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Slemani Pediatric Teaching Hospital

Guidelines 2014-2015

Contents

Acute liver failure ................................................................................. 1

Anaphylaxis ........................................................................................... 7

Arrhythmias ........................................................................................ 14

Asthma ................................................................................................ 21

Bronchial foreign body aspiration ...................................................... 23

Croup .................................................................................................. 31

Dehydration ........................................................................................ 35

Diabetes mellitus, preoperative preparation in ................................. 43

Diabetic ketoacidosis .......................................................................... 53

Febrile seizures ................................................................................... 56

G6PD deficiency .................................................................................. 58

Heart failure........................................................................................ 59

Hypoglycemia ..................................................................................... 60

NG tube insertion ............................................................................... 61

Poisoning ............................................................................................ 63

Scorpion envenoming ......................................................................... 71

Sepsis .................................................................................................. 74

Status epilepticus ............................................................................... 78

Transfusion ......................................................................................... 80

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Acute liver failure

Definition

1. Evidence of liver dysfunction within 8 wk of onset of symptoms.

2. Uncorrectable coagulopathy (6-8 hr after administration of one dose of parentral vitamin K) with INR >1.5 in a patient with hepatic encephalopathy, or INR > 2 in a patient without encephalopathy.

3. No evidence of chronic liver disease either at presentation or in the past.

Staging

1. Grade I and II: are indistinguishable, with clinical features of inconsolable crying, inattension to task, with normal or exaggerated deep tendon reflexes.

2. Grade III: somnolence, stupor, combativeness and hyperreflexia.

3. Grade IV: comatose, arousable with painful stimuli (IVa) or no response (IVb) with absent reflexes and decerebration or decortication.

General work-up

1. Blood urea, serum creatinine, serum electrolytes 2. ALT, AST, GGT, alkaline phosphatase, total and conjugated

bilirubin, PT, PTT, INR, blood group 3. Blood and urine culture, CXR

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4. Arterial blood gas, lactate, lactate dehydrogenase, blood ammonia, urine for reducing substance, serum alpha fetoprotein

Management

Ensure a quiet environment to avoid unnecessary stimulation from visitors, television or hospital personnel that can aggravate encephalopathy and increase intracranial pressure.

Monitoring of vital signs, including blood pressure every 4 hours (more frequently in unstable patients), and continuous oxygen saturation monitoring.

Neurological observation/coma grading, and checking electrolytes, arterial blood gases, and blood sugar every 12 hr (more frequently in an unstable patients). Input and output should be strictly monitored.

Fluid restriction to 70% of maintenance to reduce cerebral edema and prevent encephalopathy. Fluid should be glucose-based with glucose infusion rate of at least 4-6 mg/kg/min and titrated as per requirement.

N-acetylcysteine

Administer 100 mg/kg PO daily.

Lactulose

1. Infants: 2.5-10 mL/day PO in divided doses three to four times a day

2. Children: 40-90 mL/day PO in divided doses three to four times a day.

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

Give dose initially every hour until first stool is passed then titrate dose to achieve 2-3 soft stools/day. Assess patient regularly for abdominal distension and intravascular depletion. Excessive use of lactulose places the patient at increased risk for pneumatosis intestinalis.

Prophylactic PPI or H2 blocker

1. Ranitidine 3 mg/kg/day IV 8-hourly 2. Cimetidine 10-20 mg/kg/day IV 6-12 hourly 3. Omeprazole 2 mg/kg once daily (max. 40mg) by IV infusion

Raised ICP

1. Maintain the head in neutral position and elevated to 30 degrees.

2. Acutely hyperventilate patient maintaining pCO2 between 30 and 40 mmHg and administer mannitol 0.25-1 g/kg for impending herniation or once obvious neurological signs develop.

3. Maintain euthermia 36.5-37.5 C.

Coagulopathy

A. If patient is significantly bleeding or in anticipation of an invasive surgical procedure:

1. Transfuse FFP to a goal INR of < 1.5. Avoid giving large volumes of FFP to reach goal INR. Volume overload may worsen cerebral edema.

2. Transfuse platelet concentrate to a goal of 50,000-70,000/mm3.

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3. Consider NOVOSEVEN (40 mcg/kg IV) in patient with prolonged INR despite FFP, who are volume overloaded.

B. In the absence of bleeding or invasive procedure:

1. Prophylactic FFP to improve coagulopathy in patients with acute liver failure is not recommended.

2. Administration of cryoprecipitate is suggested in patients with fibrinogen 38 C or < 36 C, white blood count > 12,000 or < 4000/mm3, tachycardia).

Broad-spectrum coverage with a third-generation cephalosporin, vancomycin/teicoplanin, and fluconazole are recommended wherever indicated.

Renal insufficiency

1. Monitor renal function closely including input and output. 2. Avoid nephrotoxic medications. 3. Maintain adequate renal perfusion. 4. Renal replacement therapy indications includes:

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a. Uremic encephalopathy b. Severe or persistent hyperkalemia > 7 meq/L c. Severe metabolic acidosis d. Fluid overload (pulmonary edema, severe hypertension) e. Hyponatremia (120 meq/L or symptomatic) or

hypernatremia

Ascites

1. If patient has respiratory compromise due to tense ascites or there is concern for peritonitis, perform therapeutic paracentesis.

2. Infuse 25% albumin while doing paracentesis. 3. Provide < 3 mEq/kg of sodium daily to minimize water

retention and worsening the ascites. 4. Start lasix and aldactone at a ratio of 1:2.5 (maximum dose of

lasix 160 mg and aldactone 400 mg). Closely monitor fluid status including renal function, I/O and weight.

5. Consider Diuril (2-8 mg/kg/day IV in 2 divided doses or 20-40 mg/kg/day PO in 2 divided doses) for persistent ascites and/or edema.

6. Avoid overhydration.

Liver transplantation

This is the only definite treatment. King's College Hospital criteria for liver transplantation in acute liver failure are:

A. Paracetamol (acetaminophen) overdose

1. pH < 7.3 (irrespective of encephalopathy)

or all of the following:

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2. Grade III-IV encephalopathy

3. Creatinine > 300 umol/L

4. Prothrombin time > 100 seconds (INR > 6.5)

B. Non-paracetamol aetiology

1. Prothrombin time > 100 seconds

or any 3 of the following:

2. Age < 10 years or > 40 years

3. Prothrombin time > 50 seconds

4. Bilirubin > 300 umol/L

5. Time from jaundice to encephalopathy > 2 days

6. Non-A, non-B hepatitis, halothane or drug-induced acute liver

failure

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Anaphylaxis

Definition

Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death. Anaphylaxis in children, particularly infants, is frequently underdiagnosed.

It occurs when there is a sudden release of potent biologically active mediators from mast cells and basophils, leading to cutaneous (urticaria, angioedema, flushing), respiratory (bronchospasm, laryngeal edema), cardiovascular (hypotension, dysrhythmias, myocardial ischemia), and gastrointestinal (nausea, colicky abdominal pain, vomiting, diarrhea) symptoms.

Etiology

1. Food: peanuts, tree nuts (walnut, hazelnut, cashew, pistachio, Brazil nut), milk, eggs, fish, shellfish (shrimp, crab, lobster, clam, scallop, oyster), seeds (sesame, cottonseed, pine nuts, psyllium), fruits (apples, banana, kiwi, peaches, oranges, melon), grains (wheat)

2. Drugs: penicillins, cephalosporins, sulfonamides, nonsteroidal anti-inflammatory agents, opiates, muscle relaxants, vancomycin, dextran, thiamine, vitamin B12, insulin, thiopental, local anesthetics

3. Hymenoptera venom: honeybee, yellow jacket, wasp, hornet, fire ant

4. Latex 5. Allergen immunotherapy 6. Exercise: food-specific exercise, postprandial (nonfood-

specific) exercise

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7. Vaccinations: tetanus, measles, mumps, influenza 8. Miscellaneous: radiocontrast media, gamma globulin, cold

temperature, chemotherapeutic agents (asparaginase, cyclosporine, methotrexate, vincristine, 5-fluorouracil), blood products, inhalants (dust and storage mites, grass pollen)

9. Idiopathic

Diagnosis

Anaphylaxis is highly likely when any one of the following three criteria is fulfilled:

1. Acute onset of an illness (minutes to several hours) with involvement of the skin and/or mucosal tissue (e.g. generalized hives, pruritus or flushing, swollen lips/tongue/uvula); and at least one of the following:

a. Respiratory compromise (e.g., dyspnea, wheeze/bronchospasm, stridor, reduced peak PEF, hypoxemia)

b. Reduced BP or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence)

2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):

a. Involvement of the skin/mucosal tissue (e.g., generalized hives, itch/flush, swollen lips/tongue/uvula)

b. Respiratory compromise (e.g., dyspnea, wheeze/bronchospasm, stridor, reduced PEF, hypoxemia)

c. Reduced BP or associated symptoms (e.g., hypotonia [collapse], syncope, incontinence)

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d. Persistent gastrointestinal symptoms (e.g., crampy abdominal pain, vomiting)

3. Reduced BP following exposure to known allergen for that patient (minutes to several hours):

a. Infants and children: low systolic BP (age-specific) or 30% drop in systolic BP

b. Low systolic blood pressure (BP) for children is defined as less than 70 mmHg from one month to one year, less than (70 mmHg + [2 age(year)]) from one to 10 years, and less than 90 mmHg from 11 to 17 years.

