Table of Contents

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Drug Calculations (weight-based). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
STANDARD CONCENTRATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
DOSING GUIDELINES *under review* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Antimicrobial Guidelines
Antimicrobial Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Pneumonia – Community-Acquired. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Pneumonia – Ventilator/Hospital Acquired. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Cardiovascular Practices
Admission Guidelines for Postoperative Cardiac Patients. . . . . . . . . . . . . . . . . . . 24
Antibiotic Surgical Prophylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Anticoagulation Guidelines for Cardiac Patients . . . . . . . . . . . . . . . . . . . . . . . . 26
Bleeding Post Cardiac Surgery – Management Guidelines. . . . . . . . . . . . . . . . . 30
Chest Closure in the CCU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Hemodynamic Parameters in the Cardiac Patient. . . . . . . . . . . . . . . . . . . . . . . 32
Postoperative Management and Common Complications of Selected Lesions . . 33

Medical Surgical Practices

Burn Patients – Initial Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Congenital Diaphragmatic Hernia Management. . . . . . . . . . . . . . . . . . . . . . . . . 44
DKA Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Refractory Status Epilepticus – Diagnostic Approach. . . . . . . . . . . . . . . . . . . . . 48
Refractory Status Epilepticus – Drug Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . 52
Sepsis/Septic Shock Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Formulae
Acid Base. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Blood Products. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Cardiorespiratory Formulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Derived Formulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
ECMO Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Fluid and Electrolytes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Glasgow Coma Scale Score. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Needle and Catheter Gauges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Prism Scores – Infants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Theme
Intubation Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Resuscitation Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Editorial Drug Calculations (weight-based)

Every effort has been made to ensure accuracy of drug doses, however, the
reader is cautioned to check doses and schedules with the manufacturer’s Desired Concentration Calculation: Dose in mg in a 50 mL syringe
recommendations or with the SickKids Pharmacy Department or with the 0.01 microgram/kg/min = 1 mL/h 0.03 X Wt (kg)
SickKids Formulary of Drugs. 0.02 microgram/kg/min = 1 mL/h 0.06 X Wt (kg)
• For additional information on guidelines for drug usage and 0.05 microgram/kg/min = 1 mL/h 0.15 X Wt (kg)
monitoring see e-formulary. 0.1 microgram/kg/min = 1 mL/h 0.3 X Wt (kg)
• Prescribing errors 0.33 microgram/kg/min = 1 mL/h 1.0 X Wt (kg)
- avoid abbreviations of drug names 1 microgram/kg/min = 1 mL/h 3 X Wt (kg)
- avoid trailing zero (X.0 mg). Write X mg and avoid a ten fold error 2 microgram/kg/min = 1 mL/h 6 X Wt (kg)
- lack of leading zero ( .X mg). Write 0.X mg and avoid a ten fold error 5 microgram/kg/min = 1 mL/h 15 X Wt (kg)
- avoid U for (units). Write “unit” 20 microgram/kg/min = 1 mL/h 60 X Wt (kg)
- avoid q d (?day or ?dose). Write “daily or qday” 25 microgram/kg/min = 1 mL/h 75 X Wt (kg)
10 microgram/kg/h = 1 mL/h 0.5 X Wt (kg)
POTENTIALLY HIGHLY TOXIC DRUGS (High risk for calculation errors) 20 microgram/kg/h = 1 mL/h 1 X Wt (kg)
- narrow therapeutic range 0.25 mg/kg/h = 1 mL/h 12.5 X Wt (kg)
- confusing to order 1 mg/kg/day = 1 mL/h 2 X Wt (kg)
- unusual units of measure
- likelihood of tenfold errors
- requires complex calculations Dose: units in a 50 mL syringe
0.0001 Units/kg/min = 1 mL/h 0.3 X Wt (kg)
Thanks to the Critical Care Pharmacists, the many members of the . 10 Units/kg/h = 1 mL/h 10 X 50 X Wt (kg)
Critical Care Program and Elaine Lau, Drug Information Coordinator . 28 Units/kg/h = 1 mL/h 28 X 50 X Wt (kg)
who have contributed to publishing and editing of this handbook.

Dr. Peter Cox.

Editor Dose: microgram in a 50 mL syringe
5 nanogram/kg/min = 1 mL/h 15 X Wt (kg)

2 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 3
Standard Concentrations Drug Usual Start Dose Weight
Standard
Concentration Rate (mL/h)
for Continuous Infusion epinephrine CVL 0.01 mcg/kg/min <10 kg 0.1 mg/50 mL 0.3 X Wt

10 – <15 kg 0.25 mg/50 mL 0.12 X Wt

. ≥15 kg 0.5 mg/50 mL 0.06 X Wt

Vasoactive drugs: rates must be ≥1 mL/h.
0.1 mcg/kg/min <10 kg 1 mg/50 mL 0.3 X Wt
Standard
Drug Usual Start Dose Weight Concentration Rate (mL/h) 10 – <15 kg 2 mg/50 mL 0.15 X Wt
alprostadil 0.01 mcg/kg/min <15 kg 100 mcg/50 mL 0.3 X Wt
≥15 kg 4 mg/50 mL 0.075 X Wt
D5W, D10W
≥15 kg 500 mcg/50 mL 0.06 X Wt esmolol. 50 mcg/kg/min All 500 mg/50 mL . 0.3 X Wt
D5W, D10W (hang bag if . (undiluted)
rate >4 mL/h) 2500 mg/250 mL
amIODARone 5 mcg/kg/min All 50 mg/50 mL D5W 0.3 X Wt
(undiluted)
PIV*
amIODARone 5 mcg/kg/min <40 kg 150 mg/50 mL D5W 0.1 X Wt
fentaNYL 1 mcg/kg/hr ≥10 kg 2000 mcg/40 mL 0.02 X Wt
CVL†
≥40 kg 600 mg/50 mL D5W 0.025 X Wt (undiluted)
calcium 1 mmol/kg/day All 11.6 mmol/50 mL 0.18 X Wt <10 kg 1000 mcg/50 mL 0.05 X Wt
gluconate CVL (undiluted)
cisatracurium 0.3 mg/kg/hr All 20 mg/10 mL 0.15 X Wt furosemide 0.25 mg/kg/hr <10 kg 40 mg/50 mL 0.313 X Wt
(undiluted) 0.45% NaCl
dexmedetomidine 0.5 mcg/kg/hr <10 kg 200 mcg/50 mL 0.125 X Wt
10 – <40 kg 120 mg/50 mL 0.104 X Wt
≥10 kg 400 mcg/50 mL 0.063 X Wt
0.45% NaCl
DOBUTamine CVL 5 mcg/kg/min <10 kg 50 mg/50 mL 0.3 X Wt
≥40 kg 250 mg/50 mL 0.06 X Wt ≥40 kg 250 mg/25 mL 0.025 X Wt
(undiluted)
DOPamine CVL 5 mcg/kg/min <10 kg 40 mg/50 mL . 0.375 X Wt
(hang bag if . (800 mcg/mL)
RATE >4 mL/hr)
≥10 kg 160 mg/50 mL . 0.094 X Wt
(3200 mcg/mL)

4 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 5
 Standard Standard
Drug Usual Start Dose Weight Concentration Rate (mL/h) Drug Usual Start Dose Weight Concentration Rate (mL/h)
heparin 10 units/kg/hr. <20 kg 5000 units/50 mL 0.1 x Wt lidocaine 20 mcg/kg/min <10 kg 100 mg/50 mL 0.6 X Wt
PROPHYLAXIS
≥20 kg 10,000 units/50 mL 0.05 x Wt 10 – <40 kg 400 mg/50 mL 0.15 X Wt
20 units/kg/hr. <20 kg 5000 units/50 mL 0.2 x Wt
TREATMENT for. ≥40 kg 1000 mg/50 mL 0.06 X Wt
≥20 kg 10,000 units/50 mL 0.1 x Wt (undiluted)
>1 year old
Fluid-restricted 30,000 units/50 mL 0.033 X Wt midazolam 1 mcg/kg/min <20 kg 50 mg/50 mL 0.06 X Wt
28 units/kg/hr <5 kg 2500 units/50 mL 0.56 x Wt
20 – <40 kg 100 mg/50 mL 0.03 X Wt
TREATMENT for .
≥5 kg 5000 units/50 mL 0.28 x Wt
≤1 year old
≥40 kg 250 mg/50 mL . 0.012 X Wt
HYDROmorphone 1 mcg/kg/hr <20 kg 0.5 mg/50 mL 0.1 X Wt (undiluted)
≥20 kg 2 mg/50 mL 0.025 X Wt milrinone 0.33 mcg/kg/min <10 kg 5 mg/50 mL . 0.2 X Wt
0.45% NaCl
Fluid-restricted 10 mg/50 mL 0.005 X Wt
10 – <50 kg 10 mg/50 mL 0.1 X Wt
insulin . 0.01 units/kg/hr <10 kg 2 units/50 mL NS 0.25 X Wt
0.45% NaCl
- Regular, Human
10 – <40 kg 10 units/50 mL NS 0.05 X Wt
(non-DKA) ≥50 kg 40 mg/40 mL 0.02 X Wt
≥40 kg 50 units/50 mL NS 0.01 X Wt (undiluted)
insulin . 0.1 units/kg/hr All 25 units/250 mL NS 1 X Wt morphine 20 mcg/kg/h <10 kg 5 mg/50 mL 0.2 X Wt
- Regular, Human
Fluid-restricted 50 units/50 mL NS 0.1 X Wt 10 – <40 kg 10 mg/50 mL 0.1 X Wt
(DKA)
≥40 kg 50 mg/50 mL 0.02 X Wt
isoproterenol 0.01 mcg/kg/min <20 kg 0.25 mg/50 mL 0.12 X Wt
nitroglycerin 1 mcg/kg/min <5 kg 5 mg/50 mL 0.6 X Wt
≥20 kg 0.5 mg/50 mL 0.06 X Wt
5 – <15 kg 10 mg/50 mL 0.3 X Wt
0.05 mcg/kg/min <10 kg 0.25 mg/50 mL 0.6 X Wt
≥15 kg 50 mg/50 mL 0.06 X Wt
≥10 kg 0.5 mg/50 mL 0.3 X Wt
nitroprusside 1 mcg/kg/min <10 kg 10 mg/50 mL D5W 0.3 X Wt
labetalol 1 mg/kg/hr All 200 mg/40 mL 0.2 X Wt
(undiluted) 10 – <40 kg 50 mg/50 mL D5W 0.06 X Wt
≥40 kg 200 mg/50 mL D5W 0.015 X Wt

