NICU Please admit under RI, LI, PD or AP TPR q4H May breastfeed if NSD; NPO x 2hrs if CS Labs: NBS at 24 hrs old, secure consent CBC, BT (if w/ maternal illness, PROM or UTI HGT now then 1, 3, 6, 12, 24, 48 hrs old (GDM) HGT now (SGA or LGA) Medications: Erythromycin eye ointment both eyes Vit K 1 mg IM (term); 0.5 mg (PT) Hep B vaccine 0.5 ml IM, secure consent BCG 0.05 ml ID (PT); 0.1 ml (term), secure onsent SO Routine NB care Monitor VS q30 mins until stable Thermoregulate at 36.5 to 37.5°C Place under droplight (NSD); isolette (CS) Suction secretion prn Will infrom AP /AP attended delivery DENGUE FEVER Please admit under the service of Dr. TPR q4H and record DAT ( No dark colored foods) Labs: CBC, Plt (optional APTT and PT) Blood typing U/A (MSCC) IVF: D5 0.3 NaCl 1P/1L (<40 kg) at 3 – 5 cc/kg D5LR 1L (>40 kg) at 3 – 5 cc/kg Medications: Paracetamol prn q4h for T > 37.8°C Omeprazole 1mkdose max 40 mg IVTT OD SO: MIO q shift and record Monitor VS q2h and record, to include BP Continue TSB for fever Refer for Hypotension, narrow pulse pressure (< 20mmHg) Refer for signs of active bleeding like epistaxis, gum bleeding, melena, coffee ground vomitus Will inform AP Pls inform Dr of this admission Thank you. FEBRILE SEIZURE Please admit under the service of Dr. TPR q4H and record DAT once fully awake Labs: CBC U/A (MSCC) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C SO: MIO q shift and record Monitor VS q2h and record Monitor neurovital signs q4h and record Continue TSB for fever Seizure precaution at bedside as ff: Suction machine at bedside O2 with functional gauge; if with active sz give O2 at 2lpm via NC Diazepam IVTT (0.3 mkd max of 5 mg IV) prn for seizure Will inform AP Pls inform Dr of this admission Thank you. AGE Please admit under the service of Dr. TPR q4H and record DAT once fully awake; NPO x 2hrs if with vomiting Labs: CBC U/A (MSCC) F/A (Concentration Method) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C Zinc (E Zinc) Drops 10mg/ml 1ml OD (<6 mos) 1ml BID (6 mos – 2 yo) Syrup 20 mg/5ml (>2 yo) 5ml OD Ranitidine IVTT at 1mkdose (if with abdominal pain) SO:
MIO q shift and record Monitor VS q2h and record Continue TSB for fever Chart character, frequency and amount of GI losses and replace w/ PLR 1L/1P vol/vol Will inform AP Pls inform Dr of this admission Thank you. BRONCHIAL ASTHMA Please admit under the service of Dr. TPR q4H and record NPO if dyspneic Labs: CBC U/A (MSCC) ABG* CXR APL* IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C (10 – 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses Incorporate Budesonide 10 mkd LD (max 200mg IV); then 5mkd q6h IV (max of 100 mg IV) Ranitidine IVTT at 1mkdose (if on NPO) SO: MIO q shift and record Monitor VS q2h and record Refer for persistence of tachypnea, alar flaring and retractions O2 at 2 lpm via NC, refer for desaturations <95% Will inform AP Pls inform Dr of this admission Thank you. HYPERSENSITIVITY REACTION Please admit under the service of Dr. TPR q4H and record Hypoallergenic diet Labs: CBC U/A (MSCC) IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: *Epinephrine (1:1000) 0.1mg/kg/dose IM anterolateral thigh (max of 0.3 mg) *Salbutamol neb x 3 doses q 20 mins Diphenhydramine 10 mkdose LD (max of 200mg IV); thenmg IV) 5mkdose q6h IV (max of 100 Ranitidine IVTT at 1mkdose q 12h SO: MIO q shift and record Monitor VS q2h and record to include BP Continue TSB for fever O2 at 2 lpm via NC, or 6 lpm via facemask Attach to pulse oximeter, refer for desaturations <95% Will inform AP Pls inform Dr of this admission Thank you. BPN Please admit under the service of Dr. TPR q4H and record NPO if dyspneic Labs: CBC U/A (MSCC) ABG* CXR APL* IVF: D5 0.3 NaCl 1P (50cc/kg in 8 h if <2 yo) OR D5 IMB/D5 NM at MR if with NO losses D5 0.3 NaCl 1L (30cc/kg in 8 h if >2 yo) D5LR 1L at 30cc/kg in 8hif >40 kg Medications: Paracetamol prn q4h for T > 37.8°C (10 – 15 mkdose) USN with Salbutamol or Salbu+Ipratropium neb; 1 neb x 3 doses then refer NaCl (Muconase) nasal spray, 2 sprays per nostrils, then suction using bulb QID Ranitidine IVTT at 1mkdose (if on NPO) SO: MIO q shift and record Monitor VS q2h and record Continue TSB for fever Refer for persistence of tachypnea, alar flaring and retractions O2 at 2 lpm via NC, or 6 lpm via facemask Attach to pulse oximeter, refer for desaturations <95% Will inform AP Pls inform Dr of this admission Thank you.
Ilosone DS ANTIBIOTICS Amoxicillin (30 – 50 mkday) TID Pediamox Susp : 250mg/5ml Drops : 100mg/ml Himox Cap : 250mg, 500mg Moxicillin Susp : 125mg/5ml 250mg/5ml Drops : 100mg/ml Harvimox Novamox Amoxil Susp : 125mg/5ml 250mg/5ml Cap : 250mg 500mg Glamox Drops : 100mg/ml Globapen Amoxicillin + Clavulanic acid (30 – 50 mkday) Augmentin Tab: 375mg (250mg); 625 (500mg) Amoclav Susp: 156.25mg/5ml (125mg) TID 228.5mg/5ml (200mg) BID 312.5mg/5ml (250mg) TID 457mg/5ml (400mg) BID Cloxacillin (50 – 100 mkday) q6h Prostaphlin A Tab: 250mg 500mg Orbinin Susp: 125mg/5ml Flucloxacillin (50 – 100 mkday) q6h Staphloxin Susp: 125mg/5ml Cap : 250mg 500mg Chloramphenicol (50 – 75 mkd) q6h Pediachlor Susp: 125mg/5ml Chloramol Tab : 250mg 500mg Kemicetine Chloromycetin CEPHALOSPORINS 1st Generation Cefalexin (25 – 100 mkd ) q 6-8 h Lexum Cap : 250mg; 500mg Cefalin Susp : 125mg/5ml 250mg/5ml Keflex Drops : 100mg/ml Ceporex Cap : 250mg 500mg Selzef Caplet: 1 gm Granules: 125mg/5ml 250mg/5ml Drops: 125mg/1.25ml 2nd Generation Cefaclor (20 – 40 mkd ) q 8 – 12 h Ceclor Pulvule: 250mg 500mg 375mg 750mg Ceclor CD Susp: 125mg/5ml 187mg/5ml CD ext release 250mg/5ml 375mg/5ml Drops: 50mg/ml Xelent Cap : 250mg 500mg Vercef Susp : 125mg/5ml 250mg/5ml
Pulvule: 250mg Liquid: 125mg/5ml DS Liquid: 200mg/5ml Drops: 100mg/ml Clarithromycin (6 – 15 mkday OR 7.5 mkdose q12h) Klaricid Susp : 125mg/5ml 50mg/5ml Klaz Tab: 250mg 500mg Roxithromycin <6 yo 5 – 8 mkd BID 6 – 12 yo 100mg/tab BID Macrol/Rulid Tab: 150mg Ped Tab: 100mg Rulid dispensable Tab: 50mg Azithromycin
Zithromax
Clindamycin
AMOEBICIDES PO: 30 – 50 mkday q 8h IV: 30 mkday q 8h Susp : 125mg/5ml Tab : 250mg Susp: 200mg/5ml Tab : 250mg Susp : 125mg/5ml Tab : 250mg (15 – 20 mkd) TID Susp : 125mg/5ml Tab : 200mg
Metronidazole Anaerobia Servizol Flagyl Etofamide Kitnos
500mg 500mg
500mg
Diloxanide furoate (20mkd) q8h x 10 days Furamide Tab : 500mg Dilfur Susp: 125mg/5ml Secnidazole Flagentyl 2 tab now then 2 tabs after 4 hrs Ercefuryl (20mkday)
Acyclovir Cefuroxime (20 – 40mkd) q 12h Zinnat Cap : 250mg 500mg Sachet: 125mg/sat 250mg/sat Susp: 125mg/5ml Cefprozil (20 – 40mkd) q 12h Procef Susp : 125mg/5ml 250mg/5ml 3rd Generation Cefixime (6 – 12 mkd) q 12h Tergecef Susp : 100mg/5ml Zefral Drops: 20mg/ml Ultrazime Cefdinir (7mg/kg q 12h OR 14mg/kg OD) Omnicef Cap : 100mg Sachet/ Susp: mg/5ml COTRIMOXAZOLE (TM 5 – 8 mkd) q 12h Bactille – TS Susp/5ml SMZ 400mg TM 80mg Tab 800mg 160mg Bacidal Susp/5ml 400mg 80mg Trizole Susp/5ml 400mg 80mg Tab 800mg 160mg Globaxole Susp/5ml 400mg 80mg Trimethoprim + Sulfadiazone (TM 5 – 8 mkd) Triglobe Tab Sdz 410mg TM 90mg Forte 820mg 180mg Susp/5ml 205mg 45mg AMINOGLYCOSIDES Tetracycline 25 – 50 mkday q6h Doxycycline 5 mkday BID Furaxolidone 5 – 8 mkday q6h MACROLIDES Erythromycin (30 – 50 mkd) q 6h Macrocin Susp: 200mg/5ml Ethiocin Drops: 100mg/2.5ml Erycin Cap : 250mg 500mg Susp: 200mg/5ml Drops: 100mg/2.5ml Erythrocin Film tab: 250mg 500mg Granules: 200mg/5ml DS Granules: 400mg/5ml Drops: 100mg/2.5ml Ilosone/ Tab: 500mg
3 day regimen: 10 mkday x 3 days 5 day regimen: 10 mkd on day 1 5 mkd on day 2 to 5 Adult: 500mg OD day 1 250mg OD day 2 to 5 Susp: 250mg/5ml Cap : 250mg Sachet: 200mg/sachet PO: 20 – 30 mkday q 6 – 8h IV: 25 – 40vmkday q 6h Susp: 75mg/5ml Cap: 150mg 300mg Amp: 150mg/ml
Zovirax Acevir
ANTIVIRAL (20 mkdose) q 4 – 6 h Max 800mg/day x 5 days Susp: 200mg/5ml Blue: 400mg Pink: 800mg
ORAL ANTI-FUNGALS Ketoconazole (6mkd) q 4 – 6h Daktarin Adult & Child: ½ tsp q 6h Infant: ¼ tsp q 6 h Nystatin Mucostatin Susp: 100,000 u/5ml Ready mix susp Tab: 500,000 u Fluoconazole (3 – 6 mkd) OD x 2wks Diflucan Cap: 50mg 150mg Vial: 2mg/ml x 100 ml
200mg
ANTI-HELMINTHICS Oxantel + Pyrantel pamoate (10 – 20 mkd) SD Trichiuriasis: x 2 days Hookworm: x 3 days Quantrel Susp : 125mg/5ml Tab : 125mg 250mg Mebendazole *not recommended below 2 yo Antiox Susp: 50 mg/ml 100mg/ml Tab: 125mg 250mg 100 mg BID x 3 days 500mg SD (>2 yo) Albendazole <2 yo: 200mg SD >2yo: 400mg SD *may give x 3 days if with severe infestation Zentel Susp: 200mg/5ml Tab : 400mg ANTIHISTAMINE Diphenhydramine HCl (5mkd) q 6h IM/IV/PO: 1 – 2 mkdose Benadryl Syr: 12.5mg/5ml Cap: 25mg 50mg Inj: 50mg/ml Hydroxyzine (1mkd) BID Adult: 10mg BID 25mg ODHS Iterax Syr: 2mg/ml Tab: 10mg 25mg 50mg
Ceterizine
Virlix
Allerkid Alnix
Loratadine
Claritin Allerta Loradex Desloratadine
Solmux Chewable tab Carbocisteine
(0.25mkdose) 6mos - <12mos : 1ml OD 12mos - <2 yo: 1ml OD/BID 2 – 5 yo: 2ml OD / 1ml BID 6 – 12 yo: 10ml (2 tsp)OD/ 5ml BID 1 tab OD/ ½ tab BID Adult & >12yo: 1 tab OD Oral drops: 10mg/ml Oral soln: 1mg/ml Tab: 10mg Drops: 2.5mg/ml Syr: 5mg/5ml Drops: 2.5mg/ml Syr: 5mg/5ml Tab: 10mg 1 – 2 yo: 2.5 ml BID 2 – 12 yo (<30 kg): 5ml OD (>30 kg): 10ml OD Adult & > 12 y : 1 tab OD Syr: 5mg/ml Tab: 10mg
Aerius
Lovsicol
6 – 12 mos: 2ml OD 1 – 5 yo: 2.5ml OD 6 – 12 yo: 5ml OD Syr: 2mg/5ml Tab: 5mg
Ambroxol
Salinase Muconase Oxymetazoline HCl Drixine Xylometazoline HCl
2 – 4 drps/spray per nostril TID/QID 2 sprays/nostril then suction q6h x 3 days Nasal spray Nasal drops 2 – 5 yo: 2 – 3 drops/nostril BID >5 yo: 2 – 3 sprays/nostril BID Nasal spray: 0.05% Nasal soln: 0.025% < 1 yo: 1 – 2 drps OD/BID 1 – 6 yo: 1 – 2 drps OD/BID max TID Adult: 2 – 3 drps / 1 squirt TID max QID
Otrivin Oral Phenylpropanolamine HCl (0.3 – 0.5 mkdose) Disudrin 1 – 3 mos: 0.25 ml 4 – 6 mos: 0.5 ml 7 – 12 mos: 0.75 ml 1 – 2 yo: 1 ml 2 – 6 yo: 2.5 ml 7 – 12 yo: 5 ml Drops: 6.25ml q6h Syr: 12.5mg/5ml q6h Brompheniramine maleate + PPA 1 – 6 mos: 0.5ml TID/QID Dimetapp 7 – 24 mos: 1ml TID/QID 2 – 4 yo: ¾ tsp 4 – 12 yo: 5ml Adult: 5 – 10 ml 1 tab BID Infant drops: (0.1mkdose) Syr Extentab Carbinoxamine maleate + Phenylephrine HCl Rhinoport 1 – 5 yo: 5ml 6 – 12 yo: 10ml Adult & > 12yo: 1 cap / 15ml Syrup Cap Loratadine + PPA <30 kg: 2.5ml BID Loraped >30 kg: 5ml BID Syrup: 5mg/ml MUCOLYTIC Solmux Drops: 40mg/ml 1 – 3 mos: 0.5ml 3 – 6 mos 0.75ml 6 – 12 mos 1ml 1 – 2 yo 1.5 ml Susp: 200mg/5ml 2 – 3 yo 4 – 7 yo 8 – 12 yo