Pharmacological management of anaphylaxis

Drug Frequency of

administration Dosage

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

Immediately, then every 515 min as required

0.01 mg/kg up to 0.03 mg/kg

OR by age

> 6 yr: 150 mcg = 0.15 mL IM 6-12 yr: 300 mcg = 0.3 mL IM 12-18 yr: 500 mcg = 0.5 mL IM

H1 antagonists

Cetirizine PO (> 2 yr)

Single daily dose 0.25 mg/kg up to 10 mg

Loratidine Single daily dose 2-5 yr: 5 mg > 5 yr: 10 mg

Desloratidine Single daily dose 6-12 mo: 1 mg

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1-5 yr: 1.25 mg 6-11 yr: 2.5 mg > 12 yr: 5 mg

Diphenhydramine IM/IV

Every 46 hr as required for cutaneous manifestations

1.25 mg/kg up to 50 mg

Chlorpheniramine IM/IV

Repeat up to 4 times/24 hr

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

H2 antagonists

Ranitidine PO/IV

Every 8 hr as required for cutaneous manifestations

1 mg/kg up to 50 mg

Cimetidine Every 12 hr or as required

4 mg/kg up to 200 mg

Corticosteroids

Prednisone PO Every 6 hr as required

1 mg/kg up to 75 mg

Methylprednisolone IV

Every 6 hr as required

1-2 mg/kg up to 125 mg

Salbutamol Every 20 min or continuously for respiratory symptoms (wheezing or shortness of breath)

Nebulized epinephrine (1:1000)

Every 20 min to 1 hr for symptoms of upper airway obstruction (stridor)

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Post-emergency management

H1 antagonist Cetirizine or Lortin

5-10 mg once daily for 3 days

Corticosteroid Oral prednisolone

1 mg/kg up to 75 mg for 3 days

Prevention

1. Patients experiencing anaphylactic reactions to foods must be educated in allergen avoidance, including actively reading food labels and acquiring knowledge of potential contamination and high-risk situations, as well as in the early recognition of anaphylactic symptoms (sensation of warmth and facial pruritus) and ready administration of emergency medications.

2. Patients with egg allergy should be tested before receiving the influenza vaccine, which contain egg protein.

3. In cases of food-associated exercise-induced anaphylaxis, children must not exercise within 2-3 hr of ingesting the triggering food, stop exercising, and seek help immediately if symptoms develop.

4. Reactions to medications can be reduced and minimized by using oral medications in preference to injected forms.

5. Hypo-osmolar radiocontrast dyes can be used in patients in whom previous reactions are suspected.

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6. The use of powder-free, low-allergen latex gloves or non-latex gloves and materials should be used in children undergoing multiple operations.

Preventive treatment

1. Follow-up evaluation to determine/confirm etiology 2. Immunotherapy for insect sting allergy 3. Prescription for EpiPen and antihistamine 4. Provide written plan outlining patient emergency

management

Patient education

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

anaphylaxis

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Management algorithm for anaphylaxis

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Arrhythmias

Tachyarrhythmias

Tachyarrhythmias are classified into:

1. Atrial tachycardia: AF, EAT, MAT 2. Conduction system tachycardia or supraventricular

tachycardia: AVRT, AVNRT, PJRT 3. Ventricular tachycardia: VT, VF

Atrial flutter (AF)

o saw tooth flutter waves o variable AV conduction

Ectopic atrial tachycardia (EAT)

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

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Multifocal atrial tachycardia (MAT)

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

Atrioventricular re-entry tachycardia (AVRT)

o P wave follows QRS

Atrioventricular nodal re-entrytachycardia (AVNRT)

o P wave not visible, superimposed on QRS

Permanent junctional reciprocating tachycardia (PJRT)

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o inverted P waves in II, III, aVF appear to precede QRS complex o long RP interval

Ventricular tachycardia (VT)

o wide QRS complex o P wave may be dissociated from the QRS complex

Ventricular fibrillation (VF)

o chaotic, irregular rhythm

Bradyarrhythmias

Bradycardia

Heart blocks

QRS Width

Narrow QRS

P/QRS ratio

> 1:1

Regular ( Atrial Flutter)

Variable (EAT)

Chaotic (MAT/Fib)

1:1

QRS-P interval

Very long (PJRT/EAT)

short follows QRSP wave

(orthodromic AVRT)

not visible (AVNRT)

< 1:1

JET

Wide QRS

P/QRS ratio

VT (<

SVT + BBB

Antifromic AVRT

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Wide QRS

P/QRS ratio

VT (< 1:1)

VT(1:1)

SVT + BBB

Antifromic AVRT

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Management

Hemodynamically stable

1. Vagal manoeuvers:

a. Icepack/iced water for infants; apply to face for a maximum of 30 seconds.

b. Valsalva manoeuver if child is old enough (blow into a pinched straw).

2. IV adenosine: 0.1 mg/kg (max. 6 mg) rapid push; increase by 0.1 mg/kg every 2 min until tachycardia terminates or up to a maximum of 0.5 mg/kg (max. 18 mg).

3. IV propranolol 0.1 mg/kg over 5 min; can be repeated every 5 min for 3 times.

Tachyarrhythmia

Narrow QRS

Stable

vagal manoeuvers

adenosine

propranolol

amiodarone

Unstable

synchronized

cardioversion

Wide QRS

stable

amiodarone

lignocaine in ventricular tachycardia

Unstable

synchronized cardioversion

or defibrillation

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4. IV amiodarone 5 mg/kg over 1 hr or 25 mcg/kg/min for 4 hr then 5-15 mcg/kg/min until conversion.

Haemodynamically unstable

1. Synchronized DC conversion at 0.5 to 1 joule/kg.

2. In pulseless patients, defibrillate at 2 to 4 joules/kg.

Pitfalls in management

o Consult a cardiologist if these acute measures fail to revert the tachycardia.

o In Wolff-Parkinson-White syndrome digoxin is contraindicated because paroxysms of atrial flutter or fibrillation can be conducted directly into the ventricle.

o Verapamil is contraindicated in the 1st year of life. o Adenosine unmasks the atrial flutter by causing AV block and

revealing more atrial beats per QRS complex. o All bradycardias should be sent to a pediatric cardiologist. o In wide QRS complex tachycardia with 1:1 ventriculo-atrial

conduction it is reasonable to see if adenosine will cause cardioversion, thereby making a diagnosis of a conduction system dependent SVT.

o A follow-up plan should be made in consultation with a cardiologist.

Abbrevations

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

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permanent junctional reciprocating tachycardia; SVT: supraventricular tachycardia; VT: ventricular tachycardia

Pediatric advanced life support

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Asthma

Diagnosis

History: Does the patient have established disease or not? Consider differential diagnoses if this is the first presentation.

Assess severeity:

1. Mild: SpO2 >95% on room air (treated as outpatient with bronchodilator)

2. Moderate: SpO2 91%-95% on room air and PEF 50% 3. Severe: SpO2 1 yr 1 mL

4. Steroid: a. Methylprednisolone initial 2 mg/kg/dose IV, followed

by 1 mg/kg/dose IV 6-hourly b. Hydrocortisone vial initial 10 mg/kg/dose IV, followed

by 1 mg/kg/dose 4 times daily c. Prednisolone 1-2 mg/kg/day orally

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After initial treatment

Improvement No improvement

Salbutamol nebulizer hourly for 2-4 hr

OR

Oral salbutamol + short course steroid

1. Reassess the disease

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

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

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

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

Mechanical ventilator

Bronchial foreign body aspiration

Algorithm of management

Introduction

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

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Foreign body aspiration is a common pediatric problem and a leading cause of accidental death in children under 5 years of age.

4 years explore their environment, which often includes introducing objects into their mouths. It

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follows that nearly all foreign body aspirations occur in this age group.

The most commonly aspirated objects are food materials, such as peanuts, seeds (sunflower and watermelon), nuts, and beans. Some insert objects that are easily aspirated into the childs airway include small toys, buttons, toy parts, lids or straight pins.

Diagnosis of bronchial foreign body aspiration is challenging in children and delayed diagnoses occur for several reasons. The aspiration event is often unwitnessed or denied by parents. Most aspirated objects are radiolucent.

After the initial coughing paroxysm, there is usually a quiescent (relatively asymptomatic) phase for about a week before pneumonia or other complications occur. Factors that might cause delays in diagnosis are:

o Lack of parent or caregiver recognition of the choking event. o Parental denial. o Unwarranted reassurance provided by medicines that cause

temporary improvement of signs and symptoms. o Difficulty performing radiographic examinations for

radiolucent foreign bodies. o Lack of consistent formal education regarding injuries caused

by aspirated foreign bodies in many medical schools and residency programs.

Pathophysiology

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

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asphyxia and death, whether the object passes the carina or not, it depends on the patients age and physical position at the time of the aspiration.