6 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 7
 Standard Standard
Drug Usual Start Dose Weight Concentration Rate (mL/h) Drug Usual Start Dose Weight Concentration Rate (mL/h)
norepinephrine 0.01 mcg/kg/min <10 kg 0.1 mg/50 mL 0.3 X Wt propofol 30 mcg/kg/min All 500 mg/50 mL 0.18 X Wt
CVL (undiluted)
10 – <15 kg 0.25 mg/50 mL 0.12 X Wt
salbutamol 1 mcg/kg/min All 50 mg/50 mL 0.06 X Wt
≥15 kg 0.5 mg/50 mL 0.06 X Wt
(undiluted)
0.1 mcg/kg/min <10 kg 1 mg/50 mL 0.3 X Wt
vasopressin CVL 0.1 milliunit/kg/min. <10 kg 1 unit/50 mL 0.3 X Wt
10 – <15 kg 2 mg/50 mL 0.15 X Wt = 0.0001 unit/kg/min
≥15 kg 4 mg/50 mL 0.075 X Wt 10 – <25 kg 2 units/50 mL 0.15 X Wt
phentolamine 1 mcg/kg/min <5 kg 10 mg/50 mL 0.3 X Wt ≥25 kg 4 units/50 mL 0.075 X Wt
CVL
5 – <20 kg 20 mg/50 mL 0.15 X Wt *PIV = Peripheral IV †CVL = Central Venous Line **PCA = Patient Controlled Analgesia
≥20 kg 50 mg/50 mL 0.06 X Wt May 2012

phenylephrine 0.01 mcg/kg/min <10 kg 0.1 mg/50 mL§ 0.3 X Wt §Phenylephrine infusions for standard concentrations <0.5 mg/50 mL: Take 0.1 mL of .
CVL 10 mg/mL ampoule of phenylephrine and 0.9 mL Sterile Water for Injection (SWI) = .
10 – <15 kg 0.25 mg/50 mL§ 0.12 X Wt
1 mg/mL (1000 microgram/mL). Use this 1 mg/mL solution to prepare a standard
§ See dilution . ≥15 kg 0.5 mg/50 mL 0.06 X Wt concentration infusion of phenylephrine.
at end of table
0.1 mcg/kg/min <5 kg 0.5 mg/50 mL 0.6 X Wt
5 – <10 kg 1 mg/50 mL 0.3 X Wt
≥10 kg 2 mg/50 mL 0.15 X Wt
phosphate 1 mL/hr . All 15 mmol Titrate
K+/Na+ CVL (initial max 5 mL/hr) Phosphate/50 mL
potassium See High KCl All 25 mmol/50 mL. Titrate
chloride CVL IV infusion D5W/0.2% NaCl
standard order
procainamide 20 mcg/kg/min <10 kg 200 mg/50 mL NS 0.3 X Wt
≥10 kg 1000 mg/50 mL NS 0.06 X Wt

8 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 9
Drug Dosing Guidelines Cisatracurium • 0.1-0.2 mg/kg followed by 0.03 mg/kg/dose to maintain .
neuromuscular blockade
• Continuous infusion: .
Starting Dose: 0.3 mg/kg/hour and titrate up as needed to .
maintain muscle relaxed state. Patients do develop tachyphylaxis
(Doses by age and weight) and therefore may need the dose titrated upwards to a .
† reduce dose in renal impairment recommended maximum dose: 0.7 mg/kg/hour.
weight <2 kg/premature: See e-formulary .
Drug Holiday: Q shift at 06:00 and 18:00. Once a shift, stop
the cisatracurium continuous infusion to assess the patient for
underlying muscle activity (i.e. the patients are reversing from the
drug effect AND to assess that they are not seizing etc). Once any
The dosing section is being phased out. Refer to the movement is noted, i.e. respiratory effort, limb movement (NOT just
twitching!), then restart the continuous infusion..
following online resources: SickKids Electronic Formulary .
Paediatric and Neonatal Lexi-Drugs - In our CCU “Train of 4” is not used to monitor patients on .
continuous cisatracurium infusions

• Duration of action: shorter than pancuronium

• Metabolism: drug is cleared by nonenzymatic degradation .
in the bloodstream
Aminophylline • Diuresis: ♥ (Cardiac population)
Infusion: 0.25 mg/kg/h. Levels at 12h, 24h then q24h
Keep levels <50 µmol/L
Intermittent: 1.2-2.5 mg/kg/dose IV q8-12h. Daily levels.

Chlorothiazide • Cardiac population: 5 mg/kg/dose IV q6-q12h .

based on clinical response
Assess duration • Infants and Older Children: >6 mos: 4 mg/kg/DAY IV .
regularly. Step down ÷ q12h (max 20 mg/kg/DAY has been used)
to oral thiazide • Adult: 100-500 mg/DAY IV ÷ q12h (max 2 g/DAY)
when possible

10 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 11
 Desmopressin • Diagnosis and treatment of Central Diabetes Insipidus: INSULIN, REGULAR (HUMAN)
urine output >4 mL/kg/h for >2h, plasma Na >145 mmol/L,
Dosing for IV DDAVP
plasma osmol >300 mOsmol/kg with . PAY ATTENTION TO DIFFERENT CONCENTRATIONS
in children is not well
urine osmol <300 mOsmol/kg (usually <200 mOsmol/kg)
defined and depends
on clinical scenario
Dose: • Diabetic Ketoacidosis (DKA) (guidelines see page 79)
<25 kg: 2 microgram IV/dose (range 0.5-2 micrograms per dose) Administration: Use standard concentrations
≥25 kg: 4 microgram IV/dose
Diagnosis confirmed by ↓ urine output to <2 mL/kg/h and .
• Non DKA Hyperglycemia e.g. post op cardiac patients
↑ Uosmol to >300 mOsmol/kg
Administration of DDAVP will result in a ↓ urine Neonates (<1 month of age): Starting dose = 0.01 units/kg/h
output together with an ↑ urine Na concentration Administration: Use standard concentrations
Caution: Do not treat patients after craniopharyngioma resection .
or with suspected DI with a regimen of replacing urine output . • For patients ≥1 month of age: Starting Dose = 0.05 units/kg/h.
with the same volume of hypotonic saline. This will result in .
acute hyponatraemia Administration: use standard concentrations
• Diabetes Insipidus: For syringes <10 units/50 mL use Pharmacy’s 10 units/mL diluted Insulin .
Nasal: 5-20 microgram/DAY intranasally once daily or ÷ bid Regular, Human product. Withdraw insulin using a regular 1 mL syringe. .
• Coagulopathy: 0.3 microgram/kg/dose IV/sc;. Do not use an insulin syringe with the 10 units/mL product.
may repeat dose after >12 h if necessary (max 20 mcg/dose) For syringes ≥10 units/50 mL or 25 units/250 mL bags use 100 units/mL .
Insulin Regular, Human
Maximum concentration should not exceed 50 units/50 mL
Add D5W to maintenance fluid when serum glucose <15 mmol/L
Insulin, Regular • Must order as “Insulin, Regular, Human” Add D10W to maintenance fluid when serum glucose <10 mmol/L
(Human) • Availability:
10 units/mL diluted Insulin Regular, Human (wardstock, main med
room fridge).
• Monitor glucose q1h initially while on insulin infusion
100 units/mL Insulin Regular, Human (wardstock, main med room
fridge) • Hyperkalemia
0.1 units/kg IV. Give concurrently with 1 mL/kg Dextrose 50% IV (0.5 g/kg). .
see next page If no CVL use a large bore PIV. For doses <10 units use 10 units/mL diluted
Insulin Regular Human product available as wardstock (med room fridge)

The Hospital for Sick Children 13

 Ketamine • Induction: IV 1-2 mg/kg/dose Rocuronium 1 mg/kg PRN (watch BP)
IM ONLY 4-10 mg/kg/dose
• Sedation (intubated patients): 5-10 microgram/kg/min
• Analgesia: 1-4 microgram/kg/min (max 10 mg/h)
Start at lower end of range and titrate. Do not
exceed upper limit of dosing range as side effects >>
benefits. Avoid rapid increases in rate so as to avoid
hallucinations, agitation. Antidote: benzodiazepine
Opioid sparing: aim to taper opioid dose after ketamine .
is started for analgesia

Magnesium Sulfate • Bolus 0.3 mmol Mg++/kg/dose IV (over 20-60 min)

Max single doses = 10 mmol IV over 1h
High risk drug Availability: on crash carts for resuscitation only.
for 10 fold errors

