University of Santo Tomas Hospital; Department of Pediatrics ‘ Section of Pediatric Critical Care Medicine @PICUDIGO™« Pediatric Intensive Care Unit Drug Information Guide & Outline (632) 731-3001 local 2304 / 2363 local 2435 / 2292 UST Hospital (Trunk line} Pediatric Intensive Care Unit. Neonatal Intensive Care Unit. Emergency Room - Clinical Division...... local 2291 Emergency Room - Private Division...... local 2357 Poison Control (UP-PGH). (632) 521-8450 er kilograms ce At birth | 3.25 7 3-12 months Age (mos}+9 ‘Age (mos) + 11 2 1-6 years Age (yrs)x2+8 | Age (yrs)x5+17 T= i2 years Age (yrs) x7=5 ‘ge (yes) x7 +5 2 Heart Rate (beats/min) Age ‘Awake Rate Sleeping Rate Newborn to 3 months 85 to 205 80 to 160 3 months to 2 years 10010190 750 160 2 to 10 years 60 to 140 60 090 >10 years 60 to 100 50 to 90 Respiratory Rate (breaths/min) Age Rate Infant 30 to 60 Toddler 24 to 40 Preschooler 22034 School-age child 18 to 30 Adolescent 12 to 16 Estimated Blood Pressure for Age urement 50th Percentile Pye eu) Systolic BP 90 + (age in years x 2) | 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 mmHg ‘Mean Arterial | 55 + (age x1.5) 40+ (age x15) Pressure. a emende! 14s is ———————— ee | | Se SIT ec axon) 2 Sr ‘ADENOSINE Sepa N/O rapid push ove 12sec (max Gre) Oe ee pn oF 2a N/O rapid push (max 2g) Spontaneous Spontanes ‘Asthma Exacerbation: «or 20min ontaneous ‘¢ ||| [awopaviune | Asthmatsacerbalon:, Be | Tose Tospeetisouns — | 5 Fiskars rape pening | Topain Topain 2 re 1 3-12yo and young adult smoker: None. None 5 et eo neathy smoker: 0.7re/kg/he | ogme/kg/e ws Oriented Coos/babb TIROPIESULEATE | eriiopulmonany resusciatlon/acadvarda, ‘o0s/babbles 5 deerme ka/dose V ami x Best Confused rita cote dose Macainle dose: O5mein ea’: . i adolescents, Max total dase: Img in arial |icasisorets Gieste pam 3 il Shr ir ase Response | incomprehensible | hoarstorain 2 | a ose | pcos None om Na ean + ashe 2 GGLUCONATE (10%) | (28550 s00me/k/ Sahn V/PO = ahr Obeys commands | ni SH fondo not exceed 200mg/min witha yscommands | Normalspontaneous | 6 I nfuslon: do not exceed 200 Localizes to pain | Withdraws to touch $s a Bes Wihdrewsto pain | wineravatopan | 4 DEXAMETHASONE Safest ng 2 ble 4 - Motor | Abnormal lesion orm exon ec continu es cass afer etubatio Response a Saamiel : ‘roup 0.6me/ka/dose PO/IV/IM x 1 | nor ate Abnormal extension | Abnormalextenson | 2 cea eect aelee/ooce W/IMx | (decerebrate) vignamones Aareli/siw gt None None 1 DEXMEDETOMIDINE | 1 i if patient is intubated, unconscious, or preverba, the most important part of Chia: 05-2mce/kg/dose IV x1 over 10min hs sales motor response, Motor response shouldbe carefuly evaluated. folowed by 02:-imeg/ka/he infusion titrated to effec. DIAZEPAM st 7 ‘Neonate: 0.3-0.75mg/kg/dose IV q15-30min x 2.3doses; max otal dose of 2mg Child >1mo: 0.2.0 5me/kg/dose lV q15-30min; ‘max total dose <5ya is Sg; 25ya is 10mg. Nay repeat dosing in 2-4 hr as needed. ‘Adult: §-10mg/dose IV q10-15min, max total dose of 30mg in an 8-hr period. May repeat dosing in 2-ahr sensed : Dion | Vnfsin ate Rectal dose (using WV dosage frm): OSme/ha/dose medics oe naymy | Savatobw | Rage anaes eI iesnival =m : EPINEPHRINE sauteed Brat and aes ae = reais ca Sai mite Aiprosta | 00502 amelie | O0smes/te (r03mung Weressninpah (Prostaglandin £1) Infant and Chid:0,01ma/kg of 1:10,000 solution iodarone [515 eae __| Ameen (Bare) es ran PRN Me ae nf fae = eae opm esa "ALET doses O.1mg/ig 11000 