In discussion with your local PICU you have decided you are going to have to intubate the septic 11 month old in front of you. You know what you need; a fluid bolus, an adrenaline infusion, then a little bit of ketamine and some rocuronium, with push dose adrenaline on the side just in case. You have already given antibiotics but you will need a morphine and midazolam infusion for sedation once the tube is in. It’s been a while since the last paediatric resus on this scale but you can’t just prescribe “some” adrenaline, the drug nurse wants a dose, a concentration and a rate for the infusion. You pull out your phone and hope you can remember which app to look for, while a colleague starts searching the intranet for the local guideline.
As part of my day job I am lucky enough to resuscitate the simulated version of patients like this in hospitals all over Queensland and the single most common difficulty we come across is in prescribing and making up infusions for sick kids. Hospitals that have a standard agreed resource make this aspect of resuscitation look noticeably easier than those that don’t.
One resource that features widely in Australia is the “Monash book” edited by Simon Craig and Nicole Dirnbauer, the second edition of which has just been released. The format retains the same practicality that made the first one so popular. It is spiral bound so stays open on the page you want it, its laminated so compatible with any kind of Alcowipe and the layout is standard throughout the book, all you need to do to use it is open the book to the page that matches the weight of the child you are looking after.
There are quite a few really thoughtful inclusions; there is now a weight for age reference table on the front cover and several APLS guidelines are included at the front of the book. Doses have been added for adrenaline nebs in croup and TXA and blood products in haemorrhage. The rate of phenytoin administration has been increased to match the 20 mins over which it would normally be given in status epilepticus and the dose of Keppra has been adjusted to match the 40mg/kg used in ConSEPT (which should be published later this year). An algorithm for acute behavioral disturbance appears at the front as do some options for procedural sedation complete with sensible suggestions for minimum ages. Though doses for drugs that some consider too dangerous for ED use in small children such as propofol do appear, they come with an appropriate warning.
Designers of resources like this should ask themselves not “what more could be added?” but “what else could be taken away?” On this front the authors have done well. There are more paralytics than most emergency physicians are likely to need and more push dose pressors than I am likely to use but the vast majority of entries deserve their place and it is nice to see the 1mcg/kg adrenaline bolus published in a respectable resource.
The biggest problem I can see people having with this book in my corner of the world is the use of variable dose infusions. Queensland (and my hospital in particular) is quite attached to standardized concentrations of drugs in the infusions we use. The second edition of the Monash book has gone with variable concentrations and it still seems a bit odd to me to give phenytoin undiluted but the authors do have a rationale for both these recommendations.
Every hospital that may have to provide resuscitative care for a child should have a single preferred resource for drug dosing covering both bolus and infusion doses of commonly required medications. Do you know what yours is? Having one that everyone is familiar with and practices with is more important than the specifics of which one you have. If your hospital does not currently have one you should look seriously at the Monash book.
More information including some downloadable sample pages and details on how to order copies of the book can be found at https://monashchildrenshospital.org/for-health-professionals/resources/ Simon will be talking about the development of this edition of the book at DFTB18 in Melbourne in August.
Disclaimer – the publishers sent us a complimentary copy of the book but have not seen or altered this review prior to publication.