Until the age of 15 years, foreign bodies are found on either side with equal frequency, but once aspirated; objects may subsequently change position or migrate distally.

The object itself might cause obstruction or induce inflammation, edema, cellular infiltration, ulceration, and granulation tissue formation, which may contribute to airway obstruction.

Distal to the obstruction, air trapping leading to local emphysema, atelectasis, hypoxic vasoconstriction, post-obstructive pneumonia and possible volume loss, necrotizing pneumonia or abscess, suppurative pneumonia, or bronchiectasis may occur.

The likelihood of complications increases after 24-48 hrs, making quick removal of the foreign body urgent.

Assessment and evaluation

Often, the child presents after a sudden episode of coughing or choking while eating with subsequent wheezing, coughing, or strider. However, in numerous cases, the choking episode is not witnessed, and, in many cases, the choking episode is not recalled at the time the history is taken.

The most tragic cases occur when acute aspiration causes total or near-total occlusion of the airway, resulting in death or hypoxic brain damage.

The more difficult cases are those in which aspiration is not witnessed or is unrecognized and, therefore, is unsuspected.

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In these situations, the child may present with persistent or recurrent cough, wheezing, persistent or recurrent pneumonia, lung abscess, focal bronchiectasis, or hemoptysis.

If the material is in the subglottic space, symptoms may include strider, recurrent or persistent croup, and voice changes.

In one series, as many as one third of parents were unaware of the aspiration or remembered an event that occurred more than a week before the presentation. In as many as 25% of cases, aspiration occurred more than one month before presentation.

Consequently, a high index of suspicion in addition to the history may be necessary to reach the diagnosis. In another series of 280 foreign body aspirations, 47% were detected more than 24 hours after the aspiration. However, 99% had signs or symptoms or abnormal plain radiographs before the bronchoscopy.

Examination

1. Asymmetrical chest movement 2. Tracheal deviation 3. Chest signs such as wheeze or decreased breath sound. 4. The respiratory examination may be completely normal.

Management

Prevention is the most important point in management:

1. No child less than 15 months old should be offered foods such as popcorn, hard lollies, raw carrot or apples. Children under the age of 4 years should not be offered peanuts.

2. Encourage the child to sit quietly while eating and offer food one piece at a time.

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3. Avoid toys with small parts for children under the age of 3 years.

Treatment includes:

1. Bronchodilators and corticosteroids should not be used to remove the foreign body, and chest physical therapy with postural drainage may dislodge the material to an area where it may cause more harm, such as at the level of the vocal cord.

2. Place child upright in the position they feel most comfortable , Arrange for urgent removal of foreign body in the operating theatre. Rigid bronchoscopy is almost always successful.

3. Medications are not necessary before removal, although the endoscopist may observe enough focal swelling after the material is removed to recommend a short course of systemic corticosteroids.

4. Unless the airway secretions are infected with organisms present, antibiotics are not necessary.

5. Treat complications.

Complications

1. Atelectasis 2. Recurrent pneumonia 3. Penumonitis 4. Bronchial Granulomas. 5. Pneumomediastinum 6. Bronchiactasis 7. Obstructive emphysema 8. Lung abscess 9. Bronchocutanious or bronchovascular fistula if untreated.

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Aim

Aim of this guideline is to decrease morbidity and mortality associated with bronchial aspiration, and help more accurate diagnosis and choice of medication, with avoidance of misuse or overuse of medications and performing unnecessary invasive procedures.

Inclusion criteria

1. Stable children suspected of unilateral foreign body aspiration 2. Foreign body aspiration confirmed by a witness in a stable

child with respiratory complain

Exclusion criteria

1. Forign body ingestion with no respiratory complian. 2. Upper airway aspiration including laryngeal or pharyngeal

(strider, cough, hoarseness, in ability to speak) 3. Bilateral bronchial aspiration 4. Clinically unstable child with respiratory failure and

decreased level of consciousness

Key points

1. History of chocking in a clinically stable child with mild or no respiratory complain should elicit suspicion of bronchial aspiration in a child 1-4 years of age.

2. Local wheeze or local diminished air entry should be looked for, in examining a child with suspected bronchial aspiration.

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3. CXR is the most important diagnostic imaging, in which air trapping, emphysema, atelectasis or mediastinal shifting should be looked for.

4. The 3 diagnostic tools are; history physical examination and imaging, in which positive findings in 2 of them is enough to consult a brochoscopist (cardiothoracic surgeon)

5. If only history or physical examination is suggestive of aspiration, no need for consultation, but the child should be kept for further evaluation

6. If there is positive history of chocking with high risk objects (any small hard piece, organic (nuts, popcorns, seeds) or non-organic (plastic, stones, metals), with positive signs and symptoms, require urgent bronchoscopy.

7. Chocking with a low risk object (cheese, cereals, and chips) with positive signs and symptoms, and radiological findings, even if history of choking is not surely recalled, requires bronchoscopy.

8. Steroids and bronchodilators have no role initially unless recommended by the pediatric ENT-ist.

9. Chest physiotherapy initially might dislodge the foreign body in to an area where it might cause more harm.

10. No role for antibiotics, unless there is complications.

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A plain inspiratory film showing a radiopaque ear ring backing in the right main bronchus.

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Croup

Diagnosis of croup

Is life-threatening airway obstruction present?

1. Cyanosis

2. level of consciousness

Yes

No

1. 100% O2

2. Nebulized adrenaline

3. Intubation (by experienced personnel)

4. Systemic corticosteroid

Mild croup

Barking cough

Nil or intermittent stridor

No cyanosis

Severe croup

Persisting/soft stridor at rest

Marked recession

Apathetic or restless, cyanosis

Moderate croup

Persisting stridor at rest

Some recession

May have cyanosis

1. Explanation to parents

2. No specific treatment

3. Discharge

1. Dexamethasone 0.6 mg/kg

2. Observe in > 4 hr

1. Do not agitate the child

2. O2, nebulized adrenaline

4. Steroid

5. Observe in > 4 hr

Consider alternative diagnoses:

1. Inhaled foreign body

2. Congenital anomalies

3. Epiglottitis/tracheitis

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Key points of the differential diagnoses

Infectious croup: is a common viral infection. It starts with a viral prodrome of rhinorrhea, pharyngitis, low grade fever, and barking cough. Stridor appears 1-2 days later.

Spasmodic croup: is an aviral condition; it may be allergic or psychological. It has a characteristic barking, metallic cough, mostly in the evening or at night, has a sudden onset and has no viral prodrome. The attacks may be repeated at night in the second and third days but it is usually milder.

Tracheitis: is characterized by brassy cough, high fever, and toxicity with respiratory distress.

Improvement

Yes No Partial

Discharge when there is no more stridor.

1. Admit/observe

2. Repeat steroid in 12 hr

3. Explanation to parents

4. Written follow up

1. Inform consultant

2. Nebulized adrenaline (same as previous dose)

3. Steroid (same as previous dose)

4. Consider intubation

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Epiglottitis: is characterized by high fever and rapidly progressing stridor, drooling of saliva, and muffled sound. Airway obstruction becomes severe within hours.

Foreign body inhalation: has a sudden onset, is not preceded by fever, and has a history of choking.

In the treatment of croup

o Steroid should be used cautiously in Varicella infection and in TB.

o Nebulized adrenaline should be used cautiously in tachycardia, TOF, and ventricular outlet obstruction.

o Antibiotics are not indicated. o There is no role for steam inhalation or cool mist. o Sedatives and bronchodilators are contraindicated.

Indications for admission

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

Medication Croup grade Dose Notes

Systemic corticostero

id*

Moderate or severe

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

Acts within 1 hr

Repeat in 12-24 hr

Nebulized adrenaline

Moderate or severe

Adrenaline 1:1000, 1 mg/1

mL, (0.5-1 mL/dose in 3 mL of NS) nebulized

Acts within minutes

May need repeat doses

after 30 min if no response

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O2

Severe (SpO2 < 90%)

Very severe with central

cyanosis

Mask with minimum

amount of 6 L/min

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Dehydration

Signs and symptoms of severe dehydration

* These are the most reliable and helpful signs.

Management

Body weight loss >10%

General appearance Drowsy, limp, cold, sweaty, cyanotic extremities

Respiration* Deep and rapid Eyes Grossly sunken

Tears Absent Anterior fontanelle Very sunken Mucous membranes Very dry Capillary refill time* Prolonged (>3 seconds)

Tissue turgor* Retracts very slowly Radial pulse Rapid, thready, may be impalpable

Blood pressure Low

Urine output Marked oliguria

Total IV fluid requirement in severe dehydration

Treat shock

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

Maintenance

(see table below)

Ongoing losses

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

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Table. Maintenance IV fluid and electrolyte requirement

Body weight

Fluid

mL/kg/24

hr

Sodium

mmol/kg/24

hr

Potassium

mmol/kg/24

hr

1st 10kg 100 mL 2-4 1.5-2.5

2nd 10 kg 50 1-2 0.5-1.5

Subsequent kg 20 0.5-1 0.2-0.7

Initial IV fluid management in severe dehydration

20 mL/kg of 0.9% saline Send for blood urea and serum electrolyte levels

Ph

ase 1: T

reat sh

ock (0-3

0 m

in)

Ph

ase

2:

Reh

ydra

tion

No improvement* Improvement*

repeat up to 3 times

Lasix 1 mg/kg, 1 dose

Repeat lasix 1 mg/kg

Think of other causes: cardiac, anaphylactic, or septic shock

Do haemodynamic monitoring and give inotropic support

(dopamine)

no improvement

after 45 min

no improvement

no improvement after 2

hr and 3 boluses of NS

Na+

< 130

Na+

135 - 145

Na+

> 150

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* Criteria of improvement are:

1. Intact mental status 2. Normal heart rate 3. Capillary refill < 2 seconds 4. Adequate urine output

Treatment of severe dehydration

0.45% saline / 2.5% dextrose over 24 hr

fluid volume = deficit + maintenance - shock bolus

in 1st 8 hr then in 16 hr.

