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Slemani Pediatric Teaching Hospital

Guidelines
2014-2015

Contents
Acute liver failure ................................................................................. 1
Anaphylaxis........................................................................................... 7
Arrhythmias ........................................................................................ 14
Asthma................................................................................................ 21
Bronchial foreign body aspiration ...................................................... 23
Croup .................................................................................................. 31
Dehydration ........................................................................................ 35
Diabetes mellitus, preoperative preparation in ................................. 43
Diabetic ketoacidosis .......................................................................... 53
Febrile seizures ................................................................................... 56
G6PD deficiency.................................................................................. 58
Heart failure........................................................................................ 59
Hypoglycemia ..................................................................................... 60
NG tube insertion ............................................................................... 61
Poisoning ............................................................................................ 63
Scorpion envenoming ......................................................................... 71
Sepsis .................................................................................................. 74
Status epilepticus ............................................................................... 78
Transfusion ......................................................................................... 80

Acute liver failure


Definition
1. Evidence of liver dysfunction within 8 wk of onset of
symptoms.
2. Uncorrectable coagulopathy (6-8 hr after administration of
one dose of parentral vitamin K) with INR >1.5 in a patient
with hepatic encephalopathy, or INR > 2 in a patient without
encephalopathy.
3. No evidence of chronic liver disease either at presentation or
in the past.
Staging
1. Grade I and II: are indistinguishable, with clinical features of
inconsolable crying, inattension to task, with normal or
exaggerated deep tendon reflexes.
2. Grade III: somnolence, stupor, combativeness and
hyperreflexia.
3. Grade IV: comatose, arousable with painful stimuli (IVa) or no
response (IVb) with absent reflexes and decerebration or
decortication.
General work-up
1. Blood urea, serum creatinine, serum electrolytes
2. ALT, AST, GGT, alkaline phosphatase, total and conjugated
bilirubin, PT, PTT, INR, blood group
3. Blood and urine culture, CXR

4. Arterial blood gas, lactate, lactate dehydrogenase, blood


ammonia, urine for reducing substance, serum alpha
fetoprotein
Management
Ensure a quiet environment to avoid unnecessary stimulation
from visitors, television or hospital personnel that can aggravate
encephalopathy and increase intracranial pressure.
Monitoring of vital signs, including blood pressure every 4 hours
(more frequently in unstable patients), and continuous oxygen
saturation monitoring.
Neurological
observation/coma
grading,
and
checking
electrolytes, arterial blood gases, and blood sugar every 12 hr
(more frequently in an unstable patients). Input and output
should be strictly monitored.
Fluid restriction to 70% of maintenance to reduce cerebral edema
and prevent encephalopathy. Fluid should be glucose-based with
glucose infusion rate of at least 4-6 mg/kg/min and titrated as per
requirement.
N-acetylcysteine
Administer 100 mg/kg PO daily.
Lactulose
1. Infants: 2.5-10 mL/day PO in divided doses three to four
times a day
2. Children: 40-90 mL/day PO in divided doses three to four
times a day.

3. Adolescents: 30-45 mL PO three to four times a day.


Give dose initially every hour until first stool is passed then titrate
dose to achieve 2-3 soft stools/day. Assess patient regularly for
abdominal distension and intravascular depletion. Excessive use
of lactulose places the patient at increased risk for pneumatosis
intestinalis.
Prophylactic PPI or H2 blocker
1. Ranitidine 3 mg/kg/day IV 8-hourly
2. Cimetidine 10-20 mg/kg/day IV 6-12 hourly
3. Omeprazole 2 mg/kg once daily (max. 40mg) by IV infusion
Raised ICP
1. Maintain the head in neutral position and elevated to 30
degrees.
2. Acutely hyperventilate patient maintaining pCO2 between 30
and 40 mmHg and administer mannitol 0.25-1 g/kg for
impending herniation or once obvious neurological signs
develop.
3. Maintain euthermia 36.5-37.5 C.
Coagulopathy
A. If patient is significantly bleeding or in anticipation of an
invasive surgical procedure:
1. Transfuse FFP to a goal INR of < 1.5. Avoid giving large
volumes of FFP to reach goal INR. Volume overload may
worsen cerebral edema.
2. Transfuse platelet concentrate to a goal of
50,0003
70,000/mm .

3. Consider NOVOSEVEN (40 mcg/kg IV) in patient with


prolonged INR despite FFP, who are volume overloaded.
B. In the absence of bleeding or invasive procedure:
1. Prophylactic FFP to improve coagulopathy in patients with
acute liver failure is not recommended.
2. Administration of cryoprecipitate is suggested in patients
with fibrinogen <100 mg/dL.
3. Keep platelet count 20,000/mm3.
C. Give at least three days of vitamin K (5-10 mg IV slowly with a
rate no more than 1 mg/min).
Sepsis
Empirical administration of antibiotics is recommended where
infection or the likelihood of impending sepsis is high, e.g.
surveillance cultures reveal significant isolates, progression of
advanced stage III/IV, refractory hypotension, renal failure,
presence of systemic inflammatory response syndrome
components (temperature > 38 C or < 36 C, white blood count >
12,000 or < 4000/mm3, tachycardia).
Broad-spectrum coverage with a third-generation cephalosporin,
vancomycin/teicoplanin, and fluconazole are recommended
wherever indicated.
Renal insufficiency
1.
2.
3.
4.

Monitor renal function closely including input and output.


Avoid nephrotoxic medications.
Maintain adequate renal perfusion.
Renal replacement therapy indications includes:

a.
b.
c.
d.
e.

Uremic encephalopathy
Severe or persistent hyperkalemia > 7 meq/L
Severe metabolic acidosis
Fluid overload (pulmonary edema, severe hypertension)
Hyponatremia (120 meq/L or symptomatic) or
hypernatremia

Ascites
1. If patient has respiratory compromise due to tense ascites or
there is concern for peritonitis, perform therapeutic
paracentesis.
2. Infuse 25% albumin while doing paracentesis.
3. Provide < 3 mEq/kg of sodium daily to minimize water
retention and worsening the ascites.
4. Start lasix and aldactone at a ratio of 1:2.5 (maximum dose of
lasix 160 mg and aldactone 400 mg). Closely monitor fluid
status including renal function, I/O and weight.
5. Consider Diuril (2-8 mg/kg/day IV in 2 divided doses or 20-40
mg/kg/day PO in 2 divided doses) for persistent ascites
and/or edema.
6. Avoid overhydration.
Liver transplantation
This is the only definite treatment. King's College Hospital criteria
for liver transplantation in acute liver failure are:
A. Paracetamol (acetaminophen) overdose
1. pH < 7.3 (irrespective of encephalopathy)
or all of the following:

2. Grade III-IV encephalopathy


3. Creatinine > 300 umol/L
4. Prothrombin time > 100 seconds (INR > 6.5)
B. Non-paracetamol aetiology
1. Prothrombin time > 100 seconds
or any 3 of the following:
2. Age < 10 years or > 40 years
3. Prothrombin time > 50 seconds
4. Bilirubin > 300 umol/L
5. Time from jaundice to encephalopathy > 2 days
6. Non-A, non-B hepatitis, halothane or drug-induced acute liver
failure

Anaphylaxis
Definition
Anaphylaxis is defined as a serious allergic reaction that is rapid
in onset and may cause death. Anaphylaxis in children,
particularly infants, is frequently underdiagnosed.
It occurs when there is a sudden release of potent biologically
active mediators from mast cells and basophils, leading to
cutaneous (urticaria, angioedema, flushing), respiratory
(bronchospasm, laryngeal edema), cardiovascular (hypotension,
dysrhythmias, myocardial ischemia), and gastrointestinal
(nausea, colicky abdominal pain, vomiting, diarrhea) symptoms.
Etiology
1. Food: peanuts, tree nuts (walnut, hazelnut, cashew, pistachio,
Brazil nut), milk, eggs, fish, shellfish (shrimp, crab, lobster,
clam, scallop, oyster), seeds (sesame, cottonseed, pine nuts,
psyllium), fruits (apples, banana, kiwi, peaches, oranges,
melon), grains (wheat)
2. Drugs: penicillins, cephalosporins, sulfonamides, nonsteroidal
anti-inflammatory agents, opiates, muscle relaxants,
vancomycin, dextran, thiamine, vitamin B12, insulin,
thiopental, local anesthetics
3. Hymenoptera venom: honeybee, yellow jacket, wasp, hornet,
fire ant
4. Latex
5. Allergen immunotherapy
6. Exercise: food-specific exercise, postprandial (nonfoodspecific) exercise

7. Vaccinations: tetanus, measles, mumps, influenza


8. Miscellaneous: radiocontrast media, gamma globulin, cold
temperature, chemotherapeutic agents (asparaginase,
cyclosporine, methotrexate, vincristine, 5-fluorouracil), blood
products, inhalants (dust and storage mites, grass pollen)
9. Idiopathic
Diagnosis
Anaphylaxis is highly likely when any one of the following three
criteria is fulfilled:
1. Acute onset of an illness (minutes to several hours) with
involvement of the skin and/or mucosal tissue (e.g. generalized
hives, pruritus or flushing, swollen lips/tongue/uvula); and at
least one of the following:
a. Respiratory
compromise
(e.g.,
dyspnea,
wheeze/bronchospasm, stridor, reduced peak PEF,
hypoxemia)
b. Reduced BP or associated symptoms of end-organ
dysfunction (e.g., hypotonia [collapse], syncope,
incontinence)
2. Two or more of the following that occur rapidly after exposure
to a likely allergen for that patient (minutes to several hours):
a. Involvement of the skin/mucosal tissue (e.g., generalized
hives, itch/flush, swollen lips/tongue/uvula)
b. Respiratory
compromise
(e.g.,
dyspnea,
wheeze/bronchospasm, stridor, reduced PEF, hypoxemia)
c. Reduced BP or associated symptoms (e.g., hypotonia
[collapse], syncope, incontinence)

d. Persistent gastrointestinal
abdominal pain, vomiting)

symptoms

(e.g.,

crampy

3. Reduced BP following exposure to known allergen for that


patient (minutes to several hours):
a. Infants and children: low systolic BP (age-specific) or 30%
drop in systolic BP
b. Low systolic blood pressure (BP) for children is defined as
less than 70 mmHg from one month to one year, less than
(70 mmHg + [2 age(year)]) from one to 10 years, and
less than 90 mmHg from 11 to 17 years.
Pharmacological management of anaphylaxis
Drug

