Basic Vital Day to Day Knowledge

Question 1

What is the mnemonic for preparing to respond to a paediatric emergency?

Answer 1

WAFEELS GMS

WEIGHT
< 6/12: Birth weight x 2
6/12 to 1 year: Birth weight x 3
> 1 year: (Age + 4) x 2

ADRENALIN dose IV/IO (Cardiac Arrest)
10 mcg/kg
0.1 ml/kg of 100 mcg/ml

FLUID dose
10 or 20 ml/kg

ETT size (cuffed)
> 1 year is Age/4 + 3.5

ETT depth
–> ETT size x 3 (+2 for nose) = cm at lip

Lightning dose
Defib 1st dose: 2 J/kg
Defib 2nd dose: 4 J/kg

Glucose
Child: 5ml/kg of 10% glucose (different for neonates)

Morphine: 0.1mg/kg IVI

Sedation / Seizures
1. Lorazepam IO/IV 0.1 mg/kg
2 Midazolam SL 0.5mg/kg
3. Diazepam PR 0.5mg/kg

Question 2

Define premature infants neonates, infants, toddlers, children and adolescents and define the normal range of HR, RR and SBP for these.

Answer 2

PREMATURE INFANTS (Born before 37 weeks gestation)
HR 140 - 170
RR 40 - 70
MAP = Gestational age

NEONATES (0 - 28 days)
HR 120 - 170 bpm
RR 25 - 50 breaths/min
SBP 80 - 90

INFANTS (28 days - 1 year)
HR 110 - 160
RR 20 - 40
SBP 85 - 95

TODDLERS (1 - 3 years)
HR 90 - 140
RR 20 - 35
SBP 85 - 100

CHILD (3 - 12)
HR 70 - 130
RR 15 - 30
SBP 90 - 110

ADOLESCENTS (>12)
HR 60 - 110
RR 12 - 24
SBP 90 - 120

Question 3

How are CVC’s sized in paediatrics

Answer 3

< 10 kg ——-> 4 Fr

10 - 20 kg ——–> 4 - 5 Fr

20 - 40 kg ——–> 5 Fr

> 40 kg ———> 7 Fr

LENGTH: 10% of patient’s height (sizes available are 5 cm, 8cm and 13 cm)

Use smallest size and least number of lumens possible (increased complications)

Question 4

Name medication, dose and administration timing of the premeds administered frequently at red cross hospital

Answer 4

Clonidine
- 3 - 4 ug/kg PO 90 minutes preop

Midazolam
- 0.2 - 0.3 mg/kg (max 7.5mg) PO 30 minutes prop ‘on trolley’

Question 5

Describe the apnoea prevention protocol at red cross hospital

Answer 5

APNOEA PREVENTION
1. Prem babies < 60 weeks post conceptional age

Caffeine Citrate
- 20 mg/kg PO 2 hours preoperatively
- 10 mg/kg PO daily x 48 hours postoperatively

OR
Anhydrous caffeine
- 10 mg.kg PO 2 hours preoperatively
- 5 mg/kg PO daily x 48 hours postoperatively

OR
Aminophylline
- 5 - 10 mg/kg IV (slowly intraoperatively)

APNOEA MONITORING
- For 12 hours postoperatively
1. Term < 50 weeks postconceptional age
2. Prem < 60 weeks postconceptional age

Question 6

What are the medications and dosage of medications given at RXH for PONV

Answer 6

1. Ondansetron 0.15 mg/kg IV
2. Dexamethasone 0.15 mg/kg IV

Question 7

What is the name and dose of prophylactic antibiotics commonly given to patients undergoing surgery at RXH

Answer 7

1. Cefazolin 50 mg/kg
2. Metronidazole 15 mg/kg

Question 8

Describe the dose of the agents required for reversal in paediatrics

Answer 8

Neostigmine 50 ug/kg
Atropine 20 ug/kg
Glycopyrrolate 10 ug/kg

At RXH
Neostigmine 2.5 mg + Glycopyrrolate 0.4 mg draw up to 5 mls
–> Give 1ml per 10kg
OR
–> 0.1 ml per 1kg if less 10 kg

