Professional Documents
Culture Documents
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Edited by Dr A Tsang Contributed by Prof CF Chan, Prof YF Cheung, Ms SY Chiu, Dr S Chim, Dr S Chiu, Dr HK Ho, Dr SL Lee, Dr YK Ng, Dr NS Tsoi, Dr KY Wong, Dr R Wong, Dr A Yung
The University of Hong Kong Department of Paediatrics and Adolescent Medicine Queen Mary Hospital
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PREFACE
Welcome to the Department of Paediatrics and Adolescent Medicine (UPAM)! Our department, like any other units in this teaching hospital, strives for excellence in quality of patient care, academic and educational pursuits. However, we differ in that we deal with children. Hospitalisation is a very distressing event for both the children and their family. Not only do we need to have the knowledge and technical skills to treat the physical conditions, we must also develop skills in handling the social and emotional needs of the children and their families. Be motivated as this is the pre-requisite for being a good doctor. It is our aim that you will develop clinical competence in managing common paediatric problems through working under supervision and we hope you will share with us the joy of helping children and their families through their illness.
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CONTENTS
PREFACE .................................................................................................................... 2 CONTENTS ................................................................................................................. 3 SECTION 1: GENERAL INFORMATION..................................................................... 5 1.1 OUR DEPARTMENT - UPAM................................................................................. 6 1.2 GENERAL INSTRUCTIONS TO INTERNS AND RESIDENTS .............................. 7 1.3 ORIENTATION TO MEDICAL STAFF IN HKWC .................................................... 8 1.4 GOOD CLINICAL DOCUMENTATION AND CASEMIX .......................................... 9 1.5 DISEASE CODING AND COMMON ERRORS IN MAR /MOE..............................11 1.6 INFECTION CONTROL IN PAEDIATRIC WARD ................................................. 13 1.7 ADMISSION OF PAEDIATRIC PATIENTS............................................................ 18 SECTION 2: PROCEDURES IN PAEDIATRICS........................................................ 20 2.1 BLOOD SPECIMEN COLLECTION ..................................................................... 21 2.2 CAPILLARY PUNCTURE (HEEL PRICK) ............................................................ 22 2.3 BLOOD TAKING FROM CENTRAL VENOUS CATHETER.................................. 23 K8 HICKMAN CATHETER BLOOD TAKING (non-touch sterile technique) ............ 23 2.4 PRE-TRANSFUSION COMPATIBILITY TEST IN NEONATES CROSS MATCH ........................................................................................................................ 25 2.5 URINE EXAMINATION......................................................................................... 26 2.6 URINARY BLADDER CATHETERISATION ......................................................... 28 2.7 LUMBAR PUNCTURE ......................................................................................... 29 2.8 MANTOUX TEST ................................................................................................. 31 2.9 SEDATION FOR PROCEDURES ........................................................................ 32 2.10 STEROID PREMEDICATION IN RADIOLOGICAL INVESTIGATIONS .............. 38 2.11.PRE-OPERATIVE FASTING FOR PATIENTS UNDERGOING ANAESTHESIA 2.12 CARDIAC PULMONARY RESUSCITATION ...................................................... 41 2.13 MANAGEMENT OF ANAPHYLAXIS .................................................................. 42 SECTION 3: COMMON PAEDIATRIC PROBLEMS.................................................. 43 SECTION 3.1: RESPIRATORY SYSTEM ................................................................. 44 3.1.1: MANAGEMENT OF CHRONIC ASTHMA ........................................................ 45 3.1.2: MEDICATION FOR ALLERGIC RHINO-CONJUNCTIVITIS............................. 52 3.1.3: MEDICATION FOR ECZEMA........................................................................... 54 3.1.4 ACUTE ASTHMATIC ATTACK........................................................................... 56 3.1.5 ACUTE RESPIRATORY DISTRESS ................................................................. 59 3.1.6 ACUTE UPPER AIRWAY OBSTRUCTION........................................................ 60 3.1.7 ACUTE VIRAL BRONCHIOLITIS ...................................................................... 62 SECTION 3.2: INFECTION........................................................................................ 63 3.2.1 ANTIMICROBIAL THERAPY ............................................................................. 64 3.2.2 COMMONLY USED ORAL ANTIBIOTICS......................................................... 67 3.2.3 FEVER .............................................................................................................. 69 SECTION 3.3: CARDIOLOGY................................................................................... 70 3.3.1 INFECTIVE ENDOCARDITIS PROPHYLAXIS ................................................. 71 3.3.2 HEART FAILURE .............................................................................................. 72 3.3.3 SHOCK ............................................................................................................. 73 SECTION 3.4: NEUROLOGY .................................................................................... 74 3.4.1 ACUTE ENCEPHALOPATHY............................................................................ 75
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3.4.2 FEBRILE CONVULSIONS ................................................................................ 78 3.4.3 PROLONGED SEIZURE, SERIAL SEIZURE, CONVULSIVE STATUS EPILEPTICUS ................................................................................................. 79 SECTION 3.5: GENERAL PAEDIATRICS ................................................................. 85 3.5.1 DIARRHOEA ..................................................................................................... 86 3.5.2 FLUID AND ELECTROLYTES........................................................................... 88 3.5.3 CHILD ABUSE................................................................................................... 92 3.5.4 URINARY TRACT INFECTION ......................................................................... 95 3.5.5 NEPRHITIC SYNDROME ................................................................................. 96 3.5.6 ACUTE POISONING ......................................................................................... 97 SECTION 3.6 : PAEDIATRIC HAEMATOLOGY & ONCOLOGY............................. 103 3.6.1 MANAGEMENT OF NEUTROPENIC FEVER ................................................. 104 3.6.2 MANAGEMENT OF HAEMOPHILIA ............................................................... 106 3.6.3 MANAGEMENT OF THALASSEMIA MAJOR.................................................. 107 3.6.4 MANAGEMENT OF NON-IMMUNE THROMBOCYTOPENIA ........................ 109 3.6.5 MANAGEMENT OF IMMUNE THROMBOCYTOPENIA (ITP)......................... 110 3.6.6. MANAGEMENT OF TRANSFUSION REACTION...........................................111 SECTION 3.7 : NEONATOLOGY............................................................................. 114 3.7.1 NEONATAL INFECTION ................................................................................. 115 3.7.2 MANAGEMENT OF NEONATAL JAUNDICE .................................................. 117 Indications for PT/ET for babies with GA 35 weeks ................................................ 117 Assessment at K8S/K10S (see Appendix 1)............................................................. 120 Assessment of a newborn with jaundice................................................................... 126 Guidelines of use of Minolta JM-103 in postnatal ward ............................................ 132 SECTION 4 : UPAM USEFUL TELEPHONE NUMBERS ........................................ 133 NOTES ..................................................................................................................... 134
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K8 K10
D4: Paediatric Cardiology wards (General) E5: Paediatric Cardiology ICU II. Out-patient Clinic: in K block, Ground floor III. UPAM Office: in 1/F, New Clinical Building B. Admission policy 1. According to age : Day 0 to 1 month old: NICU/SCBU 1 month to 18 years old: general ward K7 2. Direct admission without going through A&E: to be arranged with team head on call
C. Departmental Meetings and educational activities
The following departmental meetings are held in 1/F, New Clinical Building: Journal Club: Monday 12:45pm (Seminar Room) Grand Round: Thursday 8:30am (Seminar Room) History Meeting: Friday 12noon (Conference Room) Each specialty area will have their own specialty meetings and ward rounds.
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children. Minimize the number of painful procedures by careful organization of investigation and treatment and perfection of skill in carrying out such procedures. Don't be over-persistent in repeating venipunctures. Avoid separation from parents. Talk and explain to the parents. Good rapport is important for good treatment outcome.
1. Develop your clinical competence in dealing with common paediatric problems "Common sense" need Be the first line of defense. Prioritize your work. Attending to a sick child is your first priority. Technical/practical skills: start with supervision (refer to log sheet of clinical procedures) Discuss with senior in case of doubt. 2. Develop good communication skills. With patients and parents: be sensitive to their needs. Listen and give appropriate information. With fellow colleagues: "coverage at the same level". Handover ill cases/unfinished procedures to intern on call. With seniors: report any significant clinical/laboratory findings once spotted; report problems with parents; confirm whether your decisions made were appropriate. With nursing staff: discuss with nurses on patient management and procedures with patience and courtesy. With referring doctors and doctors from other department: be courteous. Tell your team head or supervisor of any grievances or conflicts early. Remember that quality patient care is achieved through collaborative teamwork. 3. Always respond to calls promptly. 4. Recognize ones own limitations and know when to seek advice. 5. Maintain good medical practice by continuous learning Evidence-based practice : understand the relevance of evidence to support patient care Keep your professional knowledge and skills up to date 6. Be honest and open and act with integrity.
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Example 2: The most complex condition is the principal diagnosis A patient was admitted to hospital for acute appendicitis and peritonitis. Appendicectomy was initially performed. Whilst in hospital, the patient had a heart attack and coronary bypass surgery was performed Principal Diagnosis Secondary Diagnosis Procedures Acute Myocardial Infarction Appendicitis & Peritonitis 1. Coronary Bypass Surgery 2. Appendicectomy
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Lobectomy
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Extracted from The Importance of Good Clinical Documentation & the Role of the Clinician, Performance Office, HKWC (2010) Reference: HA intranet site see casemix project for more detail
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1. 2. 3. 4.
Special point for neonates in K8 Day centre 1. Still need to code V30.00 for inborn and V30.1 for outborn if they are admitted within 28 days or 44 weeks of corrected age 2. Code day-patient V72.9 for those admitted for NNJ assessment, ROP assessment and procedures 3. Those babies admitted for ROP screening, pick previous diagnosis for prematurity, birth weight and inborn/outborn 1. 2. 3. 4. 5. 6. 7. 8. 9. How to arrange S5 follow-up for inborn neonate Check the S5 follow-up date of the mother. Find the babys name in the ward list. Go to the <Out-patient Appointment Booking> window through the ward list. Change the <Specialty> to <OBS Obstetric Clinic>. In the <Subspecialty clinic>, choose <BBNZ Neonatal Assessment S5> Enter the follow-up date, preferably the same as that of the mother. In the box of <Appointment Type>, click <Subsequent>. Then press <Search>. Click <Accept> if the date is appropriate and then <OK>.
