PICUDIGO*“ Pediatric intensive Care Unit Drug Information Guide & Outline UST Hospital (Trunk line). (632) 731-3001 Pediatric Intensive Care Unit.mm. local 2304 / 2363 Neonatal Intensive Care Unit... local 2435 / 2292 Emergency Room - Clinical Division... Emergency Room - Private Division. Poison Control (UP-PGH) jocal 2291 local 2357 (632) 521-8450 Malte Pare Ceri Atbirth 3.25 7 3-12 months ‘Age {mos)#9 ‘Age (mos) +12 1-6 years Age (yrs) x2+8 Age (yrs) x5 +17 7-12 years ‘Age (yrs) x 7-5 ‘Age (yrs) x745 Heart Rate (beats/min) Age Newborn to 3 months 3 months to 2 years 2to10 years >10 years Respiratory Rate (breaths/min) Age Infant Toddler Prescho ler School-age child Adolescent Estimated Blood Pressure for Age eee Systolic BP | 90+ (age in yearsx 2) Ee 2 Awake Rate Sleeping Rate 85 to 205 80 to 160 100 to 190 75 to 160 60 to 140 60 to 90 60 to 100 50 to 90 Rate 30 to 60 24040 22 to 34 18030, 12t016 en) Term neonate: <60 mmHg Infants (1 to 12 months}: <70 mmHg Children 1 to 9 years old: < 70 + (age in years x 2) mmHg Children >10 years old: <90 mmllg Mean Arterial | 55+(agex 1.5) Pressure 40+ (age x 1.5)ome) cud ced Spontaneous Spontaneous 4 To speech To speech 3 ‘o pain only To pain only 2 No response No response 2 Oriented, appropriate | Coos and babbles 5 Confused Irritable cries 4 faa Inappropriate words | Cries to pain 3 tend incomprehensible | Moans to pain 2 ponse | “sounds No response No response 1 Obeyscommands | Moves spontaneously | 6 ‘and purposefully Localizes painful Withdraws to touch 5 Best stimulus motor _ | Withdraws to pain | Withdraws to pain 4 response | Flexion to pain Abnormal flexion 3 posture to pain Extensionto pain | Abnormalextension | 2 posture to pain No response No response 1 “If patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response. Motor response should be carefully evaluated. vinrsonsim Pewee 6 x Desired dose (mcg/ke/min) x we (kg) = mg drug Desired rate (mt/hr) 100 mL fluid Medication Dose Dilution in | tv infusion Rate | (mcg/ke/min) 100 mL DSW | (imt/hr is equivalent to) | | ie) 0.05-0.1 ‘0.3me/ke. 0.05meg/kg/min ‘Aniodarone | 5-15, ‘éme/ke ‘Imeg/kg/min ‘Gma/ke Imeg/kg/min Gmglkg mcg/ke/min Epinephrine | O.1-1 G.6me/ke | O.lmeg/ke/min Lidocaine 2050 ‘éme/ke Imeg/kg/min Norepinephrine | 0.1-2 O.6me/ke | O.imeg/ke/min Vasopressin | 0.5-2miliunits/kg/min | 6millimnits/kg | 1milliunit/kg/min ETI Meds: (NAVEL: naloxone, atropine, vasopressin, epinephrine, lidocaine) ~~ dilute meds to SmL with NS, follow with positive-pressure ventilation Furosemide drip : 0.05-0.4mg/ke/hr Midazolam drip: 0.05- 2mcg/kg/nr = __mLofthedrug +__mlsterile water Preparation ‘to make 24mL to run at Iml/hr 7 heome) cud ced Spontaneous Spontaneous 4 To speech To speech 3 ‘o pain only To pain only 2 No response No response 2 Oriented, appropriate | Coos and babbles 5 Confused Irritable cries 4 faa Inappropriate words | Cries to pain 3 tend incomprehensible | Moans to