(Clinical Practice Guideline)

2552
...


(Clinical Practice Guideline)
-

Preterm Infants
Febrile Convulsion
Pneumonia
ALL
Febrile Neutropenia (FN)
(Surfactant)

-
-
- Retinopathy of Prematurity
-
- Hypoglycemia



( vesicouretreic

reflux)


1.
-
- 4-5
- , , ,
,
-
- ,

-
-
- , ( encopresis)
- , ,

2.
-
-
-
- costovertebralangle
- lipoma , hair patch dimple , sinus tract lumbosacral
-
- phimosis , vaginitis , labial adhesion
- neurogenic bladder

3.
- 5-10
/ HPF (
)
-

suprapubic aspiration

( colony/)

103 colony/.
105 colony/.
1 Suprapubic aspiration
Transurethral catheterization pnimosis midstream
clean-voided urine
Catheterized
Clean-voided

4.
4.1 dehydration
4.2 empirical antibiotics
Ampicillin 50-100 ././ Gentamicin 3-5 ././
3rd generation Cephalosporins
aminoglycosides Cefotaxime 100-200 ././

Ceftriaxone 50-100 ././

/
Cotrimoxazole 6-12 . trimethoprim /./. Amoxycillin-clavulanic

acid 30 . amoxicillin /./ Cepholosporins

4.3 48-72 .
4.4 10-14 acute pyelonephritis 7-10

4.5 circumcision phimosis

7. (> 3 / ) prophylaxis Cotrimoxazole 1-2

. trimethoprim / 6-12
double-void
perineum

 (Clinical Practice Guideline)

(.. 2548)

1. paracetamol
ORS NSAID Aspirin
2. Prevent dehydration ORS
3. Follow up 3 Leakage

Admit Warning Sign Follow up Dengue Treatment Algorithm

OPD
+

Tournique + Test

Positive

negative

Hx : bleed ? vomiting. PE. : VS Liver CBC.

Follow Up 3
48 . admit Warning sign *
.
Hct
WBC > 5,000
Plt

Folow Up

Hct

Hct

WBC Plt

WBC Plt
< 100,000 /
cumm

Force oral intake

Follow Up

admit

Admit

CBC UA
Follow Up repeat
tourniquet test

 : ....
. * Warning signs
-
-
-
-
-
-
-
Leakage 2
2.1 shock
admit

1.
2.
3.
4.

Platelet count <100,000/cumm Hct rising

Warning Signs
Bleeding

admit Follow Up 48
2.2 shock - O2 canula , IV Fluid
Admit 1 1782
-Impending shock. 5% D/NSS1 rate 10-20 ml/kg/hr

-Profound shock. ( BP,Pulse ) NSS2 ml/kg push in 10 min

BP rate 5% D/NSS1 10-20 ml/kg/hr
: 1 5% D/NSS 5% DAR 5% DLR
2

Nss Ringer acetate Ringer lactate

500 ml

 ( Clinical Practice Guideline)

. .. 2548

3
1. Paracetamol
ORS NSAID Aspirin
2. IV fluid dehydration
50% Maintenance.
3. Leakage CBC
Leakage 3

1. Early Detection and early treatment of SHOCK

Vital signs ( BP , pulse Pressure ) 1-2 hrs , Hct q 4-6 hrs ,
Record intake/output Urine Sp.gr. DHF flow chart .
2. IV FLUID Replacement
IV fluid
Shock : 5% DAR 5% DLR 5% D/NSS
Non-shock : <6 5% D/N/3
6 -1 5% D/N/2
5% D/NSS
> 1
IV fluid
- Hct rising >10% IV
fluid M/2 24
- Hct rising >20% IV fluid M+5% D 24
1
- DHF grade III : IV fluid 10-20 ml/kg/hr.
- DHF grade IV : 10 ml/kg IV push BP &

push 10 ml/kg/hr.
2

3. :
3.1 (High risk patiement)
1. Young infants <1 year old.

2.
3.
4.
5.
6.

DHF grade IV or prolonged shock.

Overweight patients.
Patients with massive bleeding.
Patients with changes of cinsciousness.(encephalopathy)
Patients with underlying diseases , e.g. Thalassemia , G-6-PD def.,

CHD etc.
7. Referred patients.
3.2 Metabolic DHF Grade IV.
3.3
- 10% Tital Blood Volume (TBV = 60-80 /.)