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Common errors in MOE 1. 2. 3. 4. 5. Wrong dosage Dosage of MDI e.g. Pulmicort 200 ug per puff vs 50 ug per puff Dosage of mixed drugs e.g. Seretide 25/125 vs 25/50 Home leave prescription Be careful of drug names with similar spelling
Common errors in MAR 1. Illegible hand writing 2. Decimal points 3. For drug given once per day, must use daily instead of QD Dr YK Ng October 2010
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Airborne Precaution (negative pressure isolation) Infections spread by airborne (aerosol) route: measles, varicella, disseminated zoster (usually in an immunocompromised host) and TB in a child with 1) cavitary pulmonary TB, 2) positive sputum AFB smear 3) laryngeal involvement 4) extensive pulmonary infection. Contact Precaution Organisms that commonly contaminate large surfaces around the patient or with potentially serious infection control implications, including rotavirus, norovirus, salmonella in a diapered or incontinent child, Salmonella typhi, varicella, scabies, enterovirus, RSV, parainfluenza, adenovirus, MRSA, ESBL. Examples of preemptive contact precaution: a baby with acute bronchiolitis (suspicious for RSV), a child with vomiting and diarrhea in winter (suspicious of rotavirus), a child with vomiting and diarrhea (suspicious of norovirus). These children should be placed in a room or cohorting in a cubicle if there are many patients with the same etiology (e.g. rotavirus gastroenteritis in winter).
Reverse isolation This is indicated for an immunocompromised host to protect the patient from other patients who may be infectious. Patients with transient neutropenia secondary to a viral infection do not need reverse isolation. __________________________________________________________________________________
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HIV testing: counseling and informed consent Testing for HIV infection carries the risks for discrimination in jobs, school and child care. The parents or guardian and the patient, if old enough to comprehend, should be counseled about the possible risks (as stated above) and benefits (early effective treatment if infected, ruled out infection if not) of testing a child and the consequences of HIV infection. Consent should be obtained from the parent or legal guardian and recorded in the patients medical chart. No signed consent is necessary. Maintaining confidentiality in all cases is essential to preserving patient and parent trust and consent. Since this test creates a lot of anxiety in parents and patients, the results should be given to the parents and patient, if appropriate according to age, as soon as they are available. The turnaround report time for HIV serology is about 1 week and that of HIV RNA is about 2 weeks. Follow up appointments for testing result should be made accordingly. Varicella Outbreak There is a standard template for plan of action that should be prepared when there is an outbreak such as varicella in the ward. (See Appendix for sample.) Contact Infection Control Unit (x3553) Dr. Susan Chiu (through Hospital Operator)
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Immune group: no special action. Name Age Dx History of (ID) chickenpox WHM 11 ALL + KSL 14 Rhabdo + TWT 4 ALL HMY 10 PBMT + HKH 6 ALL + LOK 7 AML +
Quarantine -
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Chickenpox * Cholera *
14-21 1-5
Diphtheria *
2-7
Hand, foot and mouth disease Hepatitis A * Measles * Meningococcal infections (invasive)* Mumps * Rubella* Scarlet fever * Tuberculosis * Typhoid fever *
3-7
9 days from the appearance of swelling 7 days from the appearance of rash 5 days from starting the antibiotic course As advised by the doctor Until at least three consecutive stool samples collected no less than 24 hours apart are tested negative for such bacteria (the first stool sample has to be collected 48 hours after the completion of the antibiotic course) Viral gastroenteritis 1-10 Until 48 hours after the last episode of diarrhoea or vomiting Whooping cough * 7-10 5 days from starting the antibiotic course # The recommendation made above is based on the general infection period only. Other factors, such as the clinical conditions of the sick child, have to be considered as well. The attending doctor should exercise his / her professional judgment when making the final decision on the length of sick leave. * Diseases to be reported to the Centre for Health Protection, Department of Health as required by the law. Reference: http://www.chp.gov.hk/files/pdf/School_full_eng_20090115.pdf
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Response time of the department being Your action consulted Within 30 min Inform senior. Call doctor-on-call of other Within 2 hr departments and send consultation form by fax. Within 1 calendar day disregard of Sat, Sun, Send consultation form by fax. public holiday (should only use this during weekends & PH) Within 1 working day
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Purpose: To draw blood from Hickman Catheter with safe and effective method. ** Wash hands before& after procedure. Sterile items, close system. Very careful for critical area. "Clamp Here". No pulling. No scissors. Use of a 10ml or larger syringe is recommended. Blood culture from red lumen, white lumen, peripheral site. Blood for clotting profile: E.g. discard 3ml blood, take 1.5ml for CBP, LRFT, then another syringe 2ml for clotting Use betadine for blood culture, TPN. Check with staff of K7, K10.
Equipment Alcohol wipe 70% (3+3+1+1). Gloves for Standard Precaution. Heparinized saline 50 units / 5ml. Two different size syringes: one syringe to discard blood, one syringe for blood sampling. Two 10 cc syringes - one for flushing l ml Heparinized saline, then one for flushing 4ml Heparinized saline (in paediatric). Jelco to block the line or sterile needle to cap the IV tubing tip. Blood bottles. Patient labels. Procedure
1. CHECK PATIENT INDENTITY. Wash hands thoroughly with antimicrobial soap and water. 2. Prepare all items in a big tray. Draw up heparinized saline in 10ml syringes. Wear gloves. 3. For continuous infusion: Stop all IV drip, clamp another lumen to avoid the blood result
interference with the IV infusion. e.g. TPN, dextrose, electrolyte. (Press RESET Lifecare pump).
4. Swab the catheter junction with Alcohol wipe vigorously with friction for 3 times. Allow the
antiseptic to air dry. Ensure that the smooth-edged clamp of the catheter is closed.
5. Disconnect the luer lock cap / IV tubing. Cap the IV tubing end with new needle. Swab the hub
thoroughly with Alcohol wipe vigorously with friction for 3 times. Allow the antiseptic to air dry. Connect an empty 5ml syringe.
6. Release the clamp, aspirate 3ml blood to clear the catheter. (2 ml for neonate, re-infuse later). 7. Connect another syringe, unclamp the catheter, and draw the blood sample. 8. Clamp the catheter and change 1 ml heparinized saline syringe to flush the catheter. Then clamp
Connect a new injection cap to the end of catheter, or to connect with infusion tubing.
12. For continuous infusion, OPEN the catheter clamp first. To prevent accidentally rupturing of the
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well with the medium immediately. Label specimen and send with lab form. Document in patient's record. Ms SY Chiu 2004
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3. Mothers blood sample Scenario 1: mother as in-patient in OBS unit of QMH - Process cross-match with GCRS Scenario 2: mother as in-patient in another hospital - Process cross-match with <paper request form> - Double check the mothers name and ID number, special attention to the blood sample provide - Cross-match form preferred to be filled by referring hospital, do not accept GCRS form from another HA hospital Scenario 3: mother accompanies the baby - Process cross-match with <paper request form> - If other just recently discharged from QMH OBS unit, can check with blood bank if mothers blood is needed, special attention to mothers ID number, is it UN or passport number Scenario 4: mother not available - Special arrangement with blood bank Dr YK Ng October 2010
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External supports
Fig. 1
Interference lines
Feeding Draw few drops of well mixed urine sample using a disposable plastic pipette. Wipe the pipette and hold it at an angle until the tip is placed between the cover glass and the counting chamber as indicated in Fig. 2. The urine between the cover glass and the chamber is filled up by capillary action. Before the overflow of urine at the edges of the chamber, the tip of the pipette must be removed. The chamber must be cleaned and re-fed if air bubbles are seen in the chamber or urine overflows Fig. 2 into the grooves.
Possible sources of error: The counting chamber is not clean The cover glass is not placed correctly onto the chamber The chamber is not filled free of bubbles The chamber is overfilled There is not enough time for sedimentation of the urine particles
b. How to clean the counting chamber Immerse the counting chamber and the cover glass into a 10% Clorox solution for 10 minutes for disinfection. Discard the Clorox solution and then rinse the cover glass and counting chamber with tap water. Dry the cover glass and chamber with soft tissue or kimwipes and return it to the box.
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1 mm
1 mm
3 mm
1 mm
Depth = 0.1 mm
There are 9 large squares and each square is 0.1 ul in volume. Therefore, the total volume of 9 squares is 0.9 ul. Use 40x amplification to identify cells morphology. Use 10x amplification for counting. Count all 9 large squares and calculate as follow:
Number of cells ----------------------------------- = cells per ul 0.9 Dr S Chim Reviewed October 2010
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Figure 1
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available at http://www.hku.hk/hkucoi
Procedure 1. Observe universal precautions. 2. Draw up 0.1 ml Tuberculin PPD RT23 into a 1ml syringe. [Each 0.1ml of PPD RT23 contains 2 tuberculin units(MT2) which is equivalent to 5 tuberculin units of PPD-S (MT5)]. 3. Cleanse the skin on the volar aspect of the mid-forearm with alcohol and allow to dry thoroughly. 4. Stretch the skin taut. 5. Hold the syringe at 10-15 degree to the skin and introduce the needle just below the epidermis (about 2mm). Inject the tuberculin into the intradermal skin layer to produce a well-defined bleb of 6 to 10 mm in diameter. If the bleb is <6mm, repeat the process 2.5cm from the first site. 6. Document the time and site of test in the patients record. 7. Read the test results in 48 to 72 hours. Measure the size of the induration. Disregard erythema. Rub a finger lightly from the normal skin area to the indurated zone and mark the zone of induration. Measure the diameter in millimeters perpendicularly to the long axis of the forearm. DO NOT just write down positive or negative. 8. Document the result (report on the size of the induration) in the case record (and the CMS).
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One trained resident will be assigned to K8 Day ward on TUE am, WED am and THU pm to cover the regular Paediatric RD sessions.
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III. Low risk patients (ASA class I) a. Patients without the above mentioned risk factors. b. Patients sedated with oral Chloral hydrate only and without airway compromise.
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III
High
IV
High
High
High
1. Only low risk and selected moderate risk patients can be admitted to day ward for procedural sedation and analgesia. a. Healthy neonates with PCA > 44 weeks and premature babies with PCA > 60 weeks and who are oxygen independent. b. Asthmatic patients with satisfactory control. c. Epileptic patients with satisfactory control. d. Healthy children require first line iv sedation. 2. The other moderate risk and high risk patient are advised to have the procedure as in-patient. 3. High risk patients that may indicate consultation to anaesthetist and GA session for procedures: a. b. c. d. e. f. g. h. Difficult airway, airway malformations. Intractable convulsion. Required assisted ventilation. Neuromuscular diseases. Require prolong sedation. Difficult sedation such as hyperactivity. History of failed sedation with third line sedatives. History of adverse effect with sedation.
