Guidelines Children's Hospital

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**Please be advised the Guidelines Medication Administration webpage has been modified. MC and CH guidelines are on different tabs

Approval and Review of Policies and Other Guiding Documents A-2 Policy and Flowchart

Jump to: NICU | Maternity | Pediatrics

For All

Anterior Mediastinal Mass Admission - 02/2024
c.Diff Testing – 06/2021 & Screening – 12/2021
Central Venous Access Device (CVAD) Maintenance – 04/2024
Central Venous Access (CVAD) - Associated Skin Impairment - 06/2024
Chest Tube Management - Pediatric – 05/2024
Compartment Syndromes: Guideline – 09/2021 & Management Algorithm – 09/2021
Coronavirus (COVID-19) Pathways
- COVID-19 Treatment Guidance in Pediatric Patients & MIS-C of Hospitalized Patients – 04/2024
- COVID-19 Guidance on Treatment Interventions - Adult - CH – 12/2022
- LLUH Outpatient Management of Pediatric Hematology, Oncology & SCT Patients previously known to be positive for COVID-19 or lives with a person positive for COVID-19 (Algorithm) – 04/2024
Determination of Pediatric Malnutrition Severity with One Data Point for Age 1 Month to 18 years – 02/2024
Diet: Advanced Diet as tolerated - 07/2022
Code/RRT
- Acute Coronary Syndrome Activation Guidelines (STEMI) – 10/2023
- Criteria for Calling OB/Neonatal/Fetal Rapid Response Team - 08/2023
- Difficult Airway Kit – 09/2020
- Emergency Resuscitation Dosage Guidelines –12/2023
- Malignant Hyperthermia Algorithm - CH – 10/2023
- Pediatric Acute Care Activation Guidelines For First Responder Escalation Team (FRET) Rapid Response Team (RTT) Code White Team – 04/2024
- Pediatric Trauma Team Activation Guidelines - 02/2024
- Rapid Response Team – CH Guideline Adult – 10/2021
- Ryanodex for Malignant Hyperthermia – 08/2021
- Stroke Algorithm - ED - CH – 06/2023
- Stroke Algorithm - Inpatient - CH – 06/2023
Emergency Department
- Peds ED Resuscitative Thoracotomy Guideline – 04/2022
- Solid Organ Injury Management Guideline – 10/2023
- Suspected Non-Accidental Trauma (NAT) Guideline - ED Specific – 09/2021
Extravasation
- Chemotherapy Extravasation Prevention & Treatment - CH – 08/2023
- Extravasation Prevention & Treatment Guidelines for Non-Pediatric Maternity Patients – 10/2023
- Infiltration & Extravasation Prevention and Treatment Guidelines for Pediatric Non-Hazardous Medication - 12/2023
Ideal Body Weight (IBW) Calculator – 02/2024
Infectious Diseases
- Acute Pancreatitis in the Pediatric Patient – Initial Management Guideline – 08/2023
- Antimicrobial Stewardship
  - Antibiogram
  - Antimicrobial Dosing and Administration for Surgical Prophylaxis – 03/2021
  - Antimicrobial Use - CH with Restricted Antimicrobial Use Guideline – 04/2024
  - LLUCH Antiretroviral Formulary - 05/2024
  - Management of Bacteremia by Verigene Rapid Diagnostic Test Result – 04/2024
  - Outpatient Pulmonary Exacerbation Antibiotic Treatment Guidelines in Children with Chronic Lung Disease on Home Mechanical Ventilation (HMV) - 06/2022
  - Pediatric Antimicrobial Renal Dosing Guidelines – 04/2024
