Handbook of Pediatric Surgery

• We use the Parkland formula for burn resuscitation. (Major Burns):
  
• 4 cc/kg/% burn (2nd and third degree) + maintenance IVF if < 20 kg
  
• Give first ½ over 8 hours and remaining ½ over 16 hours, starting from the time of injury. This is a guide, not an absolute dictum.
  
• Labs are generally done in the ER. The frequency of labs will depend
  on the degree/percent of the burn. Those who are weepy or tend to have bleeding with treatments will require more frequent monitoring.
  
• Patients with facial burns, major burns, or those with poor nutrition status will likely require tube feedings.
  

• Patients have whirlpool therapy b.i.d. Generally we use SSD to burns
  everywhere except facial burns. With facial burns, we use polysporin
  or bacitracin.
  
• As wounds heal, we use Eucerin.
  
• Temporary coverins include biobrane, duoderm, transcyte, acticoat,
  pigskin. Often the burn unit nurses will ask you if one of these is
  appropriate. Use their expertise in burn care when considering
  different dressings.
  
• Most burns of questionable depth are given 10-14 days to heal before grafting takes place
  

• A burn diagram is available on the burn unit. Please mark affected
  

areas and total burn percent. Only include areas of partial and full
thickness.

• A CR monitor is used for 24 hours to evaluate for arrhythmias.
  
• Urine for myoglobin should be sent in the ER and may need to be
  

repeated at some point after admission.

• Patients who are not taking PO or who are within 1-2 days of the
  injury are best managed by IV analgesia: Morphine 0.1-0.2 mg/kg
  Fentanyl 1-2 mcg/kg
  
• All patients should get Versed prior to dressing changes. IV
  dose:0.1 mg/kg PO 0.3m g/kg
  
• Other pain control options are Roxicet (oxycodone, oxycontin)
  
• All patients will need Atarax and/or Benadryl at some point
  

• Make NPO at usual time (0200), begin IVF at that time if not already running
  
• Labs should include at minimum CBC/plts, Type and Cross for PRBC's. BMP
  and PT/PTT may be needed.
  

• Post operative length of stay is variable depending on the nature
  and severity of the burn.
  
• Patients should be on Ancef post-operatively or Keflex if no IV
  

access. They should remain on antibiotics until staples/sutures are
removed.

• Staples / Sutures are generally removed on Post-op day 5 or 7. Some children will require sedation for staple/suture removal. If this is the case, please schedule it with the surgery schedulers in advance as a staple and dressing removal in the burn unit with sedation by anesthesia. NPO times and IVF will be needed with this type of dressing takedown.
  

  
  

If a child or infant is going to be NPO for three or more days, consider giving either PPN or TPN. PPN is given via peripheral IV and is limited to 12.5% dextrose and an osmolarity of 900. TPN requires central access of some sort and can provide greater dextrose concentrations and electrolyte replacements.

• The newborn should (with some exceptions, such as chronic placental insufficiency) be thought of as fluid and sodium overloaded. This ‘overloading’ is worse the smaller and more premature the baby is. The first few days (i.e., 3 to 4) of life are normally a period of physiologic naturesis and diuresis. For this reason, IVF for the 0 to 3 or 4 day old newborn should not contain sodium, and should usually be limited in volume to 60 - 80 cc/kg/day.
  
• Fractional excretion of sodium, FENA, is normally a maximum of 1-2% in older children and adults; however, it can be as high as 12-13% in small premies. FENA is the percent of all filtered sodium that is actually excreted by the kidney. Additionally, newborns have high calcium requirements, and some institutions routinely add additional Ca++ to the maint. IVF. Glucose needs are high early on as well, so D10W is often used. The diuresis and naturesis are usually effectively over by the 3rd - 5th day of life, and volume as well as sodium and potassium can be increased.
  
• The small (i.e., < 1000 gm infant) may not tolerate the high glucose load of D10W, and may require D5W or less. In the smaller child, insensible losses are greater since the relative surface area of the body and lungs is commensurately greater.
  
• Monitoring of fluid status in early newborn period is primarily accomplished in 3 ways:
  
  • Serial daily weights
    
  • Serum Na+ and lytes {little else usually affects Na+ in the first few days of life, and it is therefore a good indicator of fluid balance}
    
  • Urine output.
    
• Watch these parameters closely! Weight loss is normal in the first week of life (up to 10 to 15% of initial birth weight by 7-10 days old).
  
• Calcium is added to IVF in the first week of life primarily to ensure adequate levels of ionized calcium. Some authorities feel that the micro-preemie requires even more calcium initially. Calcium is also needed to prevent demineralization of bone, but this is not so important in preparing IVF for the first few days of life, and also requires the additional administration of phosphate.
  

  
  

Maintenance IVF days 0 to 3

• *of D5W + 4.8 mEq Ca Gluc per 250cc: also, always add 3/4 units heparin/cc if running IVF into UAC or UVC.
  