≤10 kg: .
do not exceed .
3 mmoL/dose

Not an IV push drug

14 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 15
Antimicrobial Guidelines
See Sickkids Drug Handbook and Formulary for:
• Antibiotic Susceptibility Chart
• Initial Empiric Antibiotic Therapy in Children
• Use of Amphotericin B Lipid Products
• Asplenia Prophylaxis
• Endocarditis Prophylaxis
• Prophylaxis for Pneumocystis Jirovecii Pneumonia
• Surgical Prophylaxis for Neonates and Paediatric Patients
• Haematology/Oncology Guidelines
• Sickle Cell Disease – acute chest syndrome or pneumonia
16 Paediatric Critical Care Medicine Handbook of Clinical Practice
Empiric Treatment of Community-Acquired
Bacterial Pneumonia in Children
Hospitalized Patients
AGE GROUPS ORGANISMS FIRST LINE ALTERNATIVE AGENTS
1 – <3 months S. pneumoniae, For CCU Patient/moderate or severe illness:
Chlamydia cefotaxime + cefuroxime +
trachomatis, macrolide macrolide (or quinolone)
B. pertussis,
S. aureus,
H. influenzae
S. pneumoniae, Severe influenza unlikely:
≥3 months –
S. aureus,
18 years ceftriaxone ±.
H. influenzae, macrolide (or quinolone) .
S. pyogenes if atypical pathogen .
C. pneumoniae suspected .
Mycoplasma .
pneumoniae Severe influenza likely:
ceftriaxone ± vancomycin
(if MRSA Suspected) ± .
macrolide1 .
.
Severe large effusion:
ceftriaxone ± clindamycin ceftriaxone ± clindamycin
vancomcyin ± macrolide1 or cloxacillin ± macrolide1
1
Macrolide (or quinolone) should be added if suspect atypical pathogen.
.
Beta-lactam allergic patients:
For patients with significant beta-lactam allergy, macrolides are alternatives to the beta-lactams.
However, for critically ill patients please consult Infectious Diseases regarding the appropriate regimen.
The Hospital for Sick Children 17
Ventilator/Hospital Acquired Pneumonia Microbiology (almost all due to aerobic bacteria, unless immuno-compromised
• gram-negative bacilli, .
P. aeruginosa, K. pneumoniae, Enterobacter, Acinetobacter
• gram-positive cocci, .
S. aureus, MRSA
Ventilator or Hospital Acquired Pneumonia in CCU (VAP/HAP) Guidelines
• Onset of symptoms >48 h after admission to hospital in patients requiring Investigations
intermittent or continuous mechanical ventilation through a tracheostomy or • Microbiological cultures (before antibiotics)
endotracheal tube for more than 48 h BAL or tracheal aspirate
Blood culture
Diagnostic criteria • Others
New, worsening or persistent infiltrate consolidation or cavitation on CXR compatible CBC, CXR, CRP
with pneumonia
Therapy
And 1 of the following: <7 days on ventilator AND no recent antibiotics: .
• WBC ≥12,000 or <4,000 Piperacillin or Ceftriaxone
• Temperature greater than 38 degrees Celsius or less than 36 degrees Celsius
with no other recognized cause ≥7 days on ventilator OR recent antibiotics: .
Piperacillin + Gentamicin or Tobramycin ± Vancomycin*
And both of the following: *Add vancomycin if MRSA suspected
• New onset of purulent sputum, or change in character of sputum, or increase .
in respiratory secretions or increase in suctioning requirements Antibiotic principles
• Worsening gas exchange (e.g., increasing oxygen requirements, worsening . • Take cultures prior to starting antibiotics
PaO2 /FiO2 ratio, increasing in minute ventilation) • Review cultures within 72 hours of commencing antibiotics
And • If cultures are negative, stop antibiotics
• The patient is being treated with antibiotics for VAP • If cultures are positive, refine therapy based on sensitivities to an appropriate
narrow spectrum antibiotic as soon as possible
• A full course of therapy is 5-7 days, except in multi-drug resistant organisms, .
THE VAP BUNDLE: The following strategies have been shown to prevent VAP:
which should receive 10-14 days treatment
1. Elevate HOB
2. Drain ventilator tubing away from patient and remove condensation from circuit
3. Daily sedation interruption (ie. sedation vacation) with spontaneous breathing
trial and assessment of readiness to extubate
4. Perform mouth care as per current guidelines

18 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 19
Postoperative Care of the Cardiac Patient Antibiotic Prophylaxis for Cardiac Surgery

GOALS: The purpose of the admission is to provide the patient a seamless

Closed Sternum Cefazolin X 48h
transition from the OR to the CCU.

PROCESS: Sternum opened in CCU Cefazolin + Gentamicin or Tobramycin

1) (ANTICIPATE) Attend and review preoperative surgical discussion points. Admitted with open sternum X 72h
Complete postoperative order set in sufficient time to organize for proper receipt
of patient. Identify likely track (Green/Yellow/Red) based on above. Closure of sternum: Preclosure doses
and continue x 24h post closure
2) (RECEIVE & EVALUATE) Quick assessment focusing on cardiovascular stability In renally impaired patients, preclosure
and adequate ventilation (vital signs and chest movement). dose of gentamicin or tobramycin may
• Organize receiving team for proper postoperative handover. Review be sufficient
preoperative and intraoperative details with anaesthesiologist and surgeon.
• Ask specifically for intra-operative problems (e.g., difficult airway, anaesthetics Sternal reexploration Topical irrigation as per CVS. .
given, bypass times, deep circulatory arrest, heart function and residual Additional antibiotics as per
lesions arrhythmia, pacemaker use, CPB separation problems, coagulopathy, cardiovascular surgeon, however, .
medication). Clarify current physiology. may already be on antibiotics
• Confirm with the nurses and RT’s that patient is safely connected to the .
ICU support and monitoring equipment. Confirm appropriate placement . ECMO: elective or rescue Cefazolin 30 mg/kg/IV x single dose
and securement of devices (ETT, CVL/arterial lines). (max 2 g/dose)
• Review current support drugs, concentrations.
• Review anaesthetic, CP-bypass charts, and intra-operative TEE.
• Detailed physical examination, paying attention to saturations, oxygenation,
ventilation, hemodynamics, monitored pressures and neuro assessment.
3) (DOCUMENTATION) Document clinical history and findings systematically and
outline plan of care in chart. Complete admission/transfer MEDREC process.
Complete X-ray, bloodwork and ventilation orders.
4) (REVIEW & REASSESS) Review as soon as possible chest X-ray and first blood
work. Recalibrate management plan.