Epinephrine
(1:1000) IM (1
mg/mL)
Each amp = 1 mL = 1
mg

H1 antagonists
Cetirizine PO (> 2
yr)

Frequency of
administration

Dosage

Immediately, then
every 515 min as
required

0.01 mg/kg up to
0.03 mg/kg
OR by age
> 6 yr: 150 mcg =
0.15 mL IM
6-12 yr: 300 mcg =
0.3 mL IM
12-18 yr: 500 mcg =
0.5 mL IM

Single daily dose

Loratidine

Single daily dose

Desloratidine

Single daily dose

0.25 mg/kg up to 10
mg
2-5 yr: 5 mg
> 5 yr: 10 mg
6-12 mo: 1 mg

1-5 yr: 1.25 mg


6-11 yr: 2.5 mg
> 12 yr: 5 mg
Diphenhydramine
IM/IV

Chlorpheniramine
IM/IV

Every 46 hr as
required for
cutaneous
manifestations
Repeat up to 4
times/24 hr

1.25 mg/kg up to 50
mg
< 6 mo: 250 mcg/kg
(max. 2.5 mg)
6 mo-6 yr: 2.5 mg
6 yr-12 yr: 5 mg
12 yr-18 yr: 10 mg

H2 antagonists
Ranitidine PO/IV

Cimetidine

Every 8 hr as
required for
cutaneous
manifestations
Every 12 hr or as
required

1 mg/kg up to 50 mg
4 mg/kg up to 200
mg

Corticosteroids
Prednisone PO
Methylprednisolone
IV
Salbutamol
Nebulized
epinephrine
(1:1000)

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Every 6 hr as
1 mg/kg up to 75 mg
required
Every 6 hr as
1-2 mg/kg up to 125
required
mg
Every 20 min or continuously for
respiratory symptoms (wheezing or
shortness of breath)
Every 20 min to 1 hr for symptoms of
upper airway obstruction (stridor)

Post-emergency management
Cetirizine
or
H1 antagonist
Lortin
Oral
Corticosteroid
prednisolone

5-10 mg once daily for


3 days
1 mg/kg up to 75 mg
for 3 days

Prevention
1. Patients experiencing anaphylactic reactions to foods must be
educated in allergen avoidance, including actively reading
food labels and acquiring knowledge of potential
contamination and high-risk situations, as well as in the early
recognition of anaphylactic symptoms (sensation of warmth
and facial pruritus) and ready administration of emergency
medications.
2. Patients with egg allergy should be tested before receiving the
influenza vaccine, which contain egg protein.
3. In cases of food-associated exercise-induced anaphylaxis,
children must not exercise within 2-3 hr of ingesting the
triggering food, stop exercising, and seek help immediately if
symptoms develop.
4. Reactions to medications can be reduced and minimized by
using oral medications in preference to injected forms.
5. Hypo-osmolar radiocontrast dyes can be used in patients in
whom previous reactions are suspected.

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6. The use of powder-free, low-allergen latex gloves or non-latex


gloves and materials should be used in children undergoing
multiple operations.
Preventive treatment
1.
2.
3.
4.

Follow-up evaluation to determine/confirm etiology


Immunotherapy for insect sting allergy
Prescription for EpiPen and antihistamine
Provide written plan outlining patient emergency
management

Patient education
1. Instruction on avoidance of causative agent
2. Information on recognizing early signs of anaphylaxis
3. Stress early treatment of allergic symptoms to avoid systemic
anaphylaxis

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Management algorithm for anaphylaxis

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Arrhythmias
Tachyarrhythmias
Tachyarrhythmias are classified into:
1. Atrial tachycardia: AF, EAT, MAT
2. Conduction system tachycardia
tachycardia: AVRT, AVNRT, PJRT
3. Ventricular tachycardia: VT, VF

or

Atrial flutter (AF)

o
o

saw tooth flutter waves


variable AV conduction

Ectopic atrial tachycardia (EAT)

o
o
o
o

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abnormal P wave axis


P wave precedes QRS
variable rate
warm up and cool down phenomenon

supraventricular

Multifocal atrial tachycardia (MAT)

o
o
o

irregularly irregular
multiple different P wave morphologies,bizarre and chaotic
no two RR intervals the same

Atrioventricular re-entry tachycardia (AVRT)

P wave follows QRS

Atrioventricular nodal re-entrytachycardia (AVNRT)

P wave not visible, superimposed on QRS

Permanent junctional reciprocating tachycardia (PJRT)

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o
o

inverted P waves in II, III, aVF appear to precede QRS complex


long RP interval

Ventricular tachycardia (VT)

o
o

wide QRS complex


P wave may be dissociated from the QRS complex

Ventricular fibrillation (VF)

chaotic, irregular rhythm

Bradyarrhythmias
Bradycardia

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Heart blocks

QRS Width
Narrow QRS

Wide QRS

P/QRS ratio

P/QRS ratio

> 1:1
Regular ( Atrial
Flutter)
Variable (EAT)
Chaotic
(MAT/Fib)

1:1

< 1:1

QRS-P
interval

JET

VT (< 1:1)
VT(1:1)
SVT + BBB
Antifromic AVRT

Very long
(PJRT/EAT)
short follows QRSP wave
(orthodromic AVRT)
not visible (AVNRT)

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Tachyarrhythmia
Narrow QRS

Wide QRS

Stable

Unstable

stable

Unstable

vagal
manoeuvers
adenosine
propranolol
amiodarone

synchronized
cardioversion

amiodarone
lignocaine in
ventricular
tachycardia

synchronized
cardioversion
or
defibrillation

Management
Hemodynamically stable
1. Vagal manoeuvers:
a. Icepack/iced water for infants; apply to face for a
maximum of 30 seconds.
b. Valsalva manoeuver if child is old enough (blow into a
pinched straw).
2. IV adenosine: 0.1 mg/kg (max. 6 mg) rapid push; increase by
0.1 mg/kg every 2 min until tachycardia terminates or up to a
maximum of 0.5 mg/kg (max. 18 mg).
3. IV propranolol 0.1 mg/kg over 5 min; can be repeated every 5
min for 3 times.

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4. IV amiodarone 5 mg/kg over 1 hr or 25 mcg/kg/min for 4 hr


then 5-15 mcg/kg/min until conversion.
Haemodynamically unstable
1. Synchronized DC conversion at 0.5 to 1 joule/kg.
2. In pulseless patients, defibrillate at 2 to 4 joules/kg.
Pitfalls in management
o
o

o
o
o
o

Consult a cardiologist if these acute measures fail to revert the


tachycardia.
In
Wolff-Parkinson-White
syndrome
digoxin
is
contraindicated because paroxysms of atrial flutter or
fibrillation can be conducted directly into the ventricle.
Verapamil is contraindicated in the 1st year of life.
Adenosine unmasks the atrial flutter by causing AV block and
revealing more atrial beats per QRS complex.
All bradycardias should be sent to a pediatric cardiologist.
In wide QRS complex tachycardia with 1:1 ventriculo-atrial
conduction it is reasonable to see if adenosine will cause
cardioversion, thereby making a diagnosis of a conduction
system dependent SVT.
A follow-up plan should be made in consultation with a
cardiologist.

Abbrevations
AVNRT: atrioventricular nodal re-entry tachycardia; AVRT:
atrioventricular re-entry tachycardia; BBB: bundle branch block;
EAT: ectopic atrial tachycardia; Fib: fibrillation; JET: junctional
ectopic tachycardia; MAT: multifocal atrial tachycardia; PJRT:

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permanent
junctional
reciprocating
tachycardia;
supraventricular tachycardia; VT: ventricular tachycardia
Pediatric advanced life support

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SVT:

Asthma
Diagnosis
History: Does the patient have established disease or not?
Consider differential diagnoses if this is the first presentation.
Assess severeity:
1. Mild: SpO2 >95% on room air (treated as outpatient with
bronchodilator)
2. Moderate: SpO2 91%-95% on room air and PEF 50%
3. Severe: SpO2 <91% on room air and PEF <50%
Initial treatment for moderate and severe asthma
1. O2: to maintain SpO2 above 92%
2. Salbutamol nebulizer: 3 doses at 20-minute intervals
a. < 20 kg 0.5 mL + 3 mL NS
b. > 20 kg 1 mL + 3 mL NS
3. Ipratropium bromide nebulizer:
a. < 1 yr 0.5 mL
b. > 1 yr 1 mL
4. Steroid:
a. Methylprednisolone initial 2 mg/kg/dose IV, followed
by 1 mg/kg/dose IV 6-hourly
b. Hydrocortisone vial initial 10 mg/kg/dose IV, followed
by 1 mg/kg/dose 4 times daily
c. Prednisolone 1-2 mg/kg/day orally

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After initial treatment


No improvement

1. Reassess the disease


2. Give steroid and
follow these steps (after
each step if there is no
improvement go to the
next step).

Improvement

Salbutamol nebulizer
hourly for 2-4 hr
OR
Oral salbutamol +
short course steroid

Magnesium sulfate 30
mg/kg in 30 mL NS over
30 min; repeat after 6
hr.

Terbutaline
infusion
loading
dose
5-10
mcg/kg followed by
maintenance dose 2-10
mcg/kg/hour.

Aminophylline infusion
5 mg/kg in 30 mL NS
over 20 min; reduce
terbutaline by 50%.

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Mechanical ventilator

Bronchial foreign body aspiration


Algorithm of management

Introduction
Foreign body aspiration is a common pediatric problem and a
leading cause of accidental death in children under 5 years of age.
Children between the ages 1-4
4 years explore their environment,
which often includes introducing objects into their mouths. It

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follows that nearly all foreign body aspirations occur in this age
group.
The most commonly aspirated objects are food materials, such as
peanuts, seeds (sunflower and watermelon), nuts, and beans.
Some insert objects that are easily aspirated into the childs
airway include small toys, buttons, toy parts, lids or straight pins.
Diagnosis of bronchial foreign body aspiration is challenging in
children and delayed diagnoses occur for several reasons. The
aspiration event is often unwitnessed or denied by parents. Most
aspirated objects are radiolucent.
After the initial coughing paroxysm, there is usually a quiescent
(relatively asymptomatic) phase for about a week before
pneumonia or other complications occur. Factors that might cause
delays in diagnosis are:
o
o
o
o
o

Lack of parent or caregiver recognition of the choking event.