• Maintenance IVF days 3/4 tp 7/8: D10W + 4.8 mEq Ca gluconate/250
  cc + 20 mEq KCl/L + 25 mEq NaCl/L TRA rate based on estimated
  insensible loss, weight change, lytes, and urine output.
  

  
  

• Hypocalcemia:
  

10% Calcium gluconate IV. 10 mg/kg (1-2 ml/kg over 10 min.)

• Hypomagnesium
  

Mg sulfate IV or IM 25-50 mg/kg/dose, repeated q 4-6 hrs. p.r.n.

• Bicarbonate deficit
  

1/2 (the desired - observed HCO3)x wt. x .5 = mEq NaHCO3: usual formula is 0.3 x wt (kg) x Base Deficit; calculate and give 1/2

• Hypoglycemia
  

1cc/kg of D 25 W

• Hypokalemia
  

PO: 1 mEq Kcl/kg not to exceed 10 mEq IV
IV: 1/2 mEq Kcl/kg over 1 hr.
dilute 1 meq in 12 cc If giving peripherally; 1 meq in 6 cc if given via central line

• Hyperkalemia
  

Ca gluconate (10%).5-1.0 cc/kg over 2 - 5 minutes to correct cardiac defect. Effective for up to 1 hour.
NaHCO3 1-3 mEq/kg over 3 - 5 minutes (lasts several hours)
Glucose 1.0 gm/kg with 1 units insulin/4 gm glucose over 2 hours.
Kayexalate 1 gm/kg with 3cc sorbitol/gm resin divided q 6 h p.o., or with 5cc sorbitol/gm resin as retention enema over 4 - 6 hrs. 1 gm kayexalate should lower K by 1 mEq/L.
Dialysis.

• For neonates who have been NPO for significant periods, start feedings slowly.
  
• A typical regimen would be as follows:
  

Start with a slow drip of Pedialyte via a feeding tube.
Once tolerating, we will increase the rate and change to half strength formula.
Finally, we change to full strength formula and advance them to full
feeds. Full feeds is determined by the following calculation:

• Wt X 110 (RDA) / .67 (20 cal formula) / 24 hours.
  

Once tolerating full strength/volume feeds, we begin weaning to bolus feeds. First we will go 2:1 (3-hour volume over 2 hours and hold for 1 hour).
Next we go to 1:2 feeds (3-hr volume over 1 hour and hold for 2 hours).
Next we go to bolus feeds.
When the neonate is tolerating bolus feeds, we will begin PO feeds.
Watch the neonates weight gain. They can lose up to 10% of their
body weight in the first couple of weeks. On an average they should
gain 30 grams a day (< 2 kg would be 10-15 gm/kg/d).

• Neonates commonly have indirect hyperbilirubin. At a certain point, therapeutic measures in the form of phototherapy or for more extreme cases, exchange transfusion is indicated.
  
• Lab work is critical for a baby on phototherapy and bilirubins need to be checked frequently, especially in the beginning.
  
• Fluid management of babies receiving phototherapy is also important. *Phototherapy increases their insensible losses. Fluids should be run at 120 cc/kg/day depending on the medical status of the baby.
  

Hyperbilirubinemia
(Healthy Term Infant)

• Dragar - HFOV
  
• Pressure regulated -SERVO 300
  

  
  

Initial Vent Settings:
Volume VentilatorMode : IMV

• Fi02 100%
  
• Rate 12-15 bpm (older children)
  
• 15-20 bpm (small children)
  
• 20-30 bpm (infants)
  
• Tidal volume 12-15 cc/kg
  
• PEEP 3-5 torrPressure
  

VentilatorMode : IMV

• Fi02 100%
  
• Rate 2-30 bpm
  
• PIP 20-30 torr
  
• PEEP 3-5 torr
  
• I:E ratio 1:2
  

Weaning Parameters:

• Negative inspiratory force >30 torr
  
• Vital capacity 10 to 15 cc/kg
  
• Vital capacity 2 x tidal volume
  

• Routine orders
  

Standard labs, especially coags.
Isotonic IV fluids- avoid dextrose initially
HOB 30 in reverse trendelenburg
Keep PCO2 28-30
Minimize sedation
Q 1 hour neuro checks

• Skull Fractures
  

Skull fractures: key features: location, depression, open or closed.
Simple linear fractures with an intact neuro exam, no LOC, no injury to underlying brain can usually be discharged home.
Depression: greater than width of skull (i.e. >5mm) is significant. If in cosmetic region (forehead), may require operative elevation.
Openness: if associated with laceration, ascertain whether lac communicates with depressed fracture. Open depressed fractures usually require operative tx.
Look carefully on CT for injury to underlying brain: fractures of the
parietal region may be associated with epidural hematoma. Any fracture
can be associated with epidural, subdural, subarachnoid hematomas,
cerebral contusions, or cerebral edema. (see trauma section).