20 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 21
Anticoagulation Guidelines
for Cardiac Patients
IV heparin therapy should not be discontinued before the removal of central
lines unless it is anticipated that the removal will be difficult. Heparin MUST be
discontinued for 2 hours before intracardiac lines are removed. Chest tubes can .
be removed on heparin, enoxaparin and warfarin therapy.
Anticoagulation for Valve Replacement
I. Mechanical Valves (St. Jude, Duromedics, Bjork-Shiley)
1. Heparinization with unfractionated heparin (Anti Xa level of 0.35 to 0.7 u/mL)
starting at 24-48 hours postoperatively.
• Rarely a loading dose of heparin may be considered – see SickKids Formulary,
Heparin guidelines.
• initial maintenance dose:
≤1 year: 28 units/kg/hour (if necessary, consider ATIII)
>1 year: 20 units/kg/hour.
See SickKids Formulary, Heparin guidelines for further adjustments.
2. Warfarin begins with oral intake (which may be within 24 h) .
and is continued indefinitely.
• doses are age dependent – see SickKids Formulary, Warfarin guidelines
• adjust dose using INR nomogram – see SickKids Formulary, .
Warfarin guidelines
• aim for an INR of 2.5-3.5 (Monagle, Chest 2012).
3. No ASA or dipyridamole will be given.
22 Paediatric Critical Care Medicine Handbook of Clinical Practice
II. Tissue Valves (Symbion, Carpentier-Edwards)
A. Aortic valve replacement
1. ASA begins with oral intake and is continued for 3 months.
• low-dose ASA: 3-5 mg/kg/DAY. One baby ASA contains 80 mg of
acetylsalicylic acid.
• educate parents to stop ASA and use acetaminophen in the presence of fever
and/or if their child has chicken pox. The latter recommendation is because of
the association of ASA and Reyes Syndrome (Hall).
B. Mitral/Tricuspid valve replacement
1. If the patient is in atrial fibrillation or with proven intra-atrial thrombus:
• full anticoagulation as per mechanical valve guidelines to achieve an INR of
2.5-3.5 (Stein). Until INR is therapeutic, heparin bridging with dosing following
the SickKids Formulary is recommended.
2. If the patient is in normal sinus rhythm:
• full anticoagulation with warfarin for 3 months (see SickKids Coumadin
Guidelines): INR 2-3
• low-dose ASA indefinitely (Stein, Turpie).
C. Pulmonary valve replacement (including Dacron conduits & Melody Valves)
• requires evaluation in a clinical trial. Currently no treatment.
III. Homograft valves
• No anticoagulation required.
The Hospital for Sick Children 23
Anticoagulation for Single Ventricle Patients
1. Guidelines for Blalock-Taussig Shunts
i. Anticoagulation with Heparin/Enoxaparin
May begin 24 hours postoperatively without a bolus dose.
• see SickKids Formulary for Heparin monitoring and dose adjustments. Routine
anticoagulation will be continued with enoxaparin at therapeutic doses in all
shunted patients.
ii. Anticoagulation with Low molecular weight heparin
When the sternum and chest are closed and all intracardiac lines have been
removed, start enoxaparin as per SickKids guidelines. Stop heparin infusion at the
same time enoxaparin is started (1800 h at night). Enoxaparin is continued until
the bidirectional Cavopulmonary connection (BDCPC) procedure is carried out.
2. Guidelines for Cavopulmonary Shunts
a) Unilateral BDCPC patients require no routine form of anticoagulation. .
If patients have a new stent placed in PA or SVC they should receive clopidogrel
(Plavix) together with enoxaparin/warfarin for 3 months.
b) Bilateral BDCPC patients should be anticoagulated with either enoxaparin .
or warfarin (>1 year). It is recommended that this be continued until the time .
of the Fontan completion.
3. Guidelines for Fontan Patients
Anticoagulation with Warfarin
Warfarin is recommended for all Fontan patients. It should be continued for at least
3 months post procedure. If therapy cannot be started within 5 days of surgery
(i.e. poor intake, temporary pacemaker wires) the patient will be covered with
standard heparin or enoxaparin until therapeutic on warfarin. See SickKids
Formulary for additional dosing and monitoring information on warfarin.
• The usual dose is dose to 0.1 mg/kg po in patient with Fontan as a single pm dose.
• Adjust dose using INR nomogram – see SickKids Formulary
• Aim for an INR of 2-3
24 Paediatric Critical Care Medicine Handbook of Clinical Practice
4. Holding medications for procedures
a) Enoxaparin in patients with shunts and BDCPC should be held only on the
morning of catheterization or cardiac surgery. No additional anticoagulant
coverage is required. The same guidelines are recommended for non-cardiac
procedures whenever possible.
b) ASA in patients with BT shunts should not be stopped prior to catheterization .
or surgery.
c) Clopidogrel in shunted patients needs to be held for 5-7 days before surgery.
Coverage with ASA should be provided for that time period.
d) Fontan patients on ASA, warfarin or enoxaparin (or bilateral BDCPC patients
on warfarin) may have the medication held as appropriate before surgical
or catheterization procedures without additional coverage. If these patients
require anticoagulation for other reasons such as mechanical valves, history of
thrombosis etc; individualized decisions should be made by the cardiologists .
and Thrombosis Service regarding appropriate management.
e) Temporary pacing wires should be removed just prior to an enoxaparin dose .
and preferably before starting warfarin and with an INR <1.8.
Guidelines for Endovascular Stents
Heparin 50-150 units/kg given in the cath lab where indicated for the procedure.
Maintenance low dose heparin of 10 units/kg/h is variable and should be dictated
by the cath team on an individual patient basis. Pulmonary artery, RVOT conduit and
aortic stents <6 mm diameter should be fully heparinized post procedure and will be
discharged home on enoxaparin for 3 months. For the above but >6 mm diameter
or PDA stents for Hybrid, no anti-coagulation is indicated. For neonates and infants
with stents, consult responsible staff and Thrombosis service for dosing. For stents
in low flow systems including SVC/IVC stents, stents in BDCPC/Fontan circuits and
pulmonary veins, patients will be discharged on ASA 3-5 mg/kg/day for 6 months
and Clopidogrel 1 mg/kg/dose po once daily (max 75 mg/dose) for 2 months. .
For neonates and infants with stents, consult responsible Staff and Thrombosis
Service for clopidogrel dosing. PDA stents for ductal dependent pulmonary .
blood flow: heparin → enoxaparin.
The Hospital for Sick Children 25
Management of Bleeding
Post Cardiac Surgery
1. Aim: Provide analgesia for surgery in a non OR setting. Remember that this
Bleeding may be high within the first 4 hours (4-8 mL/kg/h), but should taper
off so that it is ~ 4 mL/kg/h by 4 hours postop.
2. Preparation: Communication with nurse, RT and surgeon
If maintained >4 mL/kg/h (1 mL/kg/15 min):
1. Ensure adequate physiological parameters (PT, PTT, platelets, iCa >1.2,
fibrinogen >2.0, T >36˚C). Consider Protamine for heparin reversal. .
Dose: 0.5 mg per 100 units heparin given in the OR. Give protamine .
slowly over 5-10 minutes. Be aware of anaphylaxis/hypotension.
2. Correct hypertension (analgesia/sedation +/- nitroprusside infusion)
3. Contact CV Surgery
4. Discuss re-exploration versus recombinant activated Factor VII .
In the event of sudden decrease in drainage, consider tamponade.
Chest Closure in the CCU
is actual surgery so that sterility, monitoring and documentation need to be
managed accordingly.
To do list:
a. Order blood products-PRBC’s, albumin 5% (for volume) .
and platelets if <50,000/mL and oozing,
b. Discontinue treatment dose heparin 4h prior to procedure
c. Prepare inotropes/vasopressors and prime lines as necessary
- Epinephrine/Norepinephrine
- Phentolamine may need to be discontinued
d. Connect to ETC02
e. Check pacemaker-leave outside drapes
f. Check vascular access-long tubing for access outside drapes
g. Ensure that ventilator settings are appropriate and accurate-compliance
changes with chest closure
h. Order medications, but document administered amount at end of procedure:
- antibiotics pre and post closure
- Fentanyl 2-4 mcg/kg/dose IV, titrate upward as needed .
(may require doses up to 10-30 microgram/kg IV)
- Rocuronium 1 mg/kg/dose IV, repeat if necessary
- volume-albumin 5% and/or blood
i. During procedure: observe hemodynamics (HR, CVP, SBP), Saturations and
ETC02, ventilator changes (inspiratory/expiratory tidal volume, .
minute ventilation)

3. Post procedure:
- muscle relaxation
- frequent (q1-2h) MVsat and arterial blood gases
- consider CXR post closure
26 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 27
Interpretation of Haemodynamic Parameters Post Operative Management and
Common Complications of Selected Lesions
Scenario CVP PAp LAp MABp CO
1 ↓ ↓ ↓ ↓ ↓ Shunt Lesions
2 ↑ ↑ ↕ ↓ ↓ ASD. • Goal should be for OR extubation with short observation .
3 ↑ ↓ ↓ ↓ ↓ (GREEN) in CCU for complications
4 ↑ ↑ ↑ ↓ ↓ • Sinoatrial node dysfunction and heart block
↕

↕
5 ↑ ↑ ↑ ↑ VSD. • Aim for early weaning and extubation

↕
(GREEN) • Heart block and junctional ectopic tachycardia
Scenario 1:
Hypovolemia (multiple causes); artifact • Pulmonary hypertension
Scenario 2: • Patch leak or residual VSD/AI – Tachycardia, ↑ LA and
- ↓ RV ventricular compliance secondary to hypertrophy/diastolic dysfunction PA pressures, acidosis, oliguria, pulmonary edema and
- AV dissociation cardiomegaly
- residual RVOT obstruction
- Tricuspid valve stenosis/regurgitation AVSD. • Maintain cardiac output with vasodilators and inotropes
- tamponade (GREEN/ An unbalanced AVSD who’s had a biventricular repair can
- artifact YELLOW) present additional problems of a small restrictive ventricle.
Scenario 3: • AVVR – Avoid rapid fluids loading to prevent annular
- pulmonary hypertension (or vascular obstruction distal to PA measurement) dilatation and increased regurgitation
Scenario 4: • Pulmonary hypertension
- LV hypoplasia/dysfunction • Sinoatrial node dysfunction, heart block and junctional
- residual LVOT obstruction ectopic tachycardia
- mitral regurgitation/stenosis
- residual shunt (VSD, PDA, AP collateral) • Low cardiac output – Consider AVV repair dehiscence or
- tamponade residual VSD
Scenario 5: • L A pressures – Consider LAVVR or LAVV stenosis or LVOTO
- pain/stimulation/agitation/seizure or VSD, poor ventricular function or AV dissociation (tachy
or brady)

28 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 29
TAPVC Obstructed (RED) → pulmonary edema → PHT → RV failure. Left Ventricular Outflow Tract Obstruction
Unobstructed (GREEN) → (L→R) Shunt → Rt. Atrial and
AORTIC • Hypertrophic non compliant LV – Maintain filling pressures,
ventricle dilatation → Lt. atrium and ventricle small and.
STENOSIS. avoid afterload reduction. Vigilance for residual stenosis
non compliant
(GREEN) and/or insufficiency.
• Low cardiac output – Non compliant and small left ventricle
• Low cardiac output – r/o significant residual stenosis .
Maintain high Lt. side filling pressures, and control heart rate
and/or regurgitation
• Pulmonary hypertension (r/o residual obstruction)
• Subaortic Stenosis – Mitral valve regurgitation. heart block.
• Respiratory insufficiency
• Supravalvular Stenosis – Control BP due to long suture line,
• Supraventricular Tachydysrhythmias maintain coronary perfusion pressure if concomitant ostial
TRUNCUS • Take measures to avoid PHT and support the Rt. ventricle stenosis – consider Phenylephrine or Vasopressin. Important
ARTERIOSUS with adequate filling pressures + inotropes to control tachycardia with analgesia, filling and temp control.
(RED) • Pulmonary hypertension (r/o residual VSD) • Monitor for coronary ischemia

• Low cardiac output – Rt. Ventricular dysfunction – maintain AORTIC • Tight control of hypertension to avoid bleeding (esmolol vs.
adequate preload and adequate coronary perfusion COARCTATION nitroprusside)
(GREEN) • Spinal cord ischemia
• Dysrhythmias – JET, atrial tachycardia, heart block,
ventricular ectopy • Residual coarctation
• Truncal valve stenosis / regurgitation • Low cardiac output – Look for residual and/or additional
• Residual VSD – Suggested by PHT and hemodynamic significant lesions (large VSD, aortic/mitral valve stenosis,
instability consider left ventricular dysfunction/hypoplasia
• Injuries to structures near the aortic arch – chylothorax,
recurrent laryngeal nerve and phrenic nerve injury
• Renal dysfunction
• Interrupted Arch with small LV – may have .
pulmonary hypertension

30 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 31
TETRALOGY . • Is there a residual atrial communication? STAGE I • Should receive milrinone and goal-directed therapies similar
OF FALLOT • Rt ventricular diastolic dysfunction may need high filling HYBRID to Norwood
(GREEN/ pressures with volume (GREEN) • Aim for extubation within 24 hours
YELLOW)
• Residual VSD CLASSICAL • Ventilate with low mean airway pressure and low PEEP aim
• Residual Rt ventricular outflow tract obstruction STAGE II for early spontaneous breathing
(GREEN) • Elevated SVC pressures (r/o mechanical PA obstruction +/-
• severe Rt ventricular dysfunction, may require rate controland
vasopressor therapy and support of MODS including drainage systemic arterial collaterals)
of fluid spaces and delayed sternal closure • Hypertension/Bradycardia is common due to ↑ cerebral
• Dysrhythmias – JET, heart block’s blood volume

