Slemani Pediatric Teaching Hospital

Guidelines
2014-2015

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

Definition

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

symptoms.
2. Uncorrectable coagulopathy (6-8 hr after administration of
one dose of parentral vitamin K) with INR >1.5 in a patient
with hepatic encephalopathy, or INR > 2 in a patient without
encephalopathy.
3. No evidence of chronic liver disease either at presentation or
in the past.

Staging

1. Grade I and II: are indistinguishable, with clinical features of

inconsolable crying, inattension to task, with normal or
exaggerated deep tendon reflexes.
2. Grade III: somnolence, stupor, combativeness and
hyperreflexia.
3. Grade IV: comatose, arousable with painful stimuli (IVa) or no
response (IVb) with absent reflexes and decerebration or
decortication.

General work-up

1. Blood urea, serum creatinine, serum electrolytes

2. ALT, AST, GGT, alkaline phosphatase, total and conjugated
bilirubin, PT, PTT, INR, blood group
3. Blood and urine culture, CXR

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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/mm .3

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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 <100 mg/dL.
3. Keep platelet count ≈ 20,000/mm3.

C. Give at least three days of vitamin K (5-10 mg IV slowly with a

rate no more than 1 mg/min).

Sepsis

Empirical administration of antibiotics is recommended where

infection or the likelihood of impending sepsis is high, e.g.
surveillance cultures reveal significant isolates, progression of
advanced stage III/IV, refractory hypotension, renal failure,
presence of systemic inflammatory response syndrome
components (temperature > 38 °C or < 36 °C, white blood count >
12,000 or < 4000/mm3, tachycardia).

Broad-spectrum coverage with a third-generation cephalosporin,

vancomycin/teicoplanin, and fluconazole are recommended
wherever indicated.

Renal insufficiency

1. 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 (non–food-
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

Frequency of
Drug Dosage
administration
0.01 mg/kg up to
0.03 mg/kg
Epinephrine OR by age
(1:1000) IM (1 Immediately, then > 6 yr: 150 mcg =
mg/mL) every 5–15 min as 0.15 mL IM
Each amp = 1 mL = 1 required 6-12 yr: 300 mcg =
mg 0.3 mL IM
12-18 yr: 500 mcg =
0.5 mL IM
H1 antagonists
Cetirizine PO (> 2 0.25 mg/kg up to 10
Single daily dose
yr) mg
2-5 yr: 5 mg
Loratidine Single daily dose
> 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
Every 4–6 hr as
1.25 mg/kg up to 50
Diphenhydramine required for
mg
IM/IV cutaneous
manifestations
< 6 mo: 250 mcg/kg
(max. 2.5 mg)
Chlorpheniramine Repeat up to 4
6 mo-6 yr: 2.5 mg
IM/IV times/24 hr
6 yr-12 yr: 5 mg
12 yr-18 yr: 10 mg
H2 antagonists
Every 8 hr as
required for
Ranitidine PO/IV 1 mg/kg up to 50 mg
cutaneous
manifestations
Every 12 hr or as 4 mg/kg up to 200
Cimetidine
required mg
Corticosteroids
Every 6 hr as
Prednisone PO 1 mg/kg up to 75 mg
required
Methylprednisolone Every 6 hr as 1-2 mg/kg up to 125
IV required mg
Every 20 min or continuously for
Salbutamol respiratory symptoms (wheezing or
shortness of breath)
Nebulized
Every 20 min to 1 hr for symptoms of
epinephrine
upper airway obstruction (stridor)
(1:1000)

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Post-emergency management
Cetirizine or 5-10 mg once daily for
H1 antagonist
Lortin 3 days
Oral 1 mg/kg up to 75 mg
Corticosteroid
prednisolone 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

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Heart blocks

QRS Width

Narrow QRS Wide QRS

P/QRS ratio P/QRS ratio

> 1:1 1:1 < 1:1 VT (< 1:1)

Regular ( Atrial QRS-P JET VT(1:1)

Flutter) interval SVT + BBB
Antifromic AVRT
Variable (EAT) Very long
(PJRT/EAT)
Chaotic
(MAT/Fib) short follows QRSP wave
(orthodromic AVRT)

not visible (AVNRT)

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 Tachyarrhythmia

Narrow QRS Wide QRS

Stable Unstable stable Unstable

vagal
manoeuvers amiodarone synchronized
synchronized lignocaine in cardioversion
adenosine
cardioversion ventricular or
propranolol defibrillation
tachycardia
amiodarone

Management

Hemodynamically stable

1. Vagal manoeuvers:

a. Icepack/iced water for infants; apply to face for a

maximum of 30 seconds.

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

pinched straw).

2. IV adenosine: 0.1 mg/kg (max. 6 mg) rapid push; increase by

0.1 mg/kg every 2 min until tachycardia terminates or up to a
maximum of 0.5 mg/kg (max. 18 mg).

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

min for 3 times.