0.45% saline / 2.5% dextrose over 48 hr

fluid volume = deficit + maintenance - shock bolus

in 1st 18 hr then in 30 hr

Close monitoring of clinical condition, fluid balance, blood urea, plasma creatinine and electrolytes

Assess the patient and check ABCD (D for dextrose; always check blood sugar).

Take the vital signs.

Send for emergency lab investigations (blood sugar, blood urea, serum electrolytes, serum calcium, CBC).

Insert an IV line (if needed 2 lines) within 3 min (3-4 trials); if this fails insert an intraosseous line.

38

If the patient is in shock give a shot of 20 mL/kg Ringer lactate or 0.9% normal saline within 30 min.

Reassess after first infusion; if no improvement repeat 20 mL/kg over 30 min.

Reassess after second infusion; if no improvement repeat 20 mL/kg over 30 min.

Reassess after third infusion; if no improvement transfuse fresh whole blood 20 mL/kg over 1 hr (use packed red cell if in cardiac failure).

Assess the vital signs every 5-10 min.

Treat hypoglycemia and hypocalcaemia if present.

If there is no urine output give a dose of frusemide (Lasix) 2-4 mg/kg/dose or you can give mannitol 0.5 gm/kg (2.5 ml of 20% mannitol/kg) over 1 hr and wait 30 min while running maintenance fluids (without potassium).

If there is no improvement treat as acute renal failure or think about other causes (cardiac, anaphylactic, or septic shock); do hemodynamic monitoring and give inotropic support (dopamine )

If there is improvement, UOP is positive and vital signs become better calculate 24 hr fluid needed: maintenance + deficit - fluid used for initial infusions (shock boluses).

Administer this total fluid over 24 hr using GS + 20 mEq/L KCl (according to serum potassium).

Replace ongoing losses as they occur.

39

Treatment of severe dehydration in children with

malnutrition

If plasma Na+ (> 150) then give

of total fluid in first 18 hr then in second 30 hr.

If plasma Na+ (< 130) or normal then give

of total fluid in first 8 hr then in second 16 hr.

Assess the patient and check ABCD (D for dextrose; always check blood sugar).

Take the vital signs.

Send for emergency lab investigations (blood sugar, blood urea, serum electrolytes, serum calcium, CBC).

Insert an IV line (if needed 2 lines) within 3 min (3-4 trials); if this fails insert an intraosseous line.

If the patient is in shock give a shot of 15 mL/kg Ringer lactate with 5% dextrose or GS within 1 hr.

Reassess after first infusion; if no improvement repeat 15 mL/kg over 1 hr.

Assess the vital signs every 5-10 min.

Reassess after second infusion; if there is no improvement consider the child as having septic shock.

Give maintenance IV fluid 4 mL/kg/hour while waiting for blood.

When blood is available, transfuse fresh whole blood at 10 mL/kg over 3 hr (use packed red cell if in cardiac failure).

Treat hypoglycemia, hypothermia, hypocalcaemia and hypomagnesaemia if present.

40

If there is no urine output give a dose of frusemide 1-2 mg/kg/dose or you can give mannitol 0.5 gm/kg (2.5 ml of 20% mannitol/kg) over 1 hr while running maintenance fluids.

If no improvement treat as acute renal failure or think about other causes (cardiac, anaphylactic, or septic shock); do hemodynamic monitoring and give inotropic support (dopamine )

If there is improvement, UOP is positive and vital signs become better calculate 24 hr fluid needed: maintenance + deficit - fluid used for initial infusions (shock boluses).

Administer this total fluid over 24 hr using GS + 20 mEq/L KCl.

Replace ongoing losses as they occur.

Start feeding by mouth or by NG tube.

If plasma Na+ (> 150) then give

of total fluid in first 18 hr then in second 30 hr

If plasma Na+ (< 130) or normal then give

of total fluid in first 8 hr then in second 16 hr

If the child deteriorates during the IV rehydration (breathing by 5 breaths/min or pulse by 25 beats/min) stop the infusion because IV fluid can worsen the childs condition.

41

WHO treatment of severe dehydration in infants

Insert an IV line (If needed 2 lines) within 5 minutes (3-4 trials); if this fails insert an IO line.

Draw blood for emergency lab investigations.

Start IV fluid immediately.

If the patient can drink give ORS by mouth while the drip is set up.

Give 30 mL/kg initially ringer lactate or 0.9% NS in 1 hr then give 70 mL/kg in 5 hr.

Reassess the patient every half hour. If hydration is not improving give the IV drip more rapidly.

Also give ORS (5mL/kg/hr) as soon as the patient can drink.

After 3 hr re-evaluate the patient and choose the appropriate plan to continue treatment.

Can you give IV fluids immediately?

Yes

Refer to hospital immediately for IV treatment.

If the patient can drink, provide the mother with ORS and show her how to give sips of it during the trip.

Is IV treatment available nearby (within 30 min)?

Yes

No

N

o

42

Note:

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

Are you trained to use an NG tube for

rehydration? N

o

Can the patient drink?

No

Refer URGENTLY to hospital for IV

treatment.

Start rehydration by NG tube or by mouth with ORS; give 20 mL/kg/hr.

Refer URGENTLY to hospital.

Yes

Yes

43

Diabetes mellitus, preoperative preparation in

In children with diabetes mellitus (DM) presurgical assessment should be done several days before surgery to allow for an assessment of glycemic control, electrolyte status, and ketones (in urine or blood).

If glycemic control is known to be poor and surgery is not urgent, delay the procedure until glycemic control has improved. If surgery cannot be delayed, consider admission to the hospital before surgery for stabilization of glycemic control.

The blood glucose should be maintained in the range of 90180 mg/dL during surgical procedures in children.

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

Discontinue metformin 24 h before major surgery (lasting at least 2 h) and on the day of surgery for minor surgery.

Discontinue sulfonylureas and thiazolidinediones on the day of surgery.

Patients undergoing a major surgical procedure expected to last at least 2 h should be started on an IV insulin infusion.

Preoperative preparation of children with DM

Type 1 DM or type 2 DM on insulin

Type 2 DM not on insulin

Major surgery Minor surgery

44

Type 1 DM or type 2 DM on insulin

Must be admitted to the hospital if receiving GA.

In cases with documented good control, it should be possible to admit early on the day of surgery for both minor and major procedures. Otherwise, it is preferred to admit in the afternoon before surgery to give time for correction of metabolic status overnight.

Should be scheduled as the first case of the day.

Need insulin, even if fasting, to avoid ketoacidosis.

May initially receive an IV infusion without dextrose for minor surgery or procedures (lasting for less than 2 h) if treated with basal/bolus insulin regimen or continuous subcutaneous insulin infusion (CSII).

Should initially receive an IV infusion with dextrose for major surgery or procedures (lasting for at least 2 h) or if treated with NPH insulin.

Require hourly capillary blood glucose monitoring to detect hypoglycemia and hyperglycemia before the procedure. If the blood glucose exceeds (250 mg/dL), a conservative dose of rapid-acting insulin or short-acting insulin (regular) should be administered to restore blood glucose to the target range.

Should coordinate the timing of preoperative food and fluid restrictions with the anesthetist.

45

The usual recommendation is no solid food for at least 6 h before surgery Clear fluids (and breast milk) may be allowed up to 4 h before surgery

Major surgery

On the evening before surgery give the usual evening and/or bedtime insulin(s) and bedtime snack.

Monitor blood glucose and urinary ketone concentration if blood glucose is > 250360 mg/dL.

Omit the usual morning insulin dose.

At least 2 h before surgery, start an IV insulin infusion [e.g., dilute 50 units regular (soluble) insulin in 50 mL normal saline, 1 unit = 1 mL] and provide IV maintenance fluids consisting of 5% dextrose and half-normal saline (0.45% NaCl).

Monitor blood glucose levels at least hourly before surgery and as long as the patient is receiving IV insulin.

Aim to maintain blood glucose between (90180 mg/dL) by adjusting the IV insulin dose or the rate of dextrose infusion during surgery.

When oral intake is not possible, the IV dextrose infusion should continue for as long as necessary.

Minor surgery

Require a brief general anesthetic.

The child will usually be discharged from hospital on the day of procedure.

