Color Coding Kids: The Broselow-Luten System.

Color Coding Kids:The Broselow-Luten System

Institute of Medicine Report

Deaths: 44,000 to 98,000

Cost: 17 to 29 Billion Dollars

Lesar study

Medication error rate in tertiary care center

– Greatest areasPediatrics

Emergency Department

– Pediatrics: reliance on dosage equations was major cause of error

Kaushal JAMA Study 4/01

Included major Children’s Hospital

5.7% of orders had medication errors

Dosing error most prevalent category

Institute for Safe Medication Practices (ISMP)Pediatric Pharmacy Advocacy Group (PPAG)

– “Pediatric patients need more protection from medication errors, survey shows”

Two Key Pediatric Error Issues

1) Dependence upon calculations

2) Lack of familiarity with normal vs. abnormal

1993 1995

Number 34 30

Greater than1 error 19 9

Ten fold errors 3 4

Didn’t recognize errors

ICU Patients 10 drugs orders per day.

Could translate to one 10-fold error for each 10 infants

Recognizing normal

Even The Cleaning lady would know!!

“Too many amps in the trash”

Which dose is 10 times error?

ADJUSTED BROSELOW-LUTEN ZONES

Zone CM Length Wt in KgAge in months

1 Pink 59.5-66.5 6-7 2-52 Red 66.5-74 8-9 5-113 Purple 74-84.5 10-11 11-194 Yellow 84.5-97.5 12-14 19-305 White 97.5-110 15-18 30-39.56 Blue 110-120.75 19-23 39.5-62.57 Orange 120.75-133.4 24-29 62.5-838 Green 133.4-146.5 30-36 83-107.5

Mathematical Accuracy of New Zones

Average variation from “rounded” Kg dosing for each zone or practical difference between per Kg and zone dosing: 4%

RED

PURPLE

YELLOW

WHITE

ORANGE

GREEN

BLUE

PINK 6-7KG

8-9KG

10-11KG

12-14KG

15-18KG

19-23KG

24-29KG

30-36KG

Standard Pediatric system

Gray 3kgGray 4kgGray 5kg

Gray Zones

Round to the nearest whole kilogram

RAINBOW TAPE

YELLOW

DRUGS and EQUIPMENT

“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

Rainbow Page Format

Rainbow Stripe Format

TIDAL VOLUME 60-100mL 75 - 125mL 100-150mL 125-200mL 150-250mL 200-300mL 250-400mL 350-500mL

VENTILATION

FREQUENCY(BPM) 20 - 25 20 - 25 15 - 25 15 - 25 15 - 25 12 - 20 12 - 20 12 - 20

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

BOLUS ( mL) 130 170 210 260 325 420 530 660

FLUIDS

MAINTENANCE (mL/hr) 28 35 40 45 55 65 70 75

ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN


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.

Drug administration by protocol

1)Standardized Dosing2)Medication ordering by

Protocol … Guide or “Key Word”3) Dose in mLs4) Information organized by Point of care “Flow Guides”

Dosing by “Key word”

Midazolam InductionMidazolam SedationDiazepam- sedation IV Diazepam-Seizure IV*Diazepam-seizure-RECTALDiphenhydramine IVPancuronium DefasciculationPancuronium InductionPancuronium MaintenanceVancomycin IVVancomycin

Protocol dosing in Guide Book Format

HYPERKALEMIA FLOW CHART

Give Calcium Chloride IV over 3-5 minutes, may repeat in 10 minutes

Albuterol neb

Initial Stabilzation

Initial Stabilzation

First LineDrugs

First LineDrugs

AncillaryMeasure

AncillaryMeasure

Long termPreventiveLong termPreventive

Give Sodium Bicarbonate IV over 5-10 minutes

Give Glucose and Insulin IV over 30 minutes, may repeat immediately

Kayexalate PO,NG, or PR

INSULIN DILUTIONPREPARATION

Add 1 mL(100 units) regular Insulin to 100 mL NS.Final concentration of

Insulin dilution= 1unit/mL

DEXTROSE IV

0.25 g/mL 26 mL

INSULIN IV

1.3 mL

13 mL 0.5g/mL (Dilute 1:1 with NS/D5W)

1 unit/mL as prepared above

CALCIUM CHLORIDE IV

100 mg/mL

GLUCAGON IV (IM,SC-see Alternative Routes section)