Forte: 500mg/5ml Cap: 500mg Adult & >12 yo:
Solmux Broncho
Capsule Suspension
Mucosolvan
Ambrolex Zobrixol
Salbutamol Ventolin
Ped Syr 1 – 3 yo 4 – 7 yo 8 – 12 yo
TID 5 – 7.5ml 7.5 – 10ml 10 – 15ml
1 – 1 ½ tsp 1 ½ - 2 tsp 2 – 3 tsp
Adult Susp Adult & >12 yo
TID 10 – 15ml
2 – 3 tsp
Capsule Adult & >12 yo
TID 1 cap
Infant drops Ped Syrup Adult Susp Cap Infant drops BID < 6 mo 7 – 12 mo 13 – 24 mo
BID BID BID
TID/QID
2.5ml 5 ml 7.5ml
50mg/ml 100mg/5ml 250mg/5ml 500mg 6mg/ml
75mg/ml
0.5ml 1 ml 1.25ml
2.5ml 2.5ml 5ml
0.5ml 0.75ml 1ml
BID TID TID
Adult Syrup Adult & >10 yo
5ml
TID
Retard cap Adult & >10 yo
1 cao
OD
Tab Adult & >10 yo
1 tab
TID
Inhalation <5 yo 1 – 2 inhalation of 2ml soln daily Adult & children >5 yo 1 – 2 inhalation of 2 – 3ml soln daily Infant drops 6mg/ml Ped liquid 15mg/5ml Adult liquid 30mg/5ml Retard cap 75mg Tab 30mg Inhalation Soln 15mg/2ml Ampule 15mg/2ml Infant drops 7.5mg/ml Ped liquid 15mg/5ml Adult liquid 30mg/5ml Tab 30mg B2 AGONIST (0.1 – 0.15 mkdose) Tab 2mg Syr 2mg/5ml Nebule 2.5mg/2.5ml Tab 2mg Syr 2mg/5ml
Ventar Hivent Syrup Salbutamol + Guaifenesin Tab Asmalin Broncho 1 tab TID Syrup 2 – 6 yo Pulmovent 7 – 12 yo
100mg/5ml 5ml 10ml 15ml
QID 0.25ml 0.5ml 0.75ml 1ml
Pedia Syrup <2 yo 2 – 5 yo 5 – 10 yo
DECONGESTANT Nasal NaCl
Tab: 500mg 1 tab q 8h Infant Drops <3mos 3 – 5 mos 6 – 8 mos 9 – 12 mos
5 – 10 ml 10ml
Terbutaline sulfate ( 0.075 mkdose) Terbulin Tab 2.5mg Tab 2.5mg Pulmoxel Syr 1.5mg/5ml Nebule 2.5mg/ml Bricanyl Tab 2.5mg Syr 1.5mg/5ml Nebule 5mg/2ml Expectorant Doxophelline (6 – 8 mkdose) BID x 7 – 10 days Ansimar Syrup 100mg/5ml Tab 400mg Procaterol HCl Meptin
(0.25ml/kg) Syrup Tab Nebuliser soln
Theophylline
10 – 20 mkdose 3 – 5 mkdose
5 – 10ml 1 cap
5mcg/ml 25mcg 100mcg/ml
BID/TID
Butamirate citrate
Sinecod Forte
ANTITUSSIVES 3 yo 5 ml >6 yo 10ml >12 yo 15ml Adult 15ml 1 tab Syrup 7.5mg/5ml Tab 50mg
Dextromethorphan + Guaifenesin Robitussin – DM 2 – 6 yo 2.5 – 5ml 6 – 12 yo 5ml Adult 5 – 10ml Syrup INHALED STEROIDS Budesonide Budecort 250mcg q 12h 500mcg q 12h 500mcg OD for allergic rhinitis 250mcg /ml (2ml) 500mcg /ml (2ml) 250mcg /ml (2ml) Flexotide neb 250mcg q 12h ORAL STEROIDS Prednisone Prednisolone Liquidpred
Maalox (plain, plus) Simethicone Restime
Dicycloverine Relestal Domperidone
Motilium Vometa
Ranitidine Zantac Cimetidine
Tagamet Famotidine
Paracetamol Tempra
Calpol
Defebrol Afebrin
Tylenol Naprex
Rexidol
Biogesic
Aeknil
LD: 10mkdose MD: 5mkdose 1 – 2 mkday 1 – 2 mkday Syrup 15mg/5ml
TID TID TID QID TID/QID
q 6 – 8h q 6 – 8h q 6h
200mg
ANTACIDS 5ml/10kg Available in 180ml bottle < 2 yo 0.5ml qid 2 – 12 yo 4ml qid Oral drops 40mg/ml ANTISPASMODIC 6mos – 2 yo 0.5 – 1ml TID Drops 5mg/ml Syrup 10mg/5ml 0.3 – 0.6 mkdose q 6 – 8 h 2.5 – 5ml/10kg BW TID Dyspepsia: 2.5/10kg TID Nausea: 2.5 – 5ml/kg TID 0.3 – 0.6 ml/5kg BW TID/QID Susp 1mg/ml Tab 10mg Oral drops 5mg/ml Susp 5mg/5ml Tab 10mg H2-BLOCKER 1 – 2 mkdose q 12h Tab 75mg 150mg 300mg Neonates: 5 – 20 mkday q6 – 12 h Infants: 10 – 20 mkday Child; 20 – 40 mkday Adult: 300mkdose QID 400mkdose BID 800mkdose QID Susp: 300mg/5ml Tab: 100mg 200mg 300mg 400mg 800mg PO: 0.5 mkdose q 12 h IV: 0.6 – 0.8 mkday q 8 – 12h ANTIPYRETIC (10 – 20 mkdose) q 4h Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml Tablet: 325mg 500mg Drops: 100mg/ml Syrup: 120mg/5m 250mg/5ml Syrup: 120mg/5m 250mg/5ml Drops: 60mg/0.6ml Syrup: 120mg/5ml Forte : 250mg/5ml Tablet: 600mg Drops: 80mg/ml Syrup: 160mg/5ml Drops: 60mg/0.6ml Syrup: 250mg/5ml Inj: 300mg/2ml Drops: 60mg/0.6ml Syrup: 250mg/5ml Tablet: 600mg Drops: 100mg/ml Syrup: 120mg/5m 250mg/5ml Tablet: 500mg Ampule (2ml) 150mg/ml
Opigesic Mefenamic Acid Ponstan
Suppository: 125mg 250mg (6 – 8mkdose) q 6h Suspension: 50mg/5ml Cap SF: 250mg Tab: 500mg Aspirin (60 – 100 mkd) Ibuprofen (5 – 10 mkday) q8h (max 20mkday) Dolan FP Suspension: 100mg/5ml 200mg/5ml Dolan Forte Drops: 100mg/2.5ml Advil 100mg/5 Tab: 200mg IV ANTIBIOTICS Penicillin 50,000 – 100,000 ukd q 6h Amoxicillin 50 – 100 mkd q 6 – 8 h Ampicillin 50 – 100 mkd q 6 – 8 h Chloramphenicol 50 – 100 mkd q 4 – 6 h Ampi + Cloxa 50 – 100 mkd q 6 h Oxacillin 50 – 100 mkd q 6 – 8 h Flucloxacillin 50 – 100 mkd q 6 – 8 h Gentamicin 5 – 7.5 mkd OD Netromycin 5mkd q 12 h Amikacin 15mkd q 12 h Cephalexin 50 – 100 mkd q 6 h Cefuroxime 50 – 100 mkd q 6 – 8 h Ceftriazone 50 – 100 mkd OD Ceftazidime 50 – 100 mkd q 12 h LD: 10 mkdose HYDROCORTISONE MD: 5 mkdose q 6, 8 or 12h *max dose: LD 200 MD 100 ANTICONVULSANT Diazepam 0.2 – 0.3 mkdose Drip: 1amp in 50cc D5W 10mg/amp Midazolam 0.15 mkdose OR 0.05 – 0.2 mkdose Phenobarbital LD: 10 mkdose q 12h MD: 5 mkdose q 12h ANTIHYPERTENSIVES PO: 0.75 – 1.0 mkday q 6 – 12 h Hydralazine IV: 0.1 – 0.2 mkdose Apresoline Spirinolactone 1 – 3 mkday ANTI-TB MEDS Isoniazid (10 – 12 mkd) ODAC or 2hrs PC Suspension: Comprilex Nicetal 200mg/5ml Trisofort 100mg/5ml Odinah 200mg/5ml 150mg/5ml Tablet 400mg Rifampicin (10 – 20 mkd) ODAC or 2hrs PC Natricin 100mg/5ml 200mg/5ml Rifadin 100mg/5ml 100mg/5ml Rimactane 200mg/5ml Tablet 300mg 450mg Rimaped Pyrazinamide (PZA) (16 – 30 mkd) BID/TID CIBA 250mg/5ml Zcure 500mg/5ml Zinaplex Tablet 500mg
Glucolyte Hydrite WHO Pedialyte
30 45 90
Gatorade
COMPOSITION OF ORS Na K 60 20 90 20 75 20 30 20 45 20 90 20 41 11
Cl 50 80 65 30 35 80
Glu 100 111 75
9/100
IMMUNIZATION Vaccine BCG DPT OPV/IPV Hep B
Measles MMR
Min age 1st dose At birth Before 1 mo 6 wks (2, 4, 6 mos) 6 wks 2, 4, 6 mos) At birth (0, 1, 6 mos) EPI (6, 10, 14)
No of dose 1
interval
booster
-
-
3
4 wks
3
4 wks
18 mos 4 – 6 yo Same as DPT
3
6 – 9 mos
1
6 wks from 1st dose, 8 wks from 2nd dose -
15 mos
1
Hib Pneumococcal Rotavirus Hep A Varicella
Flu
Fluid PNSS 0.45 NaCl D5 0.3 NaCl D5 LRS D5 NM D5 IMB D5 NR
2, 4, 6 mos
18 mos
6 mos (PCV7) 2 yrs (PPV) 3 and 5 mos
18 mos 2
I month
1 yr and up
2
1st: 12 – 15 mos 2nd: 4 – 6 yo 6 months
2
6 – 12 mos apart Bet 1st and 2nd dose: at least 3 mos yearly
Na 154 77 51 130 40 25 140
COMPOSITION OF IV SOLUTION K Cl 154 77 51 4 109 13 40 20 22 5 98
Na requirement : 2 – 4 meq/k/day K requirement: 2 – 3 meq/k/day KIR: 0.2 – 0.3 meq/k/hr
Head babbing Cyanosis Grunting Apnea Sensorium
Complication: Effusion Pneumothorax Action Plan
HCO3 28 16 23 27
Dxt 5 5 5 5 5
max of 40 meq
KIR = Rate x incorporation wt Electrolyte correction computation
PARAMETER Condition
ASSESSMENT OF DEHYDRATION [CDD] NO SIGN SOME SIGN Well, Alert RestlessI Irritable
Eyes Tears Mouth/Togue Thirst Skin pinch
PLAN A
PLAN B PLAN C
Normal
Sunkem
Present Moist Drinks normally Not thirsty Goes back quicly
Absent Dry Thirsty Drinks eagerly Goes back slowly
SEVERE Lethargic Unconscious Floppy Very sunken Dry Absent Very dry Drinks poorly Not able to drink Goes back very slowly
ORAL REHYDRATION THERAPY AGE Amount ORS to give/loose stool 50 – 100 ml 100 – 200 ml As much as wanted Amount of ORS to give in 1st 24 hrs: Weight (kg) x 75ml/kg AGE 30ml/kg 70ml/kg Infants (<1 yo) 1 hr 5 hrs Children (>1 yo) 30 mins 2.5 hrs
In fluid resuscitation: use 20cc/kg as bolus. Usually PLR
FLUID MANAGEMENT Severity Less than 2 yo More than 2 yo Mild 50cc/kg 30cc/kg Moderate 100cc/kg 60cc/kg Severe 150cc/kg 90cc/kg To run for 6 – 8 hrs then refer Usual fluid is D5 0.3 NaCl; if however more than 40 kg then D5 LR
VARIABLE
PCAP A Minimal Risk
PCAP PCAP B Low Risk
Comorbid Illness Compliant caregiver Ability to follow up Presence of dehydration Ability to feed Age RR 2 – 12 mos 1 – 5 yo >5 yo
None
Signs of Respiratory Failure Retractions -
PCAP D High Risk
Present
PCAP C Moderate Risk Present
Yes
Yes
No
No
Possible
Possible
Not
Not
None
Mild
moderate
Severe
Able >11 mos
Able >11 mos
Unable <11 mos
Unable <11 mos
>50/min >40/min >30/min
>50/min >40/min >30/min
>60/min >50/min >35/min
>70/min >50/min >35/min
Present
-
None
Awake
Subcostal/ Intercostal + + Irritable
Subcostal/ Intercostal + + + + Lethargy / Stupor Coma/
None
None
Present
Present
OPD f/u at end of tx
OPD f/u after 3 days
Admit to regulat ward
Admit to CCU Refer to specialist
Clinical Practice Guidelines in the Evaluation and Management of PCAP 2004 Predictors of CAP in patients with cough (3 mos to 5 yrs) – tachypnea &/or chest retractions (5 – 12 yrs) – fever, tachypnea & crackles (>12 yo) – (a) fever, tachypnea & tachycardia; (b) at least 1 AbN CXR WHO Age Specific classification for tachynea 2 – 12 mos: >50 RR 1 – 5 yrs: >40 RR >5 yrs: >30 RR PCAP A/PCAP B No diagnostic usually requested PCAP C/PCAP D The ff shud b routinely requested o CXR APL (patchy – viral; consolidated – bacterial) o WBC o C/S (blood, Pleural Fluid, tracheal aspirate on initial intubation) o Blood gas/Pulse oximeter The ff may be requested: C/S sputum The ff shud NOT be routinely requested o ESR o CRP Antibiotic Recommendation 1. PCAP A/PCAP B and is beyond 2 yo & having fever w/o wheeze 2. PCAP C and is beyond 2 yo, having high grade fever, having alveolar consolidation on CXR, having WBC >15,000 3. PCAP D – refer to specialist Antibiotic Recommendation PCAP A/PCAP B w/o previous antibiotic o Amoxicillin (40 – 50 mkday) TID PCAP C o Pen G IV (100,000 IU/k/d) QID PCAP C who had no HiB immunization o Ampicillin IV (100mkd) QID PCAP D – refer to specialist
What should be done if px is not responding to current antibiotics 1. If PCAP A/PCAP B not responding w/n 72 hrs a. Change initial antibiotic b. Start oral Macrolide c. Reevaluate dx 2. PCAP C no responding w/n 72 hrs consult w/ specialisr a. PCN resistant S pneumonia b. Complication c. Other dx 3. PCAP D not responding w/n 72hrs, then immediate consultto a specialist is warranted Switch from IV to Oral Antibiotic done in 2 – 3 days after initiation in px who: Respond to initial antibiotic Is able to feed with intact GI tract Does not have any pulmo or extra pulmo complication Ancillary Treatments O2 and Hydration Bronchodilators, CPT, steam inhalation and Nebulization Prevention Vaccines Zinc Supplementation o 10mg for infants o 20mg for children > 2 yo
DENGUE HEMORRHAGIC FEVER Serotype 1, 2, 3, & 4 Aedes egypti IP: 4 – 6 days (min 3 days; max 10 days) DHF SEVERITY GRADING GRADE I II III