46

Early morning procedures (for example, 8.009.00 am) with delayed insulin and food until immediately after completion, or reduced usual insulin dose (or give repeated small doses of short/rapid-acting insulin).

Glucose 510% infusion and frequent blood glucose monitoring are recommended in all these situations.

Elective vs emergency surgery

The above approach applies to elective surgeries without further precautions. The approach also applies in emergency in surgeries with some further precautions.

Before emergency surgery in a child with DM, always check blood glucose or urinary ketone concentration, serum electrolytes, and blood gases if ketone or blood glucose levels are high.

Do not give fluid, food, or medication by mouth because in some emergency situations, the stomach must be emptied by a nasogastric tube. Always secure IV access and check weight before anesthesia.

If ketoacidosis is present, follow an established treatment protocol for diabetic ketoacidosis and delay surgery, if possible, until circulating volume and electrolyte deficits are corrected and, ideally, until acidosis has resolved. If there is no ketoacidosis, start IV fluids and insulin management as for elective surgery.

Intraoperative care

Blood pressure should be carefully monitored. Monitor blood glucose measurements at least hourly during and immediately after GA. If necessary, begin dextrose infusion or increase

47

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

Adjust dextrose infusion and insulin dose (by subcutaneous injection of rapid-acting insulin for minor surgery) to maintain blood glucose in the range (90180 mg/dL).

For those receiving an IV insulin infusion, a single correction bolus of IV insulin (either using the childs usual correction factor or 510% of the childs usual total daily insulin dose, depending on the severity of hyperglycemia) may be given at the start of the infusion to correct hyperglycemia.

Thereafter, correction of hyperglycemia should be based on adjustment of the rate of the IV insulin infusion. If the blood glucose exceeds (250 mg/dL), urine or blood ketones should also be measured.

If there is an unexpected acute drop in blood pressure, NS (0.9% NaCl) or Ringers lactate must be infused rapidly. In this case, potassium containing fluids must not be infused rapidly.

Postoperative care

After surgery, start oral intake or continue IV dextrose infusion depending on the childs condition. Continue the IV insulin infusion or additional shorter rapid-acting insulin as necessary until oral intake is resumed.

Once the child is able to resume oral nutrition, resume the childs usual diabetes treatment regimen. Give short- or rapid-acting insulin (based on the childs usual insulin:carbohydrate ratio and

48

correction factor), if needed, to reduce hyperglycemia or to match food intake.

Patients treated with once daily basal/bolus insulin regimens

Morning operations

On the morning of the procedure, give the usual dose of long-acting insulin (glargine or detemir) if usually given at this time. If preoperative evaluation shows a pattern of low blood glucose values in the morning, consider reducing the dose of long-acting insulin by 2030%.

Omit the short- or rapid-acting insulin unless needed to correct hyperglycemia.

Commence IV fluids. Patients with a normal blood glucose may initially utilize IV fluids without dextrose. With an appropriately

Management according to different types of insulin regimens

Patients treated with once daily basal/bolus insulin regimens

Patients treated with twice daily basal and rapid- or short-acting insulins

Morning operations

Evening operations (if unavoidable)

Morning operations

Evening operations (if unavoidable)

49

titrated basal rate and careful monitoring, this approach may be more physiologic.

Afternoon operations (if unavoidable)

On the morning of the procedure, give the usual dose of long-acting insulin (if usually given at this time).

If allowed to eat breakfast, give the usual dose of rapid-acting insulin or 50% of the usual short acting insulin.

If the anesthetist allows the child to eat a light breakfast and to consume clear liquids up to 4 h before the procedure, IV fluid administration (and IV insulin infusion, if applicable) should commence 2 h before surgery or no later than midday.

Patients treated with twice daily basal and rapid- or short-

acting insulins

Morning operations

On the morning of the procedure, give 50% of the usual morning dose of intermediate acting insulin (NPH) or the full usual morning dose of long-acting insulin (detemir or glargine).

With premixed insulin, give only 50% of the equivalent dose of the basal (NPH) component.

Omit the short- or rapid-acting insulin unless it is needed to correct hyperglycemia.

Commence IV fluids containing dextrose 510%, as necessary, to prevent hypoglycemia.

Afternoon operations (if unavoidable)

50

On the morning of the procedure, give 50% of the usual dose of intermediate-acting insulin (NPH) or the full usual morning dose of long-acting insulin (detemir or glargine).

With premixed insulin, give only 50% of the equivalent dose of the basal component (NPH).

The dose of short- or rapid-acting insulin will depend on whether the child is permitted to eat breakfast.

Alternatively, give 3040% of the usual morning insulin dose of short- or rapid acting insulin (but no intermediate- or long-acting insulin) and use an IV insulin infusion beginning at least 2 h before surgery.

If the anesthetist allows the child to eat a light breakfast and to consume clear liquids up to 4 h before the procedure, IV fluid administration (and IV insulin infusion, if applicable) should commence 2 h before surgery or no later than midday.

Infusion guide for surgical procedures

Maintenance fluid guide

1. Dextrose:

For major surgery and any surgery when NPH has been given use 5% dextrose; use 10% if there is concern about hypoglycemia.

If blood glucose is high 250 mg/dL use half-normal saline (0.45% NaCl) without dextrose and increase insulin supply but add 5% dextrose when blood glucose falls below (250 mg/dL).

2. Sodium:

51

There is evidence that the risk of acute hyponatremia may be increased when hypotonic maintenance solutions (i.e.,

52

mg/dL, use 0.075 mL/kg/h between 220270 mg/dL, and use 0.1 U/kg/h if > 270 mg/dL.

Aim to maintain blood glucose between 90180 mg/dL by adjusting insulin infusion hourly.

Blood glucose must be measured at least hourly when the patient is on IV insulin

Do not stop the insulin infusion if blood glucose < 90 mg/dL as this will cause rebound hyperglycemia.

The insulin infusion may be stopped temporarily if blood glucose is < 55 mg/dL but not >1015 min.

53

Diabetic ketoacidosis

Intravenous fluid

Total amount = (85 mL/kg + maintenance)/24 hr

of this is given within 12 hr bolus given in basic life

DKA diagnostic criteria

Blood sugar > 300 mg/dL

Acidosis (serum HCO3 < 15 mEq/dL)

Complete initial evaluation

Short history: polyuria, polydypsia, abdominal pain, emesis, known case of DM

Physical examination: assess level of consciousness, asses volume state (all cases of DKA should be considered as having 8.5% dehydration), vital signs

Lab investigations: blood sugar, blood urea, serum creatinine, serum electrolytes, GUE, urine for ketone, ABG, ECG

If the patient has disturbed level of consciousness or is in coma establish basic life support:

1. Airway, breathing, circulation (put 2 cannulas, 1 for insulin and 1 for fluid)

2. Urinary catheter 3. Give 20 mL/kg N/S in 1 hour

54

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

If the patient is hypernatremic they should be rehydrated slowly over 48 hr.

Continue on N/S or N/S if available till blood sugar is < 250 mg/dL then add 5% dextrose.

Insulin therapy

Give immediately with IV fluid by infusion per 1 hr

Blood sugar (mg/dL) Unit/kg of insulin

> 600 0.1

300-600 0.05

Note: Mix 25 units of insulin with 250 mL N/S. In this way each mL will contain 0.1 unit. Thus you can give 1 cc/kg/hr.

Potassium

Potassium should be added after the 1st hr of treatment by giving 1 mEq/kg of potassium phosphate if available.

If this is not available then give KCl as follows (after checking urine output):

Serum K+ 3.5-5 give 20 mmole/L.

Serum K+ < 3 give 40 mmole/L and do an ECG.

If the patient is hyperkalemic potassium should not be given and they should be followed up.

Antibiotics

Give ceftriaxone or amoxiclave to cover underlying infections.

55

Improvement

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

No improvement

1. Stop IV fluid and start oral feeding.

2. Stop IV insulin and change to sliding scale.

Blood sugar (mg/dL) Unit/kg soluble insulin

< 100 0 100200 0.1 u/kg 200300 0.2 u/kg 300400 0.3 u/kg 400500 0.4 u/kg

> 500 0.5 u/kg

Measure blood sugar every 6 hr then given insulin accordingly. Continue on IV insulin untill hr after subcutaneous insulin has been restarted.

1. Exclude hypoglycemia.

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

Treat ICP:

1. Elevate head

2. Mannitol 0.51 g/kg/hr

3. Intubate & hyperventilate

4. NaHCO3 is indicated only if severe acidosis (pH 6.95)

5. If hyperkalemia (serum K+ 8 mEq/dL) give 1-2 mmole/kg/1-2 hr

56

Febrile seizures

Febrile seizures are seizures that occur between the age of 6-60 mo with a temperature of 38 C or higher, that are not the result of central nervous system infection or any metabolic imbalance, and that occur in the absence of a history of prior afebrile seizures.

A simple febrile seizure is a primary generalized, usually tonic-clonic attack associated with fever, lasting for a maximum of 15 min, and not recurring within a 24-hr period.

A complex febrile seizure is >15 min, focal, and/or recurs within 24 hr.