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Pharmacological intervention
1. Pharmacological intervention for painless procedures a. Neonates: Single dose: Chloral hydrate 50 mg/kg oral 30 minutes before examination. Reduced to 20-30 mg/kg for at risk or premature neonates. Consider to be high risk patient when oral sedation fails. b. Children < 8 years: Chloral hydrate 75 mg/kg oral 30 minutes before examination. First line: A top up dose of 25 mg/kg oral after 30 minutes. Maximum total dose 100 mg/kg or 2 grams. Second line: Midazolam 0.1 mg/kg slow iv. Titrate and repeat doses of 0.1 mg/kg after 2-3 minutes; Up to maximum total dose of 0.4 mg/kg or 5 mg. Ketamine 1-2 mg/kg iv. Third line: Addition boluses of 1 mg/kg after 10 minutes; Up to maximum total dose of 2-4 mg/kg iv. Prefer to have pre-medication with Atropine 0.01-0.02 mg/kg iv 2 minutes before Ketamine injection. c. Children > 8 years: Midazolam 0.1 mg/kg slow iv. First line: Titrate and repeat doses of 0.1 mg/kg after 2-3 minute; Up to maximum total dose of 0.4 mg/kg or 10 mg. Second line: Ketamine 1-2 mg/kg iv. Addition boluses of 1 mg/kg after 10 minutes; Up to maximum total dose of 2-4 mg/kg iv. Prefer to have pre-medication with Atropine 0.01-0.02 mg/kg iv 2 minutes before Ketamine injection.
2. Pharmacological intervention for short painful procedures a. Ketamine 1-2 mg/kg iv; Addition doses of 1 mg/kg after 10 minutes; Up to maximum total dose of 2-4 mg/kg iv. Prefer to have pre-medication with Atropine 0.01-0.02 mg/kg iv 2 minutes before Ketamine injection. OR b. Ketamine 2-4 mg/kg im. Do not repeat the dose if it fails as the first im dose is expected to have prolonged sedative effect. OR c. Midazolam 0.1 mg/kg iv in addition to Local Anaesthetic infiltrate. OR d. Fentanyl 1 microgram/kg iv, maximum 50 microgram/dose; Titrate with Midazolam 0.05-0.1 mg/kg iv. Addition doses after 3 minutes.
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Relative contraindications 1. Diabetes mellitus 2. Acute tuberculosis 3. Acute leukaemia and lymphoma (suspected tumour lysis syndrome) 4. Compromised immune system 5. Systemic fungal disease or other systemic infection 6. Peptic ulcer disease or diverticulitis within the past year Consult respective subspecialty teams if patients have above relative contraindications.
Recommendation for oral steroid premedication Methylprednisolone 0.8mg/kg po, rounding up to the nearest 4mg tablet (maximum 32 mg) OR Prednisolone 1mg/kg po (max 40 mg) at 12 hours and 2 hours prior to IV contrast
Recommendation for IV steroid premedication Hydrocortisone 4mg/kg IV (maximum 200mg) 6 hours before contrast study and 2mg/kg 6 hourly for 2 doses after contrast study
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Inhaled short-acting beta-2 agonist as required Add inhaled steroid 200-400 mcg per day* or leukotriene receptor antagonist if inhaled steroid cannot be used (for children aged < 5 years) Start at a dose of inhaled steroid appropriate to severity of disease for children >12 years - 400 mcg / day 5-12 years - 200 mcg / day < 5 years - higher doses may be required if there are problems in obtaining consistent drug delivery Start with twice daily dosing, can be considered to once daily dosing with good control 1:1 ratio should be assumed when changing between beclomethasone dipropionate (BDP) and budesonide and half the dosage for fluticasone insufficient response
Add inhaled long-acting beta-2 agonist (LABA) Assess control of asthma: 1. Good response to LABA and good control -> continue 2. Benefit from LABA but control still inadequate -> continue LABA and increase inhaled steroid dose to 800 mcg/day (>12 years) and 400 mcg/day (5-12 years) 3. No response to LABA -> stop LABA and increase inhaled steroid dose to 800 mcg/day (>12 years) and 400 mcg/day (5-12 years) -> if control still inadequate, trial of other add-on therapy like leukotriene receptor antagonist or sustained release theophylline
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STEPPING DOWN Review treatment every 3 months once asthma is under control. Patients should be maintained at the lowest possible dose of inhaled steroid. When deciding which drug to step down first and at what rate, the severity of asthma, the side effects of the treatment, time on current dose, the beneficial effect achieved, and the patients preference should all be taken into account. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25-50% each time. Consider stopping inhaled steroids after 6-12 months of few or no symptoms, preferably at end of the season if symptoms are seasonal. Discharge criteria and arrangement : 1. Having stopped inhaled steroids for > 1yr 2. Asthma is mild or infrequent episodic 3. Referral to GP / Govt OPD / family clinic 4. Specialty referral if patient still required regular follow up: - other paediatrics unit upon parental request - adolescent clinic if problems associated with adolescence - adult medical unit if > 18 years or after secondary school N.B. Budesonide is preferred for children < 4 year old if the daily dose of beclomethasone > 400 mcg because of the growth effect and study of fluticasone on young age is lacking. This serves as a guideline only. Please discuss with senior from step 3 onwards.
Dr SL Lee __________________________________________________________________________________
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1-3
3-5
spacer
5-8 >8
dry powder inhaler meter dose inhaler with training dry powder inhaler Autohaler
CHARACTERISTICS OF SPACER DEVICES Types Material Mask Dead-space Aerochamber (infant - red ) Plastic Small --(child - yellow) large Babyhaler Space chamber Nebuhaler Plastic Plastic Plastic Yes No No large -----
Mouth-piece No
No Yes Yes
Length(mm) 150
Valve single
Cost(HK$)
Volumatic Plastic No --Yes Nebuchamber (metal chamber) has been withdrawn from the market.
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DRY POWDER INHALER ( DPI ) WITH MULTIPLE DOSES Remarks avoid blowing into DPI as it may clog the powder some studies demonstrated that exhalation before the inhalation or breath holding afterwards is not necessary for DPI the dosage delivered from DPI increases with inspiratory flow rate, thus children should be taught to inhale rapidly through these inhalers many young children and some older children with severe wheezy cannot generate a sufficient inspiratory flow rate, therefore DPIs should not be by routine be prescribed to children younger than 5 years while some older children may need a spacer inhaler during severe acute wheeze
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ACCUHALER ( AH ) Steps 1. Hold the inhaler at horizontal level and check the indicator to see the number of doses left 2. Hold the outer case in one hand and put the thumb of the other hand on the thumb grip and push the thumb away as far as it will go 3. Slide the lever away until it clicks 4. Breath out 5. Seal the mouthpiece around the lips 6. Inhale deeply and rapidly through the mouthpiece 7. Remove AH 8. Hold breath for 10 seconds 9. Breath out slowly 10. Close the outer case 11. If more than one dose is required, repeat steps 2 to 9 Common errors : 1. Slide the lever long before inhalation 2. Forget to close the outer case before the second dose if required
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250mcg (400)
100mcg to 200mcg b.d. 100mcg to 200mcg b.d. > 4 yr 50mcg to 100mcg b.d.
Becodisk 100mcg(8) 200mcg(8) Turbuhaler 100mcg (200) 200mcg (200) 400mcg (200) Accuhaler 50mcg (60) 250mcg (60) Neulin:80mg/15ml Theodur:200mg /300mg tab Slo-theo:50mg /75mg cap
Fluticasone ( Flixotide )
Theophylline
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6/12-2yr 0.5mg b.d. >2yr 1mg b.d. Unit Cost HK$ Dosage > 6yr 5mg b.d./10 mg daily > 6yr 10mg daily
Syrup 10mg/ml
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Fluticasone ( Aqueous Flixonase ) 50mcg daily * Not recommended for children < 6 years old TOPICAL EYEDROPS Hypromellose Sodium chloride 0.9% Oculosan Cromoglycate Na 2% ( Opticrom ) Amount ( per bottle ) 10ml 10ml 10ml 10ml
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25mg 10mg 25mg Unit cost / HK$ cream ointment 10% cream 10% cream (20g) 10% cream (60g)
6mth-6yr 15mg/D to 50mg/D q.i.d. >6yr 25mg/D to 100mg/D q.i.d. >2yr 1mg/kg/D
EMOLLIENTS Aqueous Emulsifying Paraffin soft white ( Vaseline ) Urea in Petrolatum Base ( Urederm ) ANTI-PRURITICS Crotamiton ( Eurax )
TOPICAL STEROIDS + ANTI-INFECTIVES Hydrocortisone 1% + clioquinol 3% Hydrocortisone 1% + neomycin 0.5% Synalar + vioform Diflucortolone valerate 0.1% + chlorquinaldol 1% ( Nerisone C ) Triamcinolone acetonide 1mg + neomycin 2.5mg + gramicidin 0.25mg + nystatin 100,000u ( Kenacomb ) cream (5g) ointment (5g) cream (5g) cream (10g) cream (5g) ointment (5g)
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Triamcinolone Acetonide ( Aristocort ) Clobetasol Butyrate ( Eumovate ) Fluocinolone Acetonide ( Synalar ) Mometasone Furoate ( Elomet ) Betamethasone Dipropionate ( Diprosone ) Betamethasone Valerate ( Betnovate ) Fluticasone Propionate ( Cutivate ) Clobetasol Propionate ( Dermovate )
mild mod potent mod potent mod potent potent potent potent potent potent very potent
* should use mildly potent steroids for infant only and mildly or moderately potent steroids for children <5 years old Dr SL Lee
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Hypercapnea (hypoventilation) develops more readily in young children than in adults and adolescents.
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If the initial response is inadequate, repeat every 20 minutes for a total of 3 doses. Then space out 1-4 hourly until condition settles. Nebulised Salbutamol (Ventolin) ( 1mg/ml nebule) :0.15mg/kg/dose (max 5mg/dose) can be considered under the following situations: Clinical features of severe/life threatening asthma on admission Patient failed to respond to salbutamol via spacer device especially if < 2 years old Severe asthma attack Recognition of acute severe asthma in children aged over 2 years SpO2 < 92% PEF 33-50% Cant complete sentences in one breath or too breathless to talk or feed Pulse > 125 beats/min ( > 5years old) or > 140 ( 2 to 5 years old) Respiration > 30 breaths/min ( >5 years) or > 40 (2 to 5 years) Life threatening features SpO2< 92% PEF < 33-50% best or predicted Exhaustion Hypotension Confusion Coma Ix: 1. CXR indicated when Suspect pneumothorax or pneumomediastinum Life threatening signs Unsatisfactory response to treatment Signs of pneumonia 2. Blood gas consider if SpO2 < 92% on air or with any life threatening signs Investigations are rarely needed for immediate management and are not routinely indicated. Do not rely on blood gas to decide on the initial management in children.