Single Ventricle Lesions – Various Lesions
NORWOOD General:
STAGE 1 (RED) 1. Low cardiac output – Poor ventricular function, AVVR,.
elevated Qp:Qs (large BTS, residual arch obstruction)
2. Cyanosis – Pulmonary venous desaturation – pleural
effusion, pneumothorax, edema, pneumonia.
Systemic venous desaturation – anemia, ↓ cardiac output, .
↑ oxygen consumption.
Decreased pulmonary blood flow – shunt/conduit
obstruction, ↑ PVR (PHT, restrictive ASD)
3. Elevated oxygen saturation – calculate Qp:Qs. If high: take
measures to increase PVR and decrease SVR. May not be an
issue if Qs is appropriate and postoperative patient
4. Myocardial ischemia – Coronary insufficiency .
(may need to evaluate DKS)
Classical Parallel circulation – Maintain good cardiac output preferably
Norwood using vasodilators and filling pressures. May help to calculate
Qp:Qs (need Pulm Vein sat)
Norwood . Difficult to manage Qp:Qs as Qp and sat are related to
RV-PA conduit ventricular systolic function more than relative circulatory
resistances.
• Cyanosis – Same as post stage I + decompressing systemic
venous or pulmonary artery to pulmonary vein collaterals,
undiagnosed LSVC
HYBRID . • Long operation involving ductal resection, arch reconstruction
STAGE II with DKS, atrial septectomy as well as SVC-PA anastomoses
(YELLOW/RED) • Physiologic preferences for spontaneous negative pressure
ventilation is balanced with need for myocardial/respiratory
support after long operation.
FONTAN • Maximize cardiac output at the lowest CVP possible. Ventilate
(GREEN) with low mean airway pressure and low PEEP, aim for early
spontaneous breathing (OR extubation)
• Low cardiac output – Anatomic obstruction
↓ Preload
↑ PVR (anatomic distortion)
Pump failure • Arrhythmias – Sinus node dysfunction (Loss of
atrioventricular synchrony – Poorly tolerated)
• Cyanosis – Same as post stage II + large fenestration .
and possible distal Fontan pathway/PA distortion
• Effusions, ascites (think of Fontan pathway obstruction)
• Thrombosis
 Miscellaneous Lesions Burn Patients: Clinical Pearls
TGA . • Surveillance for coronary insufficiency. Avoid rapid fluid
(GREEN/ boluses (watch for regional ventricular dysfunction on ECHO)
YELLOW) • Arrhythmias – May indicate coronary insufficiency
Outcomes in major intubated pediatric burns are determined by the extent of full
• Left ventricular systolic and/or diastolic dysfunction – . thickness burn injury and the presence and degree of smoke inhalation injury.
use afterload reduction agents and filling pressures.
• Bleeding EVEN BURN INJURIES OF 80% BODY SURFACE AREA AND
ABOVE ARE SURVIVABLE WITH GOOD OUTCOMES WHEN
ALCAPA. • Surveillance for low cardiac output. Use afterload reduction. TREATED IN A VERIFIED BURN CENTER.
(RED) Avoid aggressive fluid management and use catecholamines
and vasopressors (Vasopressin) cautiously
• Low cardiac output (r/o coronary insufficiency) CURRENT MODEL OF BURN CARE AT SICKKIDS:
• LAVVR Major childhood burn injury is rare and requires experienced care providers.
• Ventricular arrhythmias
• All burn admissions to the PICU are coordinated along with the Burn Care Team
• Consider Extracorporeal Life Support (ECMO vs VAD) early
at SickKids®.
EBSTEIN’S • Vigilance for common dysrhythmias (SVT, Atrial Flutter)
ANOMALY • Low cardiac output – From TR, RV dilatation, .
LV filling problem INITIAL FLUID RESUSCITATION:
• Pulmonary insufficiency – Accompanying Lung hypoplasia In major burn injury under resuscitation is easily avoided by running continuous
• Avoid neonatal surgical intervention (primary medical infusions as opposed to boluses which will never catch up in the case of delayed
management is the goal) presentation to the ICU or inadequate resuscitation.

Reviewed by Dr. B. Sivarajan • Ringers Lactate guided by the Parkland formula is used for primary fluid
resuscitation. Remember that the Parkland formula is just a starting point .
and only a guide as to how much fluid to give. Low urine output is an indicator .
of inadequate fluid resuscitation.
• Parkland formula: amount of fluid required in the first 24 hours (mL) = 4 mL x
patient’s weight (kg) x percent body surface area. Give 1 ⁄ 2 over the first 8 h then .
1 ⁄ 2 over the next 16 hours.

34 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 35
PAIN, SEDATION AND ITCH:
Burn patient comfort is achieved by considering the combined treatment of
pain, sedation and itch. And all three modalities are of equal importance
in the pediatric burn patient and should be commenced immediately on
admission. Poorly treated pain and sedation is associated with higher rates
of long term post traumatic stress disorder in pediatric burn patients.
Pain:
• Opioids are the cornerstone of burn pain control.
• Burn pain is present in 100% of all intubated burn patients. Sources of pain
include the burn wound, healing burn wounds (may take 2-3 weeks), donor
sites from surgery (more painful than the burn itself and take 7 or more days to
heal), physiotherapy and positioning (daily routines to prevent oedema and limit
contractures), splinting. It is expected that most intubated burn patients will have
pain that requires narcotics for the entire duration of the stay in the PICU.
• BACKGROUND PAIN: Morphine is the standard opioid used in our CCU. .
Optimize pain management early on and initially expect to use higher doses
than usual (e.g. 50-100 mcg/kg/hr). If surgery is required then the background
dose needs to be increased accordingly to account for donor sites and freshly
excised burn wounds.
• BREAKTHROUGH PAIN: Morphine PRN is standardly used; if breakthrough doses
are required more than q4h for successive doses then consider increasing the
background infusion.
• PROCEDURAL PAIN: Fentanyl is a rapid onset, potent, short-acting synthetic
opiate. Consequently it provides good procedural analgesia. Anaesthetic agents
include ketamine and propofol. Ensure that you have expertise in administering
and titrating these drugs.
36 Paediatric Critical Care Medicine Handbook of Clinical Practice
Weaning narcotics (background and breakthrough pain) is generally not
recommended until the wounds are significantly healed or surgically closed.
Narcotics are regularly evaluated.
Sedation:
• Benzodiazepines (Lorazepam or Diazepam) are the cornerstone of
sedation and anxiety control.
• IV or PO dosing can be given scheduled around the clock.
Itch:
• Burn pruritus is one of the most difficult symptoms to treat in pediatric .
burn patients and can be a source of major distress and discomfort.
All current medical therapies which have any positive effect on controlling
the symptoms of burn pruritus need to be initiated for at least two or more
weeks to be effective and therefore commencing treatment on admission
to the PICU is essential.
• An anti-pruritic regimen should be initiated upon admission to PICU .
with hydroxyzine q8h. Diphenhydramine can be given PRN in addition .
to scheduled medications.
ADJUNCTIVE MEDICATIONS:
• Acetaminophen: scheduled in conjunction with narcotic infusion is required .
to potentiate the action of narcotic.
• Gabapentin: In addition to acting at a different receptor for neuropathic pain
it potentiates the action of narcotic and also has a role in burn pruritus. It is
the multiple modes of action which support the Burn Team’s desire to use this
drug instead of clonidine. This is also the recommended choice of adjunctive
medication when increasing doses of narcotic infusion are required. The other
The Hospital for Sick Children 37
 practical issue with the use of gabapentin compared to clonidine is that
gabapentin is often continued upon discharge due to the dual role for pruritus
management as well as pain control. Additionally, clonidine is not .
used in the outpatient setting and it has no known role in terms of pruritus.
• As per Dr. Fish start gabapentin dosing at 5 mg/kg enteral qdaily x 24h then
increases to 5 mg/kg enteral bid (gabapentin my also relieve pruritus associated
with healing burns). See e-formulary for additional dosing information.
• NSAIDS: PRN can be used to manage fever and pain.
• Clonidine: Administered enterally; clonidine is also used to potentiate the action
of narcotics and may be added.
GI STRESS PROPHYLAXIS:
• Famotidine or Ranitidine (IV/PO) can be administered depending on availability.
BOWEL REGIME:
• PEG 3350 (polyethylene glycol 3350) can be ordered daily upon admission .
to prevent constipation.
FEVER:
• Fever in a burn patient is not considered significant unless it is above 38.5
degrees Celsius. This is due to the new set point in the hyperdynamic state. .
This continues to be the case until the wounds are substantially closed and .
in major burn cases, this can be present for up to one year. Any fever above .
38.5 should warrant investigations similar to other critically ill patients.
• Fever can be managed with antipyretics and cool cloths.
38 Paediatric Critical Care Medicine Handbook of Clinical Practice
The criteria for SIRS in a burn patient is meaningless as all patients
with major burn injury will meet the criteria.
ANTIMICROBIALS:
Broad spectrum prophylactic antibiotics are contraindicated in burn patients.
• Prophylactic antibiotics select out resistant organisms and they have never .
been shown to be effective. Antibiotic treatment for burn cases follows the same
general principles in the PICU where broad spectrum coverage is commenced
when bacterial infection is suspected on clinical grounds with prompt narrowing
or discontinuation of antibiotics when culture results are known.
NUTRITION:
Metabolic changes due to major burn injury in the pediatric population
can be measured for up to one year or more following thermal injury.
• If no contraindications, enteral feeds should be started within hours of admission.
• Calorimetry should be done soon after admission to obtain an accurate account
of caloric requirements to ensure prevention of over/underfeeding.
• Feeds should run continuously even if the burn patient is receiving sedation .
for dressing changes. There is no reason to stop feeds for burn dressings or
pending surgery.
Authors: Dr. Joel Fish, C. Kelly NP, Dr. P. Cox, Angela Trope (Staff Pharmacist) 2012
The Hospital for Sick Children 39
CDH Management: DKA in Children – guidelines
Outline of Principles of Management
Immediate assessment and management of DKA in children

