Peri-op  

THE BELLFLOWER PERIOPERATIVE POCKET MANUAL
Maracus Magallanes, MD 2002

15.  PEDIATRIC SECTION

• Fluids
• Antibiotics
• Pain meds
• Antiemetics/ Antipyretics
• Laxatives/ Antacids

FLUIDS

After appropriate correction for hypovolemia with 10-15 ml/kg NS, routine maintenance is started as follows:

• 100 ml/kg/day for the first 10 kg of body weight
• Add 50 ml/kg/day for the next 10 kg of body weight
• Add 20 ml/kg/day for each kg over 20 kg

It is easier for the nurses to run a number divisible by 24; therefore, the following table is offered:

Kg	mL/24h	mL/h		Kg	mL/24h	mL/h
4	384	16		17	1344	56
5	480	20		18	1392	58
6	600	25		19	1461	61
7	696	29		20	1488	62
8	792	33		25	1584	66
9	888	37		30	1680	70
10	984	41		35	1800	75
11	1056	44		40	1896	79
12	1104	46		45	1992	83
13	1152	48		50	2088	87
14	1200	50		55	2184	91
15	1248	52		60	2280	95
16	1296	54

Initial bolus of crystalloid is NS 10-20 ml/kg; then D5NS, D5½NS, NS, or ½NS with maintenance volumes as above + replacement as necessary as NS or ½NS. Once voiding well, routine maintenance fluid can be D5Isolyte M, which is similar to D5¼NS but with potassium and acetate.

ANTIBIOTICS            Peri-op  

For intra-abdominal infection (e.g. appy, GI perforation), usual antibiotic doses for over one week of age:

• Ampicillin 100 mg/kg/day divided q6h
• Gentamicin 7.5 mg/kg/day divided q8h
• Metronidazole 30 mg/kg/day divided q8h

OR

• Clindamycin 40 mg/kg/day divided q6-8h
• Gentamicin 7.5 mg/kg/day divided q8h  (Check gentamicin levels with 3rd or 4th dose)

P.O. regimen for post discharge (only for patients with resolving infectious complications of appendicitis):

• Augmentin liquid (200 or 400mg per 5ml) or chewable tablet (200 or 400mg) 25-45 mg/kg BID
• For PCN allergic patients, the drugs of choice are Cefixime 8 mg/kg/day divided q12h plus Clindamycin 10-30 mg/kg/day divided q6-8h
• For PCN/cephalosporin allergy, the drugs of choice Septra one milliliter/kg/day divided q12h plus Clindamycin 10-30 mg/kg/day divided q6-8h

For treatment of Staph aureus infection:

• IV Cefazolin 50-100 mg/kg/day divided q8h
• PO Keflex 50-100 mg/kg/day divided q6h

For treatment of UTI:

• First choice TMP-SMX 1ml/kg/day divided q12h PO, unless bilirubin increased or prior hx of UTI
• Second choice Keflex 50-100 mg/kg/day divided q6h

*If patient remains symptomatic 24 hours after start of treatment for UTI, a repeat urinalysis and urine culture and change of antibiotics is warranted.

Generally contraindicated antibiotics in pediatrics are the floxacins because of cartilage damage in the growing child, tetracyclines because of tooth staining, chloramphenicol in infants because of gray baby syndrome and in older children because of idiosyncratic bone marrow suppression. Other than allergies, the remainder of the antibiotic armamentarium is not contraindicated.

Antibiotic Suspensions and Chewables for Pediatrics

Antibiotic Type Preparation Sizes (ml)

• Augmentin 125 Suspension Amox 125mg per 5ml 75, 100, 150
• Augmentin 200 Suspension Amox 200mg per 5ml 50, 75, 150
• Augmentin 400 Suspension Amox 400mg per 5ml 50, 75, 100
• Augmentin tablet Chewable Amox125mg, 200, 250, 400 (# tablets)
• Cefixime Suspension 100mg/ 5ml 50, 75, 100
• Cleocin Suspension 75mg/ 5ml 100, 200
• Septra Suspension SMX 200mg TMP 40/ 5ml 100, 150, 200

Parenteral:

· First choice PCA pump-parent or nurse may adjust dosage for patients 7 years of age or older using the standard PCA orders.

· Second choice Demerol 1mg/kg IV, 2mg/kg IM q4h

Oral:

· First choice Tylenol (per dosing chart)

· Second choice Tylenol with codeine (120mg acetaminophen/ 12mg codeine). Based on codeine dose of 0.5-1 mg/kg/dose q4h, approximate doses:

• 12-24 months -1/2 tsp q4-6h
• 24-36 months -1 tsp q4-6h
• 4-5 years old -2 tsp q4-6h

· Alternative is Ibuprofen Suspension (100mg/ 5ml)

• 4-10 mg/kg/dose q6-8h (120ml size for dispensing)

ANTIEMETICS             Peri-op  

• · First choice clear liquid diet
• · Second choice Phenergan 0.25-1mg/kg PR or IV q4h prn (as long as age over one year and no questions about mental status)
• · Third choice Odansetron but this is restricted

ANTIPYRETICS

• When it becomes necessary to treat fever in children, we recommend using acetaminophen (such as Tylenol, Tempra, Panadol). This is NOT the same as aspirin. Acetaminophen should be given 4 to 5 times daily-do not exceed 5 doses in 24 hours. (*See the dosage chart.)

Acetaminophen (Tylenol) Dosage Chart

Age Weight	Drops 0.8 ml 0.9 ml	Elixir 160 mg/5 mL	Chew Tab 80 mg	Jr. Size Tab 160 mg	Adult Size Tab 325 mg
0-3 mos 6-11 lbs	0.4	1/4 tsp	1/2 tab
4-11 mos 12-17 lbs	0.8	1/2 tsp	1 tab
12-23 mos 18-23 lbs	1.5 droperful (1/2 ml)	1/2 tsp	1.5 tabs
2-3 yrs 24-35 lbs		1 tsp	2 tabs
4-5 yrs 36-47 lbs		1.5 tsp	3 tab
6-8 yrs 48-59 lbs		2 tsp	4 tabs	2 tabs	1 tab
9-11 yrs 60-95 lbs		2.5 - 3 tsp	5-6 tabs	2.5 - 3 tabs	1.5 - 2 tabs
12-14 yrs 96+ lbs				4 tabs	2 tabs

*Kaiser Permanente does not endorse a brand name-any similar product may be used.

STIMULANT LAXATIVES          Peri-op  

· Dulcolax (bisacodyl) tablets: (results within 6-8h)

• 6-11 years old-5 mg PO per day
• 12 years or older-10 mg PO per day

· Dulcolax (bisacodyl) suppositories:

• 6-11 years old-1/2 of 10mg PR per day
• 12 years or older-10mg PR per day

· Colace (docusate) 20mg per 5ml:

• Under 3 years-10-40mg/day divided qD to QID
• 3-6 years old-20-60mg/day divided qD to QID
• 6-12 year old-40-150mg/day divided qD to QID

ANTACIDS

• · Maalox 15-30ml 4-6 times per day
• · Cimetidine 20 mg/kg/day divided q6h
• · Ranitidine 4 mg/kg/day divided q12h
• · Pepcid 0.5 mg/kg/day divided q12h up to 40mg/day

* Pediatrics section contributed by Dr. Alan Alter (Pediatrics)
   Reviewed by Dr. John  Crabtree (General Surgery)

       Peri-op  

2002