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congenital heart disease rhythm problems e.g. SVT, heart block myocarditis cardiomyopathy secondary to severe anaemia, thyrotoxicosis, sepsis...
3.
Metabolic * acidotic breathing Diabetic ketoacidosis (# Test urine x sugar & ketone) Salicylate(Aspirin) poisoning Uraemia Fulminating sepsis Other metabolic disorders: MSUD
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Refer to Clinical Guidelines on management of croup by the HK College of Paediatricians available on the eKG Paediatrics section.
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Management * Supportive treatment 1. DAT or NPO with IV fluid (if in distress) 2. AR/RR Q1 - 4 H 3. SpO2 monitoring 4. Nasal O2 to keep SpO2 > 92% 5. Trial of short acting beta-2-agonist (SABA) - continued only in those who showed a clinical improvement. 6. use of systemic steroid is not recommended 7. Antibiotics indicated only for secondary bacterial pneumonia 8. No chest physiotherapy during acute stage 9. Ribavirin is not recommended for infants with bronchiolitis although may have a place in children post transplant Investigations 1. (CBP D/C) 2. NPA x viral IF 3. CXR
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Suggested initial treatment Meningitis Age Usual organisms < 1 month Gp B streptococci(GBS), Enterobacteriaceae, Listeria monocytogenes
1-3 month
GBS, Streptococcus pneumoniae, Haemophilus influenzae b, Neiserria meningititidis, Enterobacteriaceae S. pneumoniae, Haemophilus influenzae b, Neiserria meningititidis
Empiric therapy IV Penicillin 200,000 units/kg/day div Q6h (for neonates > 7 days and > 2kg) or IV Ampicillin 200mg/kg/day div Q6H (>7 days and > 2 kg) AND IV Cefotaxime 150mg/kg/day div Q6H (>7 days and > 2 kg) Alternative: Penicillin/ Ampicillin + aminoglycoside IV Vancomycin 60 mg/kg/day div Q6-8H+ IV Cefotaxime 300mg/kg/day div Q6H for possible penicillin-resistant S. pneumoniae until susceptibility is known. IV Cefotaxime 300mg/kg/day div Q6H or IV Ceftriaxone 100mg/kg/day div Q12H PLUS IV Vancomycin 60mg/kg/day div Q6-8H for possible penicillin-resistant S. pneumoniae until susceptibility is known.
Remarks GBS & Listeria : 14-21 days treatment. Enterobacteriaceae: 21 days treatment
Remarks 10 days
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Pneumonia Age Usual organisms GBS, E. coli, Staph Neonate aureus, Listeria monocytogenes Infant/ Usually respiratory child (< 4 viruses. years) S. pneumoniae, H. influenzae, Moraxella catarrhalis
Empiric therapy IV Penicillin + Gentamicin or IV Penicillin + Cefotaxime No antibiotics Amoxicillin/clavulanate PO (35-45mg amoxicillin/kg/day BD; high does of 80-90 mg amoxiciilin/.kg/day div BD for PCN-nonsusceptible S. pneumoniae) or Cefuroxime 20-30 mg/kg/day div BID IV: Cefuroxime 100-150 mg/kg/day div Q8H, Cefotaxime 50-180 mg/kg/day div Q6-8H, Ceftriaxone 50-75mg/kd/day div Q12-24H Erythromycin PO 30-50mg/kg/day TDS/QID Amoxicillin/clavulanate PO (40 mg amoxicillin/kg/day div BD; high does of 80-90 mg amoxiciilin/kg/day div BD for PCN-nonsusceptible S. pneumoniae) IV: Cefuroxime, Cefotaxime, Ceftriaxone
Remarks Use Ampicillin instead of Penicillin if suspect Listeria. Give 10-21 days.
7-10 days Augmentin = Amoxicillin 400mg + clavulanate 57mg per 5ml, ratio 7:1
Consider Chlamydia trachomatis in infants < 3 months S. pneumoniae, H. influenzae, Moraxella catarrhalis
7-10 days
Mycoplasma pneumoniae Erythromycin PO (Atypical pneumonia) 30-50mg/kg/day TDS/QID or Clarithromycin PO 15mg/kg/day BD, or Doxycycline2-4 mg/kg/day div Q12 H the first day, then dose Q24H (for >7 yr, but consider for macrolide resistant M. pneumoniae) or Ciprofloxacin (for > 18 yr, but consider for macrolide resistant M. pneumoniae)
14 days
No data but suggest 7 days for uncomplicated pneumonia and good response
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Acute Otitis media/ Acute sinusitis Usual organisms S. pneumoniae, H. influenzae (nontyepable), Moraxella catarrhalis Empiric therapy 1st line: Amoxicillin, or high dose Amoxicillin 80-90mg/kg/day if likely to have PCN-nonsusceptible S. pneumoniae Alt for Penicillin allergy: Cefuroxime, azithromycin Persistent OM: Amoxicillin/clavulanate, Cefuroxime, or Ceftriaxone (IM/IV) Consult ENT Remarks 5-7 days for OM ( 6 yr with mild to moderate disease); 10 days for younger or with severe disease 10-14 days for sinusitis (or 7 days after clinical improvement)
Cellulitis Usual organisms Gp A Streptococci, Staphylococcus aureus Empiric therapy Remarks PO: Flucloxacillin or Amoxicillin/clavulanate 7- 10 days Alt: Cephalexin. If Penicillin allergic, clindamycin IV: Cloxacillin 50-100 mg/kg/day div Q6H (for 1 yr, maximum 4 gm/day). Alt: Cefazolin 50-100 mg/kg/day div Q8H, Clindamycin 20-40mg/kg/day div Q6-8H
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Amoxicillin & Clavulanic acid (Augmentin) 457mg/5ml (400mg Amoxicillin/57mg Clavulanic acid)
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3.2.3 FEVER
DDx: 1. Infections Respiratory tract infections (commonest) - URI, otitis media, pneumonia UTI Meningitis Gastroenteritis Infective endocarditis Bone & joints: septic arthritis, osteomyelitis Other viral diseases: EBV If prolonged fever, think of TB Typhoid Malaria 2. inflammatory: Kawasaki disease, collagen vascular disease e.g. SLE, JIA 3. Malignancy
Investigations: 1. CBP D/C, smear (thick & thin smear if suspect malaria) 2. ESR, CRP 3. LFT, RFT 4. Blood C/ST (x 3 if suspect SBE) 5. NPA x viral IF 6. Urine x R/M C/ST 7. CXR If prolonged fever, 1. Widal test 2. C3 C4 Ig pattern 3. CRP 4. ANA, anti-DNA, RF 5. Viral titre, EBV panel 6. Mantoux test 7. Stool x C/ST 8. Urine x VMA, HVA (neuroblastoma) Treatment 1. Symptomatic : Paracetamol (Panadol ) 10 mg/kg/dose Q4h prn Tepid sponging, ice pack 2. Treat underlying cause.
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Respiratory tract procedures that involve incision or biopsy of respiratory mucosa (such as tonsillectomy or adenoidectomy, but NOT simple bronchoscopic examination) Regimen as listed above. Gastrointestinal and genitourinary tract procedure Administration of prophylactic antibiotics SOLELY to prevent endocarditis is NOT recommended. (Reference: Prevention of Infective Endocarditis, Guidelines from the American Heart Association. Circulation 2007; 116:1736-1754) Prof YF Cheung Updated October 2010 __________________________________________________________________________________
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3.3.3 SHOCK
Causes 1. Hypovolaemia Blood loss Plasma loss (e.g. burns) Dehydration 2. Cardiogenic Myocarditis, cardiomyopathy Arrhythmia Hypoxia from shunting/ outflow obstruction/ respiratory failure 3. Sepsis 4. Anaphylaxis Immediate management 1. Give 100% oxygen and respiratory support if necessary. 2. Make an initial assessment based on history & PE to determine aetiology 3. Establish IV access 4. ECG monitoring 5. Unless initial assessment indicates a cardiac cause, give 10-20 ml/kg NS or Haemaccel as appropriate over 15 min. Subsequent management 1. Arrange definitive investigations e.g. CBP, blood culture, L/RFT, NaK blood gas, glucose, CXR, ECG etc. 2. ICU admission: may need intra-arterial line and CVP monitoring, urinary catheter (monitor hourly urine output), inotropic support 3. Treat underlying cause
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Causes of acute encephalopathy 1. 2. Hypoxic ischaemia respiratory / cardiac failure, asphyxia Infections & parainfectious causes meningitis, encephalitis, cerebral abscess, para-infectious demyelination (ADEM: acute demyelinating encephalomyelitis) Focal lesions Stroke ( ischemic and haemorrhagic), AVM, vasculitis, bleeding diathesis Tumour, abscess Trauma Accidental, non-accidental Toxin/poisoning Drugs (sedatives and hypnotics, anticonvulsants, antihistamines, anticholinergic), substance abuse Lead Metabolic Hypoglycaemia, DKA, non-ketotic hyperglycemia, hypo/hyperthyroidism, Addison crises,pituitary apoplexy hypo/hypernatremia, hypo/hypercalcemia hyperammonaemia, inborn error of metabolism, Reye encephalopathy Organ failure( renal, hepatic) Hypertensive encephalopathy Epileptic post-ictal state, non-convulsive status epilepticus
3.
4. 5.
6.
7. 8.
Management 1. Maintain Airway, Breathing, Circulation. 2. Record vital signs. 3. Record level of coma according to Glasgow coma scale (score 3-15).
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Verbal response
Motor response
A score of <8 is consistent with severe brain dysfunction. Treatment of acute encephalopathy 1. NPO 2. Strict I & O 3. Neuro-observation Q1h 4. SpO2 & cardiac monitoring 5. D'stix stat. Give D50 if hypoglycaemic. 6. IV fluid : restrict to 1/3 to 1/2 maintenance if suspect increase in ICP. 7. Give toxin antidote (e.g. Naloxone 5-10mcg/kg/dose IM/IV for narcotics) 8. Control seizure if present. 9. Treat underlying cause. 10. Discuss with senior. To ICU. Investigations 1. CBP D/C 2. L/RFT serum osmo 3. Na K Blood gas Ca 4. Sugar 5. NH3 6. Infection screening : Blood x C/ST, urine R/M & C/ST 7. NPA for viral IF+/- Mycoplasma PCR 8. Blood for Viral titre & Throat and rectal swab for virus study 9. Urine & blood for toxicology 10. (Lead) 11. Blood and urine for Metabolic kit (if suspect inborn error of metabolism) 12. CT scan brain urgent. MRI brain to evaluate for demyelination 13. LP contraindicated if signs of increased ICP 14. EEG __________________________________________________________________________________
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2. 3. 4.