MANIFESTATION Fever, non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain (+) Torniquet test Grade I + spontaneous bleeding; mucocutaneous, GI Grade II w/ more severe bleeding + Evidence of circulatory failure: violaceous, cold & clammy skin, restless, weak to imperceptible pulses, narrowing of
IV
CRITERIA FOR CLINICAL DX (WHO) DHF DSS Above criteria Fever, acute onset, high, lasting 2 Plus – 7 days Hypotension or narrow pulse Hemorrhagic man: pressure [SBP – DBP] o (+) Torniquet test <20mmHg o Minor & Major bleeding phenomenon 3 Thrombocytopenia <100,000/mm
LEVELS OF ASTHMA CONTROL [GINA GUIDELINES] CONTROLLED PARTLY UNCONTROLLED Daytime symptom None [2x or More than 2x a Three or more less/week] week features of partly controled asthma Limitation of None Any activities present in any week None Any Nocturnal sx/awakening None Need for More than 2x a reliever/recue tx week Lung function Normal 80% predicted (PEF OR FEV1) Exacerbation None One or more/yr One in any week
ATOPIC DERMATITIS
o o
pulse pressure to < 20mmHg to actualHPON Grade III but shock is usually refractory or irreversible and assoc w/ massive bleeding
Hereditary, AR hx of Asthma thickened, shiny, red exacerbated by dry skin, contact sty, & anxiety tx: hydrocortisone/ fluocinolone moisturizer cloxa/cefalexin if with infxn
CONTACT DERMATITIS Irritant – strong chem. e.g. diaper rash remove reactant
Allergic
e.g. cosmetic, perfume tx: high/mod petency steroid
SEBORRHEIC DERMATITS excessive sebum accumulation on scalp, face, midchest, perineum greasy scalp (cradle cap) physiologic 1st 6mos tx: low potency steroid
SHOCK CO = HR x SV CO is primarily maintained by changes in HR HYPOVOLEMIC Pump empty MC in infant Truma, hemorrhage, &children DHN Normal BV of (diarrhea/vomiting), children 80ml/kg Metabolic dse (DM) Excessive sweating CARDIOGENIC Weak/sick pump Compromise CHF, cardiomegaly, CO drug intoxication, hypothermia, after cardiac surgery DISTRIBUTIVE Sepsis Redistribution of Anaphylaxis fluid w/n Barbiturate intox vascular space CNS injury (SCI) SIGNS OF SHOCK EARLY LATE Narrowed pulse pressure Decrease systolic pressure Orthostatic changes Decrease diastolic pressure Delayed capillary filling Cold, pale skin Tachycardia Altered mental state Diaphoresis Hyperventilation Decrease urine output ED 1. Position MNGT 2. Oxygen 3. Assisted ventilation 4. Intravenous access 5. Fluid (isotonic crystalloid) 6. Reassess (look for improvement in VS, skin signs, mental status; insert foley cath & monitor UO) 7. Inotropes – help stabilize BP o Epinephrine - (0.1 – 1 ug/kg/min) Infusion of choice for Hypotensive pxs o Dobutamine - (5 – 20 ug/kg/min) Cardiogenic shock but not severely hypotensive o Dopamine – [(5 – 20 ug/kg/min αconstrictor effect) [(10 – 15 ug/kg/min] Distributive shock after successful fluid resuscitation 8. Cardiogenic shock o Diuretic – pxs may get worse after fluid challenge
Adenosine / synchronize cardioversion – SVT Defibrillation – Venticular fibrillation
MUMPS [Paramyxoviridae] MOT Direct contact, airborne droplets, fomites contaminated by saliva IP 16 – 18 days Prd of comm 1 – 2 days before onset of parotid swelling until 5 days after the onset of swelling Prodorme Fever, neck muscle pain, headache, malaise Peak in 1 – 3 days Parotid gland swelling 1st in the space between posterior border of mandible & mastoid then extends being limited above zygoma Complications Meningoenephalitis - most frequent, about 10 days; M>F Orchitis & Epididymitis Oophoritis Dacryoadenitis or optic neuritis
ANAPHYLAXIS A syndrome involving a rapid & generalized immunologically mediated rxn After exposure to foreign allergens in previously sensitized individuals A true emergency when cardio and respi system are involved ED Management o O2 o Aqueous Epinephrine 1:1000 IM (0.01ml/kg with 0.5ml max) o Prepare intubation if w/ stridor & if initial therapy of epi is not effective o Continuous monitor ECG and O2 sat & establish IV access o Antihistamine to prevent progression o H1 & H2 blocker o Diphenhydramine (1mg/kg) IM o Steroids may modify late phase or recurrent reaction (Hydrocortisone 5mg/kg/dose) o Epinephrine 1:10,000 IV (0.1ml/kg; 10ml max) o Epinephrine drip (0.01ml/kg/min) Indication for Admission o Persistent bronchospasm o Hypotension requiring vasopressors o Significant hypoxia o Patient resides some distance from a hospital facility
VIRAL INFECTIONS MEASLES (Rubeola) [Paramyxoviridae] MOT Droplet spray IP 10 – 12 days Prd of comm 4 days before & 4 days after onset of rash Enanthem Koplik spots (opposite lower molars) Prodrome High grade fever, conjunctivitis, catharr (3 – 5 days) Rash Appear during height of fever Cephalocaudal[1st along hairline, face, chest] [+] brawny desquamation – disappear w/n 7 – 10 days Complication 1. Otitis media 2. Pneumonia 3. Encephalitis 4. Diarrhea 5. Exacerbation of M tb infection Tx Vit A SD 100,000 IU orally for 6 mos – 1 yo 200,000 IU >1 yo Post Ig w/n 6 days of exposure exposure (0.25ml/kg max 15 ml) IM prophylaxis Vaccine Susceptible children >1 yo w/n 72 hrs SSPE Chronic condition due to persistent measles infxn Rare but found in 6 mo to >30 yrs of age Subtle change in behavior & deterioration o schoolwork followed by bizarre behavior Elevated titers of Ab to measles virus(IgG, IgM) Inosiplex (100mg/kg/day) may prolong survival GERMAN OR 3 DAY MEASLES [RUBELLA] [Togaviridae] MOT Oral Droplet; transplacentally to fetus IP 14 – 21 days Prd of comm 7 days before &7 days after onset of rash Enanthem Forchheimer spots [soft palate] just b4 onset of rash Rash Cephalocaudal Characteristic Retroauricular, posterior cervical & postoccipital LAD [24 hrs sign before rash & remains for 1 wk] Tx Vit A SD 100,000 IU orally for 6 mos – 1 yo 200,000 IU >1 yo Immunoglobulin [not routine] Post Considered if termination of preg is not an option exposure prophylaxis 0.55ml/kg) IM Vaccine w/n 72 hrs of exposure Congenital Greatest during 1st trimester IUGR Rubella Congenital cataract, microcephaly, PDA, “blueberry muffin” skin lesions Congenital or profound SNHL
Motor or mental retardation ROSEOLA [HSV 6] Exanthem subitum Age of onset < 3 yo with peak at 6 – 15 months High grade fever for 3 – 5 days but behave normally Rash Appears 12 – 24 hrs of fever resolution fades in 1 – 3 days HERPANGINA [Coxsackie A] Sudden onset of fever with vomiting Small vesicles & ulcers w/ red ring found in anterior tonsillar pillars, may also seen on the soft palate, uvula & pharyngeal wall
VARICELLA [HSV] MOT Direct contact IP 14 days Prd of comm 1 – 2 days before the onset of the rash until 5 – 6 days after onset & all the lesions have crusted Rash Start from the trunk then spread to othe parts of the body All stages present; pruritic Macule/papule → vesicle →crust Secondary bacterial infection Complication Encephalitis or meningitis Pneumonia Reye syndrome GN Congenital 6 -12 wks AOG: maximal interruption w/ limb devt with Varicella cicatrix(ski lesion w/ zigzag scarring) 16 – 20 wks: eye and brain involvement Tx Acyclovir 15 – 30 mg/kg/day IV or 200 – 400 mg tab q 4hrs minus midnight dose x 5 days: increased risk o severity Post VZIg 1 dose up to 96 hrs after exposure exposure Dose: 125 U/10 kg (max 625 U) IM prophylaxis NB whos mother develop varicella 5 days before to 2 days after delivery shud recv 1 vial Vaccine Susceptible children >1 yo w/n 72 hrs ERYTHEMA INFECTIOSUM [Parvovirus B 19] FIFTH DISEASE MOT Droplet spread & blood & blood products IP 16 – 17 Days average Prodrome Low grade fever, headache, URTI Erythematous facial flushing “slapped cheek” and spreads Rash rapidly to the trunk & proximal extremities as a diffuse macular erythema Palms & soles are spared Resolves w/o desquamation but tend to wax and wane in 1 – 3 wks Dengue insert Rabies JUVENILE RHEUMATOID ARTHRITIS [JRA] Criteria Age of onset <16 yo Arthritis (swelling or effusion or presence of 2 or more of: limitation of range of motion, tenderness or pain on motion, increased heat in one or more joints. Duration: 6 wks or longer Onset type defined in the 1st 6mos o Polyarthritis: (5 or more inflamed joints) o Oligoarthritis (<5) o Systemic arthritis w/ characteristic fever CM Morning stiffness, ease of fatigue esp. after school in the early afternoon, joint pain later in the day, joint swelling Pauci: LE, assoc w/ chronic uvietis Poly: both large & small joints more severe if extensors of elbow and Achilles tendon are involved Systemic: quotidian fever w/ daily temp spikes of 39°C for 2 wks; faint red macular rash over the trunk & proximal extremities Mngt NSAIDS then Methotrexate Seroid for overwhelming systemic illness SYSTEMIC LUPUS ERYTHEMATOSUS [SLE] Criteria Malar rash Discoid rash Photosensitivity Oral ulcers (painless) Nonerosive arthritis (2 or more joints) Serositis (pleuritis, serous pericarditis,Libman sacks endocarditis Renal disorder Neurologic disorder Hematologic disorder Immunologic disorder ANA abormal titer Dx Presence of 4 of 11 criteria [ANA not required dx] (+) ANA – screening Anti ds DNA – more specific; reflects the degree of disease activity Decrease C3, C4 in active dse Anti Sm Ab (most specific) Mngt NSAIDS use w/ caution Prednisone (1 – 2 mkday) Severely ill: pulse IV steroid (30mkdose) max 1 gm over 60 mins OD x 3 days Severe dse: Pulse IV Cyclophosphamide to maintain renal fxn & prevent progression
HENOCH – SCHONLEIN PURPURA [HSP] Most common cause of nonthrombocytopenic purpura in children Typically follows URTI 2 – 8 years old Hallmark Rash – palpable petechia or purpura, evolve from red to brown; last from 3 – 10 days [LE and buttocks] Arthritis of knees and ankles Intermittent abdominal pain due to edema & damage to the vasculatue of the GIT Mngt Symptomatic Steroid for severe abdominal pain
MAINTENANCE WATER HOLLIDAY – SEGAR METHOD Weight [kg] Daily Requirement [ml/kg] 3 – 10 100 ml 10 – 20 1000 + 50ml/kg for each kg >10 >20 1500 + 20ml/kg for each kg >20 Maintenace water rate 0 – 10 4ml/kg/hr 10 – 20 40 mk/hr + 2ml/kg/hr x wt >20 60 mk/hr + 1ml/kg/hr x wt