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

Haemodynamically unstable

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

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

Pitfalls in management

o 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 <91% on room air and PEF <50%

Initial treatment for moderate and severe asthma

1. O2: to maintain SpO2 above 92%

2. Salbutamol nebulizer: 3 doses at 20-minute intervals
a. < 20 kg → 0.5 mL + 3 mL NS
b. > 20 kg → 1 mL + 3 mL NS
3. Ipratropium bromide nebulizer:
a. < 1 yr → 0.5 mL
b. > 1 yr → 1 mL
4. Steroid:
a. Methylprednisolone initial 2 mg/kg/dose IV, followed
by 1 mg/kg/dose IV 6-hourly
b. Hydrocortisone vial initial 10 mg/kg/dose IV, followed
by 1 mg/kg/dose 4 times daily
c. Prednisolone 1-2 mg/kg/day orally

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 After initial treatment

No improvement Improvement

1. Reassess the disease Salbutamol nebulizer

hourly for 2-4 hr
2. Give steroid and
follow these steps (after OR
each step if there is no
improvement go to the Oral salbutamol +
next step). short course steroid

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

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

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

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Bronchial foreign body aspiration

Algorithm of management

Introduction

Foreign body aspiration is a common pediatric problem and a

leading cause of accidental death in children under 5 years of age.
Children between the ages 1-4 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 child’s
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 patient’s 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 Consider alternative
diagnoses:
1. Inhaled foreign body
Diagnosis of croup 2. Congenital anomalies
3. Epiglottitis/tracheitis

Is life-threatening airway 1. 100% O2

obstruction present? 2. Nebulized adrenaline
1. Cyanosis Yes
3. Intubation (by
2. ↓ level of consciousness experienced personnel)
4. Systemic corticosteroid
No

Mild croup Moderate croup Severe croup

Barking cough Persisting stridor Persisting/soft
at rest stridor at rest
Nil or
intermittent Some recession Marked
stridor recession
May have
No cyanosis cyanosis Apathetic or
restless, cyanosis

1. Do not agitate
1. Explanation to the child
1.
parents Dexamethasone 2. O2, nebulized
2. No specific 0.6 mg/kg adrenaline
treatment 2. Observe in > 4 4. Steroid
3. Discharge hr
5. Observe in > 4
hr

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 Improvement

Yes Partial No

Discharge when 1. Inform

1. Admit/observe consultant
there is no more
stridor. 2. Repeat steroid 2. Nebulized
in 12 hr adrenaline (same
3. Explanation to as previous dose)
parents 3. Steroid (same
4. Written follow as previous dose)
up 4. Consider
intubation

Key points of the differential diagnoses

Infectious croup: is a common viral infection. It starts with a viral

prodrome of rhinorrhea, pharyngitis, low grade fever, and barking
cough. Stridor appears 1-2 days later.

Spasmodic croup: is an aviral condition; it may be allergic or

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

Tracheitis: is characterized by brassy cough, high fever, and

toxicity with respiratory distress.

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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

Acts within 1
Systemic Dexamethasone
Moderate or hr
corticostero 0.6 mg/kg, single
severe Repeat in 12-
id* dose, IV/IM/PO
24 hr
Acts within
Adrenaline
minutes
1:1000, 1 mg/1
Nebulized Moderate or May need
mL, (0.5-1
adrenaline severe repeat doses
mL/dose in 3 mL
after 30 min if
of NS) nebulized
no response

33
 Severe (SpO2
Mask with
< 90%)
minimum
O2 Very severe
amount of 6
with central
L/min
cyanosis

34
Dehydration

Signs and symptoms of severe dehydration

Body weight loss >10%

Drowsy, limp, cold, sweaty, cyanotic
General appearance
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
* These are the most reliable and helpful signs.

Management

Total IV fluid requirement in severe dehydration

Treat shock Ongoing losses

Maintenance Fever
Fluid deficit (mL) Dehydration
= % of (see table Diarrhea & vomiting
dehydration x 10 below) Pooling of fluid in
x weight in kg the gut
Capillary leak

35
 Table. Maintenance IV fluid and electrolyte requirement

Fluid Sodium Potassium

Body weight mL/kg/24 mmol/kg/24 mmol/kg/24
hr hr 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

shock (0-30 min)

20 mL/kg of 0.9% saline

Phase 1: Treat
Send for blood urea and serum electrolyte levels
repeat up to 3 times

Improvement* No improvement*
Rehydration
Phase 2:

no improvement after 2
hr and 3 boluses of NS

Lasix 1 mg/kg, 1 dose

no improvement
↔Na+ after 45 min
↓ Na+ ↑ Na+
135 - Repeat lasix 1 mg/kg
< 130 > 150
145
no improvement

Think of other causes: cardiac,

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

36
 0.45% saline / 2.5% 0.45% saline / 2.5%
dextrose over 24 hr dextrose over 48 hr

fluid volume = deficit + fluid volume = deficit +

maintenance - shock bolus maintenance - shock bolus

½ in 1st 8 hr then ½ in 16 ½ in 1st 18 hr then ½ in 30

hr. hr

Close monitoring of clinical condition, fluid balance, blood

urea, plasma creatinine and electrolytes

* 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

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

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

37
 If the patient is in shock give a shot of 20 mL/kg Ringer
lactate or 0.9% normal saline within 30 min.
Reassess after first infusion; if no improvement repeat 20
mL/kg over 30 min.
Reassess after second infusion; if no improvement repeat 20
mL/kg over 30 min.
Reassess after third infusion; if no improvement transfuse
fresh whole blood 20 mL/kg over 1 hr (use packed red cell if
in cardiac failure).
Assess the vital signs every 5-10 min.
Treat hypoglycemia and hypocalcaemia if present.

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

mg/kg/dose or you can give mannitol 0.5 gm/kg (2.5 ml of
20% mannitol/kg) over 1 hr and wait 30 min while running
maintenance fluids (without potassium).

If there is no improvement treat as acute renal failure or think

about other causes (cardiac, anaphylactic, or septic shock); do
hemodynamic monitoring and give inotropic support
(dopamine )

If there is improvement, UOP is positive and vital signs

become better calculate 24 hr fluid needed: maintenance +
deficit - fluid used for initial infusions (shock boluses).
Administer this total fluid over 24 hr using ½ GS + 20 mEq/L
KCl (according to serum potassium).
Replace ongoing losses as they occur.