Febrile status epilepticus is a febrile seizure lasting >30 min.

Risk factors for recurrence

Major

1. Age

57

Management

1. Positioning: left lateral

2. Resuscitation

3. Stop seizure

1. History

2. Vital signs: HR, SpO2, RR, temperature, BP

3. Physical examination: consciousness, GCS, irritability, bulging fontanelle, signs of meningeal irritation (neck stiffness, Kernig sign, Brudzinski sign)

Investigations:

1. RBS, serum electrolytes (Na+, K+, Ca2+, Mg2+)

2. Lumbar puncture: indications are age < 1 yr atypical febrile seizure not regaining consciousness within 30 min post-ictal drowsiness

3. Others: infection screen (blood culture, urine culture, CXR), neuroimaging

58

G6PD deficiency

Diagnosis

History: presence of history of G6PD in the patient and/or in the family; history of precipitating factors.

Physical examination: pallor and jaundice.

Investigations: PCV (hematocrit), reticulocyte count, reticulocyte production index (RPI), Heinz bodies and fragmented RBCs on blood film.

Management

Hemoglobin (Hb) level < 7 g > 7 g

Give blood

Clinically unstable ( PR, BP, LOC)

Clinically stable

Give blood

Hb > 7 g and clinically stable

Hb < 7 g

Give blood until Hb > 7 g

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

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

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Heart failure

SI:

str

oke

ind

ex; C

I: c

ard

iac

ind

ex; S

VR

I: s

yste

mic

vas

cula

r re

sist

ance

ind

ex; T

FI:

th

orac

ic fl

uid

ind

ex.

60

Hypoglycemia

Hypoglycemia

(RBS < 45 mg/dL)

Unconscious (drowsy)

1. Insert IV cannula

2. Place a urine bag to collect next urine passed

3. Send blood for lab measurement of glucose level for confirmation

4. Give an IV bolus of 5-10 mL/kg of 10% dextrose

5. Start a continuous IV infusion of 10% dextrose/0.45% saline at a rate of 2.5-5 mL/kg/hr (6 mg/kg/min glucose)

6. Recheck RBS at 5 min intervals until RBS is stable > 54 mg/dL.

Conscious

< 1 yr milk feeding

> 1 yr quick-acting carbohydrate such as pure fruit juice

RBS > 45 mg/dL

1. Continue on maintenance fluid.

2. Gradually re-introduce feeds.

RBS < 45 mg/dL

1. Check if the cannula is patent.

2. Give another bolus of 5 mL/kg of 10% dextrose.

3. Increase the rate of the fluid 10% dextrose/0.18% saline to 6 mL/kg/hr (10-12 mL/kg/min glucose).

4. If you suspect adrenal insufficiency send blood for measurement of serum electrolytes (Na+ and K+) and give hydrocortisone 4 mg/kg IV (max. 100 mg)

5. In chronic, severe hypoglycemia you can give diazoxide.

61

NG tube insertion

Indications

1. Feeding 2. Administering drugs 3. Aspiration of gastric secretions swallowed air in

gastrointestinal obstruction preparation before surgery under GA gastric fluid for analysis

Contraindications

1. Basal skull or severe facial fractures 2. Obstructed airway 3. Esophageal varices 4. Gastric bypass surgery

Complications

Minor

1. Nose bleeds 2. Sinusitis 3. Sore throat

Major

1. Erosion of the nose 2. Esophageal perforation 3. Pulmonary aspiration and lung collapse 4. Intracranial placement of the tube

62

Placement

Before an NG tube is inserted the appropriate length must be measured from the tip of the patient's nose backwards, looping around their ear and then down to roughly 5 cm below the xiphoid process.

The tube is then marked at this level to ensure that the tube will be inserted far enough into the patient's stomach.

The end of a plastic tube is lubricated (local anesthetic, such as 2% xylocain gel, may be used).

To ensure proper placement air is injected into the tube while holding a stethoscope on the epigastric area; if the air is heard in the stomach with a stethoscope then the tube is in the correct position.

63

Poisoning

Poisons can cause harm by a wide range of mechanisms and can cause a wide range of symptoms including unconsciousness, nausea, vomiting, burning pain in the mouth or throat, headache, blurred vision, seizures, difficulty breathing, respiratory arrest, and cardiac arrest.

Harmless substances

There is a list of substances that if ingested by the child cause no harm and only re-assurance of the family is needed.

Topical antibiotic

Topical antifungal

Bubble bath soap

Calamine lotion

Candles

Chalk

Children's toy cosmetics

Clay

Contraceptives pills

Topical corticosteroids

Crayons

Deodorants' underarm

Soap of hand and dish

Diaper rash cream

Glues

Zinc oxid

Grease

Hand lotion and cream

Ink (non permemanent)

Laxatives

Lipstick

Magazines

Makeup

Matches

Mineral oil

Play- Doh

Water color

Vaseline

Shampoo

Shaving creams

Starch

Sunscreen

64

Decontamination of the patient

Separate the victim and follow these steps accordingly:

Swallowed poison

1. Induce vomiting in conscious patient by Ipecac syrup if the substance is not a strong acid or alkali substance.

2. Activated charcoal 1 g/kg every 4 hr. 3. Gastric lavage. 4. Whole bowel irrigation used only in certain modified

release or enteric coated formulations, e.g. sever lithium poisoning.

Inhaled poison

Try to make the patient breathe fresh air and oxygen.

Eye contact

Flood the eye with saline or cold water from a running tap or a cup/jug. Continue to flush for 15 min, holding the eyelids open.

Skin contact

1. Remove contaminated clothing, taking care to avoid contact with the poison.

2. Flood skin with running cold water. 3. Wash gently with soap and water and rinse well.

Management of poisoning

Decontamination Resuscitation and

supportive care Specific

management

65

Resuscitation and supportive care

Respiration

An obstructed airway requires immediate attention, from simple chin lift or jaw thrust, oro- or nasopharyngeal tube to intubation and ventilation.

Blood pressure

Hypotension usually occurs with drugs of CNS depression and should be corrected with head tilting down of the bed and IVF.

Hypertension is often transient and associated with sympathomimetic drugs as amphetamine, phencyclidine and cocaine.

Heart

These are mostly in cardiac conduction defects and arrhythmias, e.g. tricyclic antidepressants, antipsychotics and some antihistamines.

Body temperature

Hypothermia occurs mostly in patients unconscious for hours and in overdose of barbiturates or phenothiazines. The most important measure is to wrap the patient.

Hyperthermia in poisoning with CNS stimulants is managed by removing clothes, using fan, and sponging with tepid water.

Convulsion

If it is long-lasting or very frequent use lorazepam 100 mcg/kg (max. 4 mg) or diazepam 300-400 mcg/kg (max. 20 mg) slow IV or rectally or oral gel.

66

Specific management (antidotes)

Paracetamol

Acetylcysteine 150 mg/kg in 3 mL/kg of 5% GW over 15 min then 50 mg/kg in 7 mL/kg of 5% GW over 4 hr then 100 mg/kg in 14 mL/kg 5% GW over 16 hr. This should be given within 8 to 12 hr if toxic dose is ingested (75 mg/kg/24 hr).

Opioids

Naloxone 10 mg; repeat the dose in 3 min to a max. 100 mcg/kg. This should be given if there is bradycardia or coma.

Tricyclic antidepressants

Intravenous infusion of sodium bicarbonate should be given if there is prolonged QRS duration and arrhythmia.

Beta-blockers

IV atropine 40 mcg/kg (max. 3 mg) if bradycardia develops.

Iron salts

GI toxicity occurs with 20 mg/kg of elemental iron. Moderate intoxication occurs with 40 mg/kg. Severe and lethal toxicity occurs with 60 mg/kg.

% of elemental iron in iron salts is: fumarate 33%, sulfate 20%, and gluconate 12%.

Treatment is with desferrioxamine 15 mg/kg/hour.