Parental denial.
Unwarranted reassurance provided by medicines that cause
temporary improvement of signs and symptoms.
Difficulty performing radiographic examinations for
radiolucent foreign bodies.
Lack of consistent formal education regarding injuries caused
by aspirated foreign bodies in many medical schools and
residency programs.

Pathophysiology
The pathophysiology depends on the site of the impaction, age of
the child, and the nature of the foreign body. Near total
obstruction of the larynx or trachea can cause immediate

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asphyxia and death, whether the object passes the carina or not, it
depends on the patients age and physical position at the time of
the aspiration.
Until the age of 15 years, foreign bodies are found on either side
with equal frequency, but once aspirated; objects may
subsequently change position or migrate distally.
The object itself might cause obstruction or induce inflammation,
edema, cellular infiltration, ulceration, and granulation tissue
formation, which may contribute to airway obstruction.
Distal to the obstruction, air trapping leading to local emphysema,
atelectasis, hypoxic vasoconstriction, post-obstructive pneumonia
and possible volume loss, necrotizing pneumonia or abscess,
suppurative pneumonia, or bronchiectasis may occur.
The likelihood of complications increases after 24-48 hrs, making
quick removal of the foreign body urgent.
Assessment and evaluation
Often, the child presents after a sudden episode of coughing or
choking while eating with subsequent wheezing, coughing, or
strider. However, in numerous cases, the choking episode is not
witnessed, and, in many cases, the choking episode is not recalled
at the time the history is taken.
The most tragic cases occur when acute aspiration causes total or
near-total occlusion of the airway, resulting in death or hypoxic
brain damage.
The more difficult cases are those in which aspiration is not
witnessed or is unrecognized and, therefore, is unsuspected.

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In these situations, the child may present with persistent or


recurrent cough, wheezing, persistent or recurrent pneumonia,
lung abscess, focal bronchiectasis, or hemoptysis.
If the material is in the subglottic space, symptoms may include
strider, recurrent or persistent croup, and voice changes.
In one series, as many as one third of parents were unaware of the
aspiration or remembered an event that occurred more than a
week before the presentation. In as many as 25% of cases,
aspiration occurred more than one month before presentation.
Consequently, a high index of suspicion in addition to the history
may be necessary to reach the diagnosis. In another series of 280
foreign body aspirations, 47% were detected more than 24 hours
after the aspiration. However, 99% had signs or symptoms or
abnormal plain radiographs before the bronchoscopy.
Examination
1.
2.
3.
4.

Asymmetrical chest movement


Tracheal deviation
Chest signs such as wheeze or decreased breath sound.
The respiratory examination may be completely normal.

Management
Prevention is the most important point in management:
1. No child less than 15 months old should be offered foods such
as popcorn, hard lollies, raw carrot or apples. Children under
the age of 4 years should not be offered peanuts.
2. Encourage the child to sit quietly while eating and offer food
one piece at a time.

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3. Avoid toys with small parts for children under the age of 3
years.
Treatment includes:
1. Bronchodilators and corticosteroids should not be used to
remove the foreign body, and chest physical therapy with
postural drainage may dislodge the material to an area where
it may cause more harm, such as at the level of the vocal cord.
2. Place child upright in the position they feel most comfortable ,
Arrange for urgent removal of foreign body in the operating
theatre. Rigid bronchoscopy is almost always successful.
3. Medications are not necessary before removal, although the
endoscopist may observe enough focal swelling after the
material is removed to recommend a short course of systemic
corticosteroids.
4. Unless the airway secretions are infected with organisms
present, antibiotics are not necessary.
5. Treat complications.
Complications
1.
2.
3.
4.
5.
6.
7.
8.
9.

Atelectasis
Recurrent pneumonia
Penumonitis
Bronchial Granulomas.
Pneumomediastinum
Bronchiactasis
Obstructive emphysema
Lung abscess
Bronchocutanious or bronchovascular fistula if untreated.

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Aim
Aim of this guideline is to decrease morbidity and mortality
associated with bronchial aspiration, and help more accurate
diagnosis and choice of medication, with avoidance of misuse or
overuse of medications and performing unnecessary invasive
procedures.
Inclusion criteria
1. Stable children suspected of unilateral foreign body aspiration
2. Foreign body aspiration confirmed by a witness in a stable
child with respiratory complain
Exclusion criteria
1. Forign body ingestion with no respiratory complian.
2. Upper airway aspiration including laryngeal or pharyngeal
(strider, cough, hoarseness, in ability to speak)
3. Bilateral bronchial aspiration
4. Clinically unstable child with respiratory failure and
decreased level of consciousness
Key points
1. History of chocking in a clinically stable child with mild or no
respiratory complain should elicit suspicion of bronchial
aspiration in a child 1-4 years of age.
2. Local wheeze or local diminished air entry should be looked
for, in examining a child with suspected bronchial aspiration.

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3. CXR is the most important diagnostic imaging, in which air


trapping, emphysema, atelectasis or mediastinal shifting
should be looked for.
4. The 3 diagnostic tools are; history physical examination and
imaging, in which positive findings in 2 of them is enough to
consult a brochoscopist (cardiothoracic surgeon)
5. If only history or physical examination is suggestive of
aspiration, no need for consultation, but the child should be
kept for further evaluation
6. If there is positive history of chocking with high risk objects
(any small hard piece, organic (nuts, popcorns, seeds) or nonorganic (plastic, stones, metals), with positive signs and
symptoms, require urgent bronchoscopy.
7. Chocking with a low risk object (cheese, cereals, and chips)
with positive signs and symptoms, and radiological findings,
even if history of choking is not surely recalled, requires
bronchoscopy.
8. Steroids and bronchodilators have no role initially unless
recommended by the pediatric ENT-ist.
9. Chest physiotherapy initially might dislodge the foreign body
in to an area where it might cause more harm.
10. No role for antibiotics, unless there is complications.

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A plain inspiratory film showing a radiopaque ear ring backing in


the right main bronchus.

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Croup

Consider alternative
diagnoses:
1. Inhaled foreign body
2. Congenital anomalies
3. Epiglottitis/tracheitis

Diagnosis of croup

Is life-threatening airway
obstruction present?
1. Cyanosis
2. level of consciousness

Yes

1. 100% O2
2. Nebulized adrenaline
3. Intubation (by
experienced personnel)
4. Systemic corticosteroid

No

Mild croup
Barking cough
Nil or
intermittent
stridor
No cyanosis

1. Explanation to
parents
2. No specific
treatment
3. Discharge

Moderate croup
Persisting stridor
at rest
Some recession
May have
cyanosis

1.
Dexamethasone
0.6 mg/kg
2. Observe in > 4
hr

Severe croup
Persisting/soft
stridor at rest
Marked
recession
Apathetic or
restless, cyanosis

1. Do not agitate
the child
2. O2, nebulized
adrenaline
4. Steroid
5. Observe in > 4
hr

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Improvement
Yes

Discharge when
there is no more
stridor.

Partial

1. Admit/observe
2. Repeat steroid
in 12 hr
3. Explanation to
parents
4. Written follow
up

No

1. Inform
consultant
2. Nebulized
adrenaline (same
as previous dose)
3. Steroid (same
as previous dose)
4. Consider
intubation

Key points of the differential diagnoses


Infectious croup: is a common viral infection. It starts with a viral
prodrome of rhinorrhea, pharyngitis, low grade fever, and barking
cough. Stridor appears 1-2 days later.
Spasmodic croup: is an aviral condition; it may be allergic or
psychological. It has a characteristic barking, metallic cough,
mostly in the evening or at night, has a sudden onset and has no
viral prodrome. The attacks may be repeated at night in the
second and third days but it is usually milder.
Tracheitis: is characterized by brassy cough, high fever, and
toxicity with respiratory distress.

32

Epiglottitis: is characterized by high fever and rapidly progressing


stridor, drooling of saliva, and muffled sound. Airway obstruction
becomes severe within hours.
Foreign body inhalation: has a sudden onset, is not preceded by
fever, and has a history of choking.
In the treatment of croup
o
o
o
o
o

Steroid should be used cautiously in Varicella infection and in


TB.
Nebulized adrenaline should be used cautiously in
tachycardia, TOF, and ventricular outlet obstruction.
Antibiotics are not indicated.
There is no role for steam inhalation or cool mist.
Sedatives and bronchodilators are contraindicated.