• Head Trauma
  

History: key points: mechanism, loss of consciousness, memory of accident, seizure activity
Evaluation: standard neurological exam, CT head.
Glasgow Coma Score: see below

• Initial treatment:
  

HOB to 30 degrees (reverse Trendelenberg)
Mannitol 0.5-1 gm/kg if evidence of cerebral edema and depressed consciousness, if h/o seizure loading dose 10-20 mg/kg fosphenytoin, then 2-3 mg/kg q 12 hrs (check level after third dose).
CT findings: Hematomas and contusions

• Acute Subdural
  

Most common hematoma
Due to tearing of bridging veins between brain surface and overlying dura. Acute blood will appear white on CT. Follows general contours of but distorts brain surface.
Midline shift of brain usually out of proportion to hematoma size. If shift significant and/or associated with neuro deficit, urgent craniotomy indicated.

• Chronic subdural
  

Commonly seen in cases of child abuse.
Blood appears darker than brain, though may have areas of brighter acute blood admixed
Often bilateral.
Check fontanelle! If bulging then may require percutaneous subdural tap.

• Epidural: Distinct lens-shaped appearance on CT. Usually associated with overlying skull fracture. If large or causing neuro deficit, requires urgent craniotomy. May have delayed onset - “lucid interval”
  
• Subarachnoid blood
  

Common
Blood along surface of brain
Does not distort local anatomy like subdural/epidural
Diffuse pattern with preference for CSF spaces
No direct surgical treatment, though may be associated with cerebral edema (see below)

• Contusion
  

Bruise deeper within substance of brain
May cause local distortion, often enlarges over 48 hours.
Bright “spot” on CT, may be multiple, may be on opposite side of trauma (contre-coup contusion).
No direct surgical treatment unless very large, often associated with cerebral edema (see below).

• Key points
  

Maximal at 24 to 48 hours.
CT shows brain swelling, reduced ventricular size, smaller CSF spaces, especially around brainstem and midbrain, global neurological dysfunction, papilledema.

• Placement of ICP bolt: general rule is GCS of 7 or below, with radiographic or clinical evidence of cerebral edema. Gives direct reading of ICP via fiber optic lead in brain. Goal to keep cerebral perfusion pressure (MAP-ICP) 70 mmHg or greater.
  
• Cerebral edema treatment: Mannitol 0.5 – 1 gm/kg q 6 hr. Check serum osmolality q 6 hrs. as well, hold for levels >305. HOB @ 30 deg. Mild hyperventilation with pCO2 @ 30. May give pressors to elevate MAP in cases of refractory cerebral edema.
  

Mannitol: give for cerebral edema due to trauma in patient with neurological deficit or reduced level of consciousness. Dose 0.5 – 1 GRAM (not mg.) IV q4 hr. Usually start with larger initial dose i.e. 1 gm/kg in trauma room. Monitor osmol. as above.
Decadron: give for cerebral edema due to tumor. 1.5mg/kg divided q6 hrs, usually don’t go above 4mg q 6 hrs. Need to also give H2 blocker (i.e. Zantac 2-4 mg/kg/day divided q 8 hrs).
Fosphenytoin: IV version of Dilantin. Use in post-traumatic seizures, post-operative seizures, and for seizure prophylaxis in cases of trauma where there is direct injury to the cerebral cortex, i.e. penetrating trauma, depressed skull fracture with brain laceration). Dose 10-20 mg/kg load, then 4-6 mg/kg/day divided q 12 hrs. Check level after third dose- therapeutic 10-20 mcg/ml. Equivalent dose to oral Dilantin.
Zofran: preferred neurosurgical antiemetic, because it doesn’t cause depression of consciousness. 0.1 mg/kg prn.
SoluMedrol protocol. Give in cases of suspected spinal cord injury. 30mg/kg IV loading dose over 30 minutes, wait 30 minutes, then 5.4 mg/kg/hour for 23 hours. Must be given within 8 hrs of injury.
Avoid all sedatives, IV opiates, and paralytics especially long acting, in patients with head injury- in order to be able to perform accurate neurological exam.

Pediatric Glasgow Coma Scale (VEM)

• Presentation:
  

Absent or ectopic placement of anal opening
May or may not have anal dimple
Meconium on perineum or in urine (if fistula present)
Abdominal distention, sings of obstruction
May have other anomalies-VACTERL, for example

• Diagnosis
  

Examination of perineum
Urine specimen

• Radiologic studies
  

Determine level of blind rectal pouch
Plain abdominal film
Ultrasound
Determine fistulous communications
Determine presence of other congenital anomalies

• Operative Correction:
  

A low lesion near the skin can be treated with a minimal posterior sagittal anoplasty as a newborn.
A high lesion requires an emergency colostomy. The posterior sagittal anorectoplasty is done when the child is a few months old and the anatomy has been defined with further radiologic studies.