  - Pediatric Vancomycin Dosing Protocol – 04/2023
  - Restricted Antimicrobial Use Guidelines Obstetrics (OB) Patients – 10/2023
  - Selected Antibiotic Activity Spectra Chart – 10/2023
- Mpox Treatment Guidance in Hospitalized Pediatric Patients (Age less than 18 years) - 04/2023
- MRSA Screening and Decolonization Algorithm for Adult and Pediatric Patients – 07/2022
- MRSA Screening and Decolonization Guideline for Adult and Pediatric Patients - 07/2022
- PICU-CTICU Blood Culture Algorithm - CH – 04/2024
- PICU-CTICU Blood Culture Guideline for Algorithm - CH – 04/2024
- Pneumonia Guidelines
  - Aspiration Pneumonia Algorithm – 10/2023
  - Complex Chronic Pneumonia Algorithm – 10/2023
  - Complicated Community-acquired Pneumonia Algorithm – 10/2023
  - Pediatric Identification Algorithm – 10/2023
  - Pleural Effusion Drainage Algorithm –10/2023
  - Simple Community-acquired Pneumonia Algorithm – 10/2023
- Sepsis
  - Rapid Antibiotic Administration for Sepsis - CH – 06/2023
  - Sepsis Treatment Pathway (Inpatient) - Peds – 04/2024
- Skin and Soft Tissue Infection Inpatient and Outpatient/ED (SSTI) Pathway – 05/2022
- Urinary Tract Infection (UTI) - 05/2024
Lab: Lab Specimen Requirements
Medications
- Apheresis Program and Use of Uvadex Guideline - LLUCH - 08/2021
- Commonly Used Medical and Diagnostic Dyes in the OR – 02/2022
- Intravenous Medications Requiring Filtration - LLUCH – 05/2022
- IV Acetaminophen UseGuidelines - LLUCH – 06/2024
- IV Medication Administration - CH – 06/2023
- Ketamine for IM Sedation Guidelines (CCST Only) - 06/2024
- Ketamine IV for Procedural Sedation Guidelines – ADULT – 08/2023
- Ketamine Low Dose Infusion - CH – 06/2024
- Pediatric Diabetic Ketoacidosis (DKA) - 06/2024
- Medication Lists
  - AcuDose Overrideable Medication List - CH – 06/2023
  - Automatic Hard Stop Medication - CH – 08/2023
  - Filter Requirements for IV Administration - CH – 06/2022
  - Hazardous Medication List - CH – 02/2024
  - Look-Alike/Sound-Alike Medication List - CH – 08/2023
- Omegaven Use in Pediatrics Guideline – 07/2021
- PICU Emergency Pack – 08/2022
- Potassium Replacement: Pediatric Acute Care and Stepdown ICU – 06/2022
- Propofol for Moderate Sedation in Non-Intubated Maternity Patients (Non-Bronch/GI Procedures That Do Not Stimulate the Gag or Airway) - Adult (For Use with CCST Nursing only) – 12/2023
- Respiratory Conditions Antibiotic - Pediatric – 08/2015
- When to Draw Drug Levels - LLUCH – 08/2021
No One Dies Alone (NODA) Program Guidelines – 02/2024
Nutritional Services Trigger List - 01/2024
Ophthalmology: Globe Rupture – 02/2024
Pediatric Dobutamine Cardiac Stress Test with Cardiac Magnetic Resonance Imaging (MRI) Guideline – 04/2023
Provider Notification
- Physician Call Algorithm – 02/2024
- PICU-CTICU Physician Paging and BEEP Reference - LLUCH – 09/2021
Sitter Designation: Considerations, guideline, algorithm – 07/2017 to 05/2021
Transferring and Transitioning NICU Babies to Pediatrics - Guideline - 07/2023
Vascular Access
- Analgesia for Needle-Based Procedures Guideline – 08/2021
- Vascular Access Planning - Pediatric – 08/2021