Management 1. Airway. Left lateral position, suction, oxygen. 2. Check BP and vital signs. Neuro obs Q1H. 3. Check D'stix: if hypoglycaemic, IV D50 2 ml/kg 4. IV fluid (restrict to 60% maintenance) if BP normal 5. Control seizure 6. Discuss with senior. To PICU. 7. Treat underlying cause Investigations: 1. CBP D/C 2. RFT, LFT 3. Na K Blood gas sugar, Ca, Mg 4. NH3 5. Urine & blood for toxicology (*Lead), AED level if known epilepsy 6. Metabolic kit if suspect IEM 7. CT scan brain urgent. 8. L.P. contraindicated if signs of increased ICP 9. Viral titre and virus studies
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Protocol for in-hospital management of CSE Antiepileptic drug Early SE (within 20/30 min) General measures Airway: oxygen Cardio-respiratory function and regular monitoring: ECG,blood pressure and SaO2 Intravenous access Physical examination and history Blood investigations:AED level (known epilepsy) Blood glucose, blood gas Urinalysis RFT/LFT Calcium and magnesium level (for child under 1 year old) Plasma ammonia Complete blood picture (If pre-hospital benzodiazepine has been given, early initiation of treatment for established SE is recommended) 1-2 ml plasma, 1-2 ml serum and 10 ml urine saved for later analysis Blood culture Investigations Glucostix
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Refractory SE
Refractory SE : defined as failure to respond to 2 or 3 antiepileptic drugs in combination with seizure duration of at least 60 minutes. Patient should be managed in the intensive care unit. Metabolic disturbances should be monitored closely and corrected. General anaesthesia should be instituted for refractory SE as soon as possible EEG monitoring is required when managing refractory SE. Midazolam, propofol and pentobarbitone are the drugs of choice in controlling refractory SE. Intravenous sodium valproate can be an alternative to diazepam infusion in refractory SE.
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Phenobarbitone IVI: 15-20 mg/kg at a maximum rate 1 mg/kg/min High dose phenobarbitone: 10 mg/kg IVI, repeated every 30 min Thiopentone Propofol Pentobarbitone Sodium valproate Pyridoxine Paraldehyde IVI: 3-5 mg/kg bolus followed by infusion 3-5mg/kg/hr IVI: bolus of 1-2 mg/kg (max 10 mg/kg) followed by infusion of 1-2 mg/kg/hour, to a maximum of 5 mg/kg/hour. IVI: 5 mg/kg loading dose, followed by 1-3 mg/kg/hour IVI: 20-30 mg/kg, periodic dosing (twice per day) may be appropriate if seizures are terminated. If seizure continue, a continuous infusion of 5 mg/kg/hr may be effective. IVI: 50-100 mg Rectal, 0.3-0.4 ml/kg, give with same volume of olive oil
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Common anticonvulsants
Drug Indication Daily dose No. of time/day 2-3 Elimination half-life (hr) 8-24 (Chronic) 24-36 (Before autoin-duction) 9-40
Carbamazepine (Tegretol) Tab: 200mg ; CR:200mg; Syr 100mg/5ml Phenytoin (Dilantin) Cap: 30, 100mg; Syr 125mg/5ml Phenobarbitone(Luminal)Tab: 15, 30, 60mg; Elix 60mg/5ml Primidone (Mysoline) Tab: 250mg Valproic acid (Epilim) Tab: 200mg; Syr 200mg/5ml Ethosuximide (Zarontin) Cap: 250mg Clonazepam (Rivotril) Tab: 0.5, 2mg Clobazam (Frisium) Tab: 10mg Diazepam (Valium) Tab: 2, 5mg Rectal: 5, 10mg
Partial ; generalized sz
10-20 mg/kg
Generalized, partial sz
8-10 mg/kg<3 yr 4-7 mg/kg> 3 yr 3-5 mg/kg < 5 yr 2-3 mg/kg > 5 yr 10-20 mg/kg 15-40 mg/kg
Generalized, partial sz
2, or nocte
Generalized, partial sz 1_ gen epilepsies, myoclonic attacks, generalized & partial sz Absences & myoclonic sz All forms All forms, development of tolerance frequent All forms, mainly status epilepticus
2 2-3
20-40 mg/kg 0.1-0.2 mg/kg 0.5-1.0 mg/kg 0.25-1.5 mg/kg (0.1-0.3 mg/kg iv; 0.25-0.5 mg/kg rectal)
1-2 2 2
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3 2
5-7 5-7#
# Not significant, as the drug binds irreversibly to glutamate transaminase, thus _ the brain GABA level; the important half-life is that for restoration of the enzyme level.
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3.5.1 DIARRHOEA
DDx of acute diarrhoea: 1. Gastroenteritis - bacterial, viral, parasitic 2. Food poisoning 3. Systemic infection (especially in young infants) 4. Others : antibiotics-associated, Hirschsprung colitis.. 5. Watch out for intussusception Consider any of the following as possible indicators of diagnoses other than gastroenteritis: C C 1. Fever: 38 or higher in children <3 months or 39 children >3 months 2. Shortness of breath 3. Altered conscious state 4. Neck stiffness 5. Bulging fontanelle in infants 6. Non-blanching rash 7. Bloody diarrhoea (red currant jelly stool) 8. Bilious (green) vomit 9. Severe or localised abdominal pain 10. Abdominal distension or rebound tenderness. Management 1. Contact precaution for rotavirus, norovirus, salmonella in a diapered or incontinent child, Salmonella typhi. 2. ORS (oral rehydration solution) for mild/ moderate dehydration Rehydration therapy Mild to moderate dehydration:
Start maintenance therapy (100 ml/kg for infants) after signs of dehydration have gone. Maintenance fluids can be given as breast milk, formula, or other fluids appropriate for age, offered ad libitum. Ongoing losses - can be replaced by normal diets given ad libitum in children with mild diarrhea and no signs of dehydration - For those with persistent profuse diarrhea or vomiting, replace ongoing loss with ORS: For each watery or loose stool 5ml/kg For each episode of emesis 2ml/kg 3. IV fluid (Deficit + maintenance + ongoing loss) if shock diminished consciousness intractable vomiting massive stool output Refer to section on "Fluid and electrolytes". In infants less than 3 months old with significant diarrhoea
4.
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Pathogen Salmonella
Campylobacter
Shigella
Indication for antibiotics : Consider in young infants < 3 months, any ill or septic looking patient and immunocompromised patient Salmonella typhi Only of value if given early In institutional settings to shorten bacterial excretion In ill patients Those still symptomatic when pathogen is detected
Drug of choice 3rd generation cephalosporins (or oral Ciprofloxacin 15 mg/kg/dose BD in Salmonella typhi) Erythromycin Co-trimoxazole
Stop associated antibiotics. Metronidazole 30mg/kg/day Q6h If fails, use Vancomycin po 40mg/kg/day Q6h (Max 2g/day) Metronidazole 15mg/kg/day TDS Metronidazole 50mg/kg/day TDS
6. Antidiarrhoeal agents are not recommended for acute diarrhea in children. They should not be used in children with fever, toxaemia or blood in stool. Investigations 1. CBP D/C 2. Blood x C/ST (if febrile or < 3 months old) 3. Na K Blood gas 4. Urea creatinine 5. Stool x C/ST, virus 6. Fresh stool x ova & cyst (Giardia, amoeba) References Guidelines for the Management of Acute Diarrhoea in Young Children by the HK College of Paediatricians July 2003 NICE guidelines (last update Oct 2010)
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Example: 8 year old weighing 25 kg 1st 10 kg: 100 ml x 10 = 1000ml 2nd 10 kg: 50ml x 10 = 500ml additional 5 kg: 20ml x 5 = 100ml
Total = 1600ml/day
Body surface area method: assuming caloric expenditure is proportional to surface area. Should not be used for children < 10kg. Water required = 1500ml/m 2/day (Insensible water loss = 400ml/m 2)
Body surface area = square root of (height in cm x body weight in kg) divided by 60
2. Sodium 3. Potassium
2 - 3 mmol/kg/day 2 mmol/kg/day
* 5.85% NaCl 1 ml = 1 mmol Na * 14.9% KCl 1 ml = 2 mmol K Commonly used IV fluids Dextrose solutions : 5%, 10% (D5, D10) Normal saline (NS): 0.9% NaCl 1/5 solution: NaCl 0.18%+ Dextrose 4.3% (Na 31 mmol/L) 1/3 solution : NaCl 0.3% + Dextrose 3.3% (Na 51 mmol/L) 1/2 : 1/2 solution : NaCl 0.45% + Dextrose 2.5% (Na 77 mmol/L) Others Hartmanns solution : Na 131 mmol/L, K 5 mmol/L, Cl 111 mmol/L, lactate 29 mmol/L, Ca 2 mmol/L 8.4% sodium bicarbonate ( 1mEq/ml) : Na 1000 mmol/L, HCO3 1000 mmol/L 3% NaCl : Na 513 mmol/L, Cl 513 mmo/L
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Principles of management 1. Total fluid required = Maintenance requirement + Deficit replacement 2. Calculate the amount of water, sodium and potassium required over a 24 to 72 hour period. The speed of rehydration depends on the type of dehydration, chronicity of the problem and whether patient is acutely symptomatic. 3. Symptomatic hyponatremia and hypernatremic dehydration demands extra caution for fear of central pontine myelinosis and cerebral edema respectively. 4. Extreme caution where there is cardiac failure &/or renal impairment Assessment of degree of dehydration % dehydration Mild (~ 5%) Clinical signs HR 10-15% above baseline Slightly dry mucous membrane Concentrated urine Increased severity of above Decreased skin turgor Oliguria Sunken eyeball/ anterior fontanelle Marked severity of above signs BP drop Delayed capillary refill Acidosis (large base deficit)
Moderate (6-9%)
Parenteral rehydration Phase 1 Where necessary, rapid volume expansion to improve circulation & renal function: 10 - 20 ml /kg bolus NS IV Phase 2 1. Calculate deficit Volume of rehydrating fluid (ml) = BW (kg) x % dehydration x 10 2. Add on maintenance requirement and ongoing losses. 3. Rate of rehydration depends on type of dehydration:
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Deficit
Maintenance
Total required
Add maintenance potassium: 3-4 mmol/kg/day and monitor RFT. Prescription: 2000 ml fluid + 117mmol Na + 40mmol K per day (i.e. 58 mmol/L Na) = 1/3 solution 500 ml + 5 ml 5.85% NaCl + 5ml 15% KCl added to each pint, run at 83ml/hr Ongoing loss to be replaced accordingly e.g. with ORS. Need careful ongoing careful monitoring of clinical state and serum electrolytes.