pain 2 ponse | “sounds No response No response 1 Obeyscommands | Moves spontaneously | 6 ‘and purposefully Localizes painful Withdraws to touch 5 Best stimulus motor _ | Withdraws to pain | Withdraws to pain 4 response | Flexion to pain Abnormal flexion 3 posture to pain Extensionto pain | Abnormalextension | 2 posture to pain No response No response 1 “If patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response. Motor response should be carefully evaluated. vinrsonsim Pewee 6 x Desired dose (mcg/ke/min) x we (kg) = mg drug Desired rate (mt/hr) 100 mL fluid Medication Dose Dilution in | tv infusion Rate | (mcg/ke/min) 100 mL DSW | (imt/hr is equivalent to) | | ie) 0.05-0.1 ‘0.3me/ke. 0.05meg/kg/min ‘Aniodarone | 5-15, ‘éme/ke ‘Imeg/kg/min ‘Gma/ke Imeg/kg/min Gmglkg mcg/ke/min Epinephrine | O.1-1 G.6me/ke | O.lmeg/ke/min Lidocaine 2050 ‘éme/ke Imeg/kg/min Norepinephrine | 0.1-2 O.6me/ke | O.imeg/ke/min Vasopressin | 0.5-2miliunits/kg/min | 6millimnits/kg | 1milliunit/kg/min ETI Meds: (NAVEL: naloxone, atropine, vasopressin, epinephrine, lidocaine) ~~ dilute meds to SmL with NS, follow with positive-pressure ventilation Furosemide drip : 0.05-0.4mg/ke/hr Midazolam drip: 0.05- 2mcg/kg/nr = __mLofthedrug +__mlsterile water Preparation ‘to make 24mL to run at Iml/hr 7 heADENOSINE ‘Supraventricular Tachycardia 10.1 mg/kg IV/IO rapid push (max 6 mg), 2nd dose 0.2 mg/kg IV/IO rapid push (max 12 mg) AMINOPHYLLINE Asthma Exacerbation: Loading: Gmg/kg IV over 20 minutes Maintenance (continuous drip}: ‘Gwk — 6mo:0.5me/kg/hr; Go lyr: 0.6-0.7me/ke/he 1-Syo: 1-1.2mg/kg/hr; 9-12yo: 0.9me/kg/hr >12yo: 0.7mg/kg/hr ‘ATROPINE SULFATE (Bradycardia — increased vagal ‘tone; Primary AV Block) 0.02 mg/kg IV/10 (min dose 0.1 mg, max single dose child 0.5 mg, max single dose adolescent 1 img), may repeat dose once, max total dose child 1 mg, max total dose adolescent 2 mg. 0.04 to 0.05 mg/kg ET CALCIUM GLUCONATE Maintenance/Hypocalcemia: Neonate IV: 200-800mg/ke/24hr + QGhr Infant/Child IV: 200-S00mg/kg/24hr + QGhr “Do not exceed 200mg/min with max concentration of 50me/ml DEXAMETHASONE ‘Airway edema 0.5-2mg/ke/24hr IV/IM + Q6hr (begin 24hr before ertubation and continue for 4-6 doses afte extubation) ‘Croup: 0.6mg/kg/dose PO/IV/IM x1 Brain tumor associated cerebral edema Loading dose: 1-2me/kg/dose IV/IM x1 Maintenance: 1-1.5mg/kg/24hr + q4-6hr; max dose 16me/24hr_ DEXMEDETOMIDINE (Sedation) Loading dose/PRN: 0.3-1mcg/kg, Infusion: 0.25-0.7mcg/ke/hr DIAZEPAM (eizures, Status Epilepticus) Neonate: 0.3-0.75mg/kg/dose IV Q 15-30 min x 2-3 doses; max total dose: 2mg Child: >1 month ~ 0.2-0.5mg/ke/dose IV Q 15-30 min, max total dose <5 yr: Smg, 25 yr: 10mg May repeat dosing in 2-4 hr as needed. ‘Adult: 5-10mg/dose IV q10-15 min; max total dose: 30mg in an 8-hr period. May repeat dosing in 2-4 hr as needed. Rectal dose (using IV dosage form): dose followed by 0.25 mg/kg/dose EPINEPHRINE Pulseless Arrest, Bradycardia (symptomatic 0.01 mg/kg (0.1 mL/kg) 1:10,000 IV/10 q 3 to 5 minutes (max 1 mg) 0.1 mg/kg (0.1 mL/kg) 1:1000 ET @ 3 to § minutes Anaphylaxis -0.01 mg/kg (0.01 mL/kg) 1:1000 IM in thigh 4.15 minutes PRN (max singie dose 0.3mg) -0.0.1me/kg (0.1 mL/kg) 1:10,000 IV/10 q 3 to 5 minutes (max single dose Img) f hypotension is present ‘Asthma -0.01mg/kg (0.01 mL/kg) 1:1000 SQ.q 15 minutes (max0.3me) up (alternative to racer! (0.5mi/kg of 1:1000 solution of Epinephrine + mL. ‘Of NS, then nebulize a follows: 2.5mL/dose in 4yrs old. May repeat upto 3-4 doses ql.Smin or nebulze @aH PRN HYDROCORTISONE {Status Asthmaticus) Load {optional}: 4-8mg/kg/dose IV; max dose 250mg Maintenance: 8mg/kg/24hr qéhour IVINSULIN 0.1 units HR/kg IV/IO with D25W as 2mi/kg (Hyperkalemia) (0.5g/kg) over 30mins. Repeat dose in 30-60 mins, oF begin infusion of 025W 1 to 2mU/kg/ hr with regular insulin 0.1 U/kg/hr Monitor glucose hourly KETAMINE Loading dose/PRN: 1-2me/kg (Sedation) Infusion: 1-2me/kg/br KETOROLAC (NSAID) | 0.5mg/ke/dose IM/IV g6-Bhr. max dose 30mg q6hr MAGNESIUM SULFATE | Hypomagnesemia or Hypocalcemia -25-50mg/kg/dose q4-Ghr x 3-4 doses; rpt PRN. Max single dose: 2g. Max IV intermittent infusion rate: ImEq/ka/hr Severe Asthma (adjunctive therapy as bronchodilator) 25-50mg/kg/dose IV over 30 minutes géhr or as continuous infusion at 10-20me/ke/hr MANNITOL (0.5-1g/ke a4-a6hr METHYLPREDNISOLONE | <12 yr old (IIM/Iv/PO): Img/ke/24hr 12 (max (Asthma) ‘dose 60mg/24hr), Higher alternative regimen of ‘Img/kg/dose q6hr x 48hr followed by 1-2 me/ ke/2ahr q12 ‘>12 yr old (IM/IV/PO}: 40-80 mg/24 hr q12-24hr. Higher alternative regimen of 120-180 me/2ahr 6-8hr x 48hr followed by 60-80me/24hr q12 MIDAZOLAM Sedation for procedures: mo-Syr: 0.05-0.1 mg/kg/dose over 2-3min ‘May rpt dose PRN in 2-3min intervals up to ‘max total dose of 6mg G-L2yr: 0.025-0.05mg/kg/dose. May rpt dose PRN in 2-3min intervals up to max total dose of 10mg, >12 yr: 0.5-2me/dose. May rpt dose PRN in 2-3min intervals up to max total dase of 10mg fon with I intermittent: 0.05-05mngkg/aose NV qi-2hr PRN Continuous IV infusion: 1-2meg/ke/min N-Acetyloysteine Paracetamol Ingestion 300mg/g over 20 hours given a follows: 1n220kg: First infusion: 150me/kg + 05W 100mL over 15min Second infusion: SOmg/kg +DSW 250ml over hours Third infusion: 10Oma/ke + DSW 250m over 16 hours In20Kg: First infusion: 150mg/kg in 3mi/kg DSW over 15min Secondinfusion: Smaykg.in 7mU/kg DSW over 4 hours Third Infusion: 10Omea/kgin Mik DSW over 16hours NALBUPHINE (0.05-0.1me/kg/dose PHENOBARBITAL Loading Dose: 15-20me/kg/dose. May give additional (Status Epilepticus) SSme/kg doses q15-30min toa max total of 4Ome/kg Maintenance Dose: 4-6 mg/kg/day OD or BID IV push not to exceed 1mg/kg/min PHENYTOIN Loading Dose: 15-20 mg/kg IV (max dose: (Status Epilepticus) 1500m¢/24 hour) Maintenance Dose: 5-8mg/kg/24hr IV push not to exceed Img/kg/min. PROPOFOL Loading dose/PRN: 