Microbial causes of CAP accrdng to Age Birth to 20 o Grp B Strep o Gram (-) enterobacteria days o CMV o L. monocytogenesis 3 weeks to 3 o RSV o Parainfluenza virus months o S. pneumonia o B. pertussis o S. aureus 4 months to 4 o RSV, Parainfluenza virus o Influenza virus, Adeno, Rhinovirus yo o S. pneumonia o H. influenzae o M.pneumoniae o M.tuberculosis 5 years to o M.pneumoniae 15 years o C. pneumoniae o S. pneumonia o M.tuberculosis
Therapeutic Mgt of CAP OPD Mngt Birth to 20 days
Admit
3 weeks to 3 months
Afebrile: Oral Erythromycin (30-40mkd) Oral Azithromycin (10 mg/kg/day) day 1 5mkday day2 to 5 Admit: febrile or toxic
4 months to 4 yo
Oral Amoxicillin (90mkd/3doses) Alternative: Amox-Clav, AZM, Cefaclor Clarithromycin, Erythromycin
5 years to 15 years
Oral Erythromycin (30-40mkd) Oral AZM 10mkday day 1, 5mkday day 2-5 Clarithromycin 15mkday/2 doses Pneumococcal infxn: Amoxicillin alone
IN-PATIENT Birth to 20 days 3 weeks to 3 months
Ampicillin + Gentamicin w or w/o Cefotaxime Afebrile: IV Erythromycin (30-40mkd) Febrile: add Cefotaxime 200mkd Cefuroxime 150 mkd
4 months to 4 yo
If w/ pneumococcal infection: IV Ampicillin (200mkd) Cefotaxime 200mkd Cefuroxime 150 mkd
5 years to 15 years
Cefuroxime 150 mkd + Erythromycin 40mkd IV or orally for 10-14 days If pneumococcal is confirmed: Ampicillin 200mkd
CLINICAL FEATURES of PNEUMONIA Bacterial o Fever >38.5C o Chest recession o Wheeze not a sign of primary bacterial URTI Viral o Wheeze o fever < 38.5 o marked recession o RR normal or increased Mycoplasma o School children o Cough o wheeze
CXR in assessing CAP etiology Alveolar infltrates Bacterial pneumonia Interstitial infiltrates Viral pneumonia Both infiltrates Viral, Bacterial or mixed viral bacterial pneumonia
PHOTOTHERAPY 10 Bulbs o 20 watts o 200 hrs o o 30 cms Bilirubin in the skin absorbs light energy o Photo-isomerization reaction converting the toxic native o unconjugated 4Z, 15Z-bilirubin into an unconjugated configurational isomer 4Z,15E-bilirubin, which can then be excreted in bile without conjugation major product from phototherapy is lumirubin, which is an o irreversible structural isomer converted from native bilirubin and can be excreted by the kidneys in the unconjugated state o Complications o loose stools, erythematous macular rash, purpuric rash associated with transient porphyrinemia, overheating, dehydration (increased insensible water loss, diarrhea), hypothermia from exposure, and a benign condition called bronze baby syndrome dark, grayish-brown skin discoloration in infants
<3 > No No No < 7 yo Dtap is recommended > 7 yo Td is recommended If ony 3 doses of TT received, a 4th dose should be given Give TT (clean minor wounds) if > 10 y since last dose All other wounds (punctured wds, avulsions, burn) Give TT (all clean wds) if > 5 yrs since last dose
No
BILIRUBIN METABOLISM RBC Heme +Globin Heme oxygenase Biliverdin Bilirubin reductase Unconjugated bilirubin Enterohepatic pathway Liver SER Glucoronyl transferase glucoronidase
B-
Conjugated bilirubin Treatment of Hyperbilirubinemia Phototherapy Exchange o Complications: metabolic acidosis, transfusion electrolyte abnormalities, hypoglycemia, hypocalcemia, thrombocytopenia, volume overload, arrhythmias, NEC, infection, graft versus host disease, and death IV Ig o Adjunctive treatment for hyperbilirubinemia due to isoimmune hemolytic disease o (0.5–1.0 g/kg/dose; repeat in 12 hr) o Reducing hemolysis Metalloporphyrins o Competitive enzymatic inhibition of the rate limiting conversion of heme-protein to biliverdin (an intermediate metabolite to the production of unconjugated bilirubin) by heme-oxygenase o Patients with ABO incompatibility or G6PD deficiency or when blood products are discouraged as with Jehovah's Witness patients
Kidney Urobilinogen Urobilin Urine
Small intestine Stercobilinogen Stercobilin Stool
Pathogenesis of Dengue Hemorrhagic Fever Dengue Virus
Liver
Lymphoblast/plasma Cell
Liver injury maturation
Platelet
Ag-Ab reaction
Dec
Megakaryocyte VACCINES BCG DPT OPV IPV MMR, Measles Varicella Hep B Hep A Hib Typ Pneumococcal
Inc plt destruction
Live attenuated M bovis Diptheria and TT – inactivated B pertussis Sabin trivalent live attenuated virus Salk inactivated virus Live attenuated virus
Dec coagulation Thrombocytopenia Factors
Recombinant DNA, plasma derived Inactivated virus Capsular polysacc linked to carrier CHON Live typhoid vaccine – 3 doses x 2 days IMSC – Vi antigen typ vaccine Capsular polysaccharide 0.5 ml SC /IM – 23 valent purified cap Polysacc Antigen of 23 serotyp Split or whole virus IM
Inc. Bleeding Bleeding Tendency
Inc Vascular Permeability
Hypoalbuminemia Hemoconc. Pleural Effusion
Hypotension
Influenza
RABIES VACCINE VERORAB 0.5 cc/amp; 1 amp IM Day: 0 3 7 14 and 28 BERIRAB RD: 20 iu/kg 300 iu/vial ½ at wound site ½ deep IM Reqd amt in IU: wt x RD (20IU) Amount in ml = wt x RD (20) x 2 300 Ig (Human) 20 iu/kg Bayrab 300 iu/2ml Berirab 300 iu/2ml Equine 40 iu/kg Favirab 200 – 400 iu/5ml 1000 – 2000 iu/5ml Hx of Absorbed TT Unknown or
Clean minor Wound
Td Yes
TIG No
1 vial = 2ml
All other Wounds
Td Yes
TIG Yes
MANAGEMENT APPROACH BASED ON CONTROL Step 1 Step 2 Step 3 Step 4 Step 5 PRN Asthma education and Environmental B2 control agonist As needed rapid acting B2 agonist Select one Select one Add one or Add one more or more C Low dose Low dose Med to Hi Oral O ICS ICS + dose steroids N LABA ICS + LABA T R Leukotriene Medium or Leukotriene O Anti modifier Hi dose ICS Modifier L Low dose Sustained IgE L ICS + Release treatment E Leukotriene theophylline R Modifier Low dose ICS + Salbutamol Release theophylline
SEVERITY OF ASTHMA EXACERBATION MILD MODERATE SEVERE
Breathless
Walking
Talking Infant –softer shorter cry Diff feeding
Can lie
Prefers sitting
Sentence s
Phrases
Hunched Words
Usually agitated
Usually agitated
Inc
>30/min
Usually
Usually
Loud
Usually loud >120
RESPIRATORY ARREST IMMINENT
At rest Infant stops feeding
Talks in Allertness
May b agitated RR Normal RR <2 mo 2-12 mo 1-2 y 2-8 y Acessory ms Wheeze Pulse Normal PR 2-12 mo 1-2 y 2-8 y Pulsus paradoxus PEF PaO2 PaCO2
<100 <160/min <120/min <110/min Absent <10mmH g >80% Normal <45 mmHg
O2 Sat
100-200
Maybe present 10-25mmHg 60-80% >60 mmHg
Often present 20-40 mmHg <60% <60mmH g
Drowsy or confused
Paradoxical Thoracoabd movt Absence of wheeze Bradycardia
Absence suggests resp ms fatigue
<45 mmHg 91-95%
>45 mmHg
>95% <90%
SEIZURE BENIGN FEBRILE SEIZURE CRITERIA 6 mos – 6 yrs < 15 mins Febrile Family history of febrile seizure GTC Not > 1 episode in 1 febrile episode; EEG done after 2 wks of seizure episode 3% of general population develop epilepsy 1 – 2 % of BFS develop epilepsy 25% recurrence of seizure Seizure – paroxysmal, time limited change in motor activity and/or behavior that results from abnormal electrical activity in the brain Epilepsy – present when 2 or more unprovoked seizure s occur at an interval greater than 24 hrs apaet HYDROCEPHALUS Result from impaired circulation & absorption of CSF or from inceased production Obstructive or Noncommunicating o Due to obstruction w/n ventricular system o Abnormality of the aqueduct or a lesion in the 4th venticle (aqueductal stenosis) Non-obstructive or Communicating o Obliteration of the subarachnoid cisterns or malfunction of the arachnoid villi o Follows SAH that obliterates arachnoid villi; leukemic infiltrates Clinical Manifestation Infant: accelerated rate of enlargement of the head; wide anterior fontanel & bulging [Normal fontanel size: 2 x 2 cm] Eyes may deviate downward: due to impingement of the dilated suprapineal recess on the tectum [setting – sun sign] Long – tract sign: [brisk DTR, spasticity, clonus, Babinski sign] Percussion of skull produce a “crackedpot” or Macewen sign [separation of sutures] Foreshortened occiput [Chiari malformation] Prominent occiput [Dandy-Walker malformation] Treatment Depends on the cause Extracranial shunt Acetazolamide & Furosemide [provide temporary relief by reducing the rate of CSF production]
CEREBRAL PALSY Non-progressive disorder of posture & movement often associated with epilepsy & abnormalities of speech, vision & intellect resulting from defect or lesion of the developing brain Etiology: infections, toxins, metabolic, ischemia Classification Physiologic Topogrphic [major motor abnormality] [involved extremities] 1. Spastic 1. Monoplegia [1 side/portion] 2. Athetoid –worm like 2. Paraplegia 3. Rigid 3. Hemiplegia 4. Ataxic 4. Triplegia [3 limbs] 5. Tremor 5. Quadriplegia [all] 6. Atonic 6. Diplegia [LE/UE] 7. Mixed 7. Double hemiplegia 8. unclassified Clinical Manifestaion Spastic hemiplegia Arms > legs Dificulty in hand manipulation obviously by 1 yo Delayed walking or walk on tiptoes Spasticity apparent esp. in ankles Seizure & cognitivr impairment Spastic diplegia Bilateral spasticity of the legs Commando crawl Increased DTRs & (+) Babinski sign Normal intellect Spastic Most severe form, due to marked motor quadriplegia impairment of all extremities & high association with MR & seizures Swallowing difficulties Management Baseline EEG & cranial CT scan Hearing & visual function tests Multidisciplinary approach in the assessment & treatment For tight heel cord: tenotomy of the Achilles tendon
Inc <60/min <50/min <40/min <30/min Usually not Moderate
BELLS PALSY Acute unilateral facial nerve palsy that is not associated with other cranial neuropathies or brainstem dysfunction Usually develops abruptly about 2 wks after SVI [EBV, HSV, mumps] Upper and lower portions of the face are paretic Corner of the mouth droops Unable to close the eye on the involved side Protection of cornea with methylcellulose eye drops or an ocular lubricant Excellent prognosis
ESSENTIAL NEWBORN CARE PROTOCOL [from DOH] o o o
o
What should be done immediately after birth is to dry the baby because hypothermia can lead to several risks Delaying the cord clamping to 3 mins after birth (or waiting until the umbilical cord has stopped pulsing) Instead of immediately washing the NB, the baby should be placed on the mother’s chest or abdomen to provide warmth, increase the duration of breastfeeding, and allow the “good bacteria” from the mother’s skin to infiltrate the NB Washing should be delayed until after 6 hours because this exposes the NB to hypothermia and remove vernix. Washing also removes the baby’s crawling reflex.