38
 If plasma Na+ ↓ (< 130) or If ↑ plasma Na+ (> 150)
normal then give then give

½ of total fluid in first 8 hr ½ of total fluid in first 18

then ½ in second 16 hr. hr then ½ in second 30 hr.

Treatment of severe dehydration in children with

malnutrition
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 ½ GS within 1 hr.
Reassess after first infusion; if no improvement repeat 15
mL/kg over 1 hr.
Assess the vital signs every 5-10 min.
Reassess after second infusion; if there is no improvement
consider the child as having septic shock.
Give maintenance IV fluid 4 mL/kg/hour while waiting for
blood.
When blood is available, transfuse fresh whole blood at 10
mL/kg over 3 hr (use packed red cell if in cardiac failure).
Treat hypoglycemia, hypothermia, hypocalcaemia and
hypomagnesaemia if present.

39
 If there is no urine output give a dose of frusemide 1-2
mg/kg/dose or you can give mannitol 0.5 gm/kg (2.5 ml of
20% mannitol/kg) over 1 hr while running maintenance
fluids.

If no improvement treat as acute renal failure or think about

other causes (cardiac, anaphylactic, or septic shock); do
hemodynamic monitoring and give inotropic support
(dopamine )

If there is improvement, UOP is positive and vital signs

become better calculate 24 hr fluid needed: maintenance +
deficit - fluid used for initial infusions (shock boluses).
Administer this total fluid over 24 hr using ½ GS + 20 mEq/L
KCl.
Replace ongoing losses as they occur.
Start feeding by mouth or by NG tube.

If plasma Na+ ↓ (< 130) If ↑ plasma Na+ (> 150)

or normal then give then give

½ of total fluid in first 8 ½ of total fluid in first

hr then ½ in second 16 18 hr then ½ in second
hr 30 hr

If the child deteriorates during the IV rehydration (breathing

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

40
WHO treatment of severe dehydration in infants

Insert an IV line (If needed 2

lines) within 5 minutes (3-4
trials); if this fails insert an IO
line.
Draw blood for emergency lab
investigations.
Start IV fluid immediately.
If the patient can drink give ORS
by mouth while the drip is set up.
Give 30 mL/kg initially ringer
Can you give IV Yes lactate or 0.9% NS in 1 hr then
fluids immediately? 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.
No

After 3 hr re-evaluate the patient

and choose the appropriate plan
to continue treatment.

Refer to hospital immediately for

IV treatment.
Is IV treatment
Yes
available nearby If the patient can drink, provide
(within 30 min)? the mother with ORS and show
her how to give sips of it during
the trip.
No

41
 Are you trained to
Start rehydration by NG tube or
use an NG tube for Yes
by mouth with ORS; give 20
rehydration?
mL/kg/hr.
No

Can the patient Yes Refer URGENTLY to hospital.

drink?
No

Refer URGENTLY to
hospital for IV
treatment.

Note:

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

42
Diabetes mellitus, preoperative preparation in

In children with diabetes mellitus (DM) presurgical assessment

should be done several days before surgery to allow for an
assessment of glycemic control, electrolyte status, and ketones (in
urine or blood).

If glycemic control is known to be poor and surgery is not urgent,

delay the procedure until glycemic control has improved. If
surgery cannot be delayed, consider admission to the hospital
before surgery for stabilization of glycemic control.

The blood glucose should be maintained in the range of 90–180

mg/dL during surgical procedures in children.

Preoperative preparation of children with DM

Type 1 DM or type 2 DM on Type 2 DM not on insulin

insulin

Major surgery Minor surgery

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

Discontinue metformin 24 h before major surgery (lasting at least

2 h) and on the day of surgery for minor surgery.

Discontinue sulfonylureas and thiazolidinediones on the day of

surgery.

Patients undergoing a major surgical procedure expected to last

at least 2 h should be started on an IV insulin infusion.

43
 Type 1 DM or type 2 DM on insulin

Must be admitted to the hospital if receiving GA.

In cases with documented good control, it should be possible to

admit early on the day of surgery for both minor and major
procedures. Otherwise, it is preferred to admit in the afternoon
before surgery to give time for correction of metabolic status
overnight.

Should be scheduled as the first case of the day.

Need insulin, even if fasting, to avoid ketoacidosis.

May initially receive an IV infusion without dextrose for minor

surgery or procedures (lasting for less than 2 h) if treated with
basal/bolus insulin regimen or continuous subcutaneous insulin
infusion (CSII).

Should initially receive an IV infusion with dextrose for major

surgery or procedures (lasting for at least 2 h) or if treated with
NPH insulin.

Require hourly capillary blood glucose monitoring to detect

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

Should coordinate the timing of preoperative food and fluid

restrictions with the anesthetist.

44
The usual recommendation is no solid food for at least 6 h before
surgery Clear fluids (and breast milk) may be allowed up to 4 h
before surgery

Major surgery

On the evening before surgery give the usual evening and/or

bedtime insulin(s) and bedtime snack.

Monitor blood glucose and urinary ketone concentration if blood

glucose is > 250–360 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 (90–180 mg/dL) by

adjusting the IV insulin dose or the rate of dextrose infusion
during surgery.

When oral intake is not possible, the IV dextrose infusion should

continue for as long as necessary.

Minor surgery

Require a brief general anesthetic.

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

procedure.

45
 Early morning procedures (for example, 8.00–9.00 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 5–10% infusion and frequent blood glucose monitoring

are recommended in all these situations.