• Post-op:
  

NPO until bowel function is established
NG tube
Pain control
Skin care in diaper area when stooling begins
Colostomy care teaching for families
Consider PPN/TPN if NPO > 2 days

• Presentation:
  

Consistent, localized point tenderness in right lower quadrant
Fever and leukocytosis
Anorexia, nausea and vomiting

• Diagnosis:
  

History and physical
CBC with mild to moderate leukocystosis
Rectal exam to determine tenderness, pelvic mass, phlegmon or abcess
Plain abdominal film
CT scan of abdomen
Any child with abdominal pain on whom appendicitis can not be ruled out should be admitted for IV hydration and serial examinations. Abdominal pain is common, but diagnosis of appendicitis can be difficult.

• Presentation:
  

Newborn with mild-severe respiratory distress
Scaphoid abdomen
Bowel sounds in chest
Heart sounds on right

• Diagnosis:
  

Chest x-ray-reveals a loop of bowel in chest, mediastinal shift

• Treatment
  

Ventilatory support
May require ECMO
Surgical repair of diaphragmatic hernia

• Presentation:
  

Bilious vomiting
Abdominal obstruction

• Diagnosis:
  

Clinical presentation
Plain abdominal films-“double-bubble sign”
Upper GI series

• Surgical correction:
  

Duodenostomy or duodenoplasty, often laparoscopic

• Post-op:
  

NPO until bowel function is established
NG tube
FLAP diet when bowel function has returned, and UGI is normal (no leak)
Consider PPN/TPN if NPO >2 days

• Presentation:
  

History of polyhydramnios
Inability to swallow
Respiratory distress with feeding
Choking and coughing
Inability to pass NG tube into stomach
Associated with Tracheal-esophageal fistula and/or other anomalies

• Diagnosis:
  

Clinical presentation
Chest x-ray show coiled NG tube in blind pouch-Do not use contrast

• Surgical correction:
  

Bronchoscopy and Gastrostomy as newborn
Thoracotomy, esophageal anastomosis, may need to divide tracheal-esophageal fistula

Presentation:
Abdominal wall defect, usually on right side, near but not involving umbilicus
No sac

• Diagnosis:
  

visual inspection
prenatal ultrasound

• Surgical correction:
  

Primary closure
Construction of silastic pouch with serial reductions; preformed pouch
May create increased abdominal pressure requiring ventilatory support post-op
Average hospital stay of one month

• Presentation:
  

Infants usually newborns
Abdominal distention
Failure to pass meconium in 24 hours
Constipation
Bilious vomiting
Poor feeding
Older Children
Abdominal distention
Failure to thrive
Constipation
Episodes of diarrhea

• Diagnosis:
  

Clinical presentation
Plain abdominal film
Barium enema
Rectal biopsy, usually suction for nb
Anorectal manometry (uncommonly)

• Surgical correction:
  

Leveling colostomy to determine where ganglion cells are or definitive
1-stage pullthrough if no enterocolitis
Definitive correction 6-12 months later with endorectal pullthrough if diverted

• Post-op:
  

NPO until bowel function is established
Consider PPN/TPN if NPO for >2 days.
Teach parents colostomy care
Skin care of buttocks post pull-through

• Presentation
  

Inguinal bulge or scrotal swelling
Pain is not common
Doubt the dx in absence of any observed bulging or swelling

• Diagnosis:
  

History and Physical exam to distinguish between hydrocele and hernia,
incarceration.
Don't order US - it is useless
An open hernia reduces easily
Hydroceles that are present since birth, don't change significantly in
size in children < 1 yr of age can be observed to see if they resolve
Incarcerated hernia presents as painful, thickened mass up to the inguinal ring which is irreducible.

• Management:
  

Non-incarcerated hernia, repair electively
Hydroceles are observed to age one or older. If fluid persists or fluctuates, hydrocelectomy is performed.

• Incarcerated hernia-attempt to reduce hernia. Use sedation only if
  necessary. If reduced, patient should be scheduled for repair at
  earliest convenience. Don't admit routinely if reduced.
  

Irreducible hernia is a surgical emergency.

• Presentation:
  

3 mo-3 yrs (peak 9-12 mo)
Intermittent, severe crampy abdominal pain, usually with a specific time of onset
Oblong, tender, abdominal mass (usually in RUQ if the abdomen is relaxed)
Late sign-vomiting, current jelly stools

• Diagnosis:
  

History and Physical
Barium enema or air enema- This is also the treatment in 80% of all cases.

• Surgical correction:
  

The patient should be prepped for surgical reduction if not reduced in radiology.

• Post reduction:
  

If by BE or air, observe in hospital until patient stools and is tolerating a regular diet.