Resuscitation (see next two pages for chart)

ET tube placement with minimal bag mask/ventilation
Vascular access; gut decompression by nasogastric tube
Ventilation objectives – pre-ductal SaO2 ≥85% and pH >7.3 with PIP <25 cmH2O
Cardiopulmonary Management Ventilation
Conventional Ventilation
Objective: Pre-ductal SaO2 ≥85%, pH >7.3
PIP <25 cmH2O
Abstracted from 2008 Clinical Practice Guidelines, Canadian Diabetes Association
and The Joint British Diabetes Societies guideline for the management of DKA,
UK, 2011, and the Southwest Regional Paediatric Diabetes Network, UK, 2011
Modifications by Drs. Bohn and Mohseni-Bod, SickKids 2012
Reviewed 2012

High frequency oscillatory ventilation (HFOV) The incidence of clinically significant cerebral oedema in
Objective: Pre-ductal SaO2 >85%, pH >7.3 DKA is 1-2% in western countries and it has not decreased
MAP 12-16 cmH2O over the last 20 years. Cerebral oedema in DKA, in children,
is associated with high mortality and neurological morbidity.
Pulmonary Vascular Management Severe headache, change in the level of consciousness,
Cardiac echo coma in children with DKA is most commonly due to cerebral
• exclude CHD oedema. Incidence of haemodynamically significant “shock”
• assess RV function
in DKA in developed countries is very LOW. Children with DKA
• estimate PA pressure
• identify the ductus and assess shunting die of cerebral oedema not of shock. The administration of
too much fluid, too fast, and giving hypotonic solutions can
Prostaglandin may be used to maintain ductal patency lead to osmolar shift and cerebral oedema. Monitor effective
Low dose IV epinephrine to provide adequate systolic pressure. osmolarity (2[Na] + glucose) during treatment.
Trial of iNO in selected patients. (Stop if no effect on Echo)

Reviewed by Drs. Cox and Mohseni-Bod

40 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 41

Clinical history
• Polyuria • Tiredness
• Polydipsia • Vomiting
• Weight loss (weigh) • Confusion
• Abdominal pain
• Shock (hypotension,
reduced tissue perfusion)
Resuscitation
• Airway ± nasogastric tube
• Secure airway if in coma with LOSS
of airway protective reflexes; inform
senior staff before intubating a child
with DKA
• Breathing (100% O2)
• Circulation (0.9% NaCl 10 -20 mL/kg
over 1–2 h), and repeat until
circulation is restored), but do not
exceed 30 mL/kg
•Hourly BG
•Hourly fluid input and output
•Neurologic status at least hourly
Acidosis not improving
Re-evaluation
• IV fluid calculations
• Insulin delivery system
and dose
• Need for additional
resuscitation
• Consider sepsis
BG = blood glucose
PG = plasma glucose
* It has been shown in many studies
that clinical assessment of the level
of dehydration in DKA is unreliable
and often overestimates the degree of
dehydration (tachycardia and dry tongue
are common). Knowledge of a recent
weight would be most helpful.
Immediate assessment
Clinical signs* Biochemical features
• Dehydration (assess) and investigations
• Deep sighing respiration • Ketones in urine
(Kussmaul) • Elevated BG
• Smell of ketones • Acidemia
• Lethargy/drowsiness ± vomiting • Blood gases, urea, hematocrit
electrolytes including chloride
• Other investigations as indicated
Diagnosis of DKA confirmed
Contact senior staff
• Dehydration >5% • Acidotic (hyperventilation) • Minimal dehydration
• Not in shock • Vomiting • Tolerating oral fluid
IV therapy Therapy
• If not in shock commence 0.9% NaCl 3-5 mL/kg/h X 12 h • Start with SC insulin
then reassess. If IV bolus therapy required give 5-7 mL/kg • Continue oral hydration
• Correct over 48 hours
• ECG for abnormal T-waves
• Add 40 mmol/L KCl to the maintenance fluids if
serum [K] <5.5 and the patient is passing urine No improvement
• Subtract the volume of “resus” fluid bolus from the 48-hr
estimated fluid requirement
Continuous IV insulin infusion 0.1 units/kg/h
• Start the Insulin infusion 1 hour after the fluid bolus (if fluid bolus has been given)
Critical observations
• Electrolytes including chloride
every 2 h after start of IV therapy
• Monitor ECG for T -wave changes
PG = or <15 mmol/L Neurological deterioration
(Warning signs: headache,
slowing heart rate, irritability,
• Change to 0.9% Saline + Dextrose 5%; if the PG decreased level of
drops below 12 mmol/L, change the iv fluid to consciousness, incontinence,
0.9% saline + dextrose 10%
IV therapy specific neurological signs)
• The PG should not fall by more than 3-5 mmol/L/hr
• May need to adjust fluid infusion rate to promote
an increase in measured serum [Na]
• Consider reducing Insulin to 0.05 units/kg/hr, Exclude hypoglycemia
but only when pH >7.3 Is it cerebral edema?
Improvement Management
• Clinically well • Tolerating oral fluids • Give 3% NaCl 3-5 mL/kg or Mannitol
0.5-1 g/kg over 15-20 minutes
(3% NaCl is preferred)
Transition to SC insulin • Restrict IV fluids by one-third
Start SC insulin then stop IV • Call senior staff
insulin after an appropriate interval • Move to ICU if not already in the ICU
• Consider cranial imaging only
after patient stabilized
Diagnostic Approach to Children Investigations to be Completed within 24 hours of Seizure Onset

with Refractory Status Epilepticus Diagnostic Imaging

• MRI brain with gadolinium, MRA, MRV, MRS
- Ensure that “epilepsy protocol” and “vasculitis protocol” are performed
Refer to the complete document for investigations to be done beyond 72h. - 3 Tesla preferred

Serum
• CBC, differential
Definitions • Electrolytes, iCa, Mg, glucose
Refractory status epilepticus is defined as continuous seizures or recurrent seizures • AST, ALT, ALP, GGT, INR, PTT, Amylase
without return of consciousness that persist despite adequate administration • Ammonia
of 1st line therapy (lorazepam, diazepam) and 2nd line therapy (phenytoin, • ESR, CRP
phenobarbital), requiring ICU admission and high-dose suppressive therapy • Bacterial culture and sensitivity
(midazolam infusion, pentobarbital infusion or high-dose phenobarbital).
Urine
All children with refractory status epilepticus warrant • Bacterial culture and sensitivity
• Neurology consultation
• Continuous EEG monitoring Cerebrospinal fluid
• Opening pressure
Sustained refractory status epilepticus is defined as refractory status epilepticus • Cell count
lasting >24 hours. • Glucose, protein, lactate (sent on ice)
• Bacterial culture and sensitivity
• PCR for HSV and other herpesviruses, enteroviruses, parechoviruses,
M. pneumoniae
• Collect and freeze extra 10 mL for future use

Other
• Nasopharyngeal swab for respiratory viruses by PCR (influenza, adenovirus,
parainfluenza etc.)
• Throat swab for M. pneumoniae by PCR
• Stool for enteroviruses

44 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 45
 Urine
Investigations to be Completed within 48-72 hours of Seizure Onset
Organic acids
Consultations
CSF
• Infectious Diseases
• Amino acids, quantitative
• Metabolics
• Oligoclonal banding
• Rheumatology
• Anti-NMDA receptor antibody testing
• Ophthalmology
Diagnostic Imaging
Serum
• Cerebral angiography, either CT or conventional four-vessel angiography
• Before administration of blood products, obtain clotted blood specimen.
- To be considered in all cases, even in the absence of CSF, serum or
for serologies:
neuroimaging evidence of inflammatory brain disease
- HSV, EBV (with or without monospot), CMV, HHV-6, M. pneumonia, Arboviruses
• Abdominal ultrasound or MRI to assess for ovarian teratoma
(WEE, EEE, St. Louis, California, Powassan), Bartonella henselae, West Nile
virus (seasonal)
• West Nile virus PCR (seasonal)
• Amino acids, quantitative
• Urate, urinary S-sulfocysteine
• C3, C4 complement
• Immunoglobulins
• von-Willebrand factor antigen
• ANA, anti-dsDNA (Crythidia and Elisa), anti-Ro, anti-La, anti-SM (smith), anti-RNP,
anti-RF, anti-cardiolipin
• Anti-phospholipid-screen (coagulation test)
• TSH, T3, T4, anti-thyroid antibodies

46 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 47
Epilepticus/Refractory Status Epilepticus PROLONGED SEIZURES AND STATUS EPILEPTICUS .
IN INFANTS (AGE >1 MONTH), CHILDREN AND ADOLESCENTS
Seizure Onset
• Support ABCs and give oxygen
• Attach cardiac & O2 saturation monitors; establish IV access
• Rapid glucose check & consider Critical Labs (Na, Ca, Mg, etc.)
• Proceed with the following algorithm until seizures stop
Guidelines for Prolonged Seizures . • Monitor closely for loss of airway reflexes and respiratory depression, hypotension, or cardiac arrhythmias.
• Check for history of drug allergy or hypersensitivity reaction (high risk of cross-reactivity between phenytoin, .