Elective vs emergency surgery

The above approach applies to elective surgeries without further

precautions. The approach also applies in emergency in surgeries
with some further precautions.

Before emergency surgery in a child with DM, always check blood

glucose or urinary ketone concentration, serum electrolytes, and
blood gases if ketone or blood glucose levels are high.

Do not give fluid, food, or medication by mouth because in some

emergency situations, the stomach must be emptied by a
nasogastric tube. Always secure IV access and check weight
before anesthesia.

If ketoacidosis is present, follow an established treatment

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

Intraoperative care

Blood pressure should be carefully monitored. Monitor blood

glucose measurements at least hourly during and immediately
after GA. If necessary, begin dextrose infusion or increase

46
dextrose concentration of IV fluids from 5 to 10% to prevent
hypoglycemia.

Adjust dextrose infusion and insulin dose (by subcutaneous

injection of rapid-acting insulin for minor surgery) to maintain
blood glucose in the range (90–180 mg/dL).

For those receiving an IV insulin infusion, a single correction

bolus of IV insulin (either using the child’s usual correction factor
or 5–10% of the child’s 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 Ringer’s 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 child’s 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 child’s
usual diabetes treatment regimen. Give short- or rapid-acting
insulin (based on the child’s usual insulin:carbohydrate ratio and

47
 correction factor), if needed, to reduce hyperglycemia or to match
food intake.

Management according to different types of insulin regimens

Patients treated with once Patients treated with twice

daily basal/bolus insulin daily basal and rapid- or
regimens short-acting insulins

Morning operations Morning operations

Evening operations Evening operations

(if unavoidable) (if unavoidable)

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 20–30%.

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

hyperglycemia.

Commence IV fluids. Patients with a normal blood glucose may

initially utilize IV fluids without dextrose. With an appropriately

48
titrated basal rate and careful monitoring, this approach may be
more physiologic.

Afternoon operations (if unavoidable)

On the morning of the procedure, give the usual dose of 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 5–10%, as necessary, to

prevent hypoglycemia.

Afternoon operations (if unavoidable)

49
 On the morning of the procedure, give 50% of the usual dose of
intermediate-acting insulin (NPH) or the full usual morning dose
of long-acting insulin (detemir or glargine).

With premixed insulin, give only 50% of the equivalent dose of

the basal component (NPH).

The dose of short- or rapid-acting insulin will depend on whether

the child is permitted to eat breakfast.

Alternatively, give 30–40% of the usual morning insulin dose of

short- or rapid acting insulin (but no intermediate- or long-acting
insulin) and use an IV insulin infusion beginning at least 2 h
before surgery.

If the anesthetist allows the child to eat a light breakfast and to

consume clear liquids up to 4 h before the procedure, IV fluid
administration (and IV insulin infusion, if applicable) should
commence 2 h before surgery or no later than midday.

Infusion guide for surgical procedures

Maintenance fluid guide

1. Dextrose:

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

If blood glucose is high 250 mg/dL use half-normal saline (0.45%

NaCl) without dextrose and increase insulin supply but add 5%
dextrose when blood glucose falls below (250 mg/dL).

2. Sodium:

50
There is evidence that the risk of acute hyponatremia may be
increased when hypotonic maintenance solutions (i.e., <0.9%
NaCl) are used in hospitalized children. Many centers, therefore,
use saline 0.45–0.9% (77–154 mmol Na/L).

A compromise would be to give 0.45% saline with 5% dextrose,

carefully monitor electrolytes, and change to 0.9% saline if plasma
Na concentration is falling.

3. Potassium:

Monitor electrolytes. After surgery, add potassium chloride 20

mmol to each liter of intravenous fluid. Some centers add
potassium routinely only if infusion is required for more than 12
h.

Example of calculation of maintenance requirements:

Body weight (kg) Fluid requirement per 24 h

For each kg between 3–9 100 mL/kg
For each kg between 10–20 Add an additional 50 mL/kg
For each kg over 20 Add an additional 20 mL/kg

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

Insulin infusion

Add soluble (regular) insulin 50 units to 50 mL normal saline

(0.9% NaCl), making a solution of 1 unit insulin/mL; attach to
syringe pump and label clearly

Start infusion at 0.025 mL/kg/h (i.e. 0.025 U/kg/h) if blood

glucose is < ∼110–140 mg/dL, use 0.05 mL/kg/h if ∼140–220

51
 mg/dL, use 0.075 mL/kg/h between ∼220–270 mg/dL, and use
0.1 U/kg/h if > ∼270 mg/dL.

Aim to maintain blood glucose between 90–180 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 >10–15 min.

52
Diabetic ketoacidosis

DKA diagnostic criteria

Blood sugar > 300 mg/dL
Acidosis (serum HCO3 < 15 mEq/dL)

Complete initial evaluation

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

If the patient has disturbed level of consciousness or is in

coma establish basic life support:

1. Airway, breathing, circulation (put 2 cannulas, 1 for

insulin and 1 for fluid)
2. Urinary catheter
3. Give 20 mL/kg N/S in 1 hour

Intravenous fluid
Total amount = (85 mL/kg + maintenance)/24 hr
½ of this is given within 12 hr – bolus given in basic life

53
 support; the other ½ 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 ½ N/S if available till blood sugar is < 250
mg/dL then add 5% dextrose.

