Dubbo Paediatric Department Welcomes the Dubbo Hospital Junior Medical Officers to their placement on the Surgical teams.
Within the surgical teams of Dubbo Hospital in: General Surgery, Orthopaedics, Ear Nose and Throat and Urology we have a fairly high turnover of paediatric surgical cases. Please speak to your surgical colleagues around the management of your patients first and foremost.
The website is a resource for your surgical teams in the management of the concurrent medical problems while under your care.
Dubbo Paediatrics has endeavoured to put together on a single webpage the most important links for safe prescribing of fluids and medications for your surgical patients.
If you are uncertain of what is the correct option discuss with your surgical registrar and the nurse of your patient; and if your team wishes, consider discussing the options with the Paediatric Registrar on call.
Intravenous fluids (PIC) this a summary document read it in the first week of term. Feel free to discuss with the Paediatric Registrar for more information
Intravenous fluid- quick link to types of fluid per age group (ACI)
Intravenous fluid management (CHW) a big document
When a cannula tissues
Intravenous extravasation (SCHN)
4-2-1 guide
4ml/kg/hour for the first 10kg range (ie for every kg between 0 and 10kg give 4ml/kg/hour)
2ml/kg/hour for the second 10kg range (for every kg between 10kg and 20kg give 2ml/kg/hour) and ADD THIS TO 40ml/hour (10kg x4 from above)
1ml/kg/hour for every kg above 20kg and ADD THIS TO 60ml/hour from above (ie 10x4ml = 40; then 40 + 10 x2 = 40 +20= 60 ml/hour)
This 4-2-1 guide is only to be used as checking device for hourly infusion rates. It does not calculate fluid losses or deficits.
Examples
a) For the first 10kg give 4ml/kg/hour. E.g for a 8kg child, the maintenance fluids rate is: 8x4 ml/kg/hour = 32ml / hour
b) For the second 10kg add on 2ml/kg/hour:
Eg. for a 14 kg child
this is 10kg (first 10kg range) + 4kg (in the 2nd 10kg range ) = 10x4 + 2x4 ml/kg/hour
So this 40ml/kg/hour + 8ml/kg/hour
So this means a 14kg child has a maintenance fluid rate OF 48ml/kg/hour
To calculate the hourly rate of maintenance fluids, for a child who is say 32kg (which is 10kg (0 to 10kg range) + 10kg in the 10 to 20kg range and 12kg in the above 20kg range
This is 4x10 + 2x 10 + 1 x 12 ml/kg/hour= 40 + 20 + 12 ml/kg/hour
That is a 32kg child needs 72ml/hour for maintenance fluids
One of the challenges during a surgical term is when your patient is requiring IV fluids and the cannula tissues. Paediatric patients may not cooperate with the insertion of the cannula , and have smaller veins, which can make for a challenging insertion.
For older children and adolescents, the technique is much the same as adults, but it is wise to ensure a nurse is free to assist with the insertion of the IVC
TIPS
1) discuss with the nursing staff, consider calling the Paediatric Registrar
2) calm the child as much as possible, and consider wrapping them, and distract the child with YouTube videos etc
3) Find the best vein possible and , if the Registrar is in agreement, you may have one or two attempts at insertion of a cannula. Dubbo Hospital is a training hospital and with appropriate supports residents may learn to insert cannulas in children. If the venous access is difficult, it is probably unwise for junior staff to attempt cannulas.
4) best sites for veins are in the upper limbs : hands between middle finger and 4th finger, wrist , and cubital fossa
Take great care with the prescription of medication in children. There is great potential for harm and drug toxicity.
However
TIPS for safe prescribing
1) double check the patient's weight.
2) double check the patient has no drug allergies with the parent and nurse
3) check a reliable drug prescription site, such as one of the sites below
4) double check the dose per kg
5) double check the dose with a nurse on the ward. Our nurses are mostly very experienced and have years of checking dosages in children. If the nurse challenges your dose per kg, IT IS TIME TO CALL THE PAEDIATRIC REGISTRAR.
6) take great care with opioids as they are commonly prescribed and easy to overdose on. When prescribing opioids ask yourself : is there a reason why this might be dangerous (eg obesity or child with snoring who may have obstructive sleep apnoea)
DRUG INFORMATION -for safe prescribing
Meds4Kids : Children's Hospital at Westmead drug resource on general information for prescribing medication for kids
Injectable drugs (also from Children’s Hospital at Westmead): aimed at nurses drawing up IV drugs
Australian Medicines Handbook : ,Very useful from prescriptions as it has generic and trade names for drug dosing and concentrations of suspensions
MIMs: May use “Drug interactions” and “add drug” for checking for drug interactions and a fairly comprehensive side effects list
Discuss with the Pain Team around PCAs and analgesia in pre and post-operative patients
Sedation and acute pain management (RCH)
Pain management (SCHN)
Opioid infusions (RCH)
Acute otitis media (RCH)
Secondary haemmorhage post tonsillectomy and adenoid surgery - ED management
Post tonsillectomy bleed (note this is a Perth guideline and focuses on: getting IV access, considering coagulopathies as a root cause of the bleeding, giving IV fluids, considering tranexamic acid, and getting blood cross matched +/- urgent transfusion of O negative blood)
Note: in Dubbo if a child has an unexpected post tonsillectomy bleed, the emergency staff have three options on whom to call, if the surgeon involved is not contactable, and general surgeon on call expresses reservations around providing ENT cover:
1) Dr Hayder Ridha (ENT)
2) Dr Ranga Sirigiri (ENT)
Adenoidectomy post operative management (RCH)
Epistaxis (SCH) -nose bleeding guideline
Epistaxis (RCH)
Femoral fractures in ED (SCHN) goes in detail on traction, pain relief and muscle spasm treatment
Skin traction (RCH)