APGAR SCORE Evaluates the need for resuscitation Taken 1 and 5 minutes after birth 0 1 2 Color Blue, pale Body pink, All pink extremities blue HR 0 <100 >100 Reflex irritability No response Grimace Cough Activity Limp Some flexion Active Respiration Absent Slow, irregular Good The APGAR Score 8 – 10 Good cardiopulmonary adaptation 4–7 Need for resuscitation, esp ventilatory support 0–3 Need for immediate resuscitation o o
NORMAL VALUES AVERAGE WEIGHT (3,000 grams) 0 – 6 mos Age in months x 600 + BW 7 – 12 mos Age in months x 500 + BW Children 1 – 6 yo Age in years x 2+ 8 7 – 12 Age in years x 7 – 5 / 2 yo HEAD CIRCUMFERENCE [35 cm (+ 2cm)] 2.54cm) 1 – 4 months ½ inch per month
(inch =
5 – 12 mos ¼ inch per month 2 years old 1 inch per year 3 – 5 yo ½ inch per year 6 – 20 yo ½ inch per 5 years LENGTH (50 cm) 0 – 3 months 9 cm 4–6 8 cm 7–9 5 cm 10 – 12 3cm NEWBORN CARE Umbilical Cord Cut 8 inches above abdomen after 30 sec In nursery, cut the umbilical cord 1 ½ inch above the abdomen Healing should take place around 7 – 10 days Eye Prophylaxis 1% silver nitrate drops [most effective against Neisseria] Erythromycin 0.5% [Clamydia] Tetracycline 1% Povidone iodine 2.5% Vitamin K 1 mg Vit K1 PT: 0.5 mg Vaccine BCG Hep B Newborn Screening Done on 16th hr of life . can be repeated after 2 weeks Patients w/ CAH will die 7 – 14 days if not treated Patient w/ CH will have permanent growth defect and MR if not treated before 4 weeks Disorder Screened Effects Screened Effects if Screened & treated Congenital Severe MR Normal Hypothyroidism (CH) Death Alive &Normal Congenital Adrenal Hyperplasia (CAH) Galactosemia (Gal) Death of Cataract Alive &Normal Phenylketonuria PKU Severe MR Normal G6PD Normal Severe Anemia Kernicterus
NEONATAL JAUNDICE Risk Factors o Jaundice visible on first day of life o A sibling w/ neonatal jaundice or anemia o Unrecognized hemolysis o Non-optimal feeding o Deficiency: G6PD o Infection o Cephalhemaoma or bruising / Central hct >65% o East Asian/ Mediteranean in origin PHYSIOLOGIC vs PATHOLOGIC FACTORS PHYSIOLOGIC PATHOLOGIC Onset > 24 hrs of life < 24 hrs of life Rate of inc of TSB < 0.5mg/dl/hr > 0.5mg/dl/hr Persistent < 14 days FT: > 8 days PT: > 14 days Total S. Bilirubn FT: < 12 mg/dl Any level requiring PT: < 14 mg/dl phototherapy Sign/ Symptom Vomiting, lethargy, poor feeding, excess wt loss, apnea, inc RR, temp instability KRAMER CLASSIFICATION ZONE JAUNDICE mg/dl I Head/neck 6–8 II Upper trunk 9 – 12 III Lower trunk, thigh 12 – 16 IV Arms, leg, below knee 15 – 18 V Hands/feet > 15 BREAST FEEDING vs BREASTMILK JAUNDICE BREASTFEEDING BREASTMILK 3rd to 5th day of life Late; start to rise on day 4; may reach 20 – 30 mg/dl on day 14 then ↓ slowly Normal by 4 – 12 weeks Decrease milk intake → Unknown Pathophysio ↑enterohepatic circulation Prob. due to β – glucoronidase in BM which ↑ enterohepatic circulation Normal LFT; (-) hemolysis Mngt Fluid and caloricsupplement If breastfeeding is stopped, rapid decrease in bilirubin level in 48 hrs, if resumed will rise to 2 – 4 mg/dl but no precipitating previous events Parameter Onset
NEONATAL SEPSIS Classification Early: birth to 7th day of life Late: 8th to 28th day of life Risk factors Maternal infection during pregnancy Prolongrupture of membranes (18 hrs) Prematurity Common organism: Bacteria: GBS, E. coli & Listeria (early) Viruses: HSV, enteroviruses Signs & symptom Non-specific Dx: CBC, CXR, blood and urine culture, lumbar tap for CSF studies Treatment Empiric antibiotics [Ampicillin + 3rd gen Cephalosporin or Aminoglycoside) supportive
VIRAL CROUP vs EPIGLOTTITIS VIRAL CROUP EPIGLOTTITIS Age group 3 mos to 3 yrs 3 – 7 yrs Stridor 88% 8% Pathogen Parainfluenza virus H. influenzae type B Onset Prodrome (1 – 7 days) Rapid (4 – 12 hrs) Fever Severity Low grade High grade Associated sympto Barking cough, Muffled voice, hoarseness Droolong Respond to Stridor improves None racemic epinephrine CXR “steeple sign” “thumbprint sign” BRONCHIOLITIS Acute inflammation of the small airways in children <2 yrs Most commonly caused by RSV Related to exposure to cigarette smoke Risk factors for severe dse: o <6 mos o Prematurity o Heart or lung disease o immunodeficiency Signs /Symptoms low grade fever, rhinorrhea, cough, wheezing hyperresonance to percussion CXR hyperinflation, interstitial infiltrates Treatment Mild [at home]: o Increased fluids, trial of inhaled bronchodilators, aerosolized epinephrine Severe: o Admit to hospital if: Marked respratory distress; Poor feeding; O2 sat <92%; hx of prematurity < 34 wks; underlying cardiopulmonary dse; unreliable caregivers o Manage with ventilatory and O2 support, hydration, inhaled bronchodilators and ribavirin
Age mo 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Ht (cm) boys 50.5 54.6 58.1 61.1 63.7 65.9 67.8 69.5 71.0 72.3 73.6 74.9 76.1 77.2 78.3 79.4 80.4 81.4 82.4 83.3 84.2 85.1 86.0 86.8 87.6
Ht (cm) girls 49.9 53.5 56.8 59.5 62.0 64.1 65.9 67.6 69.1 70.4 71.8 73.1 74.3 75.5 76.7 77.8 78.9 79.9 80.9 81.9 82.9 83.8 84.7 85.6 86.5
Wt for Ht (cm) 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73
Boys (kg)
Girls (kg)
3.1 3.3 3.5 3.7 3.9 4.1 4.3 4.6 4.8 5.1 5.4 5.7 5.9 6.2 6.5 6.8 7.1 7.4 7.7 8.0 8.3 8.5 8.8 9.1 9.3
3.3 3.4 3.5 3.7 3.9 4.1 4.3 4.5 4.8 5.0 5.3 5.5 5.8 6.1 6.4 6.7 7.0 7.3 7.5 7.8 8.1 8.4 8.6 8.9 9.1
25 26 27 28 29 30 31 32 33 34 35 36 3.5 4 yo 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12
88.5 89.2 90.0 90.8 91.6 92.3 93.0 93.7 94.5 95.2 95.8 96.5 98.4 102.9 106 109.9 112.6 116.1 118.5 121.7 123.9 127.0 129.1 132.2 134.4 137.5 139.9 143.3 145.8 149.7
87.3 88.2 89.0 89.8 90.6 91.3 92.1 92.8 93.5 94.2 94.9 95.6 97.3 101.6 104.5 108.4 111.0 114.6 117.1 120.6 123.0 126.4 128.8 132.2 134.7 138.3 140.9 144.8 147.6 151.5
74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103-105
12.5
152.5
154.1
106-108
13
156.5
157.1
109-111
13.5
159.3
158.8
112-114
14
163.1
160.4
115-117
14.5
165.7
161.1
118-120
15
169.0
161.8
121-123
15.5
171.1
162.1
124-126
16
173.5
162.4
127-129
16.5
174.9
162.7
130-132
17
176.2
163.1
133-135
17.5
176.7
163.3
136-140
18
176.8
163.7
141-145
9.6 9.8 10.0 10.3 10.5 10.7 10.9 11.1 11.3 11.5 11.7 11.9 12.3 12.3 12.5 12.8 13.0 13.2 13.4 13.7 13.9 14.1 14.4 14.7 14.9 15.2 15.5 101.0 16.1 16.517.1 17.418.0 18.319.0 19.320.0 20.321.1 21.422.2 22.623.4 23.924.8 25.226.2 26.827.8 28.429.6 30.233.0 33.736.9
9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 11.0 11.2 11.4 11.6 11.8 11.9 12.2 12.4 12.6 12.8 13.0 13.3 13.5 13.8 14.0 14.3 14.6 14.9 15.2 15.5 15.9 16.216.7 17.017.6 17.918.6 18.919.5 19.920.6 21.021.8 22.223.1 23.624.6 25.126.2 26.828.0 28.730.1 30.8-32
Weight for Height = Actual BW (kg) P50 Wt for Ht (kg) Height for Age = Actual Height (cm) P50 Ht for Age Waterloo Classification Normal Mild Moderate Severe
Wasting (Wt for Ht) >90 81 – 90 70 – 80 <70
Stunting (Ht for Age) >95 90 – 95 85 – 89 <85
RHEUMATIC HEART DISEASE JONES CRITERIA Major Manifestation 1. Arthritis (70%) 2. Carditis (50%) a. Tachycardia b. Heart murmur of valvulitis c. Pericarditis d. Cardiomegaly e. Signs of CHF [gallop rhythm, distant heart sounds, cardiomegaly] 3. Erythema marginatum (10%) 4. Subcutaneous nodules (2 – 10%) 5. Sydenham’s chorea (15%) Minor manifestation 1. Arthralgia 2. Fever at least 38.8°C 3. Elevated Acute Phase Reactants (CRP & ESR) 4. Prolonged PR interval on the ECG Diagnosis 1. Highly probable : 2 major OR 1 major and 2 minor manifestation
INFECTIVE ENDOCARDITIS DUKE CRITERIA Major Manifestation 1. Minor manifestation Diagnosis 2. Highly probable : 2 major OR 1 major and 2 minor manifestation NURSERY NOTES Dextrosity (to get factor:
Desired – D5 D50- D5