• Presentation:
  

Bilious emesis
Abdominal distention

• Diagnosis:
  

Clinical presentation
Plain abdominal film

• Surgical correction:
  

Resection of atretic areas with primary anastomosis unless complicated
Need CF work up, although low yield

• Presentation:
  

Bilious emesis IN ANY AGE, BILIOUS EMESIS IS A SURGICAL EMERGENCY UNTIL PROVEN OTHERWISE, BY OPERATION OR UGI
Abdominal distention

• Diagnosis:
  

Clinical presentation
Plain abdominal film
Upper GI series

• Surgical correction:
  

LADD procedure: Lysis of duodenal adhesions, derotation of volvulus, resection of any necrotic bowel with possible stoma creation, incidental appendectomy.

• Presentation:
  

Bilious emesis
Failure to pass meconium

• Diagnosis:
  

Plain film: Distal bowel obstruction with disparity in size of loops - “Soap bubble” appearance in lumen. Sparsity of air-fluid levels
Water-soluble contrast enema-microcolon with insipissated meconium
Sweat chloride test confirms the diagnosis of cystic fibrosis, but
often can't get enough sweat in NB
Genetic test can be done in NB, but misses 15% of variants

• Presentation:
  

Newborn, often premature
Feeding intolerance
Temperature instability
Abdominal distention, guarding
Thrombocytopenia
Bloody stools
Episodes of apnea and bradycardia
Metabolic acidosis, unresponsive to fluid and sodium bicarbonate therapy

• Diagnosis:
  

Clinical presentation
X-rays which reveal fixed loops, peritoneal fluid, edematous bowel wall; pneumatosis intestinalis

• Management:
  

NPO and NG
IV hydration
TPN if NPO for >2 days
Follow ABG,CBC, platelet counts, KUB, and lateral decubitus x-rays every 6-8 hours until stable
Type and cross
Begin triple antibiotic therapy for 14 days from onset of NEC

• Indications for surgery:
  

Free air (perforation)
CLinical deteriration

• Relative indications for OP:
  

Cellulitis (progressive abdominal wall erythema)
Fixed Loop on X Ray
Portal venous gas
Palpable intra-abdominal mass

• Presentation:
  

Midline abdominal wall defect in the umbilical region
Small abdominal cavity
Peritoneal membrane-may be ruptured
Many have associated anomalies (cardica, Trisomy 13/15, Beckwith-Weidemann Syndrome)

• Diagnosis:
  

Visual inspection
Prenatal ultrasound

• Surgical correction:
  

Complete primary closure
OR skin closure
OR Silastic sheeting with serial reductions or preformed silo
OR Non-operative management in certain situations

• Presentation
  

3-5 weeks of age usually
Most often 1st born male-but not always
Projectile vomiting after feeding
Infant acts hungry after vomiting
Dehydration, poor weight gain or weight loss

• Diagnosis
  

History and Physical:
“Olive” palpable in epigastric area
US of abdomen
Basic Metabolic Panel-check for adequate hydration and electrolytes

• Surgical correction:
  

Laparscopic or open Pyloromyotomy

• Post-op:
  

FLAP Diet (Feed Like A Pyloric)
This expression is used as a feeding regimen for advancement on neonates and infants, used characteristically for feeding post-op pyloromyotomy patients. The regimen is as follows: Take maintenance volume, double it and give as a bolus every 2 hours. We start with Pedialyte x2 feeds then go to half strength formula x2, then full strength formula x2, then ad lib feeds. The start time for this regimen varies staff to staff.
Example of 5 kg baby: 5 x 4 = 20 cc/hr maint.

Heparin (Heparinization) 100 units/kg IV bolus followed by 20 units/kg/hr
Racemic epinephrine 0.25-0.5 ml in 2.5 saline, nebulized
Vasopressin 0.5 milliUnits/kg/hr IV for diabetes insipidus
Protamine 2 mg/kg IV slowly to reverse full heparin
Streptokinase 1000 unit/kg load over 20 min; Infusion 1000 units/kg/hr

Diphenhydamine 0.2-1.0 mg/kg/dose IV q 4-6h or 5 mg/kg/dy QID PC
Chloral hydrate 30-50 mg/kg/dose PO/PR q 4-8h
Droperidol 0.1 mg/kg/dose IM/IV q 8h
Haloperidol 0.5-4 mg/dose IM/PO
Lorzepam 0.05-1 mg/kg/dose q 8-12 (Adult 1-4 mg IV)
Midazolam 0.05-0.1 mg/kg/dose IV q 1-2h
Phenobarbitol 2-3 mg/kg/dose IV, 2-6 mg/kg/dose PO

Prednisone - 2 mg/kg/dy q 8h
Dexamethasone - 0.3-1.0 mg/kg/ once, then /q 8 h
Hydrocortisone - 10 mg/kg/dy q 4-6h

Dopamine 2-20 ug/kg/min
Dobutamine 2-20 ug/kg/min
Epinephrine 0.05 ug/kg/min
Isoproterenol(range 0.05-1.0 ug/kg/min)
Norepinephrine Adult dose: 1-4 ug/min
Nitroprusside {0.3-6 ug/kg/min{(low dose if low C.O.)
PGE10.05-0.1 ug/kg/min
Nitroglycerin{0.5-10 ug/kg/min
Amrinone {load 1-3 mg/kg with volume over 15 min;Maintenance 5-20 ug/kg/min}

