Monthly Archives: April 2008

TPN

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When we know that a child or infant is going to be NPO for three or more days, we generally consider giving either PPN or TPN. PPN is given via peripheral IV and is limited to 12.5% dextrose and an osmolarity of 900. TPN requires central access of some sort and can provide greater dextrose concentrations and electrolyte replacements. The following are general principles of parenteral nutrition in pediatric patients.

ENERGY AND PROTEIN REQUIREMENTS

CATEGORY Age (yr) Protein/kg/d Kcal/kg/d Kcal/d
Preterm* <38 wks GA 3.0 – 4.0 120 kg x 120
Infants : 0.0 – 0.5y 2.2 108 650
Infants : 0.0 – 0.5y 1.6 100 850
Children 1 – 3 1.2 100 1300
Children 4 – 6 1.1 90 1800
Children 7 -10 1.0 70 2000
Males 11 -14 1.0 55 2500
Males 15 -18 0.9 45 3000
Females 11 -14 1.0 47 2200
Females 15 -18 0.8 40 2200

To Calculate total calories provided by your prescribed solution use this calculation: (divide each by kg)

e=mc*2

__% Dextrose X ___cc/day / 100 / X 3.4= Kcals from dextrose

____cc Lipids X 2 = Kcals from fat

%AA X ____cc/day % 100 = gm of AA

Fluid Electrolytes and Nutrition

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Maintenance IV Fluids – D5 1/2 NS + 20 mEq KC/L:

  • 100 cc/kg/day – 1st 10 kg = 4cc/kg/hr
  • 50 cc/kg/day – 2nd 10 kg =2 cc/kg/hr
  • 20 cc/kg/day – over 20 – 30kg =1cc/kg/hr

    • *Exception: Newborn IV Fluids

    1. 1st 24 hrs – 80 cc/kg/day of D1OW with 4.8 mEq Ca gluconate/250 cc
    2. 2nd 24 hrs – 100 cc/kg/day of D10 1/4 NS + 5 meq KCl/250cc
    3. After 48 hours – 120 cc/kg/day of D10 1/2 NS + 5 meq KC1/250

  • Increase fluids by 20% if the newborn is receiving phototherapy or radiant heat.
  • In the 1st week of life, add 200 mg/kg/day of calcium gluconate IV if the patient is NPO
  • NG/GT Replacements- Many patients with a NG or GT to drainage will need replacement fluid. Generally the output is replaced either 1/2cc per cc of output or cc per cc of output q 4 hrs.
  • Fluid Bolus – 10-20 cc/kg of LR or NS
  • Blood Product Administration

    • PRBC’s, FFP, or 5% Albumin – 10 cc/kg/dose
    Whole blood – 10-20 cc/kg/dose
    25% Albumin – 4 cc/kg/dose (1 gm/kg/dose)
    Platelets – 3 units/kg

  • Other Considerations

    • 1. Peritoneal lavage – 10 cc/kg NS
    2. Total blood volume is about 80 cc/kg
    3. Oliguria is urine output <0.5 cc/kg/hr in infants

    Laparoscopic Splenectomy

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    1. Positioning – Place the patient supine, but put a pad/bump underneath the left kidney. The table will be rotated significantly towards the patient’s right side, and mild Trendelenberg as well. The surgeon and assistant stand on the patient’s right, with the operating surgeon nearer the head.
    2. Preoperative US or CT or both are useful: If the spleen is > 15 cm, lap splenectomy may not be possible. If the patient has spherocytosis, there may be gallstones.
    3. Preoperative vaccinations should not be forgotten. Immunisation should be given at least 2 weeks before elective splenectomy, and includes: Pneumococcal 23 valent, Hib vaccine (if not already immunized, Meningococcal immunization, and Influenza vaccination. Many needed to be repeated every 5 – 10 yrs (or shorter intervals)
    4. Preoperative labs: CBS, Lytes, Plts, PT, PTT, +/- LFT’s
    5. IV preoperative antibiotics should be given
    6. Trocars: positioning is as shown below (except the 5th port in the left flank is not used). In most children, a 12 mm port is used in the umbilicus, and the others are all 5 mm ports. The 12 mm port is exchanged for a 15 mm port and extension of the fascial incision when the spleen is ready to be removed.

    Splenectomy-ports
    7. The lower pole of the spleen is mobilized the the Harmonic scalpel (? 4 setting). Watch out for the kidney throughout, and be careful not to burn the colon with the hot Harmonic. The Harmonic can be used to divide the short gastric vessels.
    8. Once the spleen is free, the 12 mm umbilical port is switched to a 15 mm port, and the fascia is extended slightly vertically. The large endo bag is inserted, and the ring forceps is used to morcelate the spleen.
    9. The hospital stay is typically that of discharge the next morning.
    10. Post operative antibiotic and vaccine management and careful instructions regarding recognition and management of post splenectomy sepsis syndrome are essential. Usually 250 mg po BID of PCN is used until adulthood (some use 16 yrs, some 21 yrs)

    HCG Stimulation test for bilateral UDT

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    Check a baseline testosterone level and have the
    patient take 500 units of hCG subcutaneous daily for seven days.
    Repeat the patient’s testosterone level at that time to
    see if he is able to make testosterone. If there is a
    significant change between the baseline and the stimulated
    testosterone value, then the patient does have viable testicular
    tissue and will need to have a bilateral orchiopexy.