D 7.5 = 0.055 D10 = 0.11 D 12.5 = 0.166 D15 = 0.22 D 17.5 = 0.28 Limits of Dextrosity: Peripheral line = D12 Central line = D20 Total Fluid Intake (TFI): Preterm: start at 60 cckd Term: start at 80 cckd To check TFI = rate x 24 ÷ wt ex. Preterm: wt: 1.129 Day 1: start IVF with D10 water 60 x 1.219 ÷ 24 = 3.1 cc/hr x 24 hrs Add Calcium gluconate at 200 mkd q8h Ca gluc = 1.129 x 200 ÷ 3 = 75mg q8hrs for 3 doses Start antibiotics Give ranitidine HGT q 8/12 hrs OGT CBC Na, K, Ca at 48 hrs Blood c/s depends on AP Day 2: increase TFI by 10-20 (depends on AP) 70 x 1.129 ÷ 24 = 3.3 cc/hr x 24 hrs incorporate ca gluc 200 mkd to IV ex. D10 water 80 cc Ca gluc 2.2cc 82.2cc to run at 3.3ccx24hrs Day 3: increase TFI by 10-20 (depends on AP) If electrolytes are N, may use D10IMB 80 x 1.129 ÷ 24 = rate 80 x 1.129 x factor to get value of D50 water (to make D10 use 0.11) Cont Ca gluc incorporation (if feeding may discontinue) D50 water 9.9cc D5 IMB 77.9cc = D10 IMB Ca gluc 2.2cc (200mkd) 90 cc to run at 3.7cc/hrx24h If feeding already: Total volume of milk ÷ wt = cc/kg/day Subtract this amount to TFI to get value for IV (if Dr. Reinoso, divide by 2 before subtracting to TFI) ex. MF 3cc q3hrs = 24 cc in 24 hrs 24 ÷ 1.129 = 21.2 cckd from milk 80 – 21.2 = 58.8cckd (use this for IVF) 58.8 x 1.129 ÷ 24 = rate D50 water 7.3cc D5 IMB 56.5cc = D10 IMB Ca gluc 2.2cc (200mkd) 66 cc to run at 2.7cc/hrx24h Subsequent days depend on infants status….. Electrolyte requirements: Na: 2-4 mkd prep’n 2.5 mg/ml Ca: 100-200mkd prep’n 100mg/ml K: 2-4 mkd prep’n 2mg/ml Glucose Infusion Rate: Dextrosity x IVF rate x 10 ÷ 10 Wt Ex. 10 kg; IVF D10 IMB at 40cc/h GIR = 10 x 10 x 40 ÷ 10 = 6.6mkmin 60 NV: Newborn & Infants 6-8 mg/kg/min Children 4-6 mg/kg/min If HGT <40 mg/dl, give D10 water slow IV push at 2cc/kg and repeat HGT after 30 mins-1 hr (may do 3 boluses if still low, may inc dextrosity or rate) Level of Umbilical Cathetherization: (cm)
If arterial between T6-T9 Wt x 3 x 8
Prepare the ff: 2 pcs 3 way stopcock 1 pc 5 cc syringe 1 pc BT set 1 pc IV tubing 1 pc empty bottle Gloves Calcium gluconate 100 mg every 10 exchanges
If venous: (wt x 3) + 8 +1 2 ET tube size: age in yrs +4 4 ET level: if >2yo: age(yrs) +12 2 Or ET size x 3 Total Flow Rate = Tidal volume x wt x RR x I.E ratio + 2000 I.E = 2 Dead space = 2000 RR = 40-60 Tidal volume = Newborn: 6-10cck Child: 10-15cck Adult: 15cck
Criteria for Hypoxic Ischemic Encephalopathy pH < 7 (profound met. Acidosis) Apgar <3 more than 5 mins Neurologic sequelae (coma; sz) Multiorgan involvement Difficult delivery
FiO2
Nasopharyngeal cathether = Flow rate x 20 + 20 Fio2 = 40 Nasal catheter = Flow rate x 4 + 20 Ex. 1L FiO2 = 24 Extubation: Give Dexamethasone at 0.1 mkdose q 6 hours for 24 hours prior to extubation USN with epinephrine 0.5 cc + 1.5 cc PNSS q 15 mins x 3 doses then extubate then USN with Salbutamol ½ nebule + 1.5 cc PNSS q 6 hours x 24 hours O2 at 10 lpm then decrease as necessary Regular milk: 20 cal/oz Preterm milk: 24 cal/oz Ex. 1L
Total Caloric Intake: rate x 24 x caloric content of IVF ÷ wt To get factor:
Dextrosity x 0.04 = cal/cc
Caloric content of IVF D5 = 0.2 cal/cc D7.5 = 0.3 cal/cc D10 = 0.4 cal/cc D15 = 0.6 cal/cc Caloric requirement & Protein requirement Cal/kg 0-5mo 115 110 6-11mo 110 1-2 yo 3-6 yo 90 – 100 7-9 yo 80 – 90 10 – 12 yo 70 – 80 13-15 yo 55 – 65 16 – 19 yo 45 – 50 Approximate Daily Water Requirement 0 – 3 do 4 – 6 yo 120cc/k/d 10 do 7 – 9 yo 150cc/k/d 1 – 5 mo 10 – 12 yo 150cc/k/d 6 – 12 mo 13 – 15 yo 140cc/k/d 1 – 3 yo 16 – 19 yo 120cc/k/d Estimated Catch up Growth Requirement = cal/k/day (age for wt) x IBW (wt for ht) Actual BW
g/kg 3.5 3 2.5 2 1.5 1.5 1.5 1.5 100 cc/k/d 90 cc/k/d 80 cc/k/d 70 cc/k/d 50 cc/k/d
CHON reqt = CHON reqt for age x IBW Actual BW Growth and Caloric requirements AGE 0 – 3 mos 3 – 6 mos 6 – 9 mos 9 – 12 mos 1 – 3 yo 4 – 6 yo
RDA kcal/kg/day 115 110 100 100 100 90 – 100
Double Volume Exchange Therapy (DVET) Wt x 80 x 2 = Volume/ amt of fresh whole blood (Use mother’s blood type) Volume _ = # of exchange aliquots per exchange > 3 kg 2-3 kg 1-2 kg 850g-1kg < 850 g
20 ml 15 ml 10 ml 5 ml 1-3 ml
Medications Dopamine: wt x dose x 0.075 Prep’n : Single Strength: 200mg/250ml; Double Strength: 400/250ml if using double strength: wt x dose x 0.075÷2 (Dose = 5-20) Dobutamine: wt x dose x 0.06 Prep’n: 250mg/250 ml; Dobuject 50mg/ml (Dose = 5-20) If using Dobuject: Wt x dose x 60÷ concentration Concentrations: 5mg/ml = 5000 50mg/50ml = 1000 50mg/20ml = 2500 To make 5mg/ml: Dobuject 5cc D5 water 45cc To make 50mg/50ml: Dobuject 1cc D5 water 49cc To make 50mg/20ml: Dobuject 1cc D5 water 19cc Diflucan: 6 mkd OD prep’n 50mg/tab divide into pptabs and give 1 pptab OD x 2 weeks Aminophylline: 5mkd (loading dose) then 1.6 mkd q 8 hrs (maintenance) Phenobarbital 20 mkd (loading dose) then 5 mkd (maintenance) Dexamethasone 0.1 mkdose q6hrs x 24 hours For other meds, please see NEOFAX NEWBORN CARE Hypothermia hypoxia metabolic acidosis hyperglycemia Erythromycin ointment should be given an hour after birth gonococcal/chlamydial conjunctivitis Gonococcal Conjunctivitis within 7days Chemical conjunctivitis disappears within 48H Other bacterial conjunctivitis Chlamydial >10-14 days Staph 48H-5th day (2-5days) Herpes Pseudomonas-give Gentamycin Umbilical stump - sloughed off <14 days Alcohol - drying effect Cows milk allergy Onset- 3rd wk Rashes on cheeks → eyebrows → cradle cap
CRANIUM Caput succedaneum diffuse edematous swelling of soft tses of scalp extend across midline edema disappears w/in 1st few days of life molding and overriding of parietal bones-frequent disappear during 1st wks of life no specific tx Cephalhematoma subperiosteal hemorrhage limited to1 cranial bone occur 1-2 % cases no discoloration of overlying scalp swelling not visible for several hours after birth ( blding slow process) firm tense mass with palpable rim localized over 1 area of skull resorbed w/in 2wk- 3mos calcify by end of 2nd wk few remain for years 10-25% cases underlying linear skull fracture No tx but photo in hyperbil
SEIZURE Type Duration Recurrence CNS exam Sequelae
Simple
Complex
GTC
Focal then gen post ictal
< 15 min
> 15 min or may go into status Recurrent (w/in 24H) Abnormal Neurodev abn
None Normal None
DIAZEPAM
MIDAZOLAM
PHENOBARBITAL
Verbal Oriented Confused Inappropriate words Inappropriate sounds None Motor Follows command
ANTICONVULSANT 0.2 – 0.3 mkdose Drip: 1amp in 50cc D5W 10mg/amp 0.15 mkdose prn 2 – 3 mins interval IV (1, 5mg/ml) 6 mos - 5 yo 0.05 - 0.10 max of 0.6 mg/kg 6 yo - 12 yo 0.25 - 0.05 max of 0.4 mg/kg >12 yo 0.50 - 2 mg/dose over 2 mins LD: 15 – 20 mkd MD: 5 mkdose q 12h (max load 20 mkday IV Tabs: 15, 30, 60, 90, 100 mg Caps: 16 mg ELIXIR 20mg/5ml Inj: 30, 60, 65, 130 mg/ml
Dilantin
CARBAMAZEPINE Tegretol
< 6 yo 6 - 12 yo > 12 y
Tab 200mg, 100mg XR 100mg, 200mg, Susp 100mg/ 5ml (QID) Initial Increment 10 - 20 mkD BID /TID q wkly til 35 mkD 10 mkD BID 100 mg/ 24H at 1 wk interval 200 mg BID 200 mg/ 24H at 1 wk interval
chew 400mg Maintenance 20 - 30 mkD BID/ QID 800 - 1200 mg/24H BID/ QID
OXCARBAMAZEPINE
(8 - 10 mkd BID) Initial: 8 -10 mkD PO BID then Increment: increase over 2 week pd to Maintenance doses: 20 -29 kg: 900 mg/24H PO BID 29.1 -39 kg: 1200 mg/24H PO BID >39 kg: 1800 mg/24H PO BID
Trileptal
Tab 150 mg 300mg 600 mg Susp 300mg/5ml PO: Initial : 10 - 15 mkD OD - TID Increment: 10 mkD at wkly interval BID Maintenance: 30 - 60 mkD BID/TID IV: same dose as PO q 6H Rectal : (syrup mix with water 1:1) LD: 20 mkd MD: 10 -15mkd TID Tab 250 mg Syr 250mg/5ml IV 100mg/ml 2 - 16 yo Initial: 1 - 3 mkd PO q HS x 7 days then Increment: increase by 1 - 3 mkday for 1 - 2 wks then Maintenance: 5 -9 mkD BID Cap 15 mg, 25 mg Tabs 25 50 100 200mg
VALPROIC ACID
Depakene Depacon TOPIRAMATE
Topamax
Glasgow Coma Scale Activiy Eye Opening Spontaneous To speech To pain None
Response 4 3 2 1
Infants Activity Spontaneous To speech To pain None
Coos, babbles Irritable Cries to pain Moans to pain None
5 4 3 2 1
6
Normal spontaneous movement Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None
6
5 4 3 2 1
MOTOR full resistance with gravity some resistance with gravity movement with gravity movement w/o gravity flicker no movement
5 4 3 2 1
DTR very brisk brisker than average normal diminished no response
5/5 4/5 3/5 2/5 1/5 0/5
+4 +3 +2 +1 0
Bilirubin (Total)
MD: PO/ IV Neonate: 3 - 5 mkD QID/ BID Infant/child: 5 - 6 mkD 1 - 5 yo: 6 - 8 mkD 6 - 12 yo: 4 - 6 mkD > 12 yo: 1 - 3 mkD Hyperbil < 12 yo: 3 - 8 mkD BID/TID LD: 15 – 20 mg/kg/IV MD: Neonate: 5 mkD PO/ IV BID Infant/child: 5 7mkD BID/ TID 6mos – 3y: 8 – 10 mkD 4 – 6y: 7.5 – 9 mkD 7 – 9y: 7 – 8 mkD 10 – 16 y: 6 – 7 mkD Tab: 50mg 100mg TID Extended release caps 30, 100, 200, 300 mg OD, BID Inj: 50 mg/ml
PHENYTOIN
Localizes pain Withdraws to pain Abnormal flexion Abnormal extension None
5 4 3 2 1
Response 4 3 2 1
Cord Preterm Term 0 – 1 days Preterm Term 1 – 2 days Preterm Term 3 – 5 days Preterm Term Older Infants Preterm Term Adult Bilirubin (Conjugated) Neonate Infants/Children
<2 mg/dl <2 mg/dl
<34 µmol/L <34 µmol/L
<8 mg/dl <8.7 mg/dl
<137 µmol/L <149 µmol/L
<12 mg/dl <11.5 mg/dl
<205 µmol/L <197µmol/L
<16 mg/dl <12 mg/dl
<274 µmol/L <205µmol/L
<2 mg/dl <1.2 mg/dl 0.3 – 1.2 mg/dl
<34 µmol/L <21 µmol/L 5 – 12 µmol/L
<0.6 mg/dl <0.2 mg/dl
<10 µmol/L <3.4 µmol/L