Indications for admission


1. Severe stridor at rest or progressive stridor
2. Respiratory distress, hypoxia, or cyanosis
3. Depressed mental status, poor oral intake
Medication

Croup grade

Dose

Systemic
corticostero
id*

Moderate or
severe

Dexamethasone
0.6 mg/kg, single
dose, IV/IM/PO

Moderate or
severe

Adrenaline
1:1000, 1 mg/1
mL, (0.5-1
mL/dose in 3 mL
of NS) nebulized

Nebulized
adrenaline

Notes
Acts within 1
hr
Repeat in 1224 hr
Acts within
minutes
May need
repeat doses
after 30 min if
no response

33

O2

34

Severe (SpO2
< 90%)
Very severe
with central
cyanosis

Mask with
minimum
amount of 6
L/min

Dehydration
Signs and symptoms of severe dehydration
Body weight loss
General appearance
Respiration*
Eyes
Tears
Anterior fontanelle
Mucous membranes
Capillary refill time*
Tissue turgor*
Radial pulse
Blood pressure

>10%
Drowsy, limp, cold, sweaty, cyanotic
extremities
Deep and rapid
Grossly sunken
Absent
Very sunken
Very dry
Prolonged (>3 seconds)
Retracts very slowly
Rapid, thready, may be impalpable
Low

Urine output
Marked oliguria
* These are the most reliable and helpful signs.
Management
Total IV fluid requirement in severe dehydration

Treat shock
Fluid deficit (mL)
= % of
dehydration x 10
x weight in kg

Maintenance
(see table
below)

Ongoing losses
Fever
Dehydration
Diarrhea & vomiting
Pooling of fluid in
the gut
Capillary leak

35

Table. Maintenance IV fluid and electrolyte requirement

Body weight

Fluid
mL/kg/24
hr

Sodium
mmol/kg/24
hr

Potassium
mmol/kg/24
hr

1st 10kg

100 mL

2-4

1.5-2.5

2nd 10 kg

50

1-2

0.5-1.5

Subsequent kg

20

0.5-1

0.2-0.7

Initial IV fluid management in severe dehydration

Phase 2:
Rehydration

repeat up to 3 times

Improvement*

No improvement*
no improvement after 2
hr and 3 boluses of NS

Phase 1: Treat
shock (0-30 min)

20 mL/kg of 0.9% saline


Send for blood urea and serum electrolyte levels

Lasix 1 mg/kg, 1 dose


Na+
< 130

Na+
135 145

Na+
> 150

no improvement
after 45 min

Repeat lasix 1 mg/kg


no improvement

Think of other causes: cardiac,


anaphylactic, or septic shock
Do haemodynamic monitoring
and give inotropic support
(dopamine)

36

0.45% saline / 2.5%


dextrose over 24 hr

0.45% saline / 2.5%


dextrose over 48 hr

fluid volume = deficit +


maintenance - shock bolus

fluid volume = deficit +


maintenance - shock bolus

in 1st 8 hr then in 16
hr.

in 1st 18 hr then in 30
hr

Close monitoring of clinical condition, fluid balance, blood


urea, plasma creatinine and electrolytes
* Criteria of improvement are:
1.
2.
3.
4.

Intact mental status


Normal heart rate
Capillary refill < 2 seconds
Adequate urine output

Treatment of severe dehydration


Assess the patient and check ABCD (D for dextrose; always
check blood sugar).
Take the vital signs.
Send for emergency lab investigations (blood sugar, blood
urea, serum electrolytes, serum calcium, CBC).
Insert an IV line (if needed 2 lines) within 3 min (3-4 trials); if
this fails insert an intraosseous line.

37

If the patient is in shock give a shot of 20 mL/kg Ringer


lactate or 0.9% normal saline within 30 min.
Reassess after first infusion; if no improvement repeat 20
mL/kg over 30 min.
Reassess after second infusion; if no improvement repeat 20
mL/kg over 30 min.
Reassess after third infusion; if no improvement transfuse
fresh whole blood 20 mL/kg over 1 hr (use packed red cell if
in cardiac failure).
Assess the vital signs every 5-10 min.
Treat hypoglycemia and hypocalcaemia if present.

If there is no urine output give a dose of frusemide (Lasix) 2-4


mg/kg/dose or you can give mannitol 0.5 gm/kg (2.5 ml of
20% mannitol/kg) over 1 hr and wait 30 min while running
maintenance fluids (without potassium).
If there is no improvement treat as acute renal failure or think
about other causes (cardiac, anaphylactic, or septic shock); do
hemodynamic monitoring and give inotropic support
(dopamine )

If there is improvement, UOP is positive and vital signs


become better calculate 24 hr fluid needed: maintenance +
deficit - fluid used for initial infusions (shock boluses).
Administer this total fluid over 24 hr using GS + 20 mEq/L
KCl (according to serum potassium).
Replace ongoing losses as they occur.

38

If plasma Na+ (< 130) or


normal then give

If plasma Na+ (> 150)


then give

of total fluid in first 8 hr


then in second 16 hr.

of total fluid in first 18


hr then in second 30 hr.

Treatment of
malnutrition

severe

dehydration

in

children

with

Assess the patient and check ABCD (D for dextrose; always


check blood sugar).
Take the vital signs.
Send for emergency lab investigations (blood sugar, blood
urea, serum electrolytes, serum calcium, CBC).
Insert an IV line (if needed 2 lines) within 3 min (3-4 trials); if
this fails insert an intraosseous line.

If the patient is in shock give a shot of 15 mL/kg Ringer


lactate with 5% dextrose or GS within 1 hr.
Reassess after first infusion; if no improvement repeat 15
mL/kg over 1 hr.
Assess the vital signs every 5-10 min.
Reassess after second infusion; if there is no improvement
consider the child as having septic shock.
Give maintenance IV fluid 4 mL/kg/hour while waiting for
blood.
When blood is available, transfuse fresh whole blood at 10
mL/kg over 3 hr (use packed red cell if in cardiac failure).
Treat hypoglycemia, hypothermia, hypocalcaemia and
hypomagnesaemia if present.

39

If there is no urine output give a dose of frusemide 1-2


mg/kg/dose or you can give mannitol 0.5 gm/kg (2.5 ml of
20% mannitol/kg) over 1 hr while running maintenance
fluids.
If no improvement treat as acute renal failure or think about
other causes (cardiac, anaphylactic, or septic shock); do
hemodynamic monitoring and give inotropic support
(dopamine )

If there is improvement, UOP is positive and vital signs


become better calculate 24 hr fluid needed: maintenance +
deficit - fluid used for initial infusions (shock boluses).
Administer this total fluid over 24 hr using GS + 20 mEq/L
KCl.
Replace ongoing losses as they occur.
Start feeding by mouth or by NG tube.

If plasma Na+ (< 130)


or normal then give

If plasma Na+ (> 150)


then give

of total fluid in first 8


hr then in second 16
hr

of total fluid in first


18 hr then in second
30 hr

If the child deteriorates during the IV rehydration (breathing


by 5 breaths/min or pulse by 25 beats/min) stop the
infusion because IV fluid can worsen the childs condition.

40

WHO treatment of severe dehydration in infants


Insert an IV line (If needed 2
lines) within 5 minutes (3-4
trials); if this fails insert an IO
line.
Draw blood for emergency lab
investigations.
Start IV fluid immediately.
If the patient can drink give ORS
by mouth while the drip is set up.
Can you give IV
fluids immediately?

Yes

Give 30 mL/kg initially ringer


lactate or 0.9% NS in 1 hr then
give 70 mL/kg in 5 hr.
Reassess the patient every half
hour. If hydration is not
improving give the IV drip more
rapidly.

No

Also give ORS (5mL/kg/hr) as


soon as the patient can drink.
After 3 hr re-evaluate the patient
and choose the appropriate plan
to continue treatment.
Refer to hospital immediately for
IV treatment.

No

Is IV treatment
available nearby
(within 30 min)?

Yes

If the patient can drink, provide


the mother with ORS and show
her how to give sips of it during
the trip.

41

Yes

Start rehydration by NG tube or


by mouth with ORS; give 20
mL/kg/hr.

Yes

Refer URGENTLY to hospital.

No

Are you trained to


use an NG tube for
rehydration?

No

Can the patient


drink?

Refer URGENTLY to
hospital for IV
treatment.

Note:
If possible, observe the patient for at least the first 6 hours after
rehydration in order to make sure that the mother is able to keep
the child normally hydrated.

42

Diabetes mellitus, preoperative preparation in


In children with diabetes mellitus (DM) presurgical assessment
should be done several days before surgery to allow for an
assessment of glycemic control, electrolyte status, and ketones (in
urine or blood).
If glycemic control is known to be poor and surgery is not urgent,
delay the procedure until glycemic control has improved. If
surgery cannot be delayed, consider admission to the hospital
before surgery for stabilization of glycemic control.
The blood glucose should be maintained in the range of 90180
mg/dL during surgical procedures in children.
Preoperative preparation of children with DM

Type 1 DM or type 2 DM on
insulin
Major surgery

Type 2 DM not on insulin

Minor surgery

Type 2 DM not on insulin (on oral medication alone)


Discontinue metformin 24 h before major surgery (lasting at least
2 h) and on the day of surgery for minor surgery.
Discontinue sulfonylureas and thiazolidinediones on the day of
surgery.
Patients undergoing a major surgical procedure expected to last
at least 2 h should be started on an IV insulin infusion.

43

Type 1 DM or type 2 DM on insulin


Must be admitted to the hospital if receiving GA.
In cases with documented good control, it should be possible to
admit early on the day of surgery for both minor and major
procedures. Otherwise, it is preferred to admit in the afternoon
before surgery to give time for correction of metabolic status
overnight.
Should be scheduled as the first case of the day.
Need insulin, even if fasting, to avoid ketoacidosis.
May initially receive an IV infusion without dextrose for minor
surgery or procedures (lasting for less than 2 h) if treated with
basal/bolus insulin regimen or continuous subcutaneous insulin
infusion (CSII).
Should initially receive an IV infusion with dextrose for major
surgery or procedures (lasting for at least 2 h) or if treated with
NPH insulin.
Require hourly capillary blood glucose monitoring to detect
hypoglycemia and hyperglycemia before the procedure. If the
blood glucose exceeds (250 mg/dL), a conservative dose of
rapid-acting insulin or short-acting insulin (regular) should be
administered to restore blood glucose to the target range.
Should coordinate the timing of preoperative food and fluid
restrictions with the anesthetist.

44

The usual recommendation is no solid food for at least 6 h before


surgery Clear fluids (and breast milk) may be allowed up to 4 h
before surgery
Major surgery
On the evening before surgery give the usual evening and/or
bedtime insulin(s) and bedtime snack.
Monitor blood glucose and urinary ketone concentration if blood
glucose is > 250360 mg/dL.
Omit the usual morning insulin dose.
At least 2 h before surgery, start an IV insulin infusion [e.g., dilute
50 units regular (soluble) insulin in 50 mL normal saline, 1 unit =
1 mL] and provide IV maintenance fluids consisting of 5%
dextrose and half-normal saline (0.45% NaCl).
Monitor blood glucose levels at least hourly before surgery and as
long as the patient is receiving IV insulin.
Aim to maintain blood glucose between (90180 mg/dL) by
adjusting the IV insulin dose or the rate of dextrose infusion
during surgery.
When oral intake is not possible, the IV dextrose infusion should
continue for as long as necessary.
Minor surgery
Require a brief general anesthetic.
The child will usually be discharged from hospital on the day of
procedure.