Dopamine 60 mg/100 ml D5W: run at body weight
Dobutamine(kg) as ml/hr to get 10 ug/kg/min
Epinephrine1 mg/100 ml D5W:run at body weight
Isoproterenol (kg) as ml/hr to get 0.17 ug/kg/min
Norepinephrine

• Drip: 6 x Infant’s weight(kg) x Desired dose[ug/kg/min], Desired amount of fluid mL/h = mg dopamine per 100 ml of sol’t
  

Atrial arrhythmia Begin at 0.5 joules/kg
Ventricular tachycardia Begin at 1 joule/kg
Ventricular fibrillation Begin at 2 joules/kg

Marker for increased risk of testicular malignancy: The risk is increased if:

• Symptomatic
  
• History of UDT (10% incidence of CA)
  
• Family history of testicular CA
  
• Other malignancies in patient
  

Usual management in the absence of the above is US every year, monthly self-exam. If any of the above, q 3MO US is obtained.

• 24 - Hour Urinary Calciums
  
• Normal value is < 4 mg/kg/day; results needed are wt(in kg), total urine vol(TUV), and ca++(in mg/dl)
  
  1. Move the decimal point 2 steps to the left to convert 34 mg/dL
     to .34 mg/ml
     
  2. Multiply .34 mg by TUV (eg. 350 ml) to get mg / day
     
  3. Divide by weight in kg to get mg/kg/day
     

Bladder capacity for < 2 yrs old BC = (0.5 * Age+6)

• IVP
  

2 ccs of 25% hypaque/pound

• Bladder hemorrhage
  

alum 1% aluminum potassium sulfate-use 30 gms in 3L of sterile water filtered through a sterilizing filter-use 2-5 L during the 1st hours, then 1 L q 2~5 hrs. continue for 5-8 hrs after bleeding stops.

• Cystoscopy JJ Stent
  

Place Cystoscope
4.5 or 5.5 Pollock Stent
Guidewire w Fluoro
Removal of Pollock stent
Advance JJ Stent over guidewire
Fluoro confirmation of position

• Flowmax dose is 0.4 mg po qhs
  

  
  

• Follow -up for URM
  

ultrasound at 2 weeks to r/o dilation of upper tracts
VCUG at 6 months - if still has reflux, wait another 6 mo and repeat before getting excited, since there may still be poor compliance/thickening of the bladder wall, resulting in distortion.

• Follow - up for PUValves
  

VCUG at 6 wks post op
Hypospadias - older children or adult
Leave foley in
Send home with leg bag x 2 as well as ‘normal’ bag for nighttime
DC meds
antibiotics - Bactrim SS q hs
Valium 5mg po qhs - decreases erections in am
Ditropan XL 5mg day
Complication risk is significantly increased - probably occurs in about 50% of patients.

• Medical Management of Voiding Dysfunction
  

Timed voiding q 2 - 3 hrs if you feel like it or not
Void 1st thing in the morning and last thing at night
Drink plenty of fluids during the day - 1 oz of fluid per 2 lbs body weight in a 24 hr period, in addition to normal daily intake
Avoid caffeine and carbonated beverages (pop, coffee, tea, cocoa)
Avoid citrus fruits and juices (grapefruit, lime, orange, lemon)
Avoid constipation - goal is one soft stool / day
Support feet while sitting on toliet
Use brans, cereals, grains
Use stool softeners
Foods to avoid
Chocolate
Caffeine/Soda pop
Red dyes in foods and drinks
Limit dairy products to one meal only
Reward dryness and don't punish wetness
Avoid artificial sweeteners

Phimosis, from the Greek word phimos, meaning muzzle. In ancient Greece physicians deemed circumcision a superfluous procedure, set forth some questions. “Would both the diagnosis and the indication for surgical treatment of phimosis be overestimated? Would surgeons be operating on children unnecessarily?”

1. Evaluation: Karyotype with specific X and Y probe detection (even if prenatal karyotype already done)
   
2. Labs (most of these can be done in 48 hours)
   

17 OH-progesterone
Testosterone
Gonadotropin
Anti-Mullerian hormone
Serum electrolytes
Urinanalysis

1. Radiographs
   

Abdominal-pelvic ultrasound
Genitogram / VCUG

1. Involve multidisciplinary team
   

A specific diagnosis is identified in about 1/5th of infants with DSD(disorder of sexual development)

1. Complete history and Physical Exam
   
2. Catheterization of the bladder after spontaneous voiding to check residuals. Normal bladder capacity in newborn is 10 - 20 cc’s, with acceptable residual urine vol of < 5 cc. If baby not observed to spontaneously void, Crede and then check residual cath urine vol. It may be necessary to perform intermittent cath if: dilated upper tracts on preliminary ultrasound or if back defect not repaired yet and Crede cannot safely be performed.
   
