1. Color Coding Kids: The Broselow-Luten System

6. Institute of Medicine Report • Deaths: 44,000 to 98,000 • Cost: 17 to 29 Billion Dollars

7. Lesar study Medication error rate in tertiary care center • Greatest areas Pediatrics Emergency Department • Pediatrics: reliance on dosage equations was major cause of error

8. Kaushal JAMA Study 4/01 • Included major Children’s Hospital • 5.7% of orders had medication errors • Dosing error most prevalent category

9. Institute for Safe Medication Practices (ISMP) • Pediatric Pharmacy Advocacy Group (PPAG) • “Pediatric patients need more protection from medication errors, survey shows”

10. Two Key Pediatric Error Issues • 1) Dependence upon calculations • 2) Lack of familiarity with normal vs. abnormal

11. 1993 1995 Number 34 30 Greater than 1 error 19 9 Ten fold errors 3 4

12. Didn’t recognize errors • ICU Patients 10 drugs orders per day. • Could translate to one 10-fold error for each 10 infants

13. Recognizing normal

14. Even The Cleaning lady would know!!“Too many amps in the trash”

15. Which dose is 10 times error?

17. Zone CM Length Wt in Kg Age in months 1 Pink 59.5-66.5 6-7 2-5 2 Red 66.5-74 8-9 5-11 3 Purple 74-84.5 10-11 11-19 4 Yellow 84.5-97.5 12-14 19-30 5 White 97.5-110 15-18 30-39.5 6 Blue 110-120.75 19-23 39.5-62.5 7 Orange 120.75-133.4 24-29 62.5-83 8 Green 133.4-146.5 30-36 83-107.5 ADJUSTED BROSELOW-LUTEN ZONES

18. Mathematical Accuracy of New Zones • Average variation from “rounded” Kg dosing for each zone or practical difference between per Kg and zone dosing: 4%

19. Standard Pediatric system PINK 6-7KG Gray Zones Gray 3kg RED 8-9KG Gray 4kg Gray 5kg PURPLE 10-11KG YELLOW 12-14KG Round to the nearest whole kilogram WHITE 15-18KG BLUE 19-23KG ORANGE 24-29KG GREEN 30-36KG

20. RAINBOW TAPE DRUGS and EQUIPMENT YELLOW

22. “Prescribing system” A standardized pre-calculated color-coding dosing system May be used in all therapeutic environments (not protocol driven) Two formats: 1) rainbow pages 2) rainbow stripes

23. Rainbow Page Format

31. Rainbow Stripe Format VENTILATION Parameters: FiO2 100%, PEEP 3 cm H2O, Inspiratory Time >0.6 sec, PIP 2030 cm H2O, Tidal Volume 10-15 mL/kg—Start low and increase to PIP 20-20 cm H2O ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN TIDAL VOLUME 60-100mL 75 - 125mL 100-150mL 125-200mL 150-250mL 200-300mL 250-400mL 350-500mL FREQUENCY(BPM) 20 - 25 20 - 25 15 - 25 15 - 25 15 - 25 12 - 20 12 - 20 12 - 20 FLUIDS ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN BOLUS ( mL) 130 170 210 260 325 420 530 660 MAINTENANCE (mL/hr) 28 35 40 45 55 65 70 75 MINIMUM HOURLY URINE OUTPUT (mL/hr) 7-14 9--18 10-20 13-25 16-32 20-40 25-50 35-65 NOTE: The 3, 4, 5 kg weights are not part of the color coded system.The following applies to these Patients : VENTILATION Rate same as pink and red, Tidal Volume, Fluid- 3kg 1/2 (50%) pink zone, 4kg 2/3(67%) pink zone, 5kg 3/4(75%) pink zone values.

32. Drug administration by protocol • Standardized Dosing • Medication ordering by Protocol … Guide or “Key Word” 3) Dose in mLs 4) Information organized by Point of care “Flow Guides”

33. Dosing by “Key word” Midazolam Induction Midazolam Sedation Diazepam- sedation IV Diazepam-Seizure IV* Diazepam-seizure-RECTAL Diphenhydramine IV Pancuronium Defasciculation Pancuronium Induction Pancuronium Maintenance Vancomycin IV Vancomycin

34. Protocol dosing in Guide Book Format

37. HYPERKALEMIA FLOW CHART Initial Stabilzation Give Calcium Chloride IV over 3-5 minutes, may repeat in 10 minutes Give Sodium Bicarbonate IV over 5-10 minutes First Line Drugs Give Glucose and Insulin IV over 30 minutes, may repeat immediately Ancillary Measure Albuterol neb Long term Preventive Kayexalate PO,NG, or PR