1 mg/mL 0.5 mL

CALCIUM GLUCONATE IV

100 mg/mL 13 mL

(Infuse over 3 minutes, may repeat in 10 minutes )

(Infuse over 3 minutes, may repeat in 10 minutes)

GLUCOSE AND INSULIN IV DRIP

+ 1.3 mL INSULIN

27.3 mL TOTAL

(Infuse TOTAL mLs over 30 minutes, may repeat in 30-60 minutes)

26 mL DEXTROSE

2.6 mL

YELLO

W

12-14 kg

ZONE3.5 uncff

10 - 10.5

8F

50 MM

4.5 uncff

12.5-13.5

10F

6F

60 MM

5.0 uncff

14- 5

10F

6F

60 MM

4.0 uncff

11 - 12

8 - 10F

6F

60 MM

5.5 uncff

15.5-16.5

10F

14F

70 MM

6.0 cuff

17-18

10F

14F

80 MM

6.5 cuff

18.5-19.5

12F

14F

80 MM

3.5 uncff

10 - 10.5

8F

6F

50 MM

PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN

1 straight2 straight/

curved2 straight/

curved1 straight

2 straight/curved

2-3 straight/curved

2-3straight/curved

1 straight

6F

ET Tube(mm)Lip-Tip (cm) Suction L-Scope bladeStylet Oral Airway

PEDIATRIC/DETECTOR

CHILD

PEDIATRIC/DETECTOR

CHILD

ADULT/DETECTOR

CHILD

PEDIATRIC/DETECTOR

CHILD

ADULT/DECTECTOR

CHILD/ADULTADULT/

DETECTOR

ADULT

ADULT/DETECTOR

INFANT

PEDIATRIC/DETECTOR

14F 20F 22F18F 24F 26F 30F14F

INFANT

NP Airway BVM ETCO2

EQUIPMENT

Defib (1stdose) 13j 17j 20j 26j 33j 42j 53j 66j

Cardioversion

26j 34j 40j 52j 66j 84j 106j 132j


7j 8j 10j 13j 17j 21j 27j 33j

DEFIBRILLATION - CARDIOVERSION

Defib ( 2+ doses)

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.

DRUG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN

5.6 7.2 9.5 11 15 19 24 30Amoxicillin

(HIGH DOSE)

400mg/5mL

1.5 2 2.5 3 4 5 6.5 8

Acetaminsuspension

3

3.1

4

4 5

6

6.2

8

8

10

10

13

12.5

16

15

5Amoxicillin125mg/5mL

Amoxicillin250mg/5mL

COMMON ORAL MEDICATIONS (mLs)

Acetamindrops 1 1.3 1.6 2 2.5 3.2 4 5

1.8 2.5 3.6 4.6 6 7.5 9.23cefdinir125mg/5mL

3 4 6.5 8 10 13 16.55 Ibuprofensuspension

RSI FLOW CHART(Medications)

Lidocaine-RSI IV Fentanyl-RSI IV Atropine-RSI IV Pan/vecuronium-Defasiculation IV

ParalyticsSuccinylcholine IVRocuronium-Paralysis IVPan/vecuronium-Paralysis IV

Induction Agents Etomidate-Induction IVKetamine Induction IVMidazolam-Induction IVThiopental-Induction IVPropofol-Induction IV