Insulin therapy
Give immediately with IV fluid by infusion per 1 hr
Blood sugar (mg/dL) Unit/kg of insulin
> 600 0.1
300-600 0.05

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

Potassium
Potassium should be added after the 1st hr of treatment by
giving 1 mEq/kg of potassium phosphate if available.
If this is not available then give KCl as follows (after checking
urine output):
Serum K+ 3.5-5 → give 20 mmole/L.
Serum K+ < 3 → give 40 mmole/L and do an ECG.
If the patient is hyperkalemic potassium should not be given
and they should be followed up.

Antibiotics
Give ceftriaxone or amoxiclave to cover underlying infections.

54
 Improvement
(no emesis, improved consciousness, can take orally,
acidosis corrected)

1. Stop IV fluid and start oral feeding.

2. Stop IV insulin and change to sliding scale.

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

< 100 0
100–200 0.1 u/kg
200–300 0.2 u/kg
300–400 0.3 u/kg
400–500 0.4 u/kg
> 500 0.5 u/kg
Measure blood sugar every 6 hr then given insulin
accordingly. Continue on IV insulin untill ½ hr after
subcutaneous insulin has been restarted.

No improvement Treat ↑ ICP:

1. Elevate head
1. Exclude hypoglycemia. 2. Mannitol 0.5–1 g/kg/hr
3. Intubate & hyperventilate
2. Are there signs of ↑ ICP
(e.g. apnea, bradycardia, 4. NaHCO3 is indicated only
if severe acidosis (pH 6.95)
seizure, papilledema,
deterioration, ↓ LOC)? 5. If hyperkalemia (serum
Consider cerebral edema K+ 8 mEq/dL) give 1-2
mmole/kg/1-2 hr
and send for a CT scan.

55
 Febrile seizures

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

A simple febrile seizure is a primary generalized, usually 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 <1 yr
2. Duration of fever <24 hr
3. Fever 38-39 °C

Minor

1. Family history of febrile seizures

2. Family history of epilepsy
3. Complex febrile seizure
4. Day care
5. Male gender
6. Low serum Na

56
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 ① age < 1 yr ②
atypical febrile seizure ③ not regaining
consciousness within 30 min ④ post-ictal
drowsiness
3. Others: infection screen (blood culture, urine culture,
CXR), neuroimaging

57
 G6PD deficiency

Diagnosis

History: presence of history of G6PD in the patient and/or in the

family; history of precipitating factors.

Physical examination: pallor and jaundice.

Investigations: ↓ PCV (hematocrit), ↑ reticulocyte count, ↑

reticulocyte production index (RPI), Heinz bodies and fragmented
RBCs on blood film.

Management

<7g Hemoglobin (Hb) level >7g

Give blood Clinically stable

Hb > 7 g and Clinically unstable

clinically stable (↑ PR, ↓ BP, ↓ LOC)

Hb < 7 g
Give blood

Give blood until

Hb > 7 g

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

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

58
 Heart failure

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

59
 Hypoglycemia

Hypoglycemia
(RBS < 45 mg/dL)

Unconscious (drowsy) Conscious

1. Insert IV cannula < 1 yr → milk feeding
2. Place a urine bag to collect next > 1 yr → quick-acting
urine passed carbohydrate such
3. Send blood for lab as pure fruit juice
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
RBS > 45 mg/dL
of 10% dextrose/0.45% saline at
a rate of 2.5-5 mL/kg/hr (6 1. Continue on
mg/kg/min glucose) maintenance fluid.
6. Recheck RBS at 5 min intervals 2. Gradually re-
until RBS is stable > 54 mg/dL. 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.

60
NG tube insertion

Indications

1. Feeding
2. Administering drugs
3. Aspiration of ① gastric secretions ② swallowed air in
gastrointestinal obstruction ③ preparation before surgery
under GA ④ 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

61
 Placement

Before an NG tube is inserted the appropriate length must be

measured from the tip of the patient's nose backwards, looping
around their ear and then down to roughly 5 cm below the
xiphoid process.

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

The end of a plastic tube is lubricated (local anesthetic, such as

2% xylocain gel, may be used).

To ensure proper placement air is injected into the tube while

holding a stethoscope on the epigastric area; if the air is heard in
the stomach with a stethoscope then the tube is in the correct
position.

62
Poisoning

Poisons can cause harm by a wide range of mechanisms and can

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

Harmless substances

There is a list of substances that if ingested by the child cause no

harm and only re-assurance of the family is needed.

Topical Contraceptives Grease Mineral

antibiotic pills oil
Hand lotion
Topical Topical and cream Play- Doh
antifungal corticosteroids
Ink (non Water
Bubble bath Crayons permemanent) color
soap
Deodorants' Laxatives Vaseline
Calamine underarm
Lipstick Shampoo
lotion
Soap of hand
Magazines Shaving
Candles and dish
creams
Makeup
Chalk Diaper rash
Starch
cream Matches
Children's toy
Sunscreen
cosmetics Glues
Clay Zinc oxid

63
 Management of poisoning

Resuscitation and Specific

Decontamination
supportive care management

Decontamination of the patient

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

64
Resuscitation and supportive care
Respiration
An obstructed airway requires immediate attention, from
simple chin lift or jaw thrust, oro- or nasopharyngeal tube to
intubation and ventilation.
Blood pressure
Hypotension usually occurs with drugs of CNS depression and
should be corrected with head tilting down of the bed and IVF.
Hypertension is often transient and associated with
sympathomimetic drugs as amphetamine, phencyclidine and
cocaine.
Heart
These are mostly in cardiac conduction defects and
arrhythmias, e.g. tricyclic antidepressants, antipsychotics and
some antihistamines.
Body temperature
Hypothermia occurs mostly in patients unconscious for hours
and in overdose of barbiturates or phenothiazines. The most
important measure is to wrap the patient.
Hyperthermia in poisoning with CNS stimulants is managed by
removing clothes, using fan, and sponging with tepid water.
Convulsion
If it is long-lasting or very frequent use lorazepam 100 mcg/kg
(max. 4 mg) or diazepam 300-400 mcg/kg (max. 20 mg) slow
IV or rectally or oral gel.