slaon (mag a3 Sin poe meafeain a 0g te se RSC u to moc dos of 5m ‘Dobutamine 2-20 ‘6me/kg ar hn Sere ait Pm 4p to max dose of 0.5mg/ ieee /rin cisartvatn 20m Epinephrine [O12 sae tems ee beincented necesary Basege nso og 5 ma/ke —[ameaia/min : Tian [2050 wh [satan Se ee aero ‘Norepinephrine | 0.1-2 0.6me/ke imcel Sm repeat qismin x 3-4doses or athe PRN Vasopressin | 0.5-2mitiuntsie/min | émiiunits/ke | amiliunit/ke/min H14000souton alstedin or 13 on dutedin it doses a iS ETT. Meds: (NAVEL: naloxone, atropine, vasopressin, epinephrine, lidocaine) Matty nt nyo Si HYDROCORTISONE a h NS, follow with postive-pressure ventlation sic ; dilute meds to Sm with NS, folow with p i ee aa Maintenance: + ashe WV INSULIN 5 i as d/h (Seg) ove 30min eB tanec ep oho OOSN TS with regular insulin erie dics hryKETAMINE ston: Pet Srelpetv.025inene n2snghent KETOROLAC hid: 05mg/kdose IMI a6 Bh. Max dose of 30mg g6 hr or 120me/24hr ¥ (MAGNESIUM SULFATE MON SSO doe ache Sd ds ee BN Maxsige ds 25 Fo: 100205 rahe QD Gu 25 somehelsose Vere ante dese of) hou orcotros sor st ator fo dometa ma reo nfusonateof 12a ps0 sag Mg level gf to atete mail che MANNITOL OS-le/ke/dose a4-6hrs IMETHYLPREDNISOLONE ime era ‘Asthma Exacerbation Child < 12yo (IM/IV/PO}: 1-2mg/kg/24hr + q12hr. Kaleo tor oles SP ch lose gare sn amen $aL2h fae Soe Goya) ‘MIDAZOLAM for procedure eee Over 2-3in May repeat ose PAN in2-3minenval Max total dose of re Sthecoms cosngglaae ve 2h May net ee nnd ar eed sal aoe toe Sto:t6yo: 05 dme/eoze ove in, Moy reat BRN namin terval Max total dose of tome. || nth mechanical _ | iantand Cuid(inermterseGroiSme/e/ || dose gt 2h PN | {ontinuous):1-2meg/kg/min || N-ACETYLCYSTEINE Paracetamol ingestion ‘300mg/kg over 20 hours even as follows in>20i: Fist infsion: + os ort ger35sonn || Second infusion: mg/g + DSW 280 over ahous Third infusion: 100me + DSW 250ml over 16hours ||| < | BSS ssomerg nani osWovr15 15% body surface area burned ‘Volume of LRS to be replaced = (4mi) (wt in kg) (%BSA burned) Plus MAINTENANCE FLUID (D5iRS) (Childsen20kg body wt. Children >40kg: maintenance fluids are NOT included inthe estimate of fluid requirements) v Give % over the first 8 hrs (starting from the time of burn) Next 4 over the next 26 hrs NEXT 24 HOURS POST BURN = gve 5075 6 of the 1"days uid requirement “Consider colloids after 18-24 hrs (albumin 4gm/kg/day), maintain Albumin >2e/at *Withhold potassium generaly forthe fist 48 hours because ofa large release of potassium from damaged tissuesRecognize decreased mental status and perfusion. Begin high low O, Establish I/O acess min Initial resuscitation: Push boluses of 20.) isotonic saline or colloid upto over 2s aahgwtipensntgors ois: A pix hepatomegaly develop. fore cores pogrent tipsters Soeur shock not reversed? Phirecon shck pn 0 foe UastieleoneMon eens | / inte ieceraney nel woe foe cuiesimcne clits fl niin Sisto accensiceste "P| cece ‘omenanseitysrsegena | \ Saseos mete ate shock not reversed? —_ Catecholamine resistant shock Begin hydrocortisone If at isk for absolute adrenal nsutficiency ——e Monitor CVPin PICU, tan normal MAP-CVP & S00,» 70% eee a Cold shock wth Coldshockwith | Warm shock wth rormalblood pressure: | low blood presure: | tow blod pressure: 1 Tirat id. 1 Tired ‘LTiratefid epiephie,S0,>70%,| epinephrine Sor0> | norepinephrine, abo ion 710%, Hab> 10g Se10> 70% 24500, stIc 70% | 2fstl hypotensive, | 2 stl hypotensive, ae with | cesiderorepnepvine | conser vasopresn, volumelzadng (nie- | 3.1500, stk 70%, | tripresn or angotersin soasodlitos,mitnore | consider dobutamine, | 3.1500, stk 70%, ‘nna thes) | miinone,enaxmone | consdeiow dose Consderlevosimendan | orlevsimendan epinephrine — Persistent catecholamine rsstant shod Rul out and correct prcarcal ffs, pneumothorax & intra-abdominal presure>12mm/He. ‘Consider pulmonary artery PICCD,or FATD catheter 8/or doppler utasound to guide fi inotope,vasopressor vasodiator and hormonal therapies. ‘Goal L.