Paralysis MaintenancePan/Vec/Rocuronium-maintenance IV

Sedation MaintenanceLorazepam IV, or other

PreparationPreoxygenation


PretreatmentPretreatment

Paralysis/Induction

Paralysis/Induction

PlacementPlacement

Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec

Post IntubationManagement


Atropine-RSI/RESUS IV




Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec

ParalyticsSuccinylcholine IV, orRocuronium-Paralysis IV

Induction AgentEtomidate-Induction IV

Paralysis MaintenanceVecuronium maintenance IV

Sedation Maintenance Lorazepam IV

Paralysis/Induction

Paralysis/Induction

PlacementPlacement



K+ Risk +ICP Poor Perfusion AsthmaGen Sequence

RSI FLOW CHART




Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec

Paralysis/Induction

Paralysis/Induction

PlacementPlacement




ParalyticsRocuronium-Paralysis IV




+ICP Poor Perfusion AsthmaGen Sequence

RSI FLOW CHARTK+ Risk



Pretreatment*Pretreatment*

Paralysis/Induction

Paralysis/Induction

PlacementPlacement

Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec



Atropine-RSI/RESUS IVLidocaine-RSI IV



Paralysis Maintenance Vecuronium maintenance IV


K+ Risk Poor Perfusion AsthmaGen Sequence

RSI FLOW CHART+ICP





Zero minus5-10min

Zerominus3min

Zero

Zeroplus45 sec



Paralysis/Induction

Paralysis/Induction

PlacementPlacement




Induction AgentEtomidate-Induction IVorKetamine Induction IV

K+ Risk +ICP AsthmaGen Sequence

RSI FLOW CHARTPoor Perfusion





Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec


Induction AgentEtomidate-Induction IVorKetamine Induction IV



Paralysis/Induction

Paralysis/Induction

PlacementPlacement



K+ Risk +ICP Poor Perfusion AsthmaGen Sequence

RSI FLOW CHART

Putting it together

5 year old “Broselow Tape Red Zone”Hit on head with baseball bat

Glasgow Coma score is 6BP 130/100 pulse 90 Respirations

20

Needs airway management and is at risk for elevated ICP




Paralysis/Induction

Paralysis/Induction

PlacementPlacement

Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec









RSI FLOW CHART+ICP

Blue 19-24 KGS

ATROPINE

1m g/mL 0.42 mL

0.8mg/mL 0.53mL

20 mg/mL 1.6 mLFENTANY L –RSI IV

50 mcg/mL 1.3 mL

VECURONIUM-Defasiculation IV

1 mg/mL 0.2 mL

10 mg/mL 3.2 mLLIDOCAINE-RSI IV

ROCURONIUM –Defasiculation IV

2 mg/mL 0.1 mL

10 mg/mL 0. 2mL

0.4mg/mL 1 mL

PRE-TREATMENT MEDICATIONS

0.5mg/mL 0.84mL

0.05 mg/mL 8.4 mL

PANCURONIUM-Defasiculation IV

1 mg/mL 0.21 mL

0.1mg/mL 4.2 mL

(Give over 60-90 seconds)

Pretreatment Medications




Paralysis/Induction

Paralysis/Induction

PlacementPlacement

Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec









RSI FLOW CHART+ICP

ETOMIDATE- Induction IV

2m g/mL 3.2mL

50 mg/mL 0.84mL

MIDAZOLAM-Induction IV

1 mg/mL 6.3 mL

100 mg/mL 0.42 mLK ETAMINE-Induction IV

5 mg/mL 1.3 mL

10 mg/mL mL

INDUCTION AND PARALY TIC AGENTS

PROPOFOL-Induction IV

10 mg/mL 6.3 mL

10 mg/mL 4.2 mL

THIOPENTAL-Induction IV

25 mg/mL 3.4 mL50 mg/mL 1.7 mL

SUCCINY LCHOLINE

20 m g/mL 2 mL50 mg/mL 0.8 mL

100 mg/mL 0.42 mLVECURONIUM-Paralysis IV

1 mg/mL 0.2 mL

2 mg/mL 2.1 mL

PANCURONIUM-Paralysis IV

1 mg/mL 4.2 mL

ROCURONIUM-Paralysis IV

10 mg/mL 2.1 mL

Blue 19-24 KGS




Paralysis/Induction

Paralysis/Induction

PlacementPlacement

Zero minus5-10min

Zerominus3min

Zero

Zeroplus45sec









RSI FLOW CHART+ICP

VECURONIUM-Maintenance

1 mg/mL 2.1 mL

LOREZEPAM

2 mg/mL 0.5 mL4 mg/mL 0.25 mL

POST INTUBATION AGENTS

ROCURONIUM-Maintenance

10 mg/mL 0.21 mL

2 mg/mL 1 mL

PANCURONIUM-maintenance

1 mg/mL 2.1 mL

Blue 19-24 KGS

Post Intubation Agents

Are We " Dumbyfying" Medicine?