2-3mg/kg (Sedation) Infusion: 75-250meg/ke/min ‘SODIUM Cardiac Arrest: Imeq/kg IV/10 (max dose: SOmeq) BICARBONATE Metabolic acidosis: HCO3 (meq) = 0.3x wt (ke) xbase deficit or 0.5x wt{kg)x[24-serum HCO3]Relative percentage of areas affected by growth ‘Age (years) 0 1 5 10 | 15 | Adult Awofhead | 9% | 8% | 6% | 5% | 4% | 3% 8% of one 2% | 3x | a | ax | 4% | ax thigh Chofoneleg | 2% | 2% | 2x | 3 | ax | 3 PARKLAND FORMULA First 24 hours (for 2"'& 3° degree burns > 15% body surface area burned Volume of LRS to be replaced = {4mi) (wt in kg) (9BSA burned) PLUS MAINTENANCE FLUID (DSLRS) (Children<40kg: 100mi/kg for 1* 10kg, 50mi/kg for the 2” 10kg, ‘& 20mi/kg >20kg body wt. Children >40kg: maintenance fluids are NOT included in the estimate of fluid requirements) + Give % over the first 8 hrs (starting from the time of burn) Next ¥ over the next 16 hrs NEXT 24 HOURS POST BUR requirement "Consider colloids after 18-24 hrs (albumin 1gm/kg/day), maintain Albumin >2e/dt withhold potassium generally for the first 48 hours because of a large release of potassium from damaged tissues je 50 ~ 75 % of the 1"days fluidmin —_ Recognize decreased mental status and perfusion. Begin high flow 0, Establish V/1O access. & Simin Initial resuscitation: Push boluses of 20 cc/kg isotonic saline or colloid up to over nee 5 {60 cc/kg unt perfusion improves or unless rales or PIV start be hepatomegaly develop. inotrope c Correct hypoglycemia & hypocalcemia. cp Begin antibiotics. min . e Fluid refractory shock: Begin 1V/10. Pp emereee | Use atropine/ketamine IWNO/IM to obtain central dopamine ‘cess and airway f needed. upto 10 Reverse cold shock by titrating central dopamine) mca/ke/min, ‘cf resistant, titrate central epinephrine. epinepirine Reverse warm shock by titating, bch aed norepinephrine. meg/kg/min | Persistent catecholamine restart shock: Rule out and coret percarcal | ____ effusion, pneumothorax, & intra-abdominal pressure >L2mm/Hg. | Consider pulmonary artery, PICCO,, oF FATD catheter, 8/or doppler uitrasound |__toguide uid inotrope,vasopressor, vasodilator and hormonal therapies.Tadao aus | Sodium Deficit Calculation: [desired sodium (mEq/L) ~ measured sodium (mEq/L)] x 0.6 x wt(kg) *correct not <24 hours “increase Nat by not more than 10-12mEq/L/day or at 0.S5mEq/kg/hr ‘Symptomatic Hyponatremia: 4-SmL/kg of 3% Hypertonic saline solution over 3-4hours ‘means Na+ <120mEq/L with seizures or mental status changes “limit rise of sodium to 2-4meq after infusion Eades aU Free Water Deficit (mL): mL x wt x (actual sodium ~ desired sodium) “Time of Na‘ Correction; If Na* is: 145-157 mEq/l 158-170 mEa/| 171-183 mEgq/| 184-196 mEq/| “decrease Na* by not more than 10-15mEq/L/24hours Pay Dasa | . | =welinkg) x04 x(desired | if char Ke-actual K’) * discontinue exogenous sources of K" ‘= Na’ polystyrene resin (Kayexalate) “infusion of KCI of no more ‘glkg/dose q6H PO than 40 mEq/L is given at a rate not to exceed 