Neonatology

Cardiac
- NICU and CTICU Shared Management of Congenital Heart Disease (CHD) Algorithm – 11/2022
- PDA Treatment Guideline Infants Less Than 29 Weeks – 04/2022
Checklists
- Checklist for Pre- & Post-Op Care of Myelomeningocele – 04/2024
- Checklist for Pre- & Post-Op Care for VPS-VSGS-EVD Procedures – 06/2024
Diet
- Advanced Diet as Tolerated for Infants to Receive Regular Formula or Breast Milk – 07/2023
- Enteral Feeding Guidelines for Post-op Pediatric Surgery Neonates (Surgical Neonate Feeding Protocol) – 10/2021
- Human Milk (EBM- Expressed Breast Milk) Analysis – NICU Guideline – 12/2021
- Premature and Neonatal Malnutrition Criteria – 06/2022
Emergency
- Criteria for Calling OB/Neonatal/Fetal Rapid Response Team - 07/2021
Guidelines for Screening & Management of Neonatal Hyperbilirubinemia - 12/2023
NICU Diaper Care Guidelines - CH – 08/2023
NICU Hyperammonemia Emergency Care (HEC) Checklist – 05/2021
NICU Hyperammonemia Emergency Care (HEC) Guideline - Pre-Arrival – 05/2021
NICU Late Onset Sepsis (LOS) Evaluation Algorithm - 12/2023
NICU Management of Newborns Affected by Propionic Acidemia Guideline – 06/2021
NICU Necrotizing Enterocolitis (NEC) Management Guideline – 09/2021
NICU Therapeutic Hypothermia Guideline - CH – 06/2021
NICU Therapeutic Hypothermia Guideline (Cooling Guideline) – 04/2021
Neonate Hyperammonemia Algorithm – 05/2021
Neonatal Vascular Access Planning Guidelines – 05/2023
Pain
- Clinical for Pain Management - NICU – 12/2021
Respiratory
- NICU Approach to Vapotherm Algorithm – 04/2024
- NICU-TBU Ventilator Management for Extremely Low Birth Weight Guideline – 09/2023
- NICU Ventilator Weaning Protocol ≥ 1,000 g – 04/2024
Standard NICU Antibiotic Treatment for Patients With (Gastroschesis and SB Atresia Antibiotic Guidelines – 05/2021
Transitional Care of the Late Preterm and SGA Infants - 08/2022
Withdrawal of Life Sustaining Treatment - NICU – 12/2021