2. Hyponatremic dehydration (Na < 130)- correct over 24 hours 10kg infant with gastroenteritis presented with vomiting and diarrhoea for 3 days. Estimated to have 10% dehydration. Na 125. K 3.6. Urea 6.5
Same calculation as case 1 except to add the Na required to correct the hyponatremia (e.g. aim at correcting Na to 135) Na deficit (mmol) = (Proposed serum Na - current serum Na) x BW (kg) x 0.6 = (135-125) x10x0.6 = 60mmol Total Na = 87 + 30 + 60 = 177 mmol Prescription: 2000ml water + 177 mmol Na + 40 mmol K per day = : solution 500ml + 5 ml 15% KCl + 8ml 5.85% NaCl added to each pint, run at 83ml/hr If the patient is symptomatic, correct it with 3% hypertonic saline. Aim at 6mmol rise per attempt. o o Na required to treat symptomatic hyponatremia= target Na rise x BW x 0.6= 6x10x0.6 = 36 mmol Give 72ml half diluted 5.85% NaCl over 30 min to 3 hours depending on urgency of situation.
Hypernatremic dehydration (Na > 150) Circulatory disturbance is seen later as circulatory volume is relatively preserved at the expense of cellular water. Give 1/2NS as the rehydrating solution. Slow correction of rehydration over 48-72 hr. Avoid dropping serum Na >15 mmol/L over 24 hr.
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Potassium Replacement: **Always consider replacement via oral route rather than IV route** Oral Preparation: Syrup KCl 1gm/10ml (1gm = 13.3mmol) Tab KCl 600mg/tab (600mg = 8 mmol) IV Preparation : IV KCl 14.9% (1ml = 2 mmol)
1. Usual daily requirement 2mmol/kg/day over whole day fluid 2. Oral replacement i. Recommended dose 75mg/kg/day (~1mmol/kg/day) in divided dose & adjust accordingly ii. For SYRUP dilute with milk /juice. iii. For TAB SLOW K do not chew/crush to ensure slow release 3. Rapid bolus IV replacement ONLY IF patient is symptomatic or K+ < 2.5mmol/L i. Maximum concentration - Peripheral line : 40mmol/L (14.9% KCl 0.2ml in 10ml IVF) - Central line : 80mmol/L (14.9% KCl 0.4ml in 10ml IVF) ii. Recommended dose 0.5mmol/kg over 1 hr iii. Monitor patient closely vital signs, IV site, serum K+ level
Hyperkalemia 1. 2. 3. 4. 5. 6. Stop all potassium administration ( IV or oral) IV calcium chloride 25mg/kg to antagonize the effect. IV NaHCO3 1 mEq/kg IV insulin glucose insulin 0.1 unit/kg + glucose 0.5g/kg Promote potassium excretion by resin, dialysis or hemofiltration Treat underlying cause.
Metabolic acidosis Metabolic acidosis associated with dehydration will usually resolve with rehydration. Treat only if acidosis is severe especially when there is circulatory impairment. HCO3 (mmol) = Base deficit x BW (kg) x 0.3 Usually give half the dose.
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Physical abuse
Suspect physical abuse if the following features are found: 1. Fractures in a child < 2 years old 2. A history inconsistent with physical findings 3. A history of repeated accidents 4. Delay in seeking medical help 5. Multiple injuries and bruises ( especially bruises around face and mouth, over back) 6. Signs of emotional deprivation, neglect or failure to thrive 7. Retinal haemorrhages in the absence of head injury - "Shaken baby syndrome" Management 1. Take a full history. Note especially : Mode of injury & antecedent events(severity) Previous abuse history(frequency) Psychosocial background(assess risks and resourcefulness) Prior contact with social services 2. Thorough PE. Look carefully for any hidden injuries (e.g. bruises behind the ears, torn frenulum, pharyngeal injuries). Document all the injuries precisely with diagrams and clinical photos (obtain consent). Chart growth parameters. Look for retinal haemorrhages in inflicted head injury. 3. Avoid confrontation and repeated interrogation, but be honest. Tell the parents that notification is being made. Explain the assessment procedure. 4. Consult MSW fax the notification form to MSW. May consult Family and Child Protective Services Unit of Social Welfare Department (FCPSU, SWD) directly if required. (FCPSU CWSI : Telephone no. 9460 4013, 2835 2733) 5. Consult Child Psychiatrist. 6. Consult Eye or other specialists if indicated. 7. Notify Police (after discussion with team-head +/- social worker). Consult Child Abuse Investigation Team (CAIU, Police)/Child Protection Special Investigation Team (CPSIT = CAIU + FCPSU) in serious abuse (OC CAIU HKI: Telephone no. 2860 7815, 2860 7814). 8. Investigations if indicated: CBP D/C PT APTT ( if there is history of bleeding tendency) L/RFT Skeletal survey (for those under 2 years old) CT scan brain ( if suspect intracranial injury) 9. Multidisciplinary Case conference (MDCC) - Welfare of the child is the primary concern
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Investigations Pregnancy test Toxicology screen if indicated Screening for sexually transmitted diseases o HVS for gram smear and culture, Trichomonas vaginalis o Urethral( for male) and endocervical swab for N. gonorrhoea, Chlamydia culture and IF/PCR o Throat/pharynx/rectal swab for gonorrhoea if needed o VDRL o HIV serology
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Medical Treatment Emergency contraception o Preferred: Levonorgestrel 1.5mg po once ( or 0.75mg po 12 hours apart) o Alternative: Eugynon 2 tab 12 hours apart po for 2 doses ( 1 tab = Norgestrol 0.5mg + ethinylestradiol 0.05mg)
Pre-emptive treatment for STD: o Ceftibuten 400 mg orally in a single dose OR Ceftriaxone 250 mg imi single dose (for gonorrhoea) o Doxycycline 100mg BD po for 7 days OR single dose of Azithromycin 1gm ( for Chlamydia)
Other management: 1. Consult MSW. Consult FCPSU. 2. Notify Police. CAIU(Police) & FCPSU(SWD) will form CPSIT to conduct the video-recorded interview. 3. Consult Child Psychiatrist.
Discharge and follow up For adolescents, FU Adolescent Clinic in 4 weeks to see if menses return. Repeat serology test at 12 weeks. Monitor for psychosocial issues.
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MCUG DMSA (prophylaxis: Zinnat 10 mg/kg) (4-6 months after infection) Girls < 3yrs All Atypical UTI or recurrent UTI or Atypical UTI or recurrent UTI or Abnormal USG VUR grade 3-5 Boys < 3yrs All Atypical UTI or recurrent UTI or All Abnormal USG or Abnormal DMSA > 3yrs All No Recurrent UTI Prophylactic antibiotic with trimethoprim 2mg/kg nocte if VUR grade 3-5 Definition of Atypical UTI Seriously ill Poor urine flow Abdominal or bladder mass Raised serum creatinine Septicaemia Failure to respond to treatment with suitable antibiotics within 48 hours Infection with non-E.coli organisms Definition of Seriously ill Unable to arouse or if aroused does not stay awake Weak high-pitched or continuous cry Pale/mottled/blue/ashen Reduced skin turgor Bile-stained vomiting Moderate or severe chest indrawing Respiratory rate > 60/min Grunting Bulging fontanelle Appearing ill to a healthcare professional Infants < 3 months old with > 380C and infants aged 3-6 months old with > 390C Ref: 1. Wong SN et al (2010). Pediatr Nephrol 25:2083-2091 2. WONG SN ET AL (2009). HK J PAEDIATR 14:74-85 Dr S Chim, October 2010 __________________________________________________________________________________
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Management 1. Renal chart 2. Strict I & O 3. BP/P Q1-4h 4. Bed rest if hypertensive or with significant oedema 5. Restrict fluid: insensible water loss (400 ml/m2/day) + previous day urine output 6. Low salt diet 7. Oral Penicillin 50 mg/kg/day QID x 10 days 8. IV Lasix 1-4 mg/kg/day Q6h to promote diuresis 9. Control BP by Nifedipine (Adalat) 0.25 mg/kg/dose. Investigations 1. CBP D/C, ESR 2. LFT, RFT, albumin, Ca PO4 3. Blood gas Na K Ca 4. C3 C4, ANA, anti-dsDNA, Ig GAM 5. Streptozyme 6. Viral titre (including Hepatitis B markers) 7. Urine x R/M C/ST 8. 24 hour urine x protein & creatinine 9. Throat swab x C/ST 10. CXR
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HK Poison Information Center (HA) PWH Poison Treatment Center Toxicology Reference Laboratory HAHO Duty Officer
eKG : Toxicology
Cholinergic
D-efecation U-rination M-iosis, muscle fasciculations, muscle weakness B-ronchorrhea, bradycardia, bronchospasm E-mesis L-acrimation S-alivation
Blind as a batmydriasis Dry as a bonedry skin Hot as Hadesfever Red as a beetred Mad as a hattercentral nervous system stimulation Decreased gastrointestinal motilitydecreased bowel sounds Urinary retentionfull bladder
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Pphenothiazine, phencyclidine, pesticides, propranolol Llithium, lidocaine, lindane Aanticholinergics, alcohol withdrawal, amphetamine Ssalicylate, sedative-hypnotic withdrawal, sympathomimetics, strychnine Ttheophylline Iinsulin, isoniazid Ccarbon monoxide, camphor, cocaine
Principles of Management A. resuscitationattention to the ABCs (airway, breathing, and circulation) and D (disabilityaltered mental status and seizures), B. decontamination, C. administration of specific antidotes, D. enhanced elimination, and E. supportive care. Identify the suspected poison Note the dose, likely time of ingestion
GI decontamination 1. Gastric lavage Performed when risk of toxicity is high, likelihood of recovering toxin is high, or other treatment modalities are unavailable Certain agents such as anticholinergic agents or opioid agents may delay gastric emptying and slow GI transit time -may remain in the stomach for more than an hour and available for removal by lavage. Contraindicated in caustic/hydrocarbon ingestion Airway protection important Lavage with NS 15 ml/kg/cycle (max 200-400 ml in adult) till clear.