Question 9

Describe maintenance and bolus fluid management at RXH

Answer 9

Maintenance
4 ml/kg/hr - 1st 10 kg
2ml/kg/hr - 2nd 10 kg
1 ml/kg/hr - thereafter

Bolus
5 ml/kg (titrated) up to a max of 20ml/kg
–> Aim for UO of 0.5 - 1.0 ml/kg/hr

Question 10

Describe how adrenalin infusions are mixed and infused at RXH

Answer 10

60 ug/kg in 50 ml normal saline

1ml/hr = 0.02 ug/kg/min

Question 11

Describe how dexmedetomidine infusions are prepared and infused at RXH

Answer 11

Bolus: 1 ug/kg
Infusion: 10 ug/kg in 50 mls normal saline: 1 ml/hr = 0.2 ug/kg/hr

Dose range: 0.2 - 1.5 ug/kg/hr

Question 12

Describe how a ketamine TIVA is done at RXH

Answer 12

200mg ketamine in 50 ml normal saline = 4mg/ml (consider 8 mg/ml for bigger kids / longer cases)

Induction: 1 - 2 mg/kg bolus

12mg/kg/hr for 20 minutes
8mg/kg/hr for 20 minutes
4 mg/kg/hr for remainder

Question 13

Describe how milrinone is prepared and infused at RXH

Answer 13

1.5 mg/kg in 50 ml normal saline: 1 ml/hr = 0.5 ug/kg/min

Dose range: 0.25 - 0.75 ug/kg/min

Question 14

Describe how noradrenalin is prepared and infused at RXH

Answer 14

60 ug/kg in 50 ml normal saline: 1ml/hr = 0.02ug/kg/min

Question 15

Describe how remifentanil is prepared and infused at RXH

Answer 15

Concentration: 10 ug/ml

Weight (kg) x 0.6 = rate (ml/hour) = 0.1 ug/kg/minute

Dose range: 0.1 - 0.3 ug/kg/minute

Question 16

Describe how sufentanyl is prepared and infused at RXH

Answer 16

10 ml of 5 ug/ml neat solution in 50 ml normal saline

Concentration 1ug/ml

< 20 kg: 10 ml/hr
> 20kg: 20 ml/hr

Discontinue 20 minutes prior to finish

Question 17

How is Clysis mixture drawn up and administered at RXH

Answer 17

10 ml Bupivacaine 0.5% + 1 mg (1ml) adrenalin.
Take 4.5 mls of this mixture and add it to a 200 ml bag NaCl

Maximum dose 20ml/kg

Question 18

Describe the dosing and administration of LA via wound infusion catheters depending on age at red cross hospital

Answer 18

< 4 months: 0.1% bupivacaine at 0.1 - 0.2 ml/kg/hr

> 4 months: ).2% bupivacaine at 0.1 - 0.2 ml/kg/hr

Question 19

Describe the administration of caudals at Red Cross Hospital

Answer 19

0.25% bupivacaine

Sacro-lumbar block: 0.5ml/kg
Upper abdo block: 1 ml/kg
Mid thoracic block: 1.2 ml/kg (not always reliably achieved)

Note: 1ug/kg of clonidine can be added to the caudal

Question 20

summarise Fasting guidelines for children

Answer 20

Solid food/formula milk - 6 hours
Breast milk - 4 hours
Clear fluid - 1 hour

Pulmonary aspiration is a rare event in children, with an incidence of 0.07%‐0.1%.

A Provided there are no specific contraindications (e.g. gastro-oesophageal reflux, cerebral palsy) a liberal clear fluid fasting regime does not affect the incidence of pulmonary aspiration in children. With a 2‐hour clear fluids fasting policy, studies indicate that this translates into a much longer duration of fasting (6‐7 hours), which is clearly undesirable.

These prolonged periods of fasting in children can increase thirst and irritability and can lead to other adverse physiological and metabolic effects.