45

Early morning procedures (for example, 8.009.00 am) with


delayed insulin and food until immediately after completion, or
reduced usual insulin dose (or give repeated small doses of
short/rapid-acting insulin).
Glucose 510% infusion and frequent blood glucose monitoring
are recommended in all these situations.
Elective vs emergency surgery
The above approach applies to elective surgeries without further
precautions. The approach also applies in emergency in surgeries
with some further precautions.
Before emergency surgery in a child with DM, always check blood
glucose or urinary ketone concentration, serum electrolytes, and
blood gases if ketone or blood glucose levels are high.
Do not give fluid, food, or medication by mouth because in some
emergency situations, the stomach must be emptied by a
nasogastric tube. Always secure IV access and check weight
before anesthesia.
If ketoacidosis is present, follow an established treatment
protocol for diabetic ketoacidosis and delay surgery, if possible,
until circulating volume and electrolyte deficits are corrected and,
ideally, until acidosis has resolved. If there is no ketoacidosis,
start IV fluids and insulin management as for elective surgery.
Intraoperative care
Blood pressure should be carefully monitored. Monitor blood
glucose measurements at least hourly during and immediately
after GA. If necessary, begin dextrose infusion or increase

46

dextrose concentration of IV fluids from 5 to 10% to prevent


hypoglycemia.
Adjust dextrose infusion and insulin dose (by subcutaneous
injection of rapid-acting insulin for minor surgery) to maintain
blood glucose in the range (90180 mg/dL).
For those receiving an IV insulin infusion, a single correction
bolus of IV insulin (either using the childs usual correction factor
or 510% of the childs usual total daily insulin dose, depending
on the severity of hyperglycemia) may be given at the start of the
infusion to correct hyperglycemia.
Thereafter, correction of hyperglycemia should be based on
adjustment of the rate of the IV insulin infusion. If the blood
glucose exceeds (250 mg/dL), urine or blood ketones should
also be measured.
If there is an unexpected acute drop in blood pressure, NS (0.9%
NaCl) or Ringers lactate must be infused rapidly. In this case,
potassium containing fluids must not be infused rapidly.
Postoperative care
After surgery, start oral intake or continue IV dextrose infusion
depending on the childs condition. Continue the IV insulin
infusion or additional shorter rapid-acting insulin as necessary
until oral intake is resumed.
Once the child is able to resume oral nutrition, resume the childs
usual diabetes treatment regimen. Give short- or rapid-acting
insulin (based on the childs usual insulin:carbohydrate ratio and

47

correction factor), if needed, to reduce hyperglycemia or to match


food intake.
Management according to different types of insulin regimens

Patients treated with once


daily basal/bolus insulin
regimens

Patients treated with twice


daily basal and rapid- or
short-acting insulins

Morning operations

Morning operations

Evening operations
(if unavoidable)

Evening operations
(if unavoidable)

Patients treated with once daily basal/bolus insulin regimens


Morning operations
On the morning of the procedure, give the usual dose of longacting insulin (glargine or detemir) if usually given at this time. If
preoperative evaluation shows a pattern of low blood glucose
values in the morning, consider reducing the dose of long-acting
insulin by 2030%.
Omit the short- or rapid-acting insulin unless needed to correct
hyperglycemia.
Commence IV fluids. Patients with a normal blood glucose may
initially utilize IV fluids without dextrose. With an appropriately

48

titrated basal rate and careful monitoring, this approach may be


more physiologic.
Afternoon operations (if unavoidable)
On the morning of the procedure, give the usual dose of longacting insulin (if usually given at this time).
If allowed to eat breakfast, give the usual dose of rapid-acting
insulin or 50% of the usual short acting insulin.
If the anesthetist allows the child to eat a light breakfast and to
consume clear liquids up to 4 h before the procedure, IV fluid
administration (and IV insulin infusion, if applicable) should
commence 2 h before surgery or no later than midday.
Patients treated with twice daily basal and rapid- or shortacting insulins
Morning operations
On the morning of the procedure, give 50% of the usual morning
dose of intermediate acting insulin (NPH) or the full usual
morning dose of long-acting insulin (detemir or glargine).
With premixed insulin, give only 50% of the equivalent dose of
the basal (NPH) component.
Omit the short- or rapid-acting insulin unless it is needed to
correct hyperglycemia.
Commence IV fluids containing dextrose 510%, as necessary, to
prevent hypoglycemia.
Afternoon operations (if unavoidable)

49

On the morning of the procedure, give 50% of the usual dose of


intermediate-acting insulin (NPH) or the full usual morning dose
of long-acting insulin (detemir or glargine).
With premixed insulin, give only 50% of the equivalent dose of
the basal component (NPH).
The dose of short- or rapid-acting insulin will depend on whether
the child is permitted to eat breakfast.
Alternatively, give 3040% of the usual morning insulin dose of
short- or rapid acting insulin (but no intermediate- or long-acting
insulin) and use an IV insulin infusion beginning at least 2 h
before surgery.
If the anesthetist allows the child to eat a light breakfast and to
consume clear liquids up to 4 h before the procedure, IV fluid
administration (and IV insulin infusion, if applicable) should
commence 2 h before surgery or no later than midday.
Infusion guide for surgical procedures
Maintenance fluid guide
1. Dextrose:
For major surgery and any surgery when NPH has been given use
5% dextrose; use 10% if there is concern about hypoglycemia.
If blood glucose is high 250 mg/dL use half-normal saline (0.45%
NaCl) without dextrose and increase insulin supply but add 5%
dextrose when blood glucose falls below (250 mg/dL).
2. Sodium:

50

There is evidence that the risk of acute hyponatremia may be


increased when hypotonic maintenance solutions (i.e., <0.9%
NaCl) are used in hospitalized children. Many centers, therefore,
use saline 0.450.9% (77154 mmol Na/L).
A compromise would be to give 0.45% saline with 5% dextrose,
carefully monitor electrolytes, and change to 0.9% saline if plasma
Na concentration is falling.
3. Potassium:
Monitor electrolytes. After surgery, add potassium chloride 20
mmol to each liter of intravenous fluid. Some centers add
potassium routinely only if infusion is required for more than 12
h.
Example of calculation of maintenance requirements:
Body weight (kg)
For each kg between 39
For each kg between 1020
For each kg over 20

Fluid requirement per 24 h


100 mL/kg
Add an additional 50 mL/kg
Add an additional 20 mL/kg

Maximum amount = 2000 mL in females, and 2500 mL in males.


Insulin infusion
Add soluble (regular) insulin 50 units to 50 mL normal saline
(0.9% NaCl), making a solution of 1 unit insulin/mL; attach to
syringe pump and label clearly
Start infusion at 0.025 mL/kg/h (i.e. 0.025 U/kg/h) if blood
glucose is < 110140 mg/dL, use 0.05 mL/kg/h if 140220

51

mg/dL, use 0.075 mL/kg/h between 220270 mg/dL, and use


0.1 U/kg/h if > 270 mg/dL.
Aim to maintain blood glucose between 90180 mg/dL by
adjusting insulin infusion hourly.
Blood glucose must be measured at least hourly when the patient
is on IV insulin
Do not stop the insulin infusion if blood glucose < 90 mg/dL as
this will cause rebound hyperglycemia.
The insulin infusion may be stopped temporarily if blood glucose
is < 55 mg/dL but not >1015 min.

52

Diabetic ketoacidosis
DKA diagnostic criteria
Blood sugar > 300 mg/dL
Acidosis (serum HCO3 < 15 mEq/dL)

Complete initial evaluation


Short history: polyuria, polydypsia, abdominal pain, emesis,
known case of DM
Physical examination: assess level of consciousness, asses
volume state (all cases of DKA should be considered as having
8.5% dehydration), vital signs
Lab investigations: blood sugar, blood urea, serum
creatinine, serum electrolytes, GUE, urine for ketone, ABG,
ECG

If the patient has disturbed level of consciousness or is in


coma establish basic life support:
1. Airway, breathing, circulation (put 2 cannulas, 1 for
insulin and 1 for fluid)
2. Urinary catheter
3. Give 20 mL/kg N/S in 1 hour

Intravenous fluid
Total amount = (85 mL/kg + maintenance)/24 hr
of this is given within 12 hr bolus given in basic life

53

support; the other is given within the next 12 hr.


If the patient is hypernatremic they should be rehydrated
slowly over 48 hr.
Continue on N/S or N/S if available till blood sugar is < 250
mg/dL then add 5% dextrose.
Insulin therapy
Give immediately with IV fluid by infusion per 1 hr
Blood sugar (mg/dL)

Unit/kg of insulin

> 600

0.1

300-600

0.05

Note: Mix 25 units of insulin with 250 mL N/S. In this way each
mL will contain 0.1 unit. Thus you can give 1 cc/kg/hr.
Potassium
Potassium should be added after the 1st hr of treatment by
giving 1 mEq/kg of potassium phosphate if available.
If this is not available then give KCl as follows (after checking
urine output):
Serum K+ 3.5-5 give 20 mmole/L.
Serum K+ < 3 give 40 mmole/L and do an ECG.
If the patient is hyperkalemic potassium should not be given
and they should be followed up.
Antibiotics
Give ceftriaxone or amoxiclave to cover underlying infections.

54

Improvement
(no emesis, improved consciousness, can take orally,
acidosis corrected)

1. Stop IV fluid and start oral feeding.


2. Stop IV insulin and change to sliding scale.
Blood sugar (mg/dL)

Unit/kg soluble insulin

< 100
100200
200300
300400
400500
> 500

0
0.1 u/kg
0.2 u/kg
0.3 u/kg
0.4 u/kg
0.5 u/kg

Measure blood sugar every 6 hr then given insulin


accordingly. Continue on IV insulin untill hr after
subcutaneous insulin has been restarted.

No improvement

Treat ICP:
1. Elevate head

1. Exclude hypoglycemia.
2. Are there signs of ICP
(e.g. apnea, bradycardia,
seizure,
papilledema,
deterioration, LOC)?
Consider cerebral edema
and send for a CT scan.