>33& <60U/minvm? —— Refractory shock: ECMO (desired sodium (meq/l) ~ measured sodium (mEq/t)]x0.6x (ke) orrect not <24 hour | | sinasymptomatie patients, increase Nat by not more than 10-12mEqj/Lin 24 hours oF 0S-Imeq/t per hour For Symptomatic Hyponatremia: (defined as Na* <120mEq/L with seirure or mental status changes) Give 4’Smi/ag of 3% Hypertone saline solution over 15-30minutes auc! ‘Sodium Deficit Calculation: Free Water Deficit (ml) “mL xwt x (actual sodium ~ desired sodium) ‘Time of Nat Correction: Nos 2-améq a infusion Tasr157 mea/t = correct over 24 hours 158.170 mEW/L = correct over 48 hours 17183 mEq/L = correct over 72 Nours 184-196 mea/L= correct over 84 ours * decrease No by not more than ISmEa/ per 2shours to minimize kof cerebral edema Bren Py Ci >6méa/L without changes in EG: + discontinue exogenous sources ok 1g/g/dose g6H PO wt (ing 0.4 x(esired K*- actual) plus dally maintenance of 2-4méa/k—/day “Infusion of lof not more than 4oméa/L isgivenata rate not to exceed 05-ImEq/ af for2ahrs *Oralcorections preferred unless contraindeated or sexperiencing sociated signs and symptoms. Child (PO): 14méa/ig/24 hous» 810-010 ‘Adult (PO): 40-1009 2¢hours = BIO-CID “Monitor serum potassium accordingly with 1 ive one oral ofthe following: * Calum gluconate (10%) 100mg/ g/dose (Imi fg/dse) over 35min May repeat in 10min (des not lower serum K'concentraton) ‘ NaHCO, 12 mEg/kg V over 5-10min 1 Reguarinslin 0.0/keV wth D..Was 2mi/ig over 30min Repeat «Bie in 30-60min + Salbutamo! nebulization solution every 12H (28ig: 25mg 25K sme) Dials *inhypokalemia induced paralysis or “ge KCIOS-Amea/kg/éose gen se nuson ‘of OSs for 1-2hes. Maxson ate ‘of ama/ke “Dite KC as folows: ‘ad SomLof DW in <1Okg ‘Add 100m of SW in 10-20K¢ ‘Add 350m of OSW in 20:30 ‘Add 200m of DSW in >30%@ ~DONNOT give KCl undiluted or 35 1V push se wth STRICT CARDVAC MONITORING and ‘REPEAT ERUM POTASSIUM LEVEL after infusion ECG Changes: ‘Twavemersion or fattening * ST wave depresson Wide PR interval Bocca 1oWater= 2.5m IV bolus ‘D25Water = Imi/iaW bolus ‘sowster= Smif IV bolus "025 water soltion = volume ofD50 water + equal amount of sterle water[age [30 [6Mos [ive [2vs [avs [ews [evs fora | sma | Smat | smal | smat_| sran | med | Mea Siavey | Som | mm | Eom | 70mm | TOmm | Simm | "5m ex fm ja fm fe je fo |e ‘lage ferrame [a= [as [ao [ao [as as [so ao_lag fas {a a suszon [enor | eaor [aoe | aoe | a0 7 [gugten sor [acer | eaoe [oer | roe [206 so not sar [eo [aor [oer [aoe [aoazer | zaare ire [rr [ar [ar [err [arr | ar 7 Jure [sre [ar [are [arr [am [arr | tr gems | 3.4rr [aan [asi [ast [ase [ser | om *8 yr and greater: should have cuffed ETT Uncuffed ET size (mmid.) = {age in years / 4) +4 Cuffed ET size (mm ic.) = (age in years /4) + 3.5 Depth of insertion (>2y/0) i.d,= internal diameter (age in years/2) + 12 or tube id. (mm) x3 ‘Gesaena Ears of ached |hener am apectezal |iEsctncinl |) Ortho 9 cite iis) ere | eee | Coe pean Seow TOO] aE 7 Beas 