Additional antidotes

Toxin or poison Antidotes

Black widow spider Latrodectus antivenin

67

Botulinum toxin Botulin antitoxin

Calcium channel antagonists Glucagon and/or insulin and glucose

Dystonic reactions Diphenhydramine and/or benztropine

Fluoride, calcium channel blockers

Calcium salts

Heparin Protamine

Methotrexate, trimethoprim, pyrimethamine

Folinic acid

Rattlesnake envenomation Crotab-specific Fab antibodies

Sodium channel blockade (tricyclic antidepressants, type 1 antiarrhythmics

Sodium bicarbonate

Recognizable syndromes

Poison syndrome

Possible toxins Signs: Vitals | Mental status | Pupils |

Skin | Bowel sounds | Other

Sympathomimetic

BP, HR, hyperthermia

Agitated, psychosis, delirium

Dilated pupils

Diaphoretic

Normal to increased bowel sounds

Amphetamines, cocaine, ecstasy, pseudoephedrine, caffeine, theophylline

68

Anticholinergic

BP, HR, hyperthermia

Agitation, delirium, mumbling speech

Dilated pupils

Dry skin

Decreased bowel sounds

Antihistamines, tricyclic antidepressants, atropine, jimson weed, phenothiazines

Cholinergic

HR (though may show HR), BP and temperature typically normal

Confusion, coma, fasciculations

Small pupils

Diaphoretic

Hyperactive bowel sounds

Diarrhea, urination, bronchorrhea, bronchospasm, emesis, lacrimation, salivation

Organophosphates, nerve gases, Alzheimer medications

Opioids

Vitals: Respiratory depression (hallmark of toxicity), HR, BP, hypothermia

Depression, coma

Pinpoint pupils

Normal skin

Normal to decreased bowel sounds

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

Sedative-Hypnotics Barbiturates, benzodiazepines,

69

Respiratory depression, HR normal to decreased, BP normal to decreased, temperature normal to decreased

Somnolence, coma

Small pupils

Normal skin

Normal bowel sounds

ethanol

Serotonin syndrome

Hyperthermia, HR, BP or BP (autonomic instability)

Agitation, confusion, coma

Dilated pupils

Diaphoretic

Increased bowel sounds

Neuromuscular hyperexcitability: clonus, hyperreflexia (lower extremities > upper extremities)

SSRIs, lithium, MAOIs, linezolid, tramadol, meperidine

Salicylates

RR, hyperpnea, HR, hyperthermia

Agitation, confusion, coma

Normal pupils

Diaphoretic

Normal bowel sounds

Nausea, vomiting, tinnitus, ABG with primary respiratory alkalosis and primary metabolic acidosis

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

70

Withdrawal

HR, RR, hyperthermia

Lethargy, confusion, delirium

Dilated pupils

Diaphoretic

Increased bowel sounds

Withdrawal from opioids, sedative-hypnotics, ethanol

71

Scorpion envenoming

Grade 1

Diagnosis

Local pain, paresthesia, erythema, and blisters.

Management

Symptomatic treatment:

1. Ice bag to reduce the local pain 2. Local anesthetic agents 3. Paracetamol 10-15 mg/kg/dose every 6 hr 4. Tetanus toxoid vaccine

Grade 2

Diagnosis

These include symptoms of grade 1 in addition to:

1. Sympathetic overstimulation: tachycardia, peripheral vasoconstriction (cool limbs), hypertention

2. Metabolic: hyperthermia, hyperglycemia, acidosis

3. Neuromuscular: confusion, dystonia, fasciculation, ptosis, vision disorders, aberrant eye movements, mydriasis, agitation, tremor

4. Cholinergic syndrome: hypersecretions like salivation, sweating, vomiting, diarrhea, bronchial hypersecretion, priapism

72

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

Investigations: CBC, Blood glucose, serum electrolytes, blood urea.

Management

Same treatment as for grade 1 in addition to:

1. Oral hydration: IV fluid may be needed if dehydrated.

2. Benzodiazepines: diazepam 0.3 mg/kg IV slowly or rectally.

3. Antivenom: give inside 250 mL saline in hr with close observation.

4. Prazosin: 30 g/kg/dose orally. The same dose should be repeated after 3 hr according to clinical response and later every 6 hr till extremities are warm and dry and peripheral veins are visible easily.

Blood pressure, pulse rate and respiration must be monitored every 30 min for 3 hr, every hr for next 6 hr and later every 4 hr till improvement.

5. Glucose insulin regimen: can be given if there are ECG changes. The dose of glucose is 0.1 g/kg/hour (1 cc/kg/hr of 10% GW) and insulin is administered at a dose of 0.3 unit/g of glucose (0.3 unit/10 cc of 10% GW) with measuring of blood sugar.

This should be given continuously till ECG changes disappear. Potassium should be added if there is no hyperkalemia.

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

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

Grade 3

Diagnosis

Life-threatening envenoming consisting of findings of grade 2 in addition to multiorgan failure. Extra findings are:

1. Decrease O2 saturation 2. Diaphoresis 3. Convulsions, paralysis 4. GCS < 6 (in absence of sedation) 5. Heart failure, cardiogenic shock, pulmonary edema

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

Management

Same treatment as those of grades 1 and 2 in addition to:

1. Admission to ICU. 2. Dobutamine: 5-15 mcg/kg/min if the patient has pulmonary

edema or heart failure (with or without hypertension).

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Sepsis

Sepsis: is a systemic inflammatory response resulting from a suspected or proven infection.

Severe sepsis: sepsis + organ dysfunction.

Septic shock: severe sepsis + hypoperfusion or hypotension for more than one hour.

Risk groups for sepsis

1. Infants. 2. Malnourished children. 3. Immunosuppressive drug regimen, e.g. steroid,

chemotherapy. 4. Children with chronic use of antibiotics. 5. Hospital patient who has urinary catheter or endotracheal

tube.

Management

Diagnosis of sepsis

( HR, RR, BP, mental status changes)

1. Establish ABC (put I.V line, if unable then intraosseus line)

2. Give O2

3. Check HR, RR, BP, temperature, SpO2, capillary refill.

Send for

investigations

1. Blood culture 2. Urine culture 3. CSF 4. CBC, ESR, CRP 5. Blood sugar

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

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

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

Change ampicillin to vancomycin 30-60 mg/kg/day if there is a catheter or indwelling medical device.

Add amphotericin B (dose according to drug brand) for fungal infection in immunocompromised patients.

No improvement Improvement

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

Continue O2

Maintenance I.V fluid

Change antibiotics according to C/S

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Septic shock in ICU

Check: level of consciousness, HR, BP, RR, SpO2, temperature, capillary refill, and urine output.

Investigations:

1. Blood sugar, blood urea, serum electrolytes, blood gas analysis

2. CBC, ESR, CRP 3. Blood culture, urine culture, CSF 4. Liver function tests, PT, PTT

1. IV fluid (N/S) 20 mL/kg/10-15 min; can repeat 3 times or can give 60 mL/kg/1 hour.

2. Insert a foley catheter.

3. Recheck the goals (mentioned below).

No response to fluids (fluid-resistant)

Response to fluids

BP, HR and RR return to normal, capillary refill < 2 seconds.

Give dopamine 10-20 mcg/kg/min.

Response to dopamine observe

Dopamine-resistant shock

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Give adrenaline 1 mcg/kg/min.

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

Response to adrenaline observe

If there is no response for 60 min this is adrenaline-resistant shock.

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

Give fresh frozen plasma or blood if you have active bleeding.

Monitor BP, HR, RR, SpO2, and urine output.

Resuscitation goals

1. Normal mental status 2. Normal blood pressure 3. Normal heart rate with no difference

between central and peripheral pulses 4. Warm extremities 5. Urine output > 1 ml/kg/hr 6. Capillary refill < 2 seconds

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Status epilepticus

Status epilepticus is defined as a seizure that lasts for >30 min or recurrent seizures without full recovery in between seizures for >30 min.

Convulsion for more than 5 minutes should be treated as status epilepticus.

Initial management

Manage ABCs

1. Stabilization of airway 2. Maintenance of adequate ventilation 3. Circulatory support 4. RBS: give dextrose if hypoglycemic

IV line establishment

1. RBS, CBC, serum electrolytes (if abnormal treat accordingly)

2. IV diazepam 0.3 mg/kg over 2 min (max. 5 mg in infants and 10 mg in older chldren); can be repeated every 5 min for a max. of 3 times

1. Rectal diazepam 0.5 mg/kg (max. 10 mg)

2. Insert IO (intra-osseous) line if seizure is not stopped

Yes No (after 3 attempts

or 30 seconds)

Is the child on phenytoin?

Yes No

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IV phenobarbital 20 mg/kg over 20 min.

OR

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

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

Has the seizure stopped? Yes No

Admit and look for:

Evidence of trauma, papilloedema

Bulging fontanel manifestation of sepsis meningitis

Retinal hemorrhage subdural hematoma

Kussmal breathing dehydration metabolic disorder or drug intoxication

Irregular respiration brainstem dysfunction

1. Rapid sequence intubation

2. I.V / I.O midazolam 0.1 mg/kg loading dose (max. 8 mg) over 2-3 min.

Then start infusion of 120 g/kg/hr, and increase by 120 g/kg/hr every 5 min (max. 1.5mg/kg/hr).

High dose phenobarbital Thiopental infusion Propofol

Continue supportive care

Admit to ICU/call anesthetist

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Transfusion

Indications for transfusion

Packed RBCs

Red blood cells (RBCs) are transfused to increase the oxygen-carrying capacity of blood and, in turn, to maintain satisfactory tissue oxygenation.