2. Activated charcoal (Mainstay of treatment) Dose: (1 g/kg in water slurry diluted at least 1:4) Small children : 15-30 g po Adolescents: 50-60 g po *Emesis (Ipecac) No longer recommended. Contraindicated in unconscious/convulsing patient, ingestion of caustics/acids, TCA Enhanced elimination 1. Forced alkali diuresis -May be effective in salicylate or phenobarbital overdoses 2. Haemodialysis 3. Hemoperfusion __________________________________________________________________________________
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Opioids
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General supportive measures: 1. Maintain Airway, Breathing, Circulation. 2. NPO 3. IV fluid 4. BP/P/RR/SaO2 monitoring/cardiac monitoring or neuro-observation Q1h till stable Investigations 1. CBP D/C 2. Na K Blood gas 3. Blood sugar 4. L/RFT 5. Drug level if indicated e.g. salicylate, paracetamol, theophylline or anticonvulsants (arrange with lab for urgent test) 6. Blood, urine, gastric lavage for toxicology 7. ECG 8. (Urine for pregnancy test) Psychosocial assessment 1. Psychosocial history -HEADSS H: Home E: Education, Employment A: Activities D: Drugs S: Sex S: Suicide 2. Consult Psychiatrist for all cases of drug overdose. 3. Consult MSW if necessary. 4. Watch out for child abuse.
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IV
> 5 days
2.
Likelihood and severity of toxicity predicted by i. Amount ingested : Toxic dose : 150 mg/kg (about 7.5 g in adults) within 24 hours ii. plasma acetaminophen level (More accurate) For a single acute overdose of traditional or rapid-relief acetaminophen (absorbed 7 to 8 min faster), measure level at 4 h after ingestion and plot on the nomogram (Check BNF in ward). Hepatotoxicity is very unlikely if level 150 g/mL ( 990 mol/L) and absence of toxic symptoms. Higher levels indicate possible hepatotoxicity. For a single acute overdose with extended-relief acetaminophen (which has 2 peak serum levels about 4 h apart), measure levels at 4 h after ingestion and 4 h later; if either level is above the Rumack-Matthew line of toxicity, treatment is required.
Antidote: N-acetylcysteine (NAC) most effective if given within 8 hours of ingestion. After 24 hours, questionable benefit. Therapy 1-4 hr of ingestion: Give charcoal and draw level at 4 hrs > 4 hr of ingestion : Draw level and treat with NAC (* Charcoal adsorbs oral NAC; avoid simultaneous administration) Oral NAC (PO/ NG): Give NAC diluted 1:4 in carbonated beverage/fruit juice as a loading dose of 140 mg/kg, then 70 mg/kg Q4H for 17 doses. If vomiting occurs within 1 hr of ingestion, repeat the dose. IV NAC : (20 % NAC solution) Give 150 mg/kg in 200 ml D5 over 15 min. Then 50 mg/kg in 500 ml D5 over 4 hr, then 100 mg/kg in 1000 ml D5 over next 16 hrs. Small risk of anaphylaxis Check plasma level at 24 hrs.
3. 4.
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Liver failure is treated supportively. Patients with fulminant liver failure may require liver transplantation.
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Rumack-Matthew nomogram for single acute acetaminophen poisoning. Semilogarithmic plot of plasma acetaminophen levels vs time. Cautions for use of this chart: (1) The time coordinates refer to time of ingestion. (2) Serum levels drawn before 4 h may not represent peak levels. (3) The graph should be used only in relation to a single acute ingestion. (4) The lower solid line 25% below the standard nomogram is included to allow for possible errors in acetaminophen plasma assays and estimated time from ingestion of an overdose. Adapted from Rumack BH, Matthew H: Acetaminophen poisoning and toxicity. Pediatrics 55(6): 871876, 1975.
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References : Paul M, Schlesinger A, Grozinsky S, et al. Beta-lactam versus beta-lactam-aminoglycoside combination therapy in cancer patients with neutropenia. Cochrane Database of Systematic Reviews 2009, 3. 2. Paul M, Borok S, Fraser A, et al. Additional anti-Gram-positive antibiotic treatment for febrile neutropenic cancer patients. Cochrane Database of Systematic Reviews 2009, 3. 3. Goldberg E, Gafter-Gvili A, Robenshtok E, et al. Empirical antifungal therapy for patients with neutropenia and persistent fever: systematic review and meta-analysis. European Journal of cancer 2008; 44: 2192-2203. 4. NCCN Practice Guidelines in Oncology. Prevention and treatment of cancer related infections. http://www.nccn.org/professionals/physician_gls/PDF/infections.pdf.
1.
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B. Dose Calculation of coagulation Factors No of unit required = % rise required x wt. in Kg *K *K : Factor VIII : 2.0, Factor IX : 1.0 ie. A 10 Kg boy with Haemophila A & acute haemarthorsis of left ankle No. of unit required = 50 % x 10 / 2 = 250 units But if it is Haemophilia B, then it will be 50% x 10 / 1.0 = 500 units * Factor VIII is given by IV bolus q8 - 12 hrs * Factor IX is given daily or q12 hr due to its longer half life C. Measure of response Response = Measured rise x weight in kg Units given
i.e after the above 10kg boy was given 250 units of Factor VIII, the 1 hr post-level was 45%. Response = 45x 10kg /250 =1.8 (up to 1.5 is acceptable) Since the maximum response is 2, 1.8/2 x 100% = 90% response (if <75% rise, has to screen for inhibitor) D. Reminder In short, every unit of Factor VIII/kg body weight will increase the plasma Factor VIII level by 2% If in doubt, better treat first ! Double the initial dose at all times (Loading dose) Be careful of thrombosis when using intermediate purity Factor IX concentrate Following major surgery, level should not fall below 50% for at least 10 days For haematuria, treat with forced diuresis first if it is not severe. Beware of urinary tract obstruction when using coagulation factor E. Follow-up guidelines for Haemophilia 3 monthly review Clinical review and *full blood screen (all HIV + patients) 6 monthly review Clinical review and * full blood screen (all severe haemophilia) Annual review Clinical review and * full blood screen ( mild haemophilia) *Full blood screen: CBC, R/LFT, IgGAM, virology(HIV, HCV, HBV), VIII Ab screen __________________________________________________________________________________
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B. Desferal Therapy Desferal is a siderophore produced by Streptomyces pilosus, 1 gm of desferal can bind 93 mg of iron. 1. Start desferal treatment when a. Patient is 3-year-old b. Serum ferritin rises > 2000ng/ml c. Transfusions > 20 units 2. Intravenous desferal (during blood transfusion) a. 60 mg/Kg/dose over a minimal period of 10 hrs b. Not to exceed 15 mg/Kg/hr c. Given as piggy-back 3. Subcutaneous desferal (home treatment): aim at serum ferritin between 1000 to 2000 ng/ml a. Average daily dose 20-50 mg/Kg/day b. Usually not recommend to exceed 50 mg/Kg/day c. Preferably 5 to 6 days per week d. Average daily dose (mg/Kg/day) = weekly no. of ampules x 500 BW (Kg) x 7 ie. Patient 50 Kg on 4 ampules/day, 5 days/week 4 x 5 x 500 = 28.6 mg/Kg/day 50 x 7 __________________________________________________________________________________
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C. Investigations : 1. Before each transfusion : pre-transfusion Hb, cross-match, ferritin level, urine for glucose 2. After transfusion : post-transfusion Hb 3. Every 6 months : serum Ca, PO4, blood glucose, fructosamine, thyroid function, infection screening (HIV, HBV, HCV) 4. Yearly : endocrine assessment, cardiac assessment (MUGA scan, ECG, CXR), serum Zn & Cu eyes & hearing assessment
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3.