Pediatrics

Agitation
- Alcohol Withdrawal Syndrome (AWS) CIWA - Pediatric Guideline - 12/2023
- Initial Treatment of Agitation in a Pediatric Patient Algorithm – 04/2023
- Withdrawal Minimization Guideline (WMG) – 04/2024
Anticoagulation
- Anticoagulation Guidelines for Neuraxial Procedures – Non OB – 12/2022
- Anticoagulation Reversal for Serious or Life Threatening Active Bleeding - CH – 12/2023
- Enoxaparin Guidelines - CH Pediatric Inpatient – 04/2023
- Inpatient Heparin Infusion Guidelines - Adult Sized Pediatric Patients – 12/2023
- Inpatient Heparin Infusion Guidelines - Pediatric – 02/2024
- Vitamin K Administration for Elevated INR - CH – 10/2022
- Warfarin - Adult Inpatient - CH – 12/2023
- Warfarin - Pediatric Inpatient - CH – 12/2023
Cardiac ICU
- Aortopulmonary Shunt Anticoagulation Algorithm – CH Cardiac Intensive Care Unit – 06/2024
- Bivalirudin (Angiomax) Reference Sheet – 08/2022
- Cardiac Surgical Feeding Guideline: Mildly Abnormal Cardiac GI Function (Surgical Patients) – 10/2023
- Cardiac Surgical Feeding Guideline: Moderate-Severe Cardiac Lesion or Very Compromised GI Function (Surgical Patients) – 10/2023
- Cardioprotective Electrolytes Replacement Guidelines (5800 only) – 04/2024
- Congenital Heart Disease PICC Placement Guidelines – 11/2023
- CVICU Enteral Potassium Chloride Replacement Guidelines – 12/2023
- CVICU Intravenous Potassium Chloride Replacement – 12/2023
- High Risk Critical Cardiac Kid (CCK) Initial Management Algorithm – 10/2023
- Intravenous Treprostinil (Remodulin) Dosing and Titration Guidelines – 12/2023
- Management of Post-Operative Chylothorax – 06/2024
- Pediatric Cardiac Admission Guideline - CH – 04/2024
- Post-Op Anticoagulation for Aortopulmonary (BT) Shunts – 04/2021
- Prosthetic Valve Anticoagulation Guidelines – 10/2023
- Pulmonary Embolism: Evaluation and Initial Management (Pediatric Critical Care) – 10/2022
- Pulmonary Hypertension Guideline LLU NEO PEDS PH REQS – 12/2022
- Umbilical Arterial Catheter Guidelines for Patients with Congenital Heart Disease Algorithm – 08/2023
- Umbilical Arterial Catheter Guidelines for Patients with Congenital Heart Disease Guideline – 08/2023
Cardiology
- Evaluation & Treatment of Suspected Myocarditis Guideline – 06/2021
- Medical Stabilization for Severe Malnutrition with Bradycardia: Re-feeding for Patients 10 years – 08/2022
Diabetes
- Outpatient Guidelines for Pediatric Patients with Diabetes Considered High Risk – 07/2023
Diet
- Advance Diet for Adult/Peds – 07/2022
HemOnc
ICU
- ECMO: Centrifugal Pump ECMO Anticoagulation Guideline – 08/2021
- ECMO: Guidelines for Pediatric ECMO Circuit Medication Administration – 08/2023
- Post Cardiac Arrest Care of Infants and Children: PICU and PCICU Clinical Guideline – 06/2023
- Potassium Replacement: PICU – 04/2024
- Standard Titration for Intravenous Infusions - CH – 08/2023
- Total Parenteral Nutrition for Pediatric Intensive Care Units Guideline – 08/2022
- Withdrawal of Life-Sustaining Treatments for Actively Dying Patients in Pediatric ICU – 12/2022
Neurosurgery
- Cervical Spine Clearance Algorithm – 10/2023
- Intracranial Pressure Management Guideline – 12/2023
- Isolated Linear Closed Skull Fracture Guideline – 04/2024
- Severe Traumatic Brain Injury (TBI) Guideline – 10/2023
Neurology
- Epilepsy Monitoring Unit (EMU) Event Assessment Form – 12/2022
- Epilepsy Monitoring Unit (EMU) Guidelines – 12/2022
- Evaluation and Management of Acquired Demyelinating Disease Guideline – 12/2022
- Evaluation and Management of Suspected Autoimmune Encephalitis Guideline – 12/2023
- Guideline for Activating STAT Video EEG After 10 PM – 04/2023
- High Dose DHE Treatment Guideline – 07/2023
- Intranasal Midazolam Guidelines for ED – 06/2024
- PICU Brain Death Huddle Checklist and Brain Death Steps – 04/2024
- Status Epilepticus - Generalized - Algorithm – 06/2023
- Status Epilepticus-Generalized – Guideline – 06/2023
Respiratory
- Assessment for Airway Management Algorithm (Extubation or Intubation) – 09/2020
- Asthma - Pediatric
  - Albuterol Guidelines
    - Asthma Care Path Click-through Guide - Pediatrics – 09/2021
    - Asthma Continuous Albuterol Escalation Guideline – 02/2024
    - Asthma Continuous Albuterol Weaning - 02/2024
    - Asthma Intermittent Albuterol Guideline – 02/2024
    - Inhaled Halogenated Anesthetics For Status Asthmaticus - PICU – 08/2023
    - Humidified High Flow Nasal Cannula Weaning with Continuous Albuterol/Xopenex Guideline – 02/2024
  - ONLY for Albuterol Shortages use Levalbuterol Guidelines
    - Asthma Continuous Levalbuterol Escalation Alternative Guideline – 02/2024
    - Asthma Continuous Levalbuterol Weaning Alternative Guideline – 02/2024
    - Asthma Intermittent Levalbuterol Alternative Guideline – 02/2024
- Guidelines for holding intubated and mechanically ventilated patients in Pediatric Critical Care Units (PICU/Unit 5700 and Cardiac PICU/Unit 5800) “Held By Parents/Caregivers While Intubated” – 05/2024
- Humidified Highflow Nasal Cannula (HHFNC) – 02/2024
- Inhaled Nitric Oxide (iNO) Guidelines – 10/2023
- Inpatient Bronchiolitis Guideline – 06/2022
- Low-Flow Oxygen Wean Guideline Standing Guideline for Nurses and Respiratory Care Providers – 08/2021
- PICU/CTICU Patient Extubation Checklist – 08/2021
- PICU-CTICU Patient Intubation Checklist Huddle Form – 07/2021
- Pleural Effusion Drainage Algorithm – 10/2023
- Stepdown ICU Ventilator BiPAP CPAP Admission-Management - CH - 12/2023
- Pneumonia Guidelines
  - Aspiration Pneumonia Algorithm – 10/2023
  - Complex Chronic Pneumonia Algorithm – 10/2023
  - Complicated Community-acquired Pneumonia Algorithm – 10/2023
  - Pediatric Identification Algorithm – 10/2023
  - Pleural Effusion Drainage Algorithm –10/2023
  - Simple Community-acquired Pneumonia Algorithm – 10/2023
- Ventilator Wean & ERT Guideline - LLUCH - Algorithm – 12/2023
- Ventilator Weaning & Extubation Readiness Guideline - LLUCH – 12/2023