and Status Epilepticus in Infants (age >1 month), . phenobarbital, and carbamazepine)
5 minutes
Children and Adolescents Lorazepam OR Diazepam OR Midazolam
• IV: 0.1 mg/kg • IV: 0.3 mg/kg • Intranasal: 0.2 mg/kg
• PR: 0.1 mg/kg • PR: 0.5 mg/kg • Buccal: 0.5 mg/kg
• Prolonged seizures are a life-threatening condition that may result in . • SL/buccal: 0.1 mg/kg. IV max: <5yrs: 5 mg/dose. IN max: 5 mg (1 mL)/nostril
permanent neurological injury. Max: 4 mg/dose ≥5yrs: 10 mg/dose
PR max: 20 mg/dose
Buccal max: 10 mg (2 mL)

• Status Epilepticus is defined as prolonged or recurrent seizures lasting . 5 minutes

more than 30 minutes. Repeat above step

• In practice, treatment should start when a seizure continues longer than . 5 minutes Continue attempts to establish .
IV access. Once IV access is .
5 minutes, because: IV access No IV access established proceed according .
to IV access protocol
- Seizures lasting longer than 5 minutes are unlikely to stop spontaneously.
Fosphenytoin Phenobarbital Fosphenytoin
- The longer seizures continue, the more difficult they are to abort with medications. • IV: 20 mg Phenytoin. • IV: 20 mg/kg in NS or D5W . • IM: 20 mg Phenytoin .
Equivalents (PE)/kg in NS . over 20 minutes or IV push by . Equivalents (PE)/kg .
- Prolonged seizures may cause permanent neurological injury. or D5W over 5-10 min . MD over 5-10 min. Max: 1000 mg PE (<50 kg).
Max: 1000 mg PE (<50 kg). Max: 1000 mg 1500 mg PE (≥50 kg)
• Continuous cardiorespiratory monitoring is essential. Anticonvulsant medications 1500 mg PE (≥50 kg)
may cause loss of airway reflexes and respiratory depression, hypotension, and 5 minutes Max dose per IM site: 3 mL
If Fosphenytoin not available, use Phenytoin • If child >30 kg, IM dosing may not
cardiac arrhythmias. • IV: 20 mg/kg in NS only over . Fosphenytoin be practical because of large dose
20-30 minutes. • IV: 20mg Phenytoin Equivalents volume, requiring multiple IM sites.
• If IV access is not available, then other routes such as nasal, buccal, rectal, or . Max: 1000 mg (<50 kg). (PE)/kg in NS or D5W over 5-10 min.
Max: 1500 mg (≥50 kg)
intramuscular should be used without delay while IV access is being established. Max: 1000 mg PE (<50 kg).
1500 mg PE (≥50 kg) 5 minutes
• Fosphenytoin is generally preferred for the initial loading dose over phenytoin . 5 minutes
If Fosphenytoin not available, .
or phenobarbital. Phenobarbital use Phenytoin Paraldehyde
• IV: 20 mg/kg in NS or D5W . • IV: 20 mg/kg in NS only over . • PR: 400 mg (0.4 mL)/kg/dose.
• If a patient is on phenytoin maintenance, consider phenobarbital for the initial . over 20 minutes or IV push . 20-30 minutes Max: 10 g (10 mL)/dose.
by MD over 5-10 min. • Max: 1000 mg (<50 kg). Give diluted 1:1 in cooking oil .
loading dose Max: 1000 mg Max: 1500 mg (≥50 kg) (preferred) or normal saline

• For children under 18 months consider a trial of pyridoxine (vitamin B6) . 10 minutes
10 minutes
100 mg IV initial dose, then 50 mg IV/PO BID Refractory Status Epilepticus
• Call CCRT/ICU consult and Neurology consult
• Call Code Blue if more help or respiratory .
support is needed Refer to Refractory Status Epilepticus Guidelines .
• Request continuous EEG monitoring on the next page
• Arrange admission to ICU
• When in ICU, obtain arterial and central
48 Paediatric Critical Care Medicine Handbook of Clinical Practice venous lines, and initiate continous core
temperature monitoring
 REFRACTORY STATUS EPILEPTICUS
IN INFANTS (AGE >1 MONTH), CHILDREN AND ADOLESCENTS Paediatric Sepsis Algorithm
• Call CCRT/ICU consult and Neurology consult
• Call Code Blue if more help or respiratory support is needed
• Request continuous EEG monitoring
• Arrange admission to ICU
• When in ICU, obtain arterial and central venous lines, . Early Goals (within 1st hour)
and initiate continuous core temperature monitoring .
• ABCs as per PALS guidelines
If no .
Midazolam continuous infusion
seizures
• Assess: GCS, BP, HR, RR, Temp, Core-peripheral gradient, Cap refill, .
• IV: 0.15 mg/kg bolus then 2 mcg/kg/min infusion
• Increase as needed by 2 mcg/kg/min q5 minutes for 48 h Taper midazolam mottling, hydration
• Bolus 0.15 mg/kg with each increase in the • Decrease by . • Baseline labs ABG, CBC, Lytes, Coag, Lactate and Blood Cultures
infusion rate 1 mcg/kg/min q15 min
• Max infusion rate: 24 mcg/kg/min - STAT broad spectrum antimicrobials
• Establish goals of therapy with guidance from
Neurology and Critical Care If seizures recur, reinstate . - crystalloid or colloid 20 mL/kg (within 20 min) x 3
• Continue other anticonvulsant medications, . midazolam for another 48 h
Re-asses response to therapy
maintaining therapeutic serum levels
PENTObarbital continuous
If seizures persist infusion via CVL
PHENObarbital coma • see e-Formulary for . Fluid refractory shock
dosing guidelines Fluid responsive
• IV: 20 mg/kg bolus over 10 minutes Secure airway, art-line and CVL
Requires close observation
• Repeat 10 mg/kg boluses q30-60 min If no . Start Dopamine
as needed seizures
• Titrate dose to achieve desired clinical & for 48 h Taper phenobarbital Remains shocked
EEG effect • Decrease rate by . catecholamine resistant shock
• Establish goals of therapy with guidance from .
~25% per day Begin hydrocortisone
Neurology and Critical Care • Monitor phenobarbital
• Monitor phenobarbital level. Serum levels levels
>500 µmol/L will require maintenance
dose of 15 mg/kg/day or more IV divided Cool peripheries Warm peripheries If hyperthermic
q4-6 hours Low cardiac output High cardiac output
• Discontinue midazolam infusion control fever with
Low/normal CVP Low/normal CVP cooling blanket ±­­
• Continue other anticonvulsant medications,
maintaining therapeutic serum levels Low ScvO2 (<70%) Normal/incr. ScvO2 neuromuscular blocker
If seizures recur, reinstate .
phenobarbital for another 48 hrs High lactate Normal/incr. lactate
If seizures persist

Individualized therapy Cold Shock

In consultation with Critical Care and Neurology Add Epinephrine
Continue fluid therapy Warm Shock
Dosing guidelines for additional . If normal BP consider Add Norepinephine
therapeutic options vasodilator (milrinone) Continue fluid therapy
Valproate
• IV loading dose 30 mg/kg over 5 minutes, .
followed by 10 mg/kg bolus if needed
• IV maintenance: 10 mg/kg q8h
Goals to direct therapy
BP within 10% of age adjusted norms
Topiramate, high dose CVP of 10-12 mm Hg
• 10 mg/kg/day PO/NG divided BID ScvO2 >70%
• Increase by 3 mg/kg/day q1-3 days
• Max: 24 mg/kg/day
See e-formulary for authors Control blood sugar with insulin infusion if blood sugar >15 mmol/L and monitor blood sugar q 1h
• Risk of metabolic acidosis, kidney stones – . Urine output >1 mL/kg/h
consider Nephrology consult Treat hypocalcaemia
Reviewed by Dr. J. Hutchison
Paediatric Traumatic Brain Injury (TBI) Acid Base (Acute Alterations)
Algorithm for GCS ≤8
Respiratory HCO3 rises 1 mmol/L per 10 mmHg rise in PCO2
Place preprinted Doctor’s Orders and algorithm in patient’s chart
HCO3 falls 1 mmol/L per 10 mmHg fall in PCO2
Management Goals
PaO2 = 80-100 mm Hg
PaCO2 = 30-40 mm Hg Metabolic PCO2 falls 1-1.5 x the fall in HCO3
Tcore ≤37.5 ºC
IV Fluid 0.9% NaCl PCO2 rises 0.25-1.0 x the rise in HCO3
Glucose normal
Early enteral feeds
CT scan Anion Gap AG = Na – (HCO3 + Cl) N = 12 range (8-16)

Abnormal CT Scan Normal CT Scan

Metabolic Acidosis
Consult neurosurgery Supportive management
ICP monitor ↑ Anion Gap Normal AG
Art-line and CVL
Ketoacidosis Diarrhoea
Elevated ICP (>20-25 mmHg)
Head in middle
Lactic Acidosis Renal Tubular Acidosis
HOB elevated Chronic renal failure HCO3 loss:
Prevent/correct reversible causes: hypercarbia, hypoxia, hyperthermia (Tcore >37.5 ºC),
inadequate sedation/analgesia, suctioning, technical problem with ICP monitor Toxins: salicylate • Direct (GI or Renal)
Always start with treatment 1 and proceed to next therapy if prior therapy ineffective ethylene glycol • Indirect
1. Drain CSF (if EVD)
2. Mannitol 0.25 - 0.5 g/kg IV q6h PRN if osmolarity <320 mosm/L alcohols - low urine [NH4]
3. 3% saline 2 - 4 mL/kg q6 hours PRN
HCO3 dilution - organic anion excretion
4. Hypothermia therapy
5. Hyperventilation (caution) Inborn errors of metabolism
6. Barbiturate therapy
• Stat CT scan of the head and neurosurgical consult if uncontrolled intracranical hypertension Plasma Osmolality
or herniation develop – potential craniectomy 2(Na) + Glucose + urea (N 270 – 295)
• Intermittent neuromuscular blockers may be necessary for refractory ↑ ICP osmo gap = measured osmo - calculated osmo
Prevent hypotension/shock with fluid ± dopamine/norepinephrine