Math free algorithms enhance “critical thinking “

“Transparency” of critical decisions promotes team approach to error

reduction

Point of Care functional units

ALSRSIAnaphylaxisPain and SedationFluids and burnsWeapons of Mass destructionSeizures, electrolytes, etc

BURNS--------PINK

Body Surface Area Percentages for PINK zone

7%

4%

7%

3%

1) Determine % BSA of patient’s burn2) Refer to fluid charts for hourly rate for

patient’s burn

Front Back

Minimum Urine output 7-13 mL/hr

Morphine IV, IM 0.65-1.3mg

Demerol IV, IM 6.5mg

10%

%Burn

12mL/hr

RateFor 7 hrs

30% 36mL/hr40% 50mL/hr50% 60mL/hr

20% 25mL/hr

60% 70mL/hr

80% 96mL/hr90% 107mL/hr

70% 86mL/hr

Presentation1 hr post burn

2) Piggy Back Fluid (Maintenance D5W+1/4 NS) Presentation1hr Post Burn

Presentation2hr Post Burn



50mL/hrFor 7hrs

58mL/hr for6hrs

70mL/hrFor 5hrs

88mL/hrfor4hrs

1) Resuscitation Fluid (LR)

Presentation > 4hr Post Burn*If > 4 hr.s post burn, start fluids at 4hr post burn rate, treat shock with 20mL/kg fluid boluses, and consult burn center for further fluid guidelines

Presentation 2hr post burn



%Burn

RateFor 6 hrs

%Burn

RateFor 4 hrs

%Burn

RateFor 5 hrs

100% 120mL/hr

Rate for 7hrs Rate for 6 hrs Rate for 5 hrs Rate for 4 hrs

10% 21mL/hr

30% 63mL/hr40% 88mL/hr50% 106mL/hr

20% 44mL/hr

60% 125mL/hr

80% 170mL/hr90% 188mL/hr

70% 150mL/hr

100% 213mL/hr

10% 17mL/hr

30% 50mL/hr40% 70mL/hr50% 85mL/hr

20% 35mL/hr

60% 100mL/hr

80% 135mL/hr90% 150mL/hr

70% 120mL/hr

100% 170mL/hr

10% 14mL/hr

30% 42mL/hr40% 58mL/hr50% 70mL/hr

20% 29mL/hr

60% 83mL/hr

80% 113mL/hr90% 125mL/hr

70% 100mL/hr

100% 142mL/hr

Emergency infusions

Standard Pediatric System

Neonates

RED

PURPLE

YELLOW

WHITE

ORANGE

GREEN

BLUE

PINK 6-7KG

8-9KG

10-11KG

12-14KG

15-18KG

19-23KG

24-29KG

30-36KG

Standard Pediatric system

Gray 3kgGray 4kgGray 5kg

Gray Zones

RAINBOW TAPE

Purple

DRUGS and EQUIPMENT

mcg/kg/min2

mcg4

mcg6

mcg8

mcg10

mcg12

mcg14

mcg16

mcg18

mcg20

mcg0.8mL

1.6mL

2.4mL

3.2mL

4mL

4.7mL

5.5mL

6.3mL

7mL

8mL

PURPLE 10-11KG

mLs/hour

Maintenance Fluids

42 mLs/hr #1Dopamine 1600 micrograms/mL

B-L Concentration

Infusion bag label applied by pharmacist

# 1

B-L Concentration

Dopamine 6400 Micrograms/mL

Infusion bag label from pharmacy or manufacturer

mcg/kg/min2

mcg4

mcg6

mcg8

mcg10

mcg12

mcg14

mcg16

mcg18

mcg20

mcg0.8mL

1.6mL

2.4mL

3.2mL

4mL

4.7mL

5.5mL

6.3mL

7mL

8mL

PURPLE 10-11KG

mLs/hour

Maintenance Fluids


B-L Concentration

Infusion bag label applied by pharmacist

Newborn System

Pink

Miceronates(up to 1 Kg)

Red Blue

Purple Orange

White

Yellow Green

Pink

Red

Blue

Purple

yellow

White

Green

Orange

Elefants (1Kg to 4.5 Kg)