* no. of platelet transfused = no. of units x 0.55 * for apheresed platelet = no. of units x 3 i.e. SA of 1.5m^2, post-transfusion platelet count 40 x 10^9/L & pre-transfusion count 10x 10^9/L after 4 units of platelet transfusion (40 10) x 1.5 =20.45 x 10^9/L 4 x 0.55 (<7.5 x 10^9/L increment indicates refractoriness)
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Start treatment if : a. Clinical evidence of bleeding with platelet count <20x 110^9/L 1) Nose bleeding cannot be stopped for > 15 min. 2) Oral mucosal bleeding (eg. Gum bleeding, blood retention cyst) 3) GI bleeding (eg. Melena) b. Severe bleeding disregards the platelet count (eg. Intracranial hemorrhage, retinal hemorrhage) Treatment options a. Steroid induces a slower rise of platelet count (median: 4 days) but the effect is more sustained. b. IVIG induces a rapid rise of platelet count (within hours) but the effect is transient (1 to 2 weeks). c. Never give platelet transfusion except in emergency situation (eg. Intracranial hemorrhage). d. Rhogam has similar efficacy as IVIG but is associated with higher incidence of therapy-induced haemolytic anemia Steroid treatment a. Has to perform bone marrow aspirate to rule out leukaemia before starting b. Use prednisolone 2 mg/Kg/day for 2 weeks and then taper over another 1 week c. Monitor BP and urine sugar q2wks d. Advice to take after food intake or with antacid IVIG a. When a rapid rise of platelet is indicated or when there is concomitant active infection (ie. Fever) b. No difference in using small dose (500 mg/Kg) or high dose (2 gm/Kg) c. Give it over one or 2 days rather than 4 days d. Infuse the drug gradually 5 ml/15 min, then 10 ml/15 min, then 15 ml/15 min, then 20 ml/15 min Rest over 4 - 5 hrs e. Pre-medication : Piriton 0.2 mg/Kg 30 min before infusion f. Anti-Rh(D) is a special form of Ig that can be used but is associated with alloimmune haemolysis secondary to anti-Rh(D) and is not indicated for routine clinical use
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candidates for allogeneic or autologous BMT (D0 to 6 months) 2) severe immunodeficiency 3) intrauterine transfusion 4) transfusion from near relatives even in immuno-competent patients (resemble HLA-Ag may allow donor lymphocytes to escape the detection of recipient's lymphocytes but not vice versa)
Indications : 1)
B. Management of Febrile Nonhemolytic Transfusion Reaction (FNHTR) Background : Most commonly encountered type of transfusion reaction (1%) Definition : 1degree Celsius rise from basal temperature (min. 38C during or within 24 hrs after transfusion with no other medical explanation *It is a diagnosis by exclusion Caused by antileukocyte Ab present in the patient's plasma and release of cytokines from transfused WBC Can be reduced by using leukocyte filter
Management : 1. Exclude other causes of fever 2. Stop the transfusion if fever >38.5C (core temp.) & proceed to sepsis work-up 3. Give Panadol 10-15 mg/Kg PO 4. If fever subsided, can resume transfusion 30 min. later 5. Can be reduced by premedication (piriton) and use of leukopoor filtered product C. Allergic (Urticarial) Transfusion Reaction Background : Almost as common as NFHTR Probably caused by the foreign plasma protein or reagins (IgE or IgG) in the donor's product and triggers histamine & leukotrienes release Usually manifested as itchiness, local erythema and hives with or without fever __________________________________________________________________________________
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Onset Management During or within hrs of Paracetamol transfusion Use WBC filter
During transfusion
Within 30 min. after transfusion Often shortly after manage as ARF , DIC transfusion (a few ml)
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2. Urticaria
During transfusion
Piriton
Hydrocortisone
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Late onset CBP D/C infection (after 3 blood culture days of life) urine R/M culture CSF R/M culture
Dosage of antibiotics Penicillin G: 25,000-100,000 units/kg/dose IV postmenstrual age (weeks) postnatal age (days) Interval (hours) 0-28 12 29 >28 8 30-36 0-14 12 >14 8 37-44 0-7 12 >7 8 all 6 45 Gentamicin (first week of life). Check serum level if treatment is prolonged (>7days). Postmenstrual age (weeks) Dose (mg/kg/dose) Interval (hours) 34-37 4 36 4 24 38 For dosing after the first week of life, administer an initial dose of 4mg/kg. Dosing interval is guided by serum level. Cefuroxime: 30-50mg/kg/day divided q8-12h IV Cloxacillin: 50-100mg/kg/day divided q8-12h IV Vancomycin: 10-15mg/kg/dose. Serum level should be checked for neonates. Postmenstrual age (weeks) Postnatal age (days) Interval (hours) 0-14 18 29 >14 12 30-36 0-14 12 >14 8 37-44 0-7 12 >7 8 all 6 45
Postnatal age (days) 0-28 >28 0-14 >14 0-7 >7 all
Interval (hours) 12 8 12 8 12 8 6
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35+0 36+6 weeks of gestation 24 hours 48 hours PT 130 200 level(mol/L) ET 255 290 level(mol/L)
Day-Phototherapy (K10S) Giving PT during daytime while allowing home leave at night may facilitate breast feeding without adverse effect. Please check BuBc at 4pm and decide on suitability of home-leave during afternoon ward round. Cases with borderline TSB (very near PT level) can be admitted for day-PT.
Stopping PT
PT can be stopped when the TSB level is around 250 mol/L or 30-40 mol/L below PT level, whichever lower. Rebound jaundice TSB should be checked (6-24 hours after stopping PT) if possible, especially when there is a suspicion of hemolysis or if the rise of TSB before PT is significant.
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Babies can also be followed up at KGOPD as Discharge follow up (DFU). For SYPMCHC where serum bilirubin can be checked and treatment is deemed necessary (according to new guidelines), the patient can be forwarded to K10S directly for admission and treatment. (see Appendix 4) For newborns that require further follow up because of high or increasing jaundice, they can be referred for NNJ assessment as above accordingly. In cases of weekends or long holidays, the baby can be referred to K10S for assessment. The medical record of previous assessment should preferably be provided e.g. jaundice meter level, serum bilirubin level.
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*FU Routine: according to physicians discretion, depending on age of patients, abnormal physical signs, or suspicion of pathological causes of jaundice. (B) Long term follow up Long term follow up should be arranged for patients whose TSB has reached or exceeded Day 4 ET level (e.g. 385mol/L for babies with GA >37 weeks, and 325 mol/L for babies born at 35+0 36+6 weeks) A formal elective BAEP should be booked on discharge to detect hearing loss. Follow up schedule: 1 week after discharge (if jaundice has not yet resolved before discharge) 4 month (with AIMS physiotherapist assessment) 8 month (with AIMS physiotherapist assessment) 12 month (with AIMS physiotherapist assessment). Case can be closed when the childs physical assessment is normal at 12 months old. Kernicterus: Specific movement disorder dystonic cerebral palsy Hearing loss Upward gaze palsy Enamel staining
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Appendix 1 K8S Management of Neonatal Jaundice MCHC A&E Others Jaundice referred for blood test and assessment
Yes
PT needed?
* Inform Paed Resident (1280) immediately if baby is ill e.g.lethargic, pale, dehydrated, septic
*Follow up (1) within 20 mol/L below PT level FU 24 hrs (2) 21-40 mol/L below PT level FU 24-48 hrs (3) >40 mol/L below PT level FU routine
No
JM Clinical assessment by intern (General) and K10S Paed. Resident* TSB (Bu+Bc) other blood tests if indicated
No
MCHC
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e.g.
Yes
call Paedi and send pt to K8S (for biliblanket PT, assessment and TSB)
PT level
No
within 20mol/L below PT level 21-40 mol/L below PT level >40 mol/L below PT level
FU 24 hours
borderline
Yes
FU 24-48 hours
Routine FU
Inform Paed for admission to K10S Call Paed. resident to consider Day-PT e.g. breast feeding, living far away etc. Ask pt to come early next morning (to K10S) for PT.
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Worrying signs and symptoms e.g. Clay colour stool, hepatosplenomegaly, green hue, poor feeding, pallor, poor wt gain
Yes
No
No
No
Yes
Refer to QMH as new case (NNC or General) Appointment available in 1-2 weeks Refer to A&E if emergency
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Appendix 4 MCHC Referrals for NNJ Assessment and Treatment (excluding investigations for prolonged jaundice) SYP MCHC Follow Up JM
TSB
PT needed
PT not needed
Yes
Yes
Follow up needed?
No routine
Other MCHC
Referral if JM (103) 220mol/L or JM (102) 20 (similar to referral to PYNEH)
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5.1.6 full liver function tests, including albumin and coagulation profiles when liver disease suspected 5.1.7 sepsis screening including urine and blood culture 5.1.8 viral studies, syphilis serology congenital infection syndrome 5.1.9 imaging of hepatobiliary system for evidence of surgical obstruction endocrine and metabolic screening thyroid function, urine for reducing substance, 1-antitrypsin phenotype etc
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9.1
8.1.1 8.1.2
Table 1. Bilirubin/albumin ratio (B/A) can be added when considering indication for ET B/A mg/dL: g/dL mol/L:mol/L Infants 38 weeks o Well 8.0 0.94 o Hemolysis 7.2 0.84 6 Infants 35-36 /7 o Well 7.2 0.84 o Hemolysis 6.8 0.80 9.2 9.2.1 Procedures (refer to appendix on ET) double blood volume exchange (traditional) single volume exchange: 60% of blood exchange double volume exchange: 85% of blood exchange 9.2.2 use fresh whole blood (<3-5 days) or reconstituted blood components (washed red cells with plasma) 9.2.3 use wild bored intravenous catheters and exchange blood in small aliquots (central or peripheral) 9.2.4 needs cardiopulmonary monitoring during and immediate after the procedure 9.3 Complications varies with different patients status, higher rate in preterm infants 9.3.1 Procedure associated mortality <1% (well term infants) to 12% (ill or preterm infants) 9.3.2 Complications Catheter induced: thrombosis, embolism, bleeding, cardiac arrhythmia Transfusion related: blood compatibility problems, thrombocytopenia, hypothermia, apnea, bradycardia, cyanosis, metabolic acidosis, hypocalcemia, hyperkalemia, necrotising enterocolitis Infection 9.4 Risk and benefit must be weighed and explained to parents before decision for exchange transfusion, and a formal consent obtained The procedure must be performed by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities
8.1.3
8.2
9.5
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Specimens to be collected
(1) Pre-ET a. Umbilical swab for bacteriology b. Blood for CBC, LFT, blood culture, c. Na K Ca blood gas, spot glucose d. Coagulation profile e. Genetic studies (if necessary) (2) Post-ET a. Blood for CBC, LFT, blood culture, b. Na K Ca blood gas, spot glucose c. Coagulation profile d. Repeat cross match if necessary
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11 Other drugs 11.1 Metalloporphyrin heme oxygenase inhibitors not yet available 11.2 Phenobarbital has been used successfully for mothers antenatally to reduce the severity of jaundice in fetal hemolytic disease. It has also been used for patients with Crigler-Najjar syndrome. Albumin infusion has not been shown to be effective in reducing bilirubin encephalopathy in well studied trials, although theoretically it may alter the bilirubin:albumin ratio. In some studies, a dose of albumin at 1g/kg 1 hour before ET has been shown to increase the efficiency of exchange by 40%. 12 Other supportive measures Counseling and support for breast feeding and NNJ Ensure adequate hydration by liberal intake of milk; Consider additional supplementary formula milk/ expressed breast milk or intravenous fluid if dehydrated Routine water supplement has not been shown to benefit breast fed jaundiced infants
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Guidelines of use of Minolta JM-103 in postnatal ward Measure 2 readings from sternum, and take the higher reading
1. Measure at least once daily for all neonates during the first five days of hospital stay
>37+0 weeks of gestation 24 hours PT level 165 (mol/L)
48 hours 220
72 hours 265
96 hours 300
CHECK BLOOD FOR BUBC WHEN JM-103 (mol/L) >135 >190 >235 >260 >260
35+0 36+6 weeks of gestation 24 hours 48 hours PT level 130 200 (mol/L) CHECK BLOOD FOR BUBC WHEN JM-103 (mol/L) >100 >170
72 hours 230
96 hours 250
>200
>210
>210
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Paediatric general on-call MO: DECT phone # 1279 Neonatal on-call MO: DECT phone # 1278 PICU on-call MO: DECT phone # 1280
Ward/Office D4 Cardiac K7S K7N K8S K8N K10N K10S KGOPD UPAM office UPAM IT Lab (Clinical photo) DKCAC Secretary, Division of Paediatric Cardiology
Ext 5644/5645 3439/ 3440 3434/3435 3450/3451 3445/3446 3468/3469 3480/3481 3237/ 3386 ( Appointment) 3241/3343 ( Nurse) 4482 (Teresa) 4299/4945 2974 0328 3847/3848
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NOTES
134
NOTES
135
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