3. On 2nd or 3rd day of life - obtain renal ultrasound
   
4. On approximately 7th day of life - obtain urine culture and serum creatinine.
   
5. VCUG should be obtained during 1st - 2nd week of life.
   
6. Urodynamic evaluation can be scheduled at the first MM clinic evaluation.(Should be done early, since it is of great predictive value - see below)
   

General Points:

1. Level of bony defect does not have any predictive value vis. extent of bladder innervation/function.
   
2. 3% infants with MM have hydronephrosis secondary to spinal shock after MM repair.
   
3. 87% of newborns with MM have normal urinary tract on initial evaluation: 13% have hydronephrosis, VUR, or enlarged bladder.
   
4. Three urodynamic patterns are seen in newborns with MM:
   
5. dyssynergy – Definition: external sphincter fails to decrease or increases its activity during a detrussor contraction or sustained increase in intravesical pressure as the bladder is filled to capacity. Bladder emptying only at high pressures, bladder is poorly complaint, intravesical pressures are high. 71% of these patients have deterioration of the urinary tract within the first 3 years of life.
   
6. synergy – Definition: Sphincter activity is silenced during detrusor contraction or when capacity is reached at the end of bladder filling. Voiding pressures are normal. Only 17% of this group will deteriorate within the first 3 years of life.
   
7. completely denervated – Definition: No bioelectrical potentials whatsoever in sphincter region during voiding cycle or in response to Crede maneuver. 23% of these infants will have urinary tract deterioration within the first 3 years of life.
   
8. Almost all infants whose initial urinary tract studies are abnormal have dyssenergic urodynamics.
   
9. Reflux is the most common abnormality to occur when urinary tract deterioration occurs within the first year of life.
   
10. CIC (Clean Intermittent Cath) should be used liberally in newborn period, even in males. It is done 4 times/day, and nighttime caths can usually be omitted.There is an approx. 30% incidence of asymptomatic infection, but serious infection is rare.
    
11. Overall need for ureteral reimplantation is about 10% if CIC done correctly. Crede is avoided, even with catheter in bladder, since it may cause reflux and upper tract injury.
    
12. If urodynamics show poor bladder compliance and detrusor contractions reach pressures of 80 - 100 cm H2O, Oxybutynin HCL is given in dose of 1.0 mg per year of age, every 12 hours.
    
13. It is not at all uncommon for the urologic lesion to be altered as the child ages - dyssnyergia may develop, etc. It is important to R/O tethered cord, syrinx or hydromyelia of the cord, increased ICP secondary to hydrocephalus, or partial herniation of the brainstem/cerebellum. Thus, serial neurologic evaluations are of great importance.
    

    
    

Flagyl - Once a day dose of 30 mg/kg/d
Rocephin - Once a day dose of 50mg/kg/d
These are given to any child with presumed appendicitis, PERFORATED OR NOT.

Best dx is fiberoptic bronch
High frequency vent
aerosolized heparin and mucormist
steroids useless
Steroids in biliary atresia prednisone 4mg/kg when starting po then decrease the dose by 1/2 over 6-8 weeks to 0.5 mg/kg qod and keep them there. Also oral ciprofloxacin ursodeoxycholic acid (actigol) 20mg/kg/day in divided doses Kasai-mobilize triangular lig

use 15 IU
4 quadrant inject
Mix to 15 U/0.4 cc, inject 0.1 cc in each quadrant
CPT 46505 (99.29); ICD 751.3

1 to 1.5 1/10,000 thickness Erythromycin for gut motility 2 - 3 mg /
kg po tid in newborns

100 units / kg
200 units / kg
300 units / kg

50,000 units in 50 ml of NS if < 30 kg
75,000 units in 75 ml of NS if 31 - 50 kg
100,000 units in 100 ml of NS if > 50 kg
Leave in for 4 - 6 hrs, may repeat q day x 2 or3.

Grade 1-2 splenic / liver trauma -
One night of bedrest if stable
6 weeks of limited activity after dc
Follow - up in 6 weeks
Grade 3-4 splenic / liver trauma -
Two nights of bedrest if stable
6 weeks of limited activity after dc
Follow - up in 6 weeks

Double voiding and timed voiding
Sit backwards on the toliet 1 - 2 times per day
Push Fluids
Liberal use of topical emolients (eg. A and D, vaseline)
Try short courses of premarin cream
Improves with puberty
Culture drainage and treat appropriately
Vaginoscopy if any question of FB / Other

Acute fissures rarely require surgical intervention and usually improve with conservative management, such as diet, stool softeners (miralax), and Sitz baths. Symptoms often go away quickly, but 6-8 weeks may be necessary for fissure resolution. Persistent fissure is considered chronic, and chemical or surgical sphincterotomy may be considered. Efficacy of chemical sphincterotomy in the pediatric population is not clear but widely used.
Glyceryl-trinitrate (GTN) is the most widely used agent for chemical sphincterotomy. GTN 0.2% ointment is applied topically to the lower anal canal 2-3 times daily, until the fissure heals. Complications from this treatment modality are discussed below.