Pre Lumbar Tap NPO RBS by gluco prior to lumbar tap Prepare lumbar tap set 2% Lidocaine # 1 G 23 spinal needle Mannitol 250 cc 1 bottle - do not open Solvent Diazepam 1 amp 3cc syringe #2 2 manometers sterile bottles # 3 sterile gloves # 2 Sterile gauze # 1 Sterile gauze w/ Betadine #1 Sterile towel w/ hole #1 Sterile clamp #1 3-way stopcock #1 Post Lumbar Tap NPO x 4H Flat on bed Monitor NVS to include BP q 30mins x 4H, then qH CSF exams Bottle # 1 – Gm stain, AFB, India ink, KOH Bottle # 2 – Cell count, CHON, Sugar Bottle # 3 – C/S, save remaining specimen Watch out for vomiting, HA and hypotension
Contraindications to LP evidence of Inc ICP severe CP compromise Skin infection at site of puncture
Color Normal Infant (Term) Infant (Preterm)
Xantho Clear
CSF ANALYSIS Rbc Wbc Diff ct 0100 0100
0 -32 0 -15
L 100% L 100%
sugar
CHON
70 80% 70 80%
60 150 60 200
Older child Viral Mening TB/Fungal
Clear
Bacterial Mening Partially tx BM
0
0 -10
Clear
0
0 -20
Clear
0
Purulent
0
Clear
0
20 500 > 1000 100
L 100% L 100% L>N N>L L>N
> 50% 4060% < 40% < 50% > 50%
40 -60 > 100 g% > 100 g% Dec
CSF PATHWAY Choroid plexus (lateral ventricle) → Foramen of Monroe → 3rd ventricle → Aqueduct of sylvius → 4th ventricle →Foramina of Luschka (2 laterals) → & Magendie (median) → SAS → Absorbed in the arachnoid villi, then in the Venous System Dengue Drips Furosemide drip Dose: 0.04 - 0.5 80 mg + 32 cc Wt x dose = rate (cc/h) 2 Furo drip = 0.1 - 0.5mg/k/hr Prep: 20mg/2ml (2mg/ml) Rate: (wt x dose)/2 = cc/hr ex. 14.5kg x 0.45 = 3.2cc/hr To order: 8ml Furo + 32ml D5W +40 cc to run at 3.2cc/hr Precedex drip Dose: 0.2 - 0.7 1ml + 99cc D5W to run at cc/h Wt x dose = rate (cc/h) Noradrenaline (Levophed) 1mg/ml dose :(0.5 – 1 ml/kg) Wt x dose ( each ml contains 4 mcg Noradrenaline) 4 mcg ( for acute hypotension) 2ml + 500cc D5W x 2cc/H (0.5 cc/H) Dopamine ( 5 -20 mcg/kg/min)
Dobutamine
Terbutaline Bricanyl SC
Terbutaline drip Ketamine (Ketalar)
Morphine IV Naproxen
200 mg/250ml Single strength 400 mg/250ml DS (div by 2) Wt x dose x 0.075 250 mg/5ml SS 500 mg/250ml DS(div by 2) Wt x dose x 0.06 Inj: 1 mg/ml < 12y – 0.005 – 0.01 mkd x 3 doses q 15 -20 min then q2-6H > 12y – 0.25 mkd LD: 2 – 10 mcg/kg then 0.1 – 0.4 mcg/kg/min 10, 50, 100 mg/ml PO: 5mg/kg x 1 IV 0.25 - 0.5 mg/kg IM 1.5 - 2 mg/kg x 1 0.1 – 0.2 mkd q2-4H prn 250, 375, 500mg tab 125mg/5ml > 2yo – 5-7 mkd TID, BID PO
IVIG infusion Preparation: 2.5g/50cc 500g/10cc 25g/100cc 5g/100cc 10g/250cc Computation: Wt x 2 g /kg IVIG Ex wt: 7.2 kg 7.2 x 2 + 16 g IVIG 16 gIVIG 2. 5 g = 320 cc Cc 50cc # of vials = total cc 320cc = 6.4 vials 50cc 50cc 320cc x 0.03 = 9. 6 cc/h for 30 mins Transfuse 9 – 10cc/h IVIG for the 1st 30mins if no reaction, run the remaining volume for 12H Refer for any infusion reactions Close ML Monitor v/s q 30 mins while on infusion If after IVIG if still febrile, rpt IVIG after 3 D If after 2nd IVIG still febrile – start Prednisone Aspirin 80 mkD QID 30 mg, 80, 100, 300 mg KCl IV 2 meq/ml Child: 0.5 – 1meq/k/dose infusion of 0.5 meq/k/h for 1-2 h Tabs: 8, 10, 15, 20 meq Oral soln 10% ( 6.7 meq/5ml) 15% (10 meq/5ml) 20% (13.3 meq/5ml) PO : 1-4 meq/kg/24H QID IV: 0.5 – 1meq/k/dose
Urine alkalinization 84 – 840 mg (1- 10 meq)/kg/D PO QID
10-20
NaHCO3 Inj premixed: 5% (0.6 meq/ml) 500ml Tabs: 325 mg (3.8 meq), 650 mg (7.6 meq)
Ca Gluc = Children: 1cc/k/dose x 3doses; Max: 10cc/dose + equal amt of sterile water
LYSMIX Prozinc
0.3 cc/k/dose TID Ceiling = 0.4 drops 10 mg/ml < 6 mos 1 ml OD < 6 mos – 2 yo 1 ml BID syrup 20 mg/5ml > 2 yo 5ml OD 20 mkday 1-2 vials/day OD for 2 wks mix with water, milk or juice
Ercefuryl Erceflora
Protexin Restore Racecadotril (Hidrasec) < 9 kg 9 – 13 kg 13 – 27kg > 27 kg
1 sachet mix with milk OD 1.5 mg/kg for 1 wk
FWB PRBC Plasma PRP Plt conc Cryoprecipitate
10 - 20 cc/kg 5 - 10 10 - 15 10 - 15 1 u/ 7 -10 kg 1 u/kg Hemophilia A 1 bag (200mg fibrinogen) VW dse 50 -100 mg/kg Fibrinogen dse 100 cc (2-5 kg) Hemophilia A 50 u/kg Hemophilia B 100 u/kg
10 mg sachet 10 mg sachet 30 mg sachet 30 mg sachet
Factor 8
1 sachet TID 2 sachets TID 1 sachet TID 2 sachets TID
3 – 4H 3 – 4H 1–2H 1–2H FD FD
1 u FWB
= 200 cc PRBC = 50 cc platelet concentrate = 150 – 200cc PRP = 150 cc FFP MCV Hgb / rbc x 10 80 -94 MCH Hgb / rbc x 10 27 - 32 MCHC Hgb/ hct x 10 32 – 38 Absolute reticulocyte count = pt’s hct x retic % N hct for age Reticulocyte Index Absolute Retic Ct 2
> 2 hemorrhage < 2 rbc production abn
PRBC to be transfused for correction = 40 – hct x wt
Hgb Hct Wbc Plt Retic
1 - 3 days 14.5 – 22.5 .48 - .69 9 -30 birth
5 – 19.5
84 – 478 NB 0.4 - 0.6
< 1 -1.2
Glucose
1 mo
2mos 9 -14 .28 - .42
6 – 12y 11.5 -15.5 .35 - .45 6 -17.5
>12y 13-16 .37 - .49 4.5 13.5
After 1 wk, same as adult 150 - 400 0.1 -2.9
PT 20 -60 NB 30 – 60 1 d 40 -60 > 1d 50 -90
Child 60 -100
Adult 70 -105
ANC - % of neutrophils & cells that become neutrophils – multiplied by wbc ANC = wbc x (% seg + % stabs + % meta) Other formula: wbc x (seg + meta + stabs ) x 10 Ex 2.1 x 53 (seg) x 10 = 1113 ANC > 1000 Normal ANC < 2000 Neutropenia ANC 1000 -1500 Low risk of infection ANC 500 -1000 Mod risk of infection ANC < 500 High risk of infection IT ratio > 0.25 sepsis > 0.80 higher risk of death fr sepsis Anemia < 10 g 8-9g <8 g
mild anemia mod anemia severe anemia
EMERGENCY
Age
ET tube age in years + 4 4 ET diameter x 3 >10 yo cuffed
PT
Laryngoscope sizes Miller 00 or 0
Term
Miller 0
0-6mos
Miller 1
6-24 mos
Miller 2
>24 mos
Miller 2 or Mac 2
Epinephrine Amiodarone Cardioversion Albumin
Epinephrine Drip
Levophed
Dopamine
EMERGENCY MEDS (bradycardia, asystole) (1:1000) 0.1 ml/kg q 3- 5 mins 5 mg/kg rapid IV push 2 J/kg then 4 J/kg then rpt 2x 1gm x wt given in 2-4hrs. Prep: 12.5g/50ml Vol expander: 20ml/kg HypoCHONemia – 1gm/k/dose x 4H 0.1 – 1mg/k/min; 1amp = 1mg/ml Rate = (wt x dose x 60)/desired Ex: (18kg x 0.1 x 60)/100 = 2cc/hr To order: 5 amps Epi + 50cc D5W to rum at 2cc/hr (0.1mg/k/min) 0.3-2mcg/k/min Prep: 4mg/amp (1mg/ml) Rate = (wt x dose x 60)/desired Ex. Dose 0.5 1mg/20 = 0.05 x 1000 = 50mcg/ml (18kg x 0.5 x 60)/50 = 10.8cc/hr To order: 1 amp levophed + 80 cc D5W to run at 11cc/hr Renal dose 3-5 Pressor >5 - <15 alpha effect >15
ANAPHYLAXIS Epinephrine (1:1000)
0. 01ml/kg max of 0.5 mg/dose SC < 30 kg 0.15 mg > 30 kg 0.3 mg Diphen = 50mg IM (1mkdose) USN w/ Salbu x 3 doses BICARB DEFICIT CORRECTION: Ex: wt 4.9kg pH = 7.10 pCO2 = 9.1 pO2 = 36.5 HCO3 = 2.8 BE = -26.8 O2 Sat = 53.6% BE x Wt x 0.3 = 26.8 x 4.9 x 0.3 = 39.39meqs Half correction: 39.39/2 = 19.69 meqs To order: Give 20 meqs NaHCO3 + equal amt of sterile water to be given slow IVTT over 30mins. Infuse another 20 meqs NaHCO3 + equal amt sterile water as drip for 1-2 hrs. EMPIRIC: NaHCO3 1-2mkdose even w/o ABG. HCO3 correction in ABG: Half correction: Base x’s x 0.3 x wt ÷ 2 (+ equal amount of sterile water) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip) Full correction: Base x’s x 0.3 x wt ÷ 2 (1/2 via IV push, ½ via IV drip) BUN/ crea ratio Normal 10 -20 > 20 suggest DHN, pre renal azotemia or GIB < 5 – liver disease, inborn error of metabolism GFR (based on plasma creatinine and ht) GFR = k x L = ml/min/1.73 m2 SA sCr L = body length (cm) Scr = mg/dL ; divide by 88.4 if units in mmol/L Age LBW < 1 yr FT < 1 yr 2-12 y 13-21 y (female) 13 -21 y (male)
K (mean value) 0.33 0.45 0.55 0.55 0.70
KI 29.17 39.78 48.62 48.62 61.88
PT 2- 8 d 4 - 28 d 30 -90 d Term 2- 8 d 4 - 28 d 30 - 90 d 1- 6mo 6 - 12 mo 2 - 19mo 2 - 12y Adult males Adult females
BSA Weight in (kg) 0–5 6 – 10 11 – 20 20 – 40 >40
GFR
Range
11 20 50
11 – 15 15 – 28 40 – 65
39 47 58 77 103 127 127 131 117
17 – 60 26 – 68 30 – 86 39 -114 49 – 157 62 – 191 89 – 165 88 – 174 87 – 147
wt x 0.05 + 0.05 wt x 0.04 + 0.10 wt x 0.03 + 0.20 wt x 0.02 + 0.40 wt x 0.01 + 0.80
Computation for OFI (AGN & limiting OFI) 1. BSA x 400 + UO – IVF (half if w/ Furo) = OFI (then divide to 3 shifts) 2. 20cc x wt x UO – IVF
TFR
CHON
CHO
Fats
OSTERIZED FEEDING 60 - 70% = 100/feeding q 6H 10 kg x 60% TFR = 600 0.5 g/kg inc q other day by 0.5 , max of 2 g/kg Dose x wt x prep (Vamin 7%, 9%) 0.5 x 10 kg x (100 /7) = 71 g/kg CHON = 71 g/kg If no prep = dose x wt x 4 = 20 g/kg 60% (TFR – CHON) x 0.6 (600- 71) x 0.6 = 317 CHO = 317 181 (the rest are fats , divided into 6 feedings)
TPN Vamin 9% 0.67 cal/ml Start 0.5 g/k/day inc by 0.5 g until 3 -3.5g/k/day Compute = wt x dose x prep (100/9) Intralipid 10% 20% Start 0.5 g/k/day inc by 0.5 g until 3 g/k/day Compute = wt x dose x prep (100ml/ 10) = ml/24H Amino acids Start 0.5 g/k/day inc by 0.5 g until 3 g/k/day Compute = wt x dose x prep (100ml/g) = ml/24H TPN shortcut computation Wt 10 kg TFR= 100 ml/k/day