1. Premature infant

a. Stable and growing with Hb < 7 g/dL b. IRDS without oxygen requirement and Hb < 10 g/dL c. IRDS with oxygen requirement and Hb < 12 g/dL d. Mildly symptomatic anemia (e.g. apnea, tachycardia, poor

weight gain) with Hb < 10 g/dL e. Severely symptomatic anemia (e.g. worsening apnea,

hypotension, acidosis, heart disease) with Hb < 12 g/dL

2. Term infant < 4 mo of age

a. Clinical manifestations of anemia (e.g. apnea, tachycardia, poor weight gain) with Hb < 7 g/dL

b. Perioperative anemia with Hb < 10 g/dL c. Hypoxia or on ECMO or ECLS with Hb < 12 g/dL d. Cyanotic heart disease with Hb < 13 g/dL e. Acute blood loss > 10% of blood volume not responsive to

other forms of therapy f. Clinical shock or severe decrease in BP with Hb < 10 g/dL

3. Infant > 4 mo of age

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a. Acute blood loss > 15% of blood volume, or anticipation thereof, or hypovolemia not responsive to other forms of therapy

b. Postoperatively with signs of anemia (e.g. apnea) and Hb < 10 g/dL

c. Severe cardiopulmonary disease with Hb < 12 g/dL d. Patients receiving chemotherapy or irradiation, or

patients with chronic anemia not responsive to medical therapy with Hb < 7 g/dL (symptomatic patients may be transfused at a higher hemoglobin level)

e. Complications of sickle cell disease (e.g. CVA or acute chest syndrome) or for preoperative preparation of such patients, or chronic transfusion regimen for thalassemia or other red cell disorders

f. Circuit prime for plasma exchange or stem cell collection g. Clinical shock or severe decrease in BP with Hb < 10 g/dL

Platelets

A. Prophylaxis

1. Premature infants Stable premature infant: < 30,000/uL Sick premature infant:

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B. Treatment

1. Patients with active bleeding and platelet count < 50,000/uL 2. Diffuse microvascular bleeding in association with

cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO) with platelet count < 100,000/uL or laboratory value not available

3. Bleeding in a patient with a qualitative platelet defect regardless of platelet count

Granulocytes

1. Bacterial sepsis in an infant < 2 wk of age with neutrophil count < 3 x 109/L

2. Bacterial sepsis or disseminated fungal infection that is unresponsive to antibiotics in a patient > 2 wk of age with neutrophil count < 0.5 x 109/L and whose neutrophil count is expected to recover.

3. Infection that is unresponsive to antibiotics and the presence of a qualitative neutrophil defect regardless of neutrophil count.

Fresh frozen plasma

1. INR > 1.5-2 times the mean normal value in a nonbleeding patient scheduled for surgery or invasive procedure

2. Diffuse microvascular bleeding in a patient with a PT or PTT > 1.5 times the mean normal value or values not yet available

3. Warfarin overdose with major bleeding or impending surgery 4. Patients with thrombotic thrombocytopenic purpura (TTP)

undergoing transfusion or plasma exchange

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5. Protein C, protein S, anti-thrombin III deficiencies, or other single-factor deficiency where no product is available and patient is bleeding

6. Bleeding secondary to vitamin K deficiency

Cryoprecipitate

1. Quantitative fibrinogen disorder with fibrinogen < 100 mg/dL and scheduled for invasive procedure

2. Qualitative fibrinogen disorder with diffuse bleeding or scheduled for invasive procedure

3. von Willebrand disease or Hemophilia A (factor VIII deficiency) with active bleeding or invasive procedure planned, unresponsive to DDAVP and/or factor concentrates

4. Fibrin glue production

Indications for transfusion

Packed RBCs

1. Hb < 70 g/L (although lower thresholds may be acceptable in patients without symptoms and where specific therapy, e.g. iron, is available)

Transfusion may be indicated at higher thresholds for specific situations:

2. Hb < 70-100 g/L during surgery associated with major blood loss or if evidence of impaired oxygen transport

3. Hb < 80 g/L in patients on a chronic transfusion regimen or during marrow suppressive therapy (for symptom control and appropriate growth)

4. Hb < 100 g/L only for very select populations (eg. neonates)

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Platelets

1. Bone marrow failure Platelets < 10 x 109/L if no other risk factors for bleeding Platelets < 20 x 109/L if risk factors present (fever, antibiotics, haemostatic failure, risk of intracranial haemorrhage)

2. Surgery/invasive procedure Platelets < 50 x 109/L (however, higher counts may be needed in surgeries with high risk of bleeding, e.g. neurosurgery)

3. Platelet function defects Transfuse if there is bleeding or high risk of bleeding, regardless of actual platelet count

4. Bleeding/massive transfusion Maintain platelets > 50 x 109/L if thrombocytopaenia is likely contributing to bleeding Maintain platelets > 100 x 109/L in the presence of diffuse microvascular bleeding (DIC) or CNS trauma

Fresh frozen plasma

1. Warfarin effect, in the presence of life-threatening bleeding in addition to the use of vitamin K and vitamin K dependent clotting factor concentrates for bleeding with abnormal coagulation

2. Liver disease, if bleeding with abnormal coagulation 3. Acute DIC when there is bleeding and abnormal coagulation

following massive transfusion or cardiac bypass for bleeding in the presence of abnormal coagulation

Cryoprecipitate

Fibrinogen deficiency, in the setting of clinical bleeding, an invasive procedure, trauma or DIC.

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Pre-transfusion assessment

1. Determine the indication for transfusion.

2. Collect pre-transfusion sample (except in infants on ASBT protocol).

a. A sample for cross-matching must be collected in a 1.4 mL red EDTA tube (NOT bullet tubes). Patients known to have red cell antibodies or haemolytic anaemia will require a larger sample.

b. Correctly identify the patient during the collection of the pre-transfusion sample. Identification must include 3 unique identifiers (full name, DOB, and UR). This, together with completing the bedside check prior to blood administration are the most vital steps in preventing serious transfusion errors.

3. Request the appropriate blood component and special requirements:

a. Leukocyte depleted blood products should be given to: o Immuno-compromised patients (oncology, transplant

recipients, ICU patients, and other congenital and acquired immune deficiencies)

o Patients requiring chronic transfusions o Infants under 12 mo o Intrauterine or exchange transfusions b. Irradiated blood products should be given to: all immuno-

compromised patients, including all oncology patients, cardiac neonates and all patients in ICU, to prevent graft-versus host disease.

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c. CMV negative products: leucocyte depleted blood products, are considered an acceptable alternative to CMV seronegative products at RCH

Transfusion volumes and rates

Packed RBCs

o Formula: packed cells (mL) = weight (kg) x Hb rise required (g/L) x 0.4 Example: 10-kg child requiring Hb to rise from 60 to 110 g/L: 10 x 50 x 0.4 = 200 mL

o Pack sizes: 250-300 mL/pack; 50-60 mL/Pedipack o Rate: transfusion will be started at a slower rate (e.g. half the

rate) for the first 15 min; if no adverse effects occur increase the transfusion to a 2-4 hourly rate depending on the patient's condition and fluid balance

Fresh frozen plasma

o Formula: 10-20 mL/kg o Pack sizes: 300 mL/pack; 50 mL/pack (for neonatal use) o Rate: 3 mL/kg/hr over 2-3 hours (occasionally platelets are

given over 30 minutes, but this may contribute to an increased risk of some reactions (fever/chills) and fluid overload)

Cryoprecipitate

o Formula: 5-10 mL/kg o Pack sizes: 30-40 mL/pack o Rate: start at no more than 5 mL/min

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Management of transfusion

The key steps include:

1. A formal checking process prior to commencement of transfusion

2. The use of correct equipment (filters, pump, consideration of blood warmer)

3. Correct transfusion documentation including patient observations, start and finish times

Monitoring of the patient:

Observations should be undertaken for every unit transfused. Minimum monitoring of the patient should include:

o Regular visual observation throughout the transfusion episode.

o Pre-transfusion pulse (P), blood pressure (BP), temperature (T) and respiratory rate (RR). These should be taken and recorded no more than 60 minutes before starting the transfusion.

o P, BP and T should be taken 15 minutes after the start of each component transfusion. If these measurements have changed from the baseline values, then RR should also be taken.

More frequent observations may be required in e.g. rapid transfusion, or patients who are unable to complain of symptoms that would raise suspicion of a developing transfusion reaction.

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o If the patient shows signs or symptoms of a possible transfusion reaction, P, BP, T and RR should be monitored and recorded and appropriate action taken.

o Post-transfusion P, BP and T should be taken and recorded not more than 60 minutes after the end of the component transfusion.

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

Complications during transfusion

o The most common immediate adverse reactions to transfusion are fever, chills and urticaria.

o The most potentially significant reactions include acute haemolytic transfusion reactions, bacterial contamination of blood products and transfusion related acute lung injury.

o During the early stages of a reaction it may be difficult to ascertain the cause.

o All suspected transfusion reactions must be reported to the issuing blood bank immediately. The on-call haematologist will contact the clinical area to provide advice regarding investigation and ongoing transfusion support.

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Adverse effects of transfusion

The most clinically important adverse effects of transfusion in medical patients are infectious or immunological phenomena.

The most significant infectious risks are addressed during the donor screening process, and most blood centers employ bacteriological surveillance measures on certain blood products.

Transfusion-transmitted

infection

Residual risk per transfused

component

HIV 1 in 1,467,000

Hepatitis C 1 in 1,149,000

Hepatitis B 1 in 282,000

West Nile Virus Uncommon

Cytomegalovirus 50-85% of donors are carriers.

Leukocyte reduction is protective

. Bacterial Infection 1 in 2-3,000 (mostly platelets)

Parasitic Diseases Babesiosis, Chagas, Malaria

Relatively uncommon

After transfusion

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