Pink1001-1250 GMS

Red 1251-1500 GMS

Blue 2501-3000 GMS

Purple 1501-1750 GMS

Yellow 1751-2000 GMS

White 2001-2500 GMS

Green3751-4500 GMS

Orange 30001-3750

Elefants

mcg/kg/min2

mcg4

mcg6

mcg8

mcg10

mcg12

mcg14

mcg16

mcg18

mcg20

mcg0.2mL

0.4mL

0.8mL

1mL

1.4mL

1.8mL

2.2mL

2.6mL

3mL

3.6mL

mLs/hour

Maintenance Fluids


B-L Concentration

Blue 2501-3000 GMS

Newborn infusion sticker

Miceronates

Pink501-550 GMS

Red551-600 GMS

Blue751-800 GMS

Purple601-650 GMS

Yellow651-700 GMS

White701-750 GMS

Orange801-900 GMS

Green901-1000 GMs

# 2

B-L Concentration

Dopamine 6400 Micrograms/mL

Infusion bag label from pharmacy or manufacturer

mcg/kg/min2

mcg4

mcg6

mcg8

mcg10

mcg12

mcg14

mcg16

mcg18

mcg20

mcg0.2mL

0.4mL

0.8mL

1mL

1.4mL

1.8mL

2.2mL

2.6mL

3mL

3.6mL

mLs/hour

Maintenance Fluids


B-L Concentration

Pink501-550 GMS


mcg/kg/min2

mcg4

mcg6

mcg8

mcg10

mcg12

mcg14

mcg16

mcg18

mcg20

mcg0.2mL

0.4mL

0.8mL

1mL

1.4mL

1.8mL

2.2mL

2.6mL

3mL

3.6mL

mLs/hour

Maintenance Fluids


B-L Concentration

Blue


Purple10-11KG 8 %

Broselow-Luten color Per Cent of maintenance Fluid requirements

Scroll barScroll bar

4

mLs/Hour

StandardPediatric

Scroll may be used to set infusion to maintenance, twice maintenance, etc

Scroll may be used to set infusion To Broselow-Luten color

Select BL System

Infusion pump windowTo be used in coordination with infusion label

10 %



2

mLs/Hour

StandardPediatric



Blue 2501-3000 GMS

Select BL System


15%



1.5

mLs/Hour

StandardPediatric


Pink501-550 GMS


Select BL System


Computer Based

Computer Based Approach

DRUG NAME

DRUG NAME

Pancuronium

PINK

RED

PURPLE

YELLOW

WHITE

BLUE

ORANGE

GREEN

Paralyzing

Defasiculation

Maintenance

1mg/mLconcentration

2mg/mLconcentration

COLOR INDICATION CONCENTRATION

Pancuronium

PURPLE 2mg

Paralyzing

Defasiculation

Maintenance

Pancuronium

1mg/mLconcentration

2mL

RED 1.7mL 1.7mg

Paralyzing

Defasiculation

Maintenance

Pancuronium

1mg/mLconcentration

BLUE 4.2mL 4.2mg

Paralyzing

Defasiculation

Maintenance

Pancuronium

1mg/mLconcentration

ORANGE 5.3mL 5.3mg

Paralyzing

Defasiculation

Maintenance

Pancuronium

mg/mLconcentration

Setting a New Standard

November 26, 2001 3:03:00 PM ET

CHICAGO--(BW HealthWire)--Nov. 26, 2001--

Color Coding for Kids to Provide Easy Reference Guidelines for Hospitals and Help Reduce CT Radiation for Children

GE Medical Systems, a unit of the General Electric Corporation (GE: NYSE), has signed an agreement that will allow GE to apply the Broselow-Luten Pediatric System, commonly known as Color Coding for Kids, to all of its medical imaging and patient information systems. The results of this agreement could positively impact millions of pediatric patients in the years to come.

Jerome Medical

Addressing pediatric issues of airways management and spinal alignment

P1 Collar (Ages 0-2 yrs.)

P2 Collar(Ages 2-6 yrs.)


Adult(Ages > 12 yrs.)

Kids vs. AdultsOccipital Angle

P1 Collar (Ages 0-2 yrs.)



Adult(Ages > 12 yrs.)

Kids vs. AdultsNeck Length

Importance of Alignment:

Always raise the child's thorax with the appropriate height padding to accommodate the occipital prominence and to maintain c-spine alignment and open airway with or without collar.

Potential for color-coding

Unit dosing and packaging of Pediatric drugs (associated cost savings)Defibrillator settingsInfusion PumpsRespiratorsComputer order entryCar Restraints

Error Prevention for the Public

OTC Medications

Color

“A Universal Language”

Color Coding Kids: The Broselow-Luten System.

Documents

Transcript of Color Coding Kids: The Broselow-Luten System.