38. 12-14 kg YELLOW

39. EQUIPMENT ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN ET Tube(mm) 3.5 uncff 3.5 uncff 4.0 uncff 4.5 uncff 5.0 uncff 5.5 uncff 6.0 cuff 6.5 cuff Lip-Tip (cm) 10 - 10.5 10 - 10.5 11 - 12 12.5-13.5 14- 5 15.5-16.5 17-18 18.5-19.5 Suction 8F 8F 8 - 10F 10F 10F 10F 10F 12F L-Scope blade 1 straight 1 straight 1 straight 2 straight/ curved 2 straight/ curved 2 straight/ curved 2-3 straight/ curved 2-3straight/ curved Stylet 6F 6F 6F 6F 6F 14F 14F 14F Oral Airway 50 MM 50 MM 60 MM 60 MM 60 MM 70 MM 80 MM 80 MM NP Airway 14F 14F 18F 20F 22F 24F 26F 30F BVM INFANT INFANT CHILD CHILD CHILD CHILD CHILD/ ADULT ADULT ETCO2 PEDIATRIC/ DETECTOR PEDIATRIC/ DETECTOR PEDIATRIC/ DETECTOR PEDIATRIC/ DETECTOR ADULT/ DETECTOR ADULT/ DECTECTOR ADULT/ DETECTOR ADULT/ DETECTOR DEFIBRILLATION - CARDIOVERSION ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Defib (1stdose) 13j 17j 20j 26j 33j 42j 53j 66j Defib ( 2+ doses) 26j 34j 40j 52j 66j 84j 106j 132j Cardioversion 7j 8j 10j 13j 17j 21j 27j 33j NOTE: The 3, 4, 5 kg weights are not part of the color coded system.The following applies to these Patients : EQUIPMENT- same as pink and red. Defibrillation,Cardioversion 3kg 1/2 (50%) pink zone, 4kg 2/3(67%) pink zone, 5kg 3/4(75%) pink zone values.

40. COMMON ORAL MEDICATIONS (mLs) DRUG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Acetamin suspension 3.1 4 5 6.2 8 10 12.5 15 Acetamin drops 1 1.3 1.6 2 2.5 3.2 4 5 Ibuprofen suspension 3 4 5 6.5 8 10 13 16.5 Amoxicillin 125mg/5mL 3 4 5 6 8 10 13 16 Amoxicillin 250mg/5mL 1.5 2 2.5 3 4 5 6.5 8 Amoxicillin(HIGH DOSE)400mg/5mL 5.6 7.2 9.5 11 15 19 24 30 cefdinir 125mg/5mL 1.8 2.5 3 3.6 4.6 6 7.5 9.2

41. RSI FLOW CHART(Medications) Preparation Preoxygenation Zero minus 5-10min Zero minus 3min Zero Zero plus 45sec Lidocaine-RSI IV Fentanyl-RSI IV Atropine-RSI IV Pan/vecuronium-Defasiculation IV Pretreatment Paralytics Succinylcholine IV Rocuronium-Paralysis IV Pan/vecuronium-Paralysis IV Induction Agents Etomidate-Induction IV Ketamine Induction IV Midazolam-Induction IV Thiopental-Induction IV Propofol-Induction IV Paralysis/ Induction Placement Paralysis Maintenance Pan/Vec/Rocuronium-maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV, or other

42. RSI FLOW CHART Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min Zero minus 3min Zero Zero plus 45sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis/ Induction Placement Paralysis Maintenance Vecuronium maintenanceIV Post Intubation Management Sedation Maintenance Lorazepam IV

43. RSI FLOW CHART Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min Zero minus 3min Zero Zero plus 45sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis/ Induction Placement Paralysis Maintenance Vecuronium maintenanceIV Post Intubation Management Sedation Maintenance Lorazepam IV

44. RSI FLOW CHART Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min Zero minus 3min Zero Zero plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenanceIV Post Intubation Management Sedation Maintenance Lorazepam IV

45. RSI FLOW CHART Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min Zero minus 3min Zero Zero plus 45 sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Induction Agent Etomidate-Induction IV or Ketamine Induction IV Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Paralysis/ Induction Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV

46. RSI FLOW CHART Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min Zero minus 3min Zero Zero plus 45sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Induction Agent Etomidate-Induction IV or Ketamine Induction IV Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Paralysis/ Induction Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV

47. Putting it together 5 year old “Broselow Tape Red Zone” Hit on head with baseball bat Glasgow Coma score is 6 BP 130/100 pulse 90 Respirations 20 Needs airway management and is at risk for elevated ICP

48. RSI FLOW CHART Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min Zero minus 3min Zero Zero plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenanceIV Post Intubation Management Sedation Maintenance Lorazepam IV

49. RSI FLOW CHART Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min Zero minus 3min Zero Zero plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenanceIV Post Intubation Management Sedation Maintenance Lorazepam IV

50. Blue 19-24 KGS Pretreatment Medications