TFI = 1000ml/day
Vamin 7% 7 = 2 g/kg x 10kg 100 CaGluc 2ml/kg D5IMB D50W 0.11 x 1000ml
TPN for NEONATES Wt 2kg 1. TFR = 100 ml/kg/day x 2 kg 200 ml 2. Intralipid 20% 1 g/kg/day x 2kg = 2g/day 10 ml 2 g = 20g x 100ml 3. Compute for TFR 1 TFR1 = TFR – Intralipid = 200 -10ml = 90 ml 4. Vamin 7% 1 g/kg/day x 2 kg = 2g = 29 ml 2 g = 7g x 100ml 5. Multivitamins Benutrex c 0.5 ml/100ml 0.5 ml = x 1 ml 100ml 190 ml 6. Ca gluc 10% 2ml/kg/day x 2 kg 4 ml 7. Dextrosity (D10) get d50w TFR 1 x dextrosity factor (0.11) 21 ml 190 x 0.11
285 ml 20 ml 485 ml 110 ml 1000ml x 37 cc/h
8 . D5IMB = TFR 1 – (Vamin + MTV + Ca gluc + D50W) 190 – (29 + 1+ 4+ 21) = 135 ml 9. IV rate = TFR 1 / 24H 190 ml/ 24H 8 ml/H Order: Start TPN as ff: TFR= 100ml/kg/day D5 IMB 135 ml D50W 21 ml Vamin 7% 29 ml Ca Gluc 4 ml MTV 1 ml 190 ml to run at 8 ml/h Intralipid 20% 10 ml to run for 24H
Peak Flow (6 – 7 yo) (Ht cm – 100) x 5 + 170 female + 175 male Nasopharyngeal catheter = flow rate x 20 + 20 Nasal cannula = flow rate X 4 + 21
Complement level 6 – 8 wks Proteinuria 3 – 6 mos Micro hematuria 6 – 12mos Lab Dx: U/A – spec grav,cast, hematuria, chonuria Serology – culture of GABS, ASO, C3 ( dec in acute phase, rises during convalescensce) Renal fxn – bun crea- normal, hyponat Hematology – dilutional anemia, transient hypoalbuminemia Radiography – CXR , renal utz Management: Bed rest Fluid and salt restriction o Fluids: 400 – 600 ml/m2/day + UO 24H o NaCl < 2 g/day o K < 40 meq/day Penicillin 50 – 100,000 u/kg/day TID/QID x 10 days HPN, CHF o Furosemide 2 mg/k/dpse Prognosis – complete resolution, 5 – 10 % progress to chronic state
Stimulants Buclizine (syrup)
TFR= TV x RR x IE ratio + dead space (2000) TV= 10 ml x wt TFR Short cut: wt x 10 + 40 ml divide by 0.5 16.77 MILK FORMULAS 1:1 dilution 1:2 dilution Wyeth, Abbott, Unilab Mead-Johnson, Nestle, Glaxo, Dumex, Milupa 0-6 months (20cal/oz) Lactose free (0-6months) Mead-johnson: Alacta , Enfalac Mead-johnson: Enfalac lacto-free Nestle: NAN1, Nestogen Nestle: AL110 Glaxo: Frisolac Milupa: HN25 Dumex: Dulac Wyeth: S26 Lacto-free Abbott: Similac advance Milupa: Alaptamil Wyeth: S26, Bonna Unilab: Mylac 6months onwards (20cal/oz) Lactose free (6months onwards) Mead-johnson: Enfapro Mead-johnson: Enfapro lactoNestle: NAN2, Nestogen 2 free Glaxo: Frisomil Dumex: Dupro Abbott: Gain Wyeth: Bonnamil. Promil Unilab: Hi-nulac 1 year onwards (20 cal/oz) Premature Infant (24cal/oz) Mead-johnson: Enfagrow, Mead-johnson: Enfaprem Nestle: PreNAN Lactum Abbott: Similac prem Nestle: NAN3, Neslac Milupa: Preaptamil Glaxo: Frisorow Dumex: Dugrow Abbott: Gainplus Wyeth: Progress, Promil Unilab: Enervon bright Hypoallergenic (20cal/oz) Soy-Based (20cal/oz) Mead-johnson: Pregestimil Mead-johnson: Prosoybee Nestle: Alfare, NAN HA1, NAN Abbott: Isomil HA2 Wyeth: Nursoy
w/ Folic acid (Megaloblastic Anemia)
AGN inflam process affecting the kidney, lesions predom in the glomerulus Etiology Infections: a. Bacterial: Grp A B hemolytic strep, S viridans, S pneumo, Staph aureus, S epidermidis, S typhi , T pallidum, Leptospira b. Viral: HBV, Mumps, Measles, CMV, Enterovirus c. Parasitic: Toxoplasm, Malaria, Schistosoma Drugs: Toxins, Antisera, Vaccines (DPT) Miscellaneous: Tumor Ag, Thyroglobulin GABS Nephritogenic Strains Sites: URT - pharyngitis - M1 2 4 12 18 25 Skin pyoderma - M49 55 57 60 Pathophysio – Immune complex disease Clinical & Lab -hematuria -hypocomplementenemia -proteinuria -oliguria -edema -n & v -hpn 82% -dull lumbar pain Typical course Latent: few days – 3wks Oliguric: 7 – 10 days Diuretic: 7 – 10 days Convalescent: 7 – 10 days
Iron Deficiency Anemia
Normalization of urine sediment Parameter Gross hematuria
Resolved by
2 – 3 wks
Pizotifen (drowsiness) MTV w/ Iron w/ Serotonin (for migraine + dec wt)
VITAMINS Mosegar Vita 0.25 mg/day prep 0.25 /5 ml Appetens Propan Appebon 2 - 8yo 5 - 10 ml OD 7 - 14yo 10 - 20 ml OD Molvite 7 - 12yo 10 - 15 ml OD 3 - 6yo 5 - 10 ml OD 1 - 2yo 2.5 - 5 ml OD Iberet Ferlin (10 mcg folic acid) Macrobee 1 - 2yo 2.5 - 5 cc OD 3 - 6yo 5 - 10 cc OD 7 - 12yo 10 - 15 cc OD Mosegor vita syr Appetens Propan w/ iron syr (Fe So4; elem fe 30mg) Appebon w/ iron syr (FeSo4; elem fe 10mg) Mosegor vita Mosegor plain Appeten Jagaplex syrup 1-2yo 5ml OD 3-6yo 10 ml OD 7-12yo 15 ml OD Clusivol Power syrup syr 100mg/5ml 2-6yo 5 ml OD 7-12yo 10 ml OD Zeeplus <2yo 2.5 ml OD 2-6yo 5 ml OD 7-12yo 5-10 ml OD Polynerv 1-2yo 2.5 ml OD 3-6yo 5 ml OD 7-12yo 10 ml OD 0-6mo 0.5 ml-1 ml OD 7mo-1yr 1-1.5 ml OD 1-2yrs 1.5-2ml OD Supplemental Iron = Therapeutic Dose: 5 - 6 mkday for 3 mos Maintenance Dose: 3 - 4 mkday Elemental iron 20% of FeSo4 12% Fe gluconate 33% Fe fumarate Wt x Dose x Prep Ferlin drops15mg/ml Fe 75 mg Prophylactic dose Term 1 mg/k/Day, start 4 mos-1y PT 2 mkD, start 2 mos-1y Therapeutic dose 3 mkD BID, QID for 4-6mos Ferlin syrup 30mg/ml Fe 149.3 mg Supplemental dose 10-15 mg OD Therapeutic dose 3 mkD TID, QID for 4-6mos Sangobion syr (Fe gluc 250mg elem Fe 30mg) Incremin with Iron Syrup 30 mg elem Fe
F. Daily Electrolyte Requirements Electrolytes Neonates 1-6 mos
TPN in Pediatrics A. Energy Requirment AGE/WT Caloric Rquirement Neonates
(mmol/kg)
90-120 kcal/kg
Infants & Older Children <10 kg 11-20 kg
10-120 kcal/kg
(mmol/kg)
1500 + 20 for each more than 20
B. Fluid Requirement AGE/WT Fluid Rquirement
3–5
3–4
Potassium
2–4
2–3
2–3
80 – 120
Cal gluc
0.6 – 1.0
0.25 – 1.2 (max of 4.7)
0.25 – 1.2 (max of 4.7)
4.7
Phosphate
1.0
1–2
1–2
30 – 45
Magnesium
0.1250.250
0.1250.250
0.1250.250
4–8
G.
VLBW (≤ 1500 gm)
(mmol/kg)
NaCl
Neonates Initiate at 40 – 60 ml/kg/day and increase by 10 ml/kg/day till 120 ml/kg is reached
AGA & LBW
Neonates under radiant heaters or on phototx an extra 30ml/kg/day of water Infants & Older Children <10 kg
100 – 120 ml/kg
11-20 kg
1000ml + 50 ml foe each kg > 10
>20
1500 + 20 for each more than 20
C. Protein Requirement AGE/WT
(mg)
Zinc
400
(ug/kg) 100 – 500
Copper
50
20
0.5 – 1.5
Chromium
0.3
0.14 – 0.2
0.01 – 0.04
Manganese
10
2 – 10
0.15 – 0.5
Iodine
8
8
0.2
Selenium
4
4
0.3
Flouride
57
57
0.9
Dosage (gm/kg/day)
VLBW (≤ 1500 gm)
2.25
0 – 12 months
2.50 Wt 15 1.50 – 2.0
8 yrs and above
1.00 – 1.50
A. B. C.
With the initiation of PB|N, start w/ 0.5gm/kg/day and gradually increased by 0.5gm/kg/day till recommended protein is reached. D. Carbohydrate Requirement % dextrose = gram dextrose x 100
D.
Vol infused (ml
Shud provide 50 – 60 % 0f total non-protein calories Requirement ranges frm 10 to 25 gm/kg/day Infusion shud not exceed 12.5mg/kg/min Shud b decreased if urinary glucose ≥0.5% (2+) or blood sugar exceeds 7 mmol/L in neoanate or 9.7 mmol/L I above 1 mo of age
E. Fat Requirement AGE
F. Dosage (gm/kg/day)
0 – 12 months
2
1 – 8 yrs
4
8 yrs and above
E.
G.
80kcal/kg Energy: 15 x 80 = 1, 200 kcal/day TFR: 1,250 ml/day CHON: (1gm/day) 15 x 1 Prep: Aminosteril 6% (6gms/100ml) 6gms x 15 gms = 250 ml 100 x CHO: % = gm x 100 10% x = 125 gms Vol 1250 Prep: D50W 50 gm = 125gm 100 ml x Lipids: ( 1 gm) 15 x 1 =15 Prep: 10% Intralipid (10gms/100ml) 10 gms x 15 gm = 150 100 ml x Sodium: (3 mmol/kg) Prep: 2.5 mmol/ml 2.5 mmol x 45 = 18 ml ml x Potassium: (2 mmol/kg) Prep; 2 mmol/ml 2.0mmol x 30 = 15 ml ml x
15 x 3 = 45 mmol/kg
15 x 2 = 30 mmol/kg
2.5 H.
Calcium gluc: (0.25 mmol/kg) Prep: 10% Cal gluc 0.25 mmol x 3.75 = 15 ml ml x
15 x 0.25 = 3.75
I.
Magnesium: (0.25 mmol/kg) Prep: 25% MgSO4
15 x 0.25 = 3.75
30 – 40 % of total calories shud b provided as fats 2 – 4% as EFA Start at 0.5 gm/kg/day and gradually increase by 0.5 gm/kg/day till recommended amt is reached
2.5 – 4
In the absence of available prep of trace elements; weekly blood transfusion may be given at 20 ml/kg Iron: 2 mg/kg, with dose increased to 6 mg/kg if Fe def is documntd; provided by adding iron dextran to amino acid soln
Sample Solving:
1 – 8 yrs
60 – 100
Calcium gluconate contains 100 mg calcium gluconate or 9 mg elemental calcium/ml 1 gm of calcium gluconate contains 4.7 mEq or 2.35 mmol of Ca. Trace Elemental Requirements Prematures Adolescents Trace Infants & Elemental Children (ug/kg)
Initiate at 60 ml/kg/day and increase by 15 ml/kg/day till 120 ml/kg is reached on the 5th day of PN
Adolescents
(mmol/kg) 3–4
1000kcal + 50 kcal foe each kg > 10
>20
6 mo -11 yr
2 mmol x 3.75 = 1.9 ml x 2 = 4 ml ml x J.
Total Mixture: Aminostril D50W Na K Cal gluc MgSO4
24 hrs 250 250 18 15 15 4 ml
12 hrs 125 125 9 7.5 7.5 2 ml
Total
552
276