Maternity

Codes/RRT
- Criteria for Calling OB/Neonatal/Fetal Rapid Response Team - 07/2021
- OB NICU Code RRT Activation Algorithm – 04/2024
General
- Anticoagulation Guidelines For Neuraxial Procedures at LLUCH – Obstetrics – 04/2023
- Diabetic Ketoacidosis In Pregnancy - CH – 04/2023
- Guideline for Opioid Use Disorder in Hospitalized Obstetric Patients – 10/2023
- Intensivist Caring for the Pregnant Patient - Tip Sheet – 03/2022
- Intrapartum Management of Women on Buprenorphine Guideline - 12/2023
- Maternal Early Warning System (MEWS) OB Guideline – 05/2021
- Maternal Sepsis – CH – 06/2022
- Maternal Vancomycin Dosing for Prevention of Group B Streptococcal – 10/2023
- OB Hemorrhage Guideline – 04/2024
- Obstetric Checklist for Maternal Substance Use Disorder (SUD) Patients – 10/2023
- Obstetric Toxicology Testing Standards and Guidelines – 09/2023
- Preeclampsia Protocol Identification and Treatment Algorithm – 06/2024
- Respiratory Failure in Pregnancy Management Guideline – 10/2023
- Trauma Informed Care - Obstetric Guidelines – 09/2023
Newborn
- Blood Glucose Guideline – Infants Born at 35 0/7 to 36 6/7 Weeks GA – Maternity Services – 03/2021
- Maternity Services Bedside Phototherapy Guideline – 08/2023
OB ED/Triage
- Cervical Ripening, Outpatient - 12/2022
- First Trimester Bleeding Evaluation and Ectopic Pregnancy Management – 12/2023
- Maternal Services Abdominal Pain Algorithm – 10/2023
- Maternal Services Chest Pain – 10/2023
- Maternal Services Decreased Fetal Movement – 08/2023
- Maternal Services Headache Algorithm – 10/2023
- Maternal Services Nausea and Vomiting Algorithm – 10/2023
- Maternal Services Preterm Labor Algorithm – 10/2023
- Maternal Services Preterm Premature Rupture of Membranes Algorithm – 10/2023
- Maternal Services Shortness of Breath Algorithm – 10/2023
- Maternal Services Term Labor Algorithm – 10/2023
- Minor Trauma Algorithm – Maternity Services – 08/2023
- Term Spontaneous Rupture of Membranes (SROM) Algorithm – 08/2023
- Vaginal Bleeding Algorithm – Maternity Services – 08/2023

For changes to Guidelines on this page, please contact

Children’s Hospital, Patricia Turrisi (x88111) and Rikki Tambunan (x55670), Christina Ramos (x14935), and Julie Fluitt (x87483)

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