The Best Use of Fresh Frozen Plasma (FFP)
Laboratory testing is only useful in the context of a good patient and family history for bleeding tendency. Start with a history and clinical assessment.
Accepted Indications for FFP – Reflected in the Transfusion Requisition
Patient > 4 mo old with PT/PTT > 18/43 with active bleeding / requiring invasive surgery Specific factor deficiency < 35% normal for which a factor concentrate is not available Replacement therapy for plasma exchange, Protein C or S deficiency Massive transfusion > 150% of total blood volume ECMO, CPB, dialysis, apheresis Preparation of reconstituted whole blood At risk for intracranial or other organ hemorrhage Intraoperative with unexplained bleeding Pre-op order – this means “hold for OR”, not FFP to be given in the pre-op time
The American Society of Anesthesiologists Task Force (2005) recommends FFP for the correction of excessive microvascular bleeding in the presence of a PT greater then 1.5 times the normal range or an INR greater then 2.0 or an aPTT greater then 2 times normal. This is consistent with recommendations from AABB and CAP.
For children > 4 months our normal ranges for PT is 12.4-15.4 and for PTT is 24.5-37.5. Neonates have a dynamic coagulation system and normal values are higher and approximate.
With these recommendations in mind the Transfusion Committee established a PT of 18 (12.4 x 1.5 = 18.6) for audit criteria. For PTT, our normal range was lower when the audit criteria were established. But given out current normal range, 43 represents 24.5 x 1.8 = 44. A full 2 times normal as recommended would be a PTT of 49.
The most common cause of an elevated PTT is heparin contamination from a line draw. When the lab receives a line draw and the patient is not on heparin and the PTT is elevated, we report the initial PTT and then neutralize the heparin and report the heparin neutralized PTT. Wait for this second result before assuming the PTT is elevated.
Another common cause of an elevated PTT in a non-bleeding patient is non–specific inhibitors associated with viral diseases in children. FFP will not correct this elevation.
PT is commonly elevated due to low Factor 7 or hypofibrinogenemia. You only need 30-40% of normal Factor 7 for effective coagulation. Factor 7 only has a half life of 2-5 hours after transfusion. Give FFP as close to the actual surgery as possible.
Cryoprecipitate, not FFP, is the product of choice for fibrinogen and Factor 13. There are specific products for Factors 7, 8, 9 and Antithrombin III. Do not use FFP.

1. Inclusion - perf appendix = hole or stool
   
2. Exclusion - immunodeficiency or complex comorbidity
   
3. Controls - ceftriaxone 50 mg/kg/day one dose, and metronidazole 30
   mg/kg/day one dose. 5 days of IV abts, home if OK, Afeb, and nl
   wbc. If wbc up, then 2 days more + reck, then 3 days more + reck
   
4. Test grp - same til afeb x 12 hrs and OK on oral pain meds. Home
   augmentin fortotal 7 day crse.
   
5. 2 wk fu with pill bottle
   

Overall theory is that infectious endocarditis (IE) is a) much more likely to be due to random daily bacteremia than for dental / GI / GU procedure and 2) Prophylaxis will only prevent a tiny number of IE cases, and 3) There is significant risk of adverse antibiotic associated events.
Heart conditions with highest risk of Adverse outcome from IE: 1. Prosthetic valve 2. Previous IE 3. Congenital Heart Disease*
Unrepaired cyanotic CHD, inculding shunts and conduits
Completely repaired CHDwith prosthetic material or device in 1st 6mo after repair
Repaired CHD with residual defects at or adjacent to the site of a patch or prosthetic device
Cardiac transplant with valvulopathy
Abt prophylaxis is not needed for any other form of CHD
Who needs prophylaxis:

1. Dental procedures with gingival manipulation, periapical teeth or
   oral mucosal perforation
   
2. Respiratory tract (including T and A)
   
3. Infected Skin
   
4. Skin structures
   
5. Musculoskeletal Tissue
   

NOT for GI or GU procedures!

Glyceryl trinitrate (GTN) 0.2% ointment is one of the most commonly used agents for 'chemical sphincterotomy'. It releases nitric oxide, decreases internal anal sphincter pressure and causes selective anodermal vasodilation, increasing tissue perfusion. It decreased mean maximum anal resting pressures, and at 3 months, all fissures had healed and pressure returned to baseline (112.3 ± 44 cmH20). (Lund et al.) A total of 35% developed recurrent symptoms which resolved with conservative measures; 43% of patients experienced transient headache, a common concern with nitrate therapy. There was no incontinence reported. A follow-up study in 15 children demonstrates effective healing with GTN dosed at 0.05% and 0.1%. Headaches were noted in approximately 15% of both groups.