0.5-ImEq/kg/hr “correct not <24hours - ata paralysis or hypokalemia- or all of induced ECG changes*: * Calcium gluconate (10%) 100mg/kg/dose “give KCIO.SmEq/ke + 25mL_ | over 3-Smin, May repeat in 10min f does of sterile water over 30-60 not lower serum K* concentration minutes IV infusion + NaHCO, 1-2 mEq/kg IV over 5-10min + Regular Insulin 0.1U/kg IV with D..W as ECG Changes: 2ml/kg over 30min. Repeat dose in ‘* Twave inversion or flattening | 30-60min. '*S-T wave depression * Salbutamol nebulization solution. Wide P-R interval 1-2H (<25kg: 2.5mg; >25kg: Sng) + Dialysis D10Water = 2.5ml/kg IV bolus DSOWater = 0.5mU/kg IV bolus *D25 water solution = volume of D50 water + equal amount of distilled water ‘CONCOCTION OF 3% HYPERTONIC SALINE SOLUTION: \ ‘Amount of NaC solution (ml) = {26of solution used) x desired volume (ml) (146mg/100ml or 40mEq/ml) 146Compensated shock (systolic BP ‘maintained but has signs of plasma leakage Foran ena BOX.A, Obtain baseline CBC. Fluid resuscitation with | Plain isotonic crystalloid at 10m\/kg over 1 hour. | Give oxygen support . Lifimproved -> Go Box 8 Go to Box D Pie 4. If patient is stable for 8 = Blending 48 H, stop IVF or give € ~ Calcium and other ‘maintenance fluids/ORS ; See reoHypotensive shock Try to obtain a HCT level before fluid resuscitation Start isotonic crystalloid or colloid {hypotension persists, check for: A acidosis) - do ABG B (bleeding) ~ check hemoglobin and hematocrit C (Calcium and other electrolytes) ~ correct imbalances S (sugar) - check capillary blood glucose‘Term gestation? Yes Infant stay with mother for Breathing ocrying? oui ce Binh one ae temperature. Postion arway and dlear secretions if needed, dry No Ongoing evaluation Warm and maintain normal temperature Position airway Clear secretions if needed, Dry, stimulate No t 8 ao. | No Labored breathing or HR < 100/min? _ case, persistent cyanosis, ves | ve | = Position and clear airway PON.S00, Onno SpO, monitoring Consider’ ‘ae Supblemental ar needed No 1 HR < 100/min? > Pestresuscitation care vw | Ventilation corrective steps it needed ‘torah ETT or laryngeal mask if needed gery | 3min 70% 75% a amin 75%80% HR < 60/min? aan |» V Epinephrine persistently Intubation, Chest compression we oe Coordinate with PPV, 100%, _ 5 an < go/min? od Seiiere ECG Monitoring hypovolemia or Consider emergency UVC pneumothorax Pink body with blue extremities {acrocyanotic)Start CPR? * Give 0, * Hook to cardiac monitor/defibrillator Persea oy VENTRICULAR FIBRILLATION or PULSELESS VENTRICULAR TAMA (sHock ~Defibrillate 21/kg “initial adult dose: 120-2003 CPR for 2min “insert iV/i0 1 \ sHockasie? =| ~Defibrillate 4I/kg “adult: 120-200) or higher. ‘Max 360) CPR for 2min No ASYSTOLE or PULSELESS ELECTRICAL ACTIVITY V CPR2min *IV/AO access *Epinephrine (1:10,000) 0.1mL/ kg q3-5 min “Consider advanced airway 4 { sHocKABLe? wo CPR 2min ‘identify & Treat Reversible Causes? | “CPR Quality “Push hard >1/ of anteroposterior diameter of chest) and allow complete chest recoil ‘Minimize interruptions in compressions ‘avoid: ventilation ‘*Rotate compressor every 2min or ‘sooner if fatigued “it no advanced airway, 15:2 ‘compression-ventilation ratio 'Reversible Causes ‘sHypovolemia ‘Hypoxia ‘Hydrogen ion (acidosis) ‘Tension pneumothorax ‘sTamponade, cardiac Toxins _sThrombosis, pulmonary ‘Thrombosis, coronaryIdentify and Treat Underlying Causes + Maintain patency of airway, assist breathing if needed * Give O2 * Hook to cardiac monitor and identify the rhythm * IW/O access + 12-Lead ECG if available + Do not delay therapy ‘SINUS BRADYCARDIA ‘CARDIOPULMONARY COMPROMISE? No_ + Hypotension * Acutely altered mental status + Signs of shock Do CPRif HR <60/min with poor perfusion Despite oxygenation and ventilation “support CABS |x Give Onygen “Observe < Consider EXPERT ‘Still with Bradycardia? CONSULTATION | Give: * Epinephrine (110,000) 0.1mU/kg .g3-Smin IV/O. Epinephrine O.1mg/kg (2:2,000) er. “atropine 0.02m@/kg IV/I0. Min dose O.Amg. Max dose 05mg * Consider transthoracic pacing/ transverse pacing * Identify & Treat Reversible Causes? | If pulseless arrest devel to ‘ATROPINE CARDIAC ARREST ALGORITHM reat es ee or:Identify and Treat Underlying Causes * Maintain patency of airway, assist breathing if needed + Give 02 + Hook to cardiac monitor and identify the rhythm + IMAO access Do 12 Leads ECG Evaluate QRS duration uate Rhythm: NARROW QRS<0.09sec | WIDE QRS >0.09 sec a VENTRICULAR ‘TACHYCARDIA EE cass 2 = compubleHtoy, “Compromise?” + Hypotension + Acutely altered mental status | + Signs of shock CARDIOVERSION: — Regular Rhythm Treat the cae monomorphic Give: *adenosine | foo) deat kg q3-Smin EXPERT CONSULT 10. Epinephrine ‘+ Amiodarone* .ame/eg (21,000) + Procainamidet OR *SYNCHRONIZED ‘CARDIOVERSION* ifno 1V/10 or BepinwithOs- ive, Sanosne ls ifnot effective, increase to 2i/kg. I Sedate ifneeded but do ’Amiodarone *ypovolemia not delay cardioversion Sma/kg over pines 20-50minutes * Hydrogen ion (acidosis) “Adenosine * kalemia “Begin with 0.5-1i/kg, — “Procainamide ‘Tension pneumothorax if not effective, increase -15mg/kg over ‘Tamponade, cardiac to kg Sedate if needed but do routinely administer «Thrombosis, pulmonary ‘not delay cardioversion _with Amiodarone ‘*Thrombosis, coronaryMos [6Mos [ive [2s ie Age Beat smut | smat [Sat | Smal away _|edme | 60mm | Sdn | 7Omm aa ex fa fa fat dee i Bde te sean fae as fas sae «SS oe ervsie [25 [25 [83 [23 [So [So [ses [ioe sion [ear] a0H | 6 ioe | oR lore | 10F Yor a0F|12FF es at [SSE fe | oer wae [aaa | sere pe far parr fe foe fore fore [mee fae coe [ar [Sarr [ase [ase [aor SR [air [SR |r Serer fe sheer ey and greater shou have cueGETT Uncutfed Er sine (mm id) = age in years / 4) +4 Cuffed ET size(mmid.) = [age in years /4) +35. Depth of insertion (>2y/o) = (age in years/2) + 12 or tube i.d. 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