65
 Specific management (antidotes)
Paracetamol
Acetylcysteine 150 mg/kg in 3 mL/kg of 5% GW over 15 min
then 50 mg/kg in 7 mL/kg of 5% GW over 4 hr then 100 mg/kg
in 14 mL/kg 5% GW over 16 hr. This should be given within 8
to 12 hr if toxic dose is ingested (75 mg/kg/24 hr).
Opioids
Naloxone 10 mg; repeat the dose in 3 min to a max. 100
mcg/kg. This should be given if there is bradycardia or coma.
Tricyclic antidepressants
Intravenous infusion of sodium bicarbonate should be given if
there is prolonged QRS duration and arrhythmia.
Beta-blockers
IV atropine 40 mcg/kg (max. 3 mg) if bradycardia develops.
Iron salts
GI toxicity occurs with 20 mg/kg of elemental iron. Moderate
intoxication occurs with 40 mg/kg. Severe and lethal toxicity
occurs with 60 mg/kg.
% of elemental iron in iron salts is: fumarate 33%, sulfate 20%,
and gluconate 12%.
Treatment is with desferrioxamine 15 mg/kg/hour.

Additional antidotes

Toxin or poison Antidotes

Black widow spider Latrodectus antivenin

66
Botulinum toxin Botulin antitoxin
Glucagon and/or insulin and
Calcium channel antagonists
glucose
Diphenhydramine and/or
Dystonic reactions
benztropine
Fluoride, calcium channel
Calcium salts
blockers
Heparin Protamine
Methotrexate, trimethoprim,
Folinic acid
pyrimethamine
Rattlesnake envenomation Crotab-specific Fab antibodies
Sodium channel blockade
(tricyclic antidepressants, Sodium bicarbonate
type 1 antiarrhythmics

Recognizable syndromes

Poison syndrome
Signs: Vitals | Mental status | Pupils | Possible toxins
Skin | Bowel sounds | Other
Amphetamines,
Sympathomimetic
cocaine, ecstasy,
↑ BP, ↑ HR, hyperthermia pseudoephedrine,
Agitated, psychosis, delirium caffeine,
theophylline
Dilated pupils
Diaphoretic
Normal to increased bowel sounds

67
 Antihistamines,
Anticholinergic
tricyclic
↑ BP, ↑ HR, hyperthermia antidepressants,
Agitation, delirium, mumbling speech atropine, jimson
weed,
Dilated pupils phenothiazines
Dry skin
Decreased bowel sounds
Organophosphates,
Cholinergic
nerve gases,
↓ HR (though may show ↑ HR), BP and Alzheimer
temperature typically normal medications
Confusion, coma, fasciculations
Small pupils
Diaphoretic
Hyperactive bowel sounds
Diarrhea, urination, bronchorrhea,
bronchospasm, emesis, lacrimation,
salivation
Methadone,
Opioids
suboxone,
Vitals: Respiratory depression (hallmark morphine,
of toxicity), ↓ HR, ↓ BP, hypothermia oxycodone, heroin,
Depression, coma etc.

Pinpoint pupils
Normal skin
Normal to decreased bowel sounds
Barbiturates,
Sedative-Hypnotics
benzodiazepines,

68
Respiratory depression, HR normal to ethanol
decreased, BP normal to decreased,
temperature normal to decreased
Somnolence, coma
Small pupils
Normal skin
Normal bowel sounds
SSRIs, lithium,
Serotonin syndrome
MAOIs, linezolid,
Hyperthermia, ↑ HR, ↑ BP or ↓ BP tramadol,
(autonomic instability) meperidine
Agitation, confusion, coma
Dilated pupils
Diaphoretic
Increased bowel sounds
Neuromuscular hyperexcitability:
clonus, hyperreflexia (lower extremities
> upper extremities)
Aspirin, bismuth
Salicylates
subsalicylate
↑ RR, hyperpnea, ↑ HR, hyperthermia (Pepto-Bismol),
Agitation, confusion, coma methyl salicylates

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

69
 Withdrawal from
Withdrawal
opioids, sedative-
↑ HR, ↑ RR, hyperthermia hypnotics, ethanol
Lethargy, confusion, delirium
Dilated pupils
Diaphoretic
Increased bowel sounds

70
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

71
 ECG changes: QT prolongation, increased or inverted T waves, ST
segment abnormalities.

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

Management

Same treatment as for grade 1 in addition to:

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

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

3. Antivenom: give inside 250 mL saline in ½ hr with close

observation.

4. Prazosin: 30 µg/kg/dose orally. The same dose should be

repeated after 3 hr according to clinical response and later
every 6 hr till extremities are warm and dry and peripheral
veins are visible easily.

Blood pressure, pulse rate and respiration must be monitored

every 30 min for 3 hr, every hr for next 6 hr and later every 4
hr till improvement.

5. Glucose insulin regimen: can be given if there are ECG

changes. The dose of glucose is 0.1 g/kg/hour (1 cc/kg/hr of
10% GW) and insulin is administered at a dose of 0.3 unit/g of
glucose (0.3 unit/10 cc of 10% GW) with measuring of blood
sugar.

This should be given continuously till ECG changes disappear.

Potassium should be added if there is no hyperkalemia.