2. Mannitol 0.51 g/kg/hr


3. Intubate & hyperventilate
4. NaHCO3 is indicated only
if severe acidosis (pH 6.95)
5. If hyperkalemia (serum
K+ 8 mEq/dL) give 1-2
mmole/kg/1-2 hr

55

Febrile seizures
Febrile seizures are seizures that occur between the age of 6-60
mo with a temperature of 38 C or higher, that are not the result
of central nervous system infection or any metabolic imbalance,
and that occur in the absence of a history of prior afebrile
seizures.
A simple febrile seizure is a primary generalized, usually tonicclonic attack associated with fever, lasting for a maximum of 15
min, and not recurring within a 24-hr period.
A complex febrile seizure is >15 min, focal, and/or recurs within
24 hr.
Febrile status epilepticus is a febrile seizure lasting >30 min.
Risk factors for recurrence
Major
1. Age <1 yr
2. Duration of fever <24 hr
3. Fever 38-39 C
Minor
1.
2.
3.
4.
5.
6.

56

Family history of febrile seizures


Family history of epilepsy
Complex febrile seizure
Day care
Male gender
Low serum Na

Management
1. Positioning: left lateral
2. Resuscitation
3. Stop seizure

1. History
2. Vital signs: HR, SpO2, RR, temperature, BP
3. Physical examination: consciousness, GCS, irritability,
bulging fontanelle, signs of meningeal irritation (neck
stiffness, Kernig sign, Brudzinski sign)

Investigations:
1. RBS, serum electrolytes (Na+, K+, Ca2+, Mg2+)
2. Lumbar puncture: indications are age < 1 yr
atypical febrile seizure not regaining
consciousness within 30 min post-ictal
drowsiness
3. Others: infection screen (blood culture, urine culture,
CXR), neuroimaging

57

G6PD deficiency
Diagnosis
History: presence of history of G6PD in the patient and/or in the
family; history of precipitating factors.
Physical examination: pallor and jaundice.
Investigations: PCV (hematocrit), reticulocyte count,
reticulocyte production index (RPI), Heinz bodies and fragmented
RBCs on blood film.
Management
<7g

Hemoglobin (Hb) level

Give blood

Hb > 7 g and
clinically stable
Hb < 7 g

>7g

Clinically stable

Clinically unstable
( PR, BP, LOC)

Give blood

Give blood until


Hb > 7 g

1. Follow up for 24 hr; do G6PD assay after few weeks.


2. Give folic acid 1 mg/day for 2 wk; avoid precipitating factors.

58

SI: stroke index; CI: cardiac index; SVRI: systemic vascular resistance index; TFI: thoracic fluid index.

Heart failure

59

Hypoglycemia
Hypoglycemia
(RBS < 45 mg/dL)

Unconscious (drowsy)
1. Insert IV cannula
2. Place a urine bag to collect next
urine passed
3. Send blood for lab
measurement of glucose level for
confirmation
4. Give an IV bolus of 5-10 mL/kg
of 10% dextrose
5. Start a continuous IV infusion
of 10% dextrose/0.45% saline at
a rate of 2.5-5 mL/kg/hr (6
mg/kg/min glucose)
6. Recheck RBS at 5 min intervals
until RBS is stable > 54 mg/dL.

Conscious
< 1 yr milk feeding
> 1 yr quick-acting
carbohydrate such
as pure fruit juice

RBS > 45 mg/dL


1. Continue on
maintenance fluid.
2. Gradually reintroduce feeds.

RBS < 45 mg/dL


1. Check if the cannula is patent.
2. Give another bolus of 5 mL/kg of 10% dextrose.
3. Increase the rate of the fluid 10% dextrose/0.18% saline to
6 mL/kg/hr (10-12 mL/kg/min glucose).
4. If you suspect adrenal insufficiency send blood for
measurement of serum electrolytes (Na+ and K+) and give
hydrocortisone 4 mg/kg IV (max. 100 mg)
5. In chronic, severe hypoglycemia you can give diazoxide.

60

NG tube insertion
Indications
1. Feeding
2. Administering drugs
3. Aspiration of gastric secretions swallowed air in
gastrointestinal obstruction preparation before surgery
under GA gastric fluid for analysis
Contraindications
1.
2.
3.
4.

Basal skull or severe facial fractures


Obstructed airway
Esophageal varices
Gastric bypass surgery

Complications
Minor
1. Nose bleeds
2. Sinusitis
3. Sore throat
Major
1.
2.
3.
4.

Erosion of the nose


Esophageal perforation
Pulmonary aspiration and lung collapse
Intracranial placement of the tube

61

Placement
Before an NG tube is inserted the appropriate length must be
measured from the tip of the patient's nose backwards, looping
around their ear and then down to roughly 5 cm below the
xiphoid process.
The tube is then marked at this level to ensure that the tube will
be inserted far enough into the patient's stomach.
The end of a plastic tube is lubricated (local anesthetic, such as
2% xylocain gel, may be used).
To ensure proper placement air is injected into the tube while
holding a stethoscope on the epigastric area; if the air is heard in
the stomach with a stethoscope then the tube is in the correct
position.

62

Poisoning
Poisons can cause harm by a wide range of mechanisms and can
cause a wide range of symptoms including unconsciousness,
nausea, vomiting, burning pain in the mouth or throat, headache,
blurred vision, seizures, difficulty breathing, respiratory arrest,
and cardiac arrest.
Harmless substances
There is a list of substances that if ingested by the child cause no
harm and only re-assurance of the family is needed.
Topical
antibiotic

Contraceptives
pills

Topical
antifungal

Topical
corticosteroids

Bubble bath
soap

Crayons

Calamine
lotion
Candles
Chalk
Children's toy
cosmetics
Clay

Deodorants'
underarm
Soap of hand
and dish
Diaper rash
cream
Glues

Grease
Hand lotion
and cream

Mineral
oil
Play- Doh

Ink (non
Water
permemanent) color
Laxatives

Vaseline

Lipstick

Shampoo

Magazines

Shaving
creams

Makeup
Matches

Starch
Sunscreen

Zinc oxid

63

Management of poisoning

Decontamination

Resuscitation and
supportive care

Specific
management

Decontamination of the patient


Separate the victim and follow these steps accordingly:
Swallowed poison
1. Induce vomiting in conscious patient by Ipecac syrup if the
substance is not a strong acid or alkali substance.
2. Activated charcoal 1 g/kg every 4 hr.
3. Gastric lavage.
4. Whole bowel irrigation used only in certain modified
release or enteric coated formulations, e.g. sever lithium
poisoning.
Inhaled poison
Try to make the patient breathe fresh air and oxygen.
Eye contact
Flood the eye with saline or cold water from a running tap or a
cup/jug. Continue to flush for 15 min, holding the eyelids open.
Skin contact
1. Remove contaminated clothing, taking care to avoid
contact with the poison.
2. Flood skin with running cold water.
3. Wash gently with soap and water and rinse well.

64

Resuscitation and supportive care


Respiration
An obstructed airway requires immediate attention, from
simple chin lift or jaw thrust, oro- or nasopharyngeal tube to
intubation and ventilation.
Blood pressure
Hypotension usually occurs with drugs of CNS depression and
should be corrected with head tilting down of the bed and IVF.
Hypertension is often transient and associated with
sympathomimetic drugs as amphetamine, phencyclidine and
cocaine.
Heart
These are mostly in cardiac conduction defects and
arrhythmias, e.g. tricyclic antidepressants, antipsychotics and
some antihistamines.
Body temperature
Hypothermia occurs mostly in patients unconscious for hours
and in overdose of barbiturates or phenothiazines. The most
important measure is to wrap the patient.
Hyperthermia in poisoning with CNS stimulants is managed by
removing clothes, using fan, and sponging with tepid water.
Convulsion
If it is long-lasting or very frequent use lorazepam 100 mcg/kg
(max. 4 mg) or diazepam 300-400 mcg/kg (max. 20 mg) slow
IV or rectally or oral gel.

65

Specific management (antidotes)


Paracetamol
Acetylcysteine 150 mg/kg in 3 mL/kg of 5% GW over 15 min
then 50 mg/kg in 7 mL/kg of 5% GW over 4 hr then 100 mg/kg
in 14 mL/kg 5% GW over 16 hr. This should be given within 8
to 12 hr if toxic dose is ingested (75 mg/kg/24 hr).
Opioids
Naloxone 10 mg; repeat the dose in 3 min to a max. 100
mcg/kg. This should be given if there is bradycardia or coma.
Tricyclic antidepressants
Intravenous infusion of sodium bicarbonate should be given if
there is prolonged QRS duration and arrhythmia.
Beta-blockers
IV atropine 40 mcg/kg (max. 3 mg) if bradycardia develops.
Iron salts
GI toxicity occurs with 20 mg/kg of elemental iron. Moderate
intoxication occurs with 40 mg/kg. Severe and lethal toxicity
occurs with 60 mg/kg.
% of elemental iron in iron salts is: fumarate 33%, sulfate 20%,
and gluconate 12%.
Treatment is with desferrioxamine 15 mg/kg/hour.

Additional antidotes
Toxin or poison
Black widow spider

66

Antidotes
Latrodectus antivenin

Botulinum toxin

Botulin antitoxin

Calcium channel antagonists

Glucagon and/or insulin and


glucose

Dystonic reactions

Diphenhydramine and/or
benztropine

Fluoride, calcium channel


blockers

Calcium salts

Heparin

Protamine

Methotrexate, trimethoprim,
pyrimethamine

Folinic acid

Rattlesnake envenomation

Crotab-specific Fab antibodies

Sodium channel blockade


(tricyclic antidepressants,
type 1 antiarrhythmics

Sodium bicarbonate

Recognizable syndromes
Poison syndrome
Signs: Vitals | Mental status | Pupils |
Skin | Bowel sounds | Other
Sympathomimetic
BP, HR, hyperthermia
Agitated, psychosis, delirium

Possible toxins
Amphetamines,
cocaine,
ecstasy,
pseudoephedrine,
caffeine,
theophylline

Dilated pupils
Diaphoretic
Normal to increased bowel sounds

67

Anticholinergic
BP, HR, hyperthermia
Agitation, delirium, mumbling speech
Dilated pupils

Antihistamines,
tricyclic
antidepressants,
atropine,
jimson
weed,
phenothiazines

Dry skin
Decreased bowel sounds
Cholinergic
HR (though may show HR), BP and
temperature typically normal

Organophosphates,
nerve
gases,
Alzheimer
medications

Confusion, coma, fasciculations


Small pupils
Diaphoretic
Hyperactive bowel sounds
Diarrhea,
urination,
bronchorrhea,
bronchospasm, emesis, lacrimation,
salivation
Opioids
Vitals: Respiratory depression (hallmark
of toxicity), HR, BP, hypothermia
Depression, coma

Methadone,
suboxone,
morphine,
oxycodone, heroin,
etc.

