs age) (Age X 7)-5/2
Height( >2 yrs) (Age X 6) +77
pAo2 (760-47) X FiO2 - paCO2/0.8

Subcutaneous effusion of IV fluid especially Calcium
Apply Nitroglycerine ointment locally every 4 hours