72
6. Calcium: ampoule can be given with infusion if there is
hypocalcemia.

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

Grade 3

Diagnosis

Life-threatening envenoming consisting of findings of grade 2 in

addition to multiorgan failure. Extra findings are:

1. 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).

73
 Sepsis

Sepsis: is a systemic inflammatory response resulting from a

suspected or proven infection.

Severe sepsis: sepsis + organ dysfunction.

Septic shock: severe sepsis + hypoperfusion or hypotension for

more than one hour.

Risk groups for sepsis

1. Infants.
2. Malnourished children.
3. Immunosuppressive drug regimen, e.g. steroid,
chemotherapy.
4. Children with chronic use of antibiotics.
5. Hospital patient who has urinary catheter or endotracheal
tube.

Management

Diagnosis of sepsis
(↑ HR, ↑ RR, ↓ BP, mental status changes)

Send for
1. Establish ABC (put I.V line, if investigations
unable then intraosseus line)
1. Blood culture
2. Give O2 2. Urine culture
3. Check HR, RR, BP, temperature, 3. CSF
SpO2, capillary refill. 4. CBC, ESR, CRP
5. Blood sugar

74
Give 20 mL/kg isotonic fluid (N/S or Ringer).

Antibiotics: ampicillin 100 mg/kg/day (divided 6 hourly) +

ceftriaxone 50-100 mg/kg once (in 50 mL N/S).

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

Change ampicillin to vancomycin 30-60 mg/kg/day if there is

a catheter or indwelling medical device.

Add amphotericin B (dose according to drug brand) for fungal

infection in immunocompromised patients.

Improvement No improvement

Continue O2
Transfer patient to
Maintenance I.V
ICU with diagnosis
fluid
of severe sepsis or
Change antibiotics septic shock.
according to C/S

75
 Septic shock in ICU

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

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

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

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

No response to fluids
Response to fluids
(fluid-resistant)

↑ BP, HR and RR return Give dopamine 10-20

to normal, capillary mcg/kg/min.
refill < 2 seconds.

Response to dopamine →
Dopamine-resistant shock
observe

76
 Give adrenaline 1
mcg/kg/min.
Response to adrenaline →
observe Adrenaline drip 1 mg +
100 mL N/S at 0.1
mL/kg/min).

Give hydrocortisone 50 If there is no response for

mg/kg bolus, then 50 60 min this is adrenaline-
mg/kg/day. resistant shock.

Give fresh frozen plasma

Monitor BP, HR, RR, SpO2,
or blood if you have active and urine output.
bleeding.

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

77
 Status epilepticus

Status epilepticus is defined as a seizure that lasts for >30 min or

recurrent seizures without full recovery in between seizures for
>30 min.

Convulsion for more than 5 minutes should be treated as status

epilepticus.

Initial management

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

No (after 3 attempts
Yes or 30 seconds)
IV line establishment

1. RBS, CBC, serum electrolytes

1. Rectal diazepam 0.5
(if abnormal treat accordingly)
mg/kg (max. 10 mg)
2. IV diazepam 0.3 mg/kg over
2. Insert IO (intra-
2 min (max. 5 mg in infants and
osseous) line if seizure
10 mg in older chldren); can be
is not stopped
repeated every 5 min for a max.
of 3 times

Is the child on phenytoin?

Yes No

78
IV phenobarbital 20 mg/kg over 20
min.
IV/IO phenytoin 20
OR mg/kg in normal
saline over 20 min
IV/IO phenytoin 10 mg/kg in (max. 100 mg) with
normal saline over 20 min (max. ECG monitoring.
500 mg) (should not be given in
glucose containing fluid) with ECG
monitoring.

Yes No
Has the seizure stopped?

Admit and look for: 1. Rapid sequence

intubation
Evidence of trauma, papilloedema
Bulging fontanel → manifestation 2. I.V / I.O midazolam
of sepsis ± meningitis 0.1 mg/kg loading
dose (max. 8 mg) over
Retinal hemorrhage → subdural 2-3 min.
hematoma
Kussmal breathing ± dehydration Then start infusion of
→ metabolic disorder or drug 120 µg/kg/hr, and
intoxication increase by 120
µg/kg/hr every 5 min
Irregular respiration → brainstem (max. 1.5mg/kg/hr).
dysfunction

Continue supportive care High dose phenobarbital

Thiopental infusion
Admit to ICU/call anesthetist
Propofol

79
 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

80
 a. Acute blood loss > 15% of blood volume, or anticipation
thereof, or hypovolemia not responsive to other forms of
therapy
b. Postoperatively with signs of anemia (e.g. apnea) and Hb <
10 g/dL
c. Severe cardiopulmonary disease with Hb < 12 g/dL
d. Patients receiving chemotherapy or irradiation, or
patients with chronic anemia not responsive to medical
therapy with Hb < 7 g/dL (symptomatic patients may be
transfused at a higher hemoglobin level)
e. Complications of sickle cell disease (e.g. CVA or acute
chest syndrome) or for preoperative preparation of such
patients, or chronic transfusion regimen for thalassemia
or other red cell disorders
f. Circuit prime for plasma exchange or stem cell collection
g. Clinical shock or severe decrease in BP with Hb < 10 g/dL

Platelets

A. Prophylaxis

1. Premature infants
Stable premature infant: < 30,000/uL
Sick premature infant: <50,000/uL
2. Term infants
< 4 mo: <20,000/uL
> 4 mo: <10,000/uL
3. Prior to lumbar puncture if platelet count <10,000/uL (and
patient is not actively bleeding)
4. Patient scheduled for invasive procedure and platelet count is
< 50,000/uL