Pinpoint pupils
Normal skin
Normal to decreased bowel sounds
Sedative-Hypnotics

68

Barbiturates,
benzodiazepines,

Respiratory depression, HR normal to


decreased, BP normal to decreased,
temperature normal to decreased

ethanol

Somnolence, coma
Small pupils
Normal skin
Normal bowel sounds
Serotonin syndrome
Hyperthermia, HR, BP or BP
(autonomic instability)

SSRIs,
lithium,
MAOIs,
linezolid,
tramadol,
meperidine

Agitation, confusion, coma


Dilated pupils
Diaphoretic
Increased bowel sounds
Neuromuscular
hyperexcitability:
clonus, hyperreflexia (lower extremities
> upper extremities)
Salicylates
RR, hyperpnea, HR, hyperthermia
Agitation, confusion, coma

Aspirin,
bismuth
subsalicylate
(Pepto-Bismol),
methyl salicylates

Normal pupils
Diaphoretic
Normal bowel sounds
Nausea, vomiting, tinnitus, ABG with
primary respiratory alkalosis and
primary metabolic acidosis

69

Withdrawal
HR, RR, hyperthermia
Lethargy, confusion, delirium
Dilated pupils
Diaphoretic
Increased bowel sounds

70

Withdrawal from
opioids, sedativehypnotics, ethanol

Scorpion envenoming
Grade 1
Diagnosis
Local pain, paresthesia, erythema, and blisters.
Management
Symptomatic treatment:
1.
2.
3.
4.

Ice bag to reduce the local pain


Local anesthetic agents
Paracetamol 10-15 mg/kg/dose every 6 hr
Tetanus toxoid vaccine

Grade 2
Diagnosis
These include symptoms of grade 1 in addition to:
1. Sympathetic overstimulation: tachycardia, peripheral
vasoconstriction (cool limbs), hypertention
2. Metabolic: hyperthermia, hyperglycemia, acidosis
3. Neuromuscular: confusion, dystonia, fasciculation, ptosis,
vision disorders, aberrant eye movements, mydriasis,
agitation, tremor
4. Cholinergic syndrome: hypersecretions like salivation,
sweating, vomiting, diarrhea, bronchial hypersecretion,
priapism

71

ECG changes: QT prolongation, increased or inverted T waves, ST


segment abnormalities.
Investigations: CBC, Blood glucose, serum electrolytes, blood urea.
Management
Same treatment as for grade 1 in addition to:
1. Oral hydration: IV fluid may be needed if dehydrated.
2. Benzodiazepines: diazepam 0.3 mg/kg IV slowly or rectally.
3. Antivenom: give inside 250 mL saline in hr with close
observation.
4. Prazosin: 30 g/kg/dose orally. The same dose should be
repeated after 3 hr according to clinical response and later
every 6 hr till extremities are warm and dry and peripheral
veins are visible easily.
Blood pressure, pulse rate and respiration must be monitored
every 30 min for 3 hr, every hr for next 6 hr and later every 4
hr till improvement.
5. Glucose insulin regimen: can be given if there are ECG
changes. The dose of glucose is 0.1 g/kg/hour (1 cc/kg/hr of
10% GW) and insulin is administered at a dose of 0.3 unit/g of
glucose (0.3 unit/10 cc of 10% GW) with measuring of blood
sugar.
This should be given continuously till ECG changes disappear.
Potassium should be added if there is no hyperkalemia.

72

6. Calcium: ampoule can be given with infusion if there is


hypocalcemia.
7. Blood transfusion: is indicated if there are signs of hemolysis.

Grade 3
Diagnosis
Life-threatening envenoming consisting of findings of grade 2 in
addition to multiorgan failure. Extra findings are:
1.
2.
3.
4.
5.

Decrease O2 saturation
Diaphoresis
Convulsions, paralysis
GCS < 6 (in absence of sedation)
Heart failure, cardiogenic shock, pulmonary edema

Electrolyte abnormalities: decreasing Na+ and Ca2+, increasing K+.


Management
Same treatment as those of grades 1 and 2 in addition to:
1. Admission to ICU.
2. Dobutamine: 5-15 mcg/kg/min if the patient has pulmonary
edema or heart failure (with or without hypertension).

73

Sepsis
Sepsis: is a systemic inflammatory response resulting from a
suspected or proven infection.
Severe sepsis: sepsis + organ dysfunction.
Septic shock: severe sepsis + hypoperfusion or hypotension for
more than one hour.
Risk groups for sepsis
1. Infants.
2. Malnourished children.
3. Immunosuppressive
drug
regimen,
e.g.
steroid,
chemotherapy.
4. Children with chronic use of antibiotics.
5. Hospital patient who has urinary catheter or endotracheal
tube.
Management
Diagnosis of sepsis
( HR, RR, BP, mental status changes)

Send for
investigations

1. Establish ABC (put I.V line, if


unable then intraosseus line)
2. Give O2
3. Check HR, RR, BP, temperature,
SpO2, capillary refill.

74

1.
2.
3.
4.
5.

Blood culture
Urine culture
CSF
CBC, ESR, CRP
Blood sugar

Give 20 mL/kg isotonic fluid (N/S or Ringer).


Antibiotics: ampicillin 100 mg/kg/day (divided 6 hourly) +
ceftriaxone 50-100 mg/kg once (in 50 mL N/S).

Add acyclovir 10-20 mg/kg x 3 if herpes simplex is suspected.


Change ampicillin to vancomycin 30-60 mg/kg/day if there is
a catheter or indwelling medical device.
Add amphotericin B (dose according to drug brand) for fungal
infection in immunocompromised patients.

Improvement

No improvement

Continue O2
Maintenance
fluid

I.V

Change antibiotics
according to C/S

Transfer patient to
ICU with diagnosis
of severe sepsis or
septic shock.

75

Septic shock in ICU

Check: level of consciousness, HR, BP, RR, SpO2, temperature,


capillary refill, and urine output.
Investigations:
1. Blood sugar, blood urea, serum electrolytes, blood gas
analysis
2. CBC, ESR, CRP
3. Blood culture, urine culture, CSF
4. Liver function tests, PT, PTT

1. IV fluid (N/S) 20 mL/kg/10-15 min; can repeat 3 times or


can give 60 mL/kg/1 hour.
2. Insert a foley catheter.
3. Recheck the goals (mentioned below).

Response to fluids

76

No response to fluids
(fluid-resistant)

BP, HR and RR return


to normal, capillary
refill < 2 seconds.

Give dopamine
mcg/kg/min.

Response to dopamine
observe

Dopamine-resistant shock

10-20

Give
adrenaline
mcg/kg/min.
Response to adrenaline
observe

Adrenaline drip 1 mg +
100 mL N/S at 0.1
mL/kg/min).

Give hydrocortisone 50
mg/kg bolus, then 50
mg/kg/day.

If there is no response for


60 min this is adrenalineresistant shock.

Give fresh frozen plasma


or blood if you have active
bleeding.

Monitor BP, HR, RR, SpO2,


and urine output.

Resuscitation goals
1. Normal mental status
2. Normal blood pressure
3. Normal heart rate with no difference
between central and peripheral pulses
4. Warm extremities
5. Urine output > 1 ml/kg/hr
6. Capillary refill < 2 seconds

77

Status epilepticus
Status epilepticus is defined as a seizure that lasts for >30 min or
recurrent seizures without full recovery in between seizures for
>30 min.
Convulsion for more than 5 minutes should be treated as status
epilepticus.
Initial management
Manage ABCs
1. Stabilization of airway
2. Maintenance of adequate ventilation
3. Circulatory support
4. RBS: give dextrose if hypoglycemic
Yes

IV line establishment
1. RBS, CBC, serum electrolytes
(if abnormal treat accordingly)
2. IV diazepam 0.3 mg/kg over
2 min (max. 5 mg in infants and
10 mg in older chldren); can be
repeated every 5 min for a max.
of 3 times

No (after 3 attempts
or 30 seconds)

1. Rectal diazepam 0.5


mg/kg (max. 10 mg)
2. Insert IO (intraosseous) line if seizure
is not stopped

Is the child on phenytoin?


Yes

78

No

IV phenobarbital 20 mg/kg over 20


min.
OR
IV/IO phenytoin 10 mg/kg in
normal saline over 20 min (max.
500 mg) (should not be given in
glucose containing fluid) with ECG
monitoring.
Yes

IV/IO phenytoin 20
mg/kg in normal
saline over 20 min
(max. 100 mg) with
ECG monitoring.

Has the seizure stopped?

Admit and look for:


Evidence of trauma, papilloedema
Bulging fontanel manifestation
of sepsis meningitis
Retinal hemorrhage subdural
hematoma
Kussmal breathing dehydration
metabolic disorder or drug
intoxication
Irregular respiration brainstem
dysfunction

Continue supportive care


Admit to ICU/call anesthetist

No

1. Rapid sequence
intubation
2. I.V / I.O midazolam
0.1 mg/kg loading
dose (max. 8 mg) over
2-3 min.
Then start infusion of
120 g/kg/hr, and
increase by 120
g/kg/hr every 5 min
(max. 1.5mg/kg/hr).

High dose phenobarbital


Thiopental infusion
Propofol

79

Transfusion
Indications for transfusion
Packed RBCs
Red blood cells (RBCs) are transfused to increase the oxygencarrying capacity of blood and, in turn, to maintain satisfactory
tissue oxygenation.
1. Premature infant
a.
b.
c.
d.

