*Please fax your order to 515-241-6732*

Neonatal and Pediatric Order Form

For more information contact:

Jessica Dinh, RN, BSN

Pediatric Simulation Educator

515-241-3537

IV SUPPLIES

Infant and Pediatric

Quantity / Item /

Qty Sent

Infant Mini IV Arm Board (1-1/2 x 4)
Pediatric IV Arm Board (2 x 6)
IV Arm Board (3-1/2 x 9)
IV House (infant)
IV House (child)

Miscellaneous IV/IO Supplies

Quantity / Item /

Qty Sent

24 Gauge IV catheters

15 Gauge Intraosseous Needle

18 Gauge Intraosseous Needle
7” IV Extension Set with Adapter
Triple Lumen IV Extension Set
Minibore IV Extension Set
Hy-Tape
Fluid Dispensing Connector

IV Fluids

Quantity / Item /

Qty Sent

Normal Saline IV Solution 250 ml
D10W IV Solution 250 ml

UMBILICAL LINE SUPPLIES

Quantity / Item /

Qty Sent

3.5 Fr. Single Lumen Umbilical catheter
5 Fr. Single Lumen Umbilical catheter
3.5 Fr. Dual lumen umbilical catheter
5 Fr. Dual lumen umbilical catheter
Umbilical vessel procedure tray
Umbilical Cord Clamp

AIRWAY SUPPLIES

Infant/ Pediatric

Quantity / Item /

Qty Sent

Neonatal Resuscitation mask
Infant Resuscitation mask
Toddler Resuscitation Mask
Child Resuscitation Mask
Infant Disposable Ambu Bag (includes infant mask)
Pediatric Disposable Ambu Bag (includes child mask)
Nebulizer Tubing and Pediatric Aerosol Mask
Infant Simple Mask
Pediatric Simple Mask
Pediatric Non-Rebreather
Infant Nasal Cannula
Pediatric Nasal Cannula
Anesthesia Bag 1 L
Infant RAM Cannula (comes with 1 anesthesia bag) for infants >2500 grams

Oral Airway

Quantity / Item /

Qty Sent

Oral Airway 4 cm
Oral Airway 6 cm (small child)
Oral Airway 8 cm (child)
Laryngeal Mask Airway #1
½ Cobra PLA

Nasopharyngeal Airway

Quantity / Item /

Qty Sent

Nasopharyngeal Airway 12 FR
Nasopharyngeal Airway 14 FR
Nasopharyngeal Airway 16 FR
Nasopharyngeal Airway 18 FR
Nasopharyngeal Airway 20 FR

ETT

Quantity / Item /

Qty Sent

2.5 mm Endotracheal tube (uncuffed)
3.0 mm Endotracheal tube (uncuffed)
3.5 mm Endotracheal tube (uncuffed)
4.0 mm Endotracheal tube (uncuffed)
4.5 mm Endotracheal Tube (uncuffed)
5.0 mm Endotracheal Tube (uncuffed)
Endotracheal tube holder
Endotracheal tube stylet (for ETT sizes 2.0-3.5)
Pedi Caps- CO2 Detector

SUCTION SUPPLIES

Quantity / Item /

Qty Sent

Preemie Nasal Aspirator
Nasal Aspirator
6 Fr. Suction catheter
8 Fr. Suction catheter
10 Fr Suction Catheter Kit
12 Fr Suction Catheter Kit
Pediatric Yankauer Suction Tip
Meconium Suctioning Device

CHEST TUBE SUPPLIES

Quantity / Item /

Qty Sent

10 Fr. Chest tube
12 Fr. Chest tube
16 Fr Trocar Chest Tube
20 Fr Trocar Chest Tube
24 Fr Trocar Chest Tube
28 Fr Trocar Chest Tube
Pleurovac for chest tube

FEEDING TUBES & NG TUBES

Quantity / Item /

Qty Sent

5 Fr Feeding Tube
8 Fr Feeding Tube
8 Fr Replogle Suction Catheter
10 Fr Replogle Suction Catheter
12 Fr Salem Sump NG Tube
14 Fr Salem Sump NG Tube
16 Fr Salem Sump NG Tube
18 Fr Salem Sump NG Tube

FOLEY(URINARY) CATHETERS

Quantity / Item /

Qty Sent

8 Fr 3 cc Foley Catheter
10 Fr 3 cc Foley Catheter
12 Fr 5 cc Foley Catheter
14 Fr 3 cc Foley Catheter
5 Fr Pedi Catheter Kit
8 Fr Pedi Catheter Kit

C COLLARS

Quantity / Item /

Qty Sent

C-Collar No-Neck 2”
C-Collar Pediatric 3”

MISCELLANEOUS

Quantity / Item /

Qty Sent

Neonatal Massimo Pulse Oximeter Probe
Infant EKG Electrode
Preemie Pacifiers Soothies
Newborn UA Bags

Central Iowa Hospital Corporation d/b/a Blank Children’s Hospital does not warrant the medical supplies and equipment supplied pursuant to this order form for merchantability and fitness for a particular purpose. Furthermore, Central Iowa Hospital Corporation d/b/a Blank Children’s Hospital does not warrant the products to be free from defects and shall not be responsible for any defects in quality and workmanship or inappropriate usage.

______hereby releases Central Iowa Hospital Corporation d/b/a Blank Children’s Hospital, their officers, directors, employees and agents from any and all liability associated with the supply, storage or usage of these products.

______

Signature

______

Title

______

Date

Information belowmust be completed for proper shipment and data collection:

Email Address ______

Contact Person ______Phone (______) ______

Name of Hospital/EMS______

Shipping Address______

City______County______State______Zip ______