81
 B. Treatment

1. Patients with active bleeding and platelet count < 50,000/uL

2. Diffuse microvascular bleeding in association with
cardiopulmonary bypass or extracorporeal membrane
oxygenation (ECMO) with platelet count < 100,000/uL or
laboratory value not available
3. Bleeding in a patient with a qualitative platelet defect
regardless of platelet count

Granulocytes

1. Bacterial sepsis in an infant < 2 wk of age with neutrophil

count < 3 x 109/L
2. Bacterial sepsis or disseminated fungal infection that is
unresponsive to antibiotics in a patient > 2 wk of age with
neutrophil count < 0.5 x 109/L and whose neutrophil count is
expected to recover.
3. Infection that is unresponsive to antibiotics and the presence
of a qualitative neutrophil defect regardless of neutrophil
count.

Fresh frozen plasma

1. INR > 1.5-2 times the mean normal value in a nonbleeding

patient scheduled for surgery or invasive procedure
2. Diffuse microvascular bleeding in a patient with a PT or PTT >
1.5 times the mean normal value or values not yet available
3. Warfarin overdose with major bleeding or impending surgery
4. Patients with thrombotic thrombocytopenic purpura (TTP)
undergoing transfusion or plasma exchange

82
5. Protein C, protein S, anti-thrombin III deficiencies, or other
single-factor deficiency where no product is available and
patient is bleeding
6. Bleeding secondary to vitamin K deficiency

Cryoprecipitate

1. Quantitative fibrinogen disorder with fibrinogen < 100 mg/dL

and scheduled for invasive procedure
2. Qualitative fibrinogen disorder with diffuse bleeding or
scheduled for invasive procedure
3. von Willebrand disease or Hemophilia A (factor VIII
deficiency) with active bleeding or invasive procedure
planned, unresponsive to DDAVP and/or factor concentrates
4. Fibrin glue production

Indications for transfusion

Packed RBCs

1. Hb < 70 g/L (although lower thresholds may be acceptable in

patients without symptoms and where specific therapy, e.g.
iron, is available)
Transfusion may be indicated at higher thresholds for specific
situations:
2. Hb < 70-100 g/L during surgery associated with major blood
loss or if evidence of impaired oxygen transport
3. Hb < 80 g/L in patients on a chronic transfusion regimen or
during marrow suppressive therapy (for symptom control
and appropriate growth)
4. Hb < 100 g/L only for very select populations (eg. neonates)

83
 Platelets

1. Bone marrow failure

Platelets < 10 x 109/L if no other risk factors for bleeding
Platelets < 20 x 109/L if risk factors present (fever, antibiotics,
haemostatic failure, risk of intracranial haemorrhage)
2. Surgery/invasive procedure
Platelets < 50 x 109/L (however, higher counts may be needed
in surgeries with high risk of bleeding, e.g. neurosurgery)
3. Platelet function defects
Transfuse if there is bleeding or high risk of bleeding,
regardless of actual platelet count
4. Bleeding/massive transfusion
Maintain platelets > 50 x 109/L if thrombocytopaenia is likely
contributing to bleeding
Maintain platelets > 100 x 109/L in the presence of diffuse
microvascular bleeding (DIC) or CNS trauma

Fresh frozen plasma

1. Warfarin effect, in the presence of life-threatening bleeding in

addition to the use of vitamin K and vitamin K dependent
clotting factor concentrates for bleeding with abnormal
coagulation
2. Liver disease, if bleeding with abnormal coagulation
3. Acute DIC when there is bleeding and abnormal coagulation
following massive transfusion or cardiac bypass for bleeding
in the presence of abnormal coagulation

Cryoprecipitate

Fibrinogen deficiency, in the setting of clinical bleeding, an

invasive procedure, trauma or DIC.

84
Pre-transfusion assessment

1. Determine the indication for transfusion.

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

protocol).

a. A sample for cross-matching must be collected in a 1.4 mL

red EDTA tube (NOT bullet tubes). Patients known to have
red cell antibodies or haemolytic anaemia will require a
larger sample.
b. Correctly identify the patient during the collection of the
pre-transfusion sample. Identification must include 3
unique identifiers (full name, DOB, and UR). This, together
with completing the bedside check prior to blood
administration are the most vital steps in preventing
serious transfusion errors.

3. Request the appropriate blood component and special

requirements:

a. Leukocyte depleted blood products should be given to:

o Immuno-compromised patients (oncology, transplant
recipients, ICU patients, and other congenital and acquired
immune deficiencies)
o Patients requiring chronic transfusions
o Infants under 12 mo
o Intrauterine or exchange transfusions
b. Irradiated blood products should be given to: all immuno-
compromised patients, including all oncology patients,
cardiac neonates and all patients in ICU, to prevent graft-
versus host disease.

85
 c. CMV negative products: leucocyte depleted blood
products, are considered an acceptable alternative to CMV
seronegative products at RCH

Transfusion volumes and rates

Packed RBCs

o 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

86
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.

87
 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.

88
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 Residual risk per transfused

infection component
HIV 1 in 1,467,000
Hepatitis C 1 in 1,149,000
Hepatitis B 1 in 282,000
West Nile Virus Uncommon
50-85% of donors are carriers.
Cytomegalovirus
Leukocyte reduction is protective
. Bacterial Infection 1 in 2-3,000 (mostly platelets)
Parasitic Diseases
Relatively uncommon
Babesiosis, Chagas, Malaria

After transfusion

Document the effect of transfusion on the patient's condition

including Hb if repeated.

89