1000:2000-| “734 t 5 78 [6-88 poo0 3000-3438 | Oa 35 3 00 Ss 7 eats eee oar "Ma. Louisa U.Peratta, MD Chair Pediatric rial Care Medicine Felowship Training, UST Hosptal Fossil of infant Jesus, Mans UST Hospital Toh A-One, WD Ting Ofer Pediat Ctl Cre Meine Felowship Ting UST Posptal Perpetual SuccorHosptal, Manls;UST Hosptal ‘Anita G: Marasigan, MD Member Pesatrc tical Care Medicine Fellowship Tarng, UST Hospital nO _HUNRIaE Media Center Gueton Cty Ost Nessie UST MOSPPa | Ain € Florentine, MD Member, Pediatric Critcal Care Medicine Feiawship Training, UST Hosp] SUM Gezon ty and Global Cy, UST Hospital” an UST Hosp ee MC Cieon Cay one bel iy, st oe Ral eae of Marie Vicora Rosanne Member Pediatric Creal Care Medicine Feiowship Tang, UST Hospital Nottie Metro North Wecal Center and Hosptt Gueror iy; Aiko Care re "alenavela Gry Tondo General Hosptial Paul. Cobarrbias, MD * Eaton PICUDIGO ‘Amang Rodiguer Memorial Medical Center, Marikina LMC Global City ‘Marissa G.Salas, MD 1" Edition PCUDIGO / Our Lady of Lourdes Hosp, ta, Mesa, Mania] net Maria Doris Peaemee Meh ertoeea Senrmg se. teen. | aeecrtoren te SEE Taiiatr,, | Reece | tet an Meso Coher Rogando, MO_ Pocholo Madamba, MD_ USA” a lg rad eet ee raetere® vest) | cesses Maa Vion sy wo Secrest, | faeeee Mo tere ea cane Stree Ansa Oncog, Mo Goer y wa Gu MO soe Bone Vaasa Uy eae Srila ee Cire Cesare ‘General Hosp UST Clans Docos papa | MEOts How, Boho” | eta Rachel Faby Slta aaucina mo LAER | Sena Eris Aha Ment Steere TE no mma fares Memes ce Rercustsazortpta, | aoa Wong PaedesDx MO | wt eas vr MO Manis: USTHosptalY “| Chinese Genes Hosp a: | Meo tery Medea Career ‘Wa chan, Mo, sspsriieeite, | Meena Mecca oe prin eer Redes eft tsey terme | Newaomece cries | | Katha ea Indonesia Coeaieeey le? ‘Ine; San Pedro Hospital of Davao City, Inc. FEENEY coins rac Gertr, MO | Tyome La MO ea ne aster Sa er ie ck ed ane fe ta Ca ce a MLUPeraltaAGMarasignACFlorentinalAOngMVRNCruxCNSGrantozaTVlariego‘BOX A. Obtain baseline CBC. Fluid resuscitation with, plain isotonic crystalloid at 10ml/kg over 1 hour. Give oxygen support. Start isotonic crystalloid or colloid YES: ious cate BOX. Reduce IV crystalloid: esta S-7myig/hrfor3-24| | poxc. BOXD.tfwith Nomad 3-5ml/kg/hr for 2-4H Administer | | signsof t0nukg/hr 2-3mL/kg/hr for 2-4H 2° bolus of occult/overt for 1H Maintenance fluids crystaloids/ | | bleeding, should not exceed colloids tite FW ¥ 10mi/kg in 1H | | transfusion WonSIGE at 20mi/kg or eyes Veystalloid/ 12H Pee | | gal beh) ras ae Liimproved > GoBoxs | | ®,7mUta/te aomifeg/he vor <= 2.fno improvement pie '30-60;nins hemodynamic > GoBoxE ey status frequently 23 mU/ke/hr for 24H Seer mame) Patient tbl, |] Patients urstabe, Wry stableandHCT | HCT decreases | | HCTincreases increases by 10%, |-> GotoBoxB || -> Do ABCS sone NO correlate clinically Y isnoted, and assess need to - reduced fluids ‘Administer 3° bolus of x LES colloids 10mU/kgin 1H soorainay 2 If patients unstable uo Reduce y and Hct increases Stop IV fluids itil > Goto BoxB at 48 hours: for 1-2 ay Patient 3.leatientis unstable | improved > | | does not improve peered Goto BoxB || ->startinotropes " See drop in Het ~ || | afacidosis)= do aB6 > Goto BoxD +A Acidosis B ~ Bleeding 4, If patient is stable for = Calcium and other 48H, stop IVFor give electrolyte imbalances maintenance fluids/ORS eisigar 8 (bleeding) ~ check hemoglobin and hematocrit (Calcium and other electrolytes) ~ correct imbalances S (sugar) ~ check capillary blood glucose Colloid” 10-20 mifg/he Evaluate. toconsder blood transfusion ifnodinical improveStart CPR! + Give Oxygen re ‘+ Hook to cardiac monitor/defibrillator ‘normal VENTRICULAR FIBRILLATION or ASYSTOLE or z| (“pamermny camenes PULSELESS VENTRICULAR PULSELESS ELECTRICAL | mesic cy strate peo “eu <—om Ty eas a ST | suoex aa siyno access Petrie 2 4)/ CPR Quality ae cron oo ‘adult: same dose or higher. Syren e sreessons Man 360) Meveetititeteon” ee Eee eee ieee “Amiodarone |V/IO Sme/ “if no advanced airway, 15:2 (single jon Blue or pale | Pink body with ‘Completely pink he: Nea repeat up nat nota ta ee ore blue eemies Adult dose! 1" dose of 300mg: | th arsed away e810 benth/ (acrocyanotic) 2 dose of 150mg rimvithcontasous chest compression ‘Absent Slow (<100/min)_| >100/min or tkdocaine WO imate RE 2 loading doses. poet No response | Grimace Cry or active Maintenance: 20-SOmee/ke/ Hypoxia zl withdrawal min infusion (repeat bolus dose + Hydrogen in (acidosis) inp Some flexion Active motion if infusion inated >15min regen Seete ont —— after intial bolus therapy famponade, cardiac ‘Absent Waker (Good, crying identify & Treat Reversible porense en Causes?Identify and Treat Underlying Causes * Maintain patency of airway, assist breathing if needed * Give Oxygen * Hook to cardiac monitor and identify the rhythm. Monitor Blood Pressure and oximetry < eIv/lO access * 12-Lead ECG if available * Donot delay therapy SINUS BRADYCARDIA, v CARDIOPULMONARY COMPROMISE? No_ + Hypotension * Acutely altered mental status * Signs of shock Give: "Epinephrine (1:10,000) 0.1mI/kg q3- ‘Smin per IV/IO or Epinephrine 0.1mL/kg (2:1,000) per ET "Atropine* 0.02mg/kg IV/1O. Repeat ‘once. Min dose 0.1mg. Max dose 0.5mg Consider transthoracic pai transvenous pacing Identify & Treat Reversible Causes? es. “for increased vagal tone of primary AV Block *Reversibl ‘sHypovolemia “Hypoxia *Hydrogen ion (acidosis) *Hypo/hyperkalemia “Tension pneumothorax STamponade, cardiac “Toxine *Thromboss, pulmona “Thrombosis coronary” Identify and Treat Underlying Causes + Maintain patency of airway, assist breathing if needed * Give Oxygen * Hook to cardiac monitor and identify the rhythm, + Ivf access ‘= Donot delay therapy v Do 12 Leads ECG Evaluate QRS duration ‘and Evaluate Rhythm, bled Probable SINUS Probable TACHYCARDIA VENTRICULAR + Heart Rate: TACHYCARDIA <22ojmin iors)» He fae ret orale: <120/min(cildren) > Baton (infants) J ~Campatberoy, 3 b0/mi ern) cinasurtwininonn = Conpabereseyy carepulmonary Pua pesent/ Nataryefaountee”* HYBotension history of abraptate changes PEM acutely altered mental status ‘+ Signs of shock normal + Variable R-R and constant PR interval | anges + P wave absent/ abnormal Ident nat eres —>| SYNCHRONIZED Consider Treat the CARDIOVERSION: _Adenesineit cause* ‘Regular Rhythm 208s monomorphic Give: I *Adenosine’ if IWNO access is peerreretes present Maeda @ + Procainamidet “*SYNCHRONIZED CARDIOVERSION! if no IV/IO access 4Synchror d or adenosine Cardioversio inetfectve ieee, nese -Reversible Caus to U/kg 4 Hypovolemia Sedatel needed but do Smg/te over Shypox ‘Hydrogen ion (acidosis) *Hypo/hyperkalemia ‘Tension pneumothorax ‘STamponade, cardiac Toxins ‘Thrombosis, pulmonary ‘Thrombosis, coronary ot delay cardioversion 20-6Ominutes “Adenosine 4 Fist dose: mg/kg 15me/kg over {imax me) rapidbolus 30-60min. 0 not Second dose: 0.2mg/kg routinely administer {max 12mg) rapid bolus with Amiodarone