Reviewed by Dr. J. Hutchison

The Hospital for Sick Children 53
Blood Products (see: e-Blood Products) Cardiorespiratory Formulae

(guide to initial therapy only) PAO2 = PiO2 – PaCO2/RQ [PiO2 = FiO2 X (PB – 47)]

Platelets 1 unit/5 kg will increase count 50-100,000 (A-a) DO2 = PAO2 – PaO2
FFP 10 mL/kg (has all clotting factors)
Cryoprecipitate 25 mg/mL fibrinogen VD/VT = (PaCO2 – PECO2)/PaCO2
1 bag/5 kg for replacement
5-10 units/mL factor VIII PaCO2 = VCO2
1 unit/kg increases factor VIII by 2% VA

Packed red cells 10 mL/kg will increase Hgb. by 2-3 g MAP = (It X PIP + Et X PEEP)/It + Et

Albumin 5% 0.5-1 g/kg IV (10 mL - 20 mL/kg/dose) O2 content = 1.39 X Hb X SaO2 + 0.003 X PO2
(N = 17-20 mL/dL)
Albumin 25% 0.5-1 g/kg IV (2 mL - 4 mL/kg/dose)

O2 delivery = CO [(1.39 X Hb X SaO2) + (0.003 X PaO2)]

AT III Dose (IU)= desired % increase x wt (kg),
usual dose ~ 100 IU/kg Qs/Qt = CcO2 – CaO2
CcO2 – CvO2
Factor VIIa 35-90 mcg/kg/dose IV at 2-6h intervals
Reconstitute with diluent (water), then 1 mL= 600 mcg Qp/Qs = SaAo – SaSVC
vial sizes: 1200 mcg, 2400 mcg, 4800 mcg SaPV – SaPA

IVIG See Transfusion Medicine Pocket Card or e-Blood Products

54 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 55
Derived Formulae Respiratory ECMO Criteria

See: e-formulary Oxygenation Index = MAP X FiO2 X 100 >40 for >4 h
PaO2
CI = CO/BSA (3.5-5.5) L/min/m 2

SVRI = MAP – CVP. 10-20 Woods Units

Inclusion Criteria
CI
>35/52; <10 d CMV; no nonpulmonary disease, no ICH,
Wt >2.0 kg no coagulopathy
PVRI = MPAP – PCWP. 1-3 Woods Units
CI
ECMO Prime Heparin: load 50 units/kg then 10-30 units/kg/h
ACT 160-180
Heparin level 0.3-0.5 u/mL
Woods = Dyne.sec/cm5/m2.
Units 80

O2 Availability = CaO2 X CI X 10 (550-650) mL/min/m2

O2 Consumption (VO2) = CI X a-v DO2 X 10 (120-200) mL/min/m2

Body Surface Area See: e-formulary

(BSA)

56 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 57
Fluids and Electrolytes Glasgow Coma Scale Score

For 100% maintenance fluids (isotonic IV fluids) <1 Year >1 Year
<10 kg 4 mL/kg/h Eye 4 Spontaneously Spontaneously
10-20 kg 40 mL + 2 mL/kg/h for each kg >10 Opening 3 To shout To verbal command
>20 kg 60 mL + 1 mL/kg/h for each kg >20 2 To pain To pain
80% maintenance for intubated, ventilated patients 1 No response No response

Daily Na 3 mmol/kg/24 h <1 Year >1 Year

K 2 mmol/kg/24 h Best Motor 6 Obeys
Response 5 Localizes pain Localizes pain
Na Deficit = 0.6 X Wt (kg) X (140 – measured)
Aim to correct to Na 125 mmol/L 4 Flexion withdrawal Flexion withdrawal
3% NaCl = 0.5 mmol/mL 3 Decorticate flexion Decorticate flexion
2 Decerebrate extension Decerebrate extension
H2O Deficit (
measured Na
= 0.6 X Wt (kg) X 1 – desired Na . ) 1 No response No response

Treat shock, then aim to correct H2O deficit
over 24-48 h (Na should fall not more than 0.5 mmol/h) 0-23 months 2-5 years >5 years
Prerenal ARF Intrinsic ARF Best Verbal Smiles, coos Appropriate Oriented,
5
UNa (mEq/L) <20 >50 Response appropriately words converses
Uosm >500 <300 Inappropriate Disoriented,
4 Appropriate cry
RFI <1 >1 words converses
FENa <1% >2% Inappropriate . Inappropriate
3 Cries or screams
cry or scream words
UNa
RFI (Renal failure Index) = Incomprehensible .
(U/P creatinine) 2 Grunts Grunts
sounds
UNa P creat 100 1 No response No response No response
FENa = X X
PNa U creat

58 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 59
Needle and Catheter Gauges PRISM Scores (Infant <1yr of age)

Ext dia Needles Catheters Ext dia Needles Catheters Variable Value Score
Systolic BP <40 7
mm SWG FG, FR, CH mm SWG FG, FR, CH 40-54 6
55-65 2
0.32 30 1 3.0 - 9 130-160 2
>160 6
0.42 27 - 3.3 - 10 Diastolic BP >110 6
Heart Rate <90 4
0.51 25 - 4.0 8 12 >160 4
0.61 23 - 4.7 6 14 Resp. Rate apnoea* 5
61-90 1
0.67 - 2 5.3 - 16 >90 5
PaO2/FiO2 <200 3
0.81 21 - 6.0 4 18 200 -300 2
PaCO2 51-65 1
0.91 20 - 6.7 - 20 >65 5
1.0 - 3 7.0 2 - G.C.S. <8 6
Pupils unequal or dilated 4
1.3 18 4 7.3 - 22 fixed and dilated 10
PT PTT >1.5 x control 2
1.6 16 5 8.0 1/0 24 Bilirubin (>1 mth of age) >60 6
Potassium <3.0 5
2.0 14 6 8.7 2/0 26 3.0-3.5 1
6.5-7.5 1
2.3 - 7 9.3 3/0 28 >7.5 5
2.7 12 8 10.0 - 30 Calcium Ionised Total
<0.8 <1.75 6
SWG = Standard Wire Gauge = British Imperial Gauge 0.8-0.85 1.75-2.0 2
= 20-20 (log of external diameter) approx 1.3-1.5 3.0-3.75 2
>1.5 >3.75 6
FG = FR = French = Charriere (CH) = 3 x ext diam mm Glucose <2.0 8
- 1FR = 0.33 mm 2.0-3.3 4
- 0.015" guidewire goes through the 24G (yellow) angio 13.8-22 4
- 0.018" guidewire goes through the 22G (blue) and 20G (pink) angio >22 8
Bicarb <16 3
>32 3
* Does not include iatrogenic apnoea (i.e., paralysis or hyperventilation)

60 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 61
Selected Intubation Drugs Resuscitation Drugs (see e-formulary)

Atropine 0.01-0.02 mg/kg/dose IV/ETT Note: There is variability between CCU and SickKids Formulary doses
Minimum dose: 0.1 mg Oxygen
Maximum dose: 0.6 mg Na Bicarb (1 mmol/mL) 1-2 mL/kg stat then 1-2 mL/kg as per blood gases
Epinephrine 1:10,000 soln 0.1 mL/kg IV/ETT (0.01 mg/kg)
Fentanyl Up to 5 micrograms/kg/dose IV
CaCl2 (10% soln) 0.1 mL/kg IV (10 mg/kg)
Ketamine 1-2 mg/kg/dose IV Max: 1 gram (10 mL)
Contraindicated in head injury patients re: to rise in ICP Lidocaine 1 mg/kg slow IV Infuse 15-50 µg/kg/min
observe for laryngospasm or obstructive apnea Atropine 0.02 mg/kg IV/ETT (min 0.1 mg/dose)
Lidocaine 1 mg/kg/dose IV/ETT Max cumulative dose: 0.04 mg/kg or 2 mg, whichever is less
Blunts rise in ICP with intubation of head injury patients Dextrose 1 mL/kg D50W
Midazolam 0.1-0.2 mg/kg/dose over 3-5 min Isoprenaline (10 µg/mL) 0.3 mL/kg IV
Neonates: 0.05 mg/kg/dose IV D.C. Shock Defibrillation 2 joules (watt sec-1)/kg
Cardioversion 0.5-1.0 joules/kg
Pancuronium 0.1 mg/kg/dose IV Direct vs transthoracic
Propofol 2-5 mg/kg/dose IV
Rocuronium 1.2 mg/kg IV Age Wt kg HR BP (50%) ETT SA m2
Succinylcholine 1-2 mg/kg/dose IV Birth 3.5 90-140 65/40 3.0-3.5 0.23
1 mth 115-190 80/50
3 mth 5.5 85/50 0.31
6 mth 7.5 110-180 90/55 3.5- 4.0 0.38
1 yr 10 100-160 90/55 4.0 0.47
3 yrs 15 90-150 92/55 4.5 0.61
5 yrs 20 80-150 95/58 5.0-5.5 0.7
10 yrs 30 60-110 100/62 6.5-7.0 1.1
13 yrs 40 55-110 110/65 7.0 1.3
ETT size Formula: one year of age or more
(Age in years)/4) + 4 = tube size in mm

62 Paediatric Critical Care Medicine Handbook of Clinical Practice The Hospital for Sick Children 63
Notes

64 Paediatric Critical Care Medicine Handbook of Clinical Practice