Stable and growing with Hb < 7 g/dL


IRDS without oxygen requirement and Hb < 10 g/dL
IRDS with oxygen requirement and Hb < 12 g/dL
Mildly symptomatic anemia (e.g. apnea, tachycardia, poor
weight gain) with Hb < 10 g/dL
e. Severely symptomatic anemia (e.g. worsening apnea,
hypotension, acidosis, heart disease) with Hb < 12 g/dL

2. Term infant < 4 mo of age


a. Clinical manifestations of anemia (e.g. apnea, tachycardia,
poor weight gain) with Hb < 7 g/dL
b. Perioperative anemia with Hb < 10 g/dL
c. Hypoxia or on ECMO or ECLS with Hb < 12 g/dL
d. Cyanotic heart disease with Hb < 13 g/dL
e. Acute blood loss > 10% of blood volume not responsive to
other forms of therapy
f. Clinical shock or severe decrease in BP with Hb < 10 g/dL
3. Infant > 4 mo of age

80

a. Acute blood loss > 15% of blood volume, or anticipation


thereof, or hypovolemia not responsive to other forms of
therapy
b. Postoperatively with signs of anemia (e.g. apnea) and Hb <
10 g/dL
c. Severe cardiopulmonary disease with Hb < 12 g/dL
d. Patients receiving chemotherapy or irradiation, or
patients with chronic anemia not responsive to medical
therapy with Hb < 7 g/dL (symptomatic patients may be
transfused at a higher hemoglobin level)
e. Complications of sickle cell disease (e.g. CVA or acute
chest syndrome) or for preoperative preparation of such
patients, or chronic transfusion regimen for thalassemia
or other red cell disorders
f. Circuit prime for plasma exchange or stem cell collection
g. Clinical shock or severe decrease in BP with Hb < 10 g/dL
Platelets
A. Prophylaxis
1. Premature infants
Stable premature infant: < 30,000/uL
Sick premature infant: <50,000/uL
2. Term infants
< 4 mo: <20,000/uL
> 4 mo: <10,000/uL
3. Prior to lumbar puncture if platelet count <10,000/uL (and
patient is not actively bleeding)
4. Patient scheduled for invasive procedure and platelet count is
< 50,000/uL

81

B. Treatment
1. Patients with active bleeding and platelet count < 50,000/uL
2. Diffuse microvascular bleeding in association with
cardiopulmonary bypass or extracorporeal membrane
oxygenation (ECMO) with platelet count < 100,000/uL or
laboratory value not available
3. Bleeding in a patient with a qualitative platelet defect
regardless of platelet count
Granulocytes
1. Bacterial sepsis in an infant < 2 wk of age with neutrophil
count < 3 x 109/L
2. Bacterial sepsis or disseminated fungal infection that is
unresponsive to antibiotics in a patient > 2 wk of age with
neutrophil count < 0.5 x 109/L and whose neutrophil count is
expected to recover.
3. Infection that is unresponsive to antibiotics and the presence
of a qualitative neutrophil defect regardless of neutrophil
count.
Fresh frozen plasma
1. INR > 1.5-2 times the mean normal value in a nonbleeding
patient scheduled for surgery or invasive procedure
2. Diffuse microvascular bleeding in a patient with a PT or PTT >
1.5 times the mean normal value or values not yet available
3. Warfarin overdose with major bleeding or impending surgery
4. Patients with thrombotic thrombocytopenic purpura (TTP)
undergoing transfusion or plasma exchange

82

5. Protein C, protein S, anti-thrombin III deficiencies, or other


single-factor deficiency where no product is available and
patient is bleeding
6. Bleeding secondary to vitamin K deficiency
Cryoprecipitate
1. Quantitative fibrinogen disorder with fibrinogen < 100 mg/dL
and scheduled for invasive procedure
2. Qualitative fibrinogen disorder with diffuse bleeding or
scheduled for invasive procedure
3. von Willebrand disease or Hemophilia A (factor VIII
deficiency) with active bleeding or invasive procedure
planned, unresponsive to DDAVP and/or factor concentrates
4. Fibrin glue production
Indications for transfusion
Packed RBCs
1. Hb < 70 g/L (although lower thresholds may be acceptable in
patients without symptoms and where specific therapy, e.g.
iron, is available)
Transfusion may be indicated at higher thresholds for specific
situations:
2. Hb < 70-100 g/L during surgery associated with major blood
loss or if evidence of impaired oxygen transport
3. Hb < 80 g/L in patients on a chronic transfusion regimen or
during marrow suppressive therapy (for symptom control
and appropriate growth)
4. Hb < 100 g/L only for very select populations (eg. neonates)

83

Platelets
1. Bone marrow failure
Platelets < 10 x 109/L if no other risk factors for bleeding
Platelets < 20 x 109/L if risk factors present (fever, antibiotics,
haemostatic failure, risk of intracranial haemorrhage)
2. Surgery/invasive procedure
Platelets < 50 x 109/L (however, higher counts may be needed
in surgeries with high risk of bleeding, e.g. neurosurgery)
3. Platelet function defects
Transfuse if there is bleeding or high risk of bleeding,
regardless of actual platelet count
4. Bleeding/massive transfusion
Maintain platelets > 50 x 109/L if thrombocytopaenia is likely
contributing to bleeding
Maintain platelets > 100 x 109/L in the presence of diffuse
microvascular bleeding (DIC) or CNS trauma
Fresh frozen plasma
1. Warfarin effect, in the presence of life-threatening bleeding in
addition to the use of vitamin K and vitamin K dependent
clotting factor concentrates for bleeding with abnormal
coagulation
2. Liver disease, if bleeding with abnormal coagulation
3. Acute DIC when there is bleeding and abnormal coagulation
following massive transfusion or cardiac bypass for bleeding
in the presence of abnormal coagulation
Cryoprecipitate
Fibrinogen deficiency, in the setting of clinical bleeding, an
invasive procedure, trauma or DIC.

84

Pre-transfusion assessment
1. Determine the indication for transfusion.
2. Collect pre-transfusion sample (except in infants on ASBT
protocol).
a. A sample for cross-matching must be collected in a 1.4 mL
red EDTA tube (NOT bullet tubes). Patients known to have
red cell antibodies or haemolytic anaemia will require a
larger sample.
b. Correctly identify the patient during the collection of the
pre-transfusion sample. Identification must include 3
unique identifiers (full name, DOB, and UR). This, together
with completing the bedside check prior to blood
administration are the most vital steps in preventing
serious transfusion errors.
3. Request the appropriate blood component and special
requirements:
a. Leukocyte depleted blood products should be given to:
o Immuno-compromised patients (oncology, transplant
recipients, ICU patients, and other congenital and acquired
immune deficiencies)
o Patients requiring chronic transfusions
o Infants under 12 mo
o Intrauterine or exchange transfusions
b. Irradiated blood products should be given to: all immunocompromised patients, including all oncology patients,
cardiac neonates and all patients in ICU, to prevent graftversus host disease.

85

c. CMV negative products: leucocyte depleted blood


products, are considered an acceptable alternative to CMV
seronegative products at RCH
Transfusion volumes and rates
Packed RBCs
o

o
o

Formula: packed cells (mL) = weight (kg) x Hb rise required


(g/L) x 0.4
Example: 10-kg child requiring Hb to rise from 60 to 110 g/L:
10 x 50 x 0.4 = 200 mL
Pack sizes: 250-300 mL/pack; 50-60 mL/Pedipack
Rate: transfusion will be started at a slower rate (e.g. half the
rate) for the first 15 min; if no adverse effects occur increase
the transfusion to a 2-4 hourly rate depending on the patient's
condition and fluid balance

Fresh frozen plasma


o
o
o

Formula: 10-20 mL/kg


Pack sizes: 300 mL/pack; 50 mL/pack (for neonatal use)
Rate: 3 mL/kg/hr over 2-3 hours (occasionally platelets are
given over 30 minutes, but this may contribute to an
increased risk of some reactions (fever/chills) and fluid
overload)

Cryoprecipitate
o
o
o

86

Formula: 5-10 mL/kg


Pack sizes: 30-40 mL/pack
Rate: start at no more than 5 mL/min

Management of transfusion
The key steps include:
1. A formal checking process prior to commencement of
transfusion
2. The use of correct equipment (filters, pump, consideration of
blood warmer)
3. Correct transfusion documentation including patient
observations, start and finish times
Monitoring of the patient:
Observations should be undertaken for every unit transfused.
Minimum monitoring of the patient should include:
o

Regular visual observation throughout the transfusion


episode.

Pre-transfusion pulse (P), blood pressure (BP), temperature


(T) and respiratory rate (RR). These should be taken and
recorded no more than 60 minutes before starting the
transfusion.

P, BP and T should be taken 15 minutes after the start of each


component transfusion. If these measurements have changed
from the baseline values, then RR should also be taken.
More frequent observations may be required in e.g. rapid
transfusion, or patients who are unable to complain of
symptoms that would raise suspicion of a developing
transfusion reaction.

87

If the patient shows signs or symptoms of a possible


transfusion reaction, P, BP, T and RR should be monitored and
recorded and appropriate action taken.

Post-transfusion P, BP and T should be taken and recorded


not more than 60 minutes after the end of the component
transfusion.

Patients should be observed during the subsequent 24 hours


for (or, if discharged, counselled about the possibility of) late
adverse reactions. Organisations should ensure that systems
are in place to ensure patients have 24-hour access to clinical
advice.

Complications during transfusion

88

The most common immediate adverse


transfusion are fever, chills and urticaria.

reactions

to

The most potentially significant reactions include acute


haemolytic transfusion reactions, bacterial contamination of
blood products and transfusion related acute lung injury.

During the early stages of a reaction it may be difficult to


ascertain the cause.

All suspected transfusion reactions must be reported to the


issuing blood bank immediately. The on-call haematologist
will contact the clinical area to provide advice regarding
investigation and ongoing transfusion support.

Adverse effects of transfusion


The most clinically important adverse effects of transfusion in
medical patients are infectious or immunological phenomena.
The most significant infectious risks are addressed during the
donor screening process, and most blood centers employ
bacteriological surveillance measures on certain blood products.
Transfusion-transmitted
infection
HIV

Residual risk per transfused


component
1 in 1,467,000

Hepatitis C

1 in 1,149,000

Hepatitis B
West Nile Virus

1 in 282,000
Uncommon
50-85% of donors are carriers.
Leukocyte reduction is protective
1 in 2-3,000 (mostly platelets)

Cytomegalovirus
. Bacterial Infection
Parasitic Diseases
Babesiosis, Chagas, Malaria

Relatively uncommon

After transfusion
Document the effect of transfusion on the patient's condition
including Hb if repeated.

89

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