Clear fluids are defined as water, clear (nonopaque) fruit juice or squash/cordial, ready diluted drinks, and nonfizzy sports drinks. Non‐thickened, non‐carbonated. The starting point would be 3 mL/kg based on estimated weight or banding according to age. This would mean 1‐ to 5‐year olds are allowed up to 55 mL, 6‐12 years up to 140 mL, and greater than 12 years up to 250 mL. Such banding avoids the need to wait for a current weight (if it is unknown) that could delay the offer of an appropriate volume.

The preoperative fasting for elective procedures for children aged 0-16 years of age are as follows:

Question 21

Describe the epidural protocol at RXH

Answer 21

Estimated depth of epidural space from skin:
1mm/kg.
Length in epidural space = 3 - 4 cm

Bolus: 0.25% bupivacaine
–> 0.5ml/kg thoracic
–> 0.75 ml/kg lumbar
Alternatively use 0.5 - 1 ml per dermatome needing to be covered (check toxic dose)

Infusion
Bupivacaine: 0.1% bupivacaine
–> >6/12 and > 5kg: 0.1 - 0.4 ml/kg/hr
–> <6/12 or < 5kg: 0.1 - 0.2 ml/kg/hour

Question 22

Describe the names and doses of 8 medications used for intra-operative analgaesia

Answer 22

Paracetamol 15mg/kg (20mg/kg loading)
*Diclofenac (PR) 1mg/kg
*Paracoxib 1mg/kg
Ketamine 0.25 - 0.5 mg/kg
Clonidine 1 - 2 ug/kg
Fentanyl 1 - 2 ug/kg
Morphine 0.1 ug/kg
Alfentanyl 10ug/kg

Question 23

Describe the names and doses of 7 medications used for post op analgaesia at RXH

Answer 23

Paracetamol 15 mg/kg PO 6 hrly
*Ibuprofen 5 - 10 mg/kg PO 8 hrly
Clonidine 2 - 5 ug/kg PO 8 hrly
Morphine infusion: 0.5mg/kg in 50 ml NaCl @ 1 - 3 ml/hr
Morphine (oral):
–> Neonate: 0.05 mg/kg 6hrly
–> 1/12 to 1 yr: 0.05 - 0.2 mg/kg 4 - 6 hrly
–> >1yr: 0.2 - 0.4 mg/kg 4 - 6 hrly
Ketamine: 0.2 - 0.3 mg/kg/hr
–> 5mg/kg in 50 ml NaCl @ 2 -3 ml/hour
Gabapentin: 3 - 10 mg/kg 8 hourly
–> Initiate and wean over 3 days
E.g. Day 1: nocte. Day 2: 12 hourly. Day 3 8 hrly.

Question 24

Describe the antiemetics and their doses used at RXH

Answer 24

1st line: Ondansetron 0.15mg/kg IV 8 hrly
2nd line: Droperidol 0.02mg/kg (max 0.5 mg) IV 6 - 8 hrly
3rd line: Metoclopramide 0.3 mg/kg (max 15 mg) IV 8 hrly

Question 25

What stool softener is preferable and what is its dose at RXH

Answer 25

Lactulose 0.5 ml/kg PO 12 hrly PRN

Question 26

What is the revised FLACC score?

Answer 26

The revised FLACC (Face, Legs, Activity, Cry, Consolability) is a behavioural pain assessment scale for use with children unable to self-report their level of pain due to developmental disabilities.

Observe child for 1 - 3 minutes if awake and 5 minutes if asleep

1 - 3 mild
4-6 moderate
7 - 10 severe pain

Question 27

What is NIPS

Answer 27

Neonatal Infant Pain Scale

FLAACB - 0 - 1 - 2

Face relaxed - contracted - /
Legs Relaxed - flexed or stretched - /
Arms Relaxed - flexed or stretched - /
Alertness Calm - uncomfortabe - /
Cry - Absent - mumbling - Vigorous
Breathing - Relaxed - off baseline - /

0 - 2 = mild pain
2 - 4 = moderate
> 4 = severe pain