- Thalassemia, G-6-PD deficiency hemolysis

- unstable vital signs rate IV fluid
Hct IV fluid ()
3.4 platelet : massive bleeging.
3.5 invasive NG tube.
Convalescence

- IV fluid concalescence.
- bowel sound
blood electrolyte.

1. 24 ( shock 48 )

2.
3. complications.


NSS DLR DAR IV drip free flow 10-15
10 /. IV push grade IV

BP

BP

rate 10 /./. 1-2 . IV

5% D/NSS 5%DLR 5%DAR

10 / . IV bolus ( 1 )

rate 7.5
3 /./. off
IV

blood sogar , blood gas , electrolyte , Ca , LFT ,

BUN . Cr* ()
Hct
Hct

Hct

Dextran 40. 10 / ./.

FWB 10 /.

(
Dextran 40. 10/ ./.)

venous cut down CVP

CVP 10 .

dopamine , debutec

CVP 10 .

Dextran 40

Vitamin K, Ca, NaHCo,

*

 ( 15-40 .)
( 100,000 /.. Hct 10-20 %)
5% D/NSS 5% DLR 5% DAR 5 /./.
vital signs 1-2 . Hct 4 .

Vital signs

/ Hct

Hct stable
vital signs

Hct .

rate 5-7 /./.

3-4 .

rate 7 /./.

Rate 3 /./.

rate 10 /./.
2 .

,
pulse pressure ,

Hct

rate IV
vital signs stable, Hct ,
fluid 24-48 .

Dextran 40
10 / ./.

Hct

FWB
10 / ./

crystalloid rate 7,5,3 /./.

15 . IV fluid rate 6-7 /./.

40 . IV fluid rate 3-4 /./.
1

 ..
( 1 13 .. 2548)
Visible jaundice

Term infant

Preterm infant

Onset < 24 hr.

Onset 24-72 hr.

Onset 24 hr.

Hct,MB

Hct,MB

Hct,MB

BW < 2000 gm

Admit

BW 2000 gm

term infant

MB <5mg% MB 5mg%
Advice/

MB <15mg% MB 15mg%

Admit

Advice

Admit

Hct,MB

MB <5mg%

MB 5-13 mg%

MB 13 mg%

Advice

F/U Hct,MB

Admit

Hct , MB 3 1781
1784 24


1. Healthy term infant
Visible jaundice

Onset < 24 hr

Onset 24-72 hr

Onset 72 hr

Hct,MB

Hct,MB

Hct,MB

MB 8-13 mg MB 13mg%
MB <5 mg

MB 5-8 mg

MB Smg

F/U Hct,MB
4-6 hr

No Rx

Rate of rising
>0.5 mg%/hr.

MB <15 mg% MB 15mg%

F/U Hct,MB
Next 12 hr

No Rx

Rate of rising
>0.5 mg%/hr.

Investigation :
- CBC, blood smeat
- Reticuyte count, Heinz body
- Blood group, Coombsteat ,
- G6PD screening

Management :
- Consider phototherapy exchange transfusion 1
-

F/U Hct,MB 4-6 hemolysis

F/U Hct,MB 12-24 hemolysis

Prolonged jaundice
TB OB

>7

>14
congenital hypothyroidism

term

>

14

preterm

thyroid screening

 * (Healthy term
newborn) hyperbilirubinemia
Total bilirubin (TB) (mg/dl)
Age (hrs)

24( 1 )
24-48
49-72
>72

Phototherapy

Intensive ( 2)
Phototherapy

12
15
17

Exchange
Exchange transfusion and
transfusion intensive phototherapy
If intensive
Phototherapy fail( 3 )

15
18
20

20
25
25

25
30
30

* hemolysis
exchange transfusion TB > 20 mg/dl
(1) 24

(2) intensive phototherapy special blue
2
(3) intensive phototherapy failure TB 1-2 mg/dl 4-6 .
TB
exchange transfusion

: American

Academy of Pediatrics. Provisional Committee for Quality

Improcement and Subcommittee on Hyperbilirubinemia. Pracice parameter :
management of hyperbilirubinemia in the helthy tem newborn. Pediatricd\s 1994;94 :
558.

2. Preterm infant

500 - 1000 g
1001 - 1500 g
1501 - 2000 g
2001 - 2500 g

Total bilirubin (TB) (mg/dl)

Phototherapy
3-5
5 - 10
10 - 15
> 15

Exchange
Variable
Variable
Variable
Variable

(1) sick preterm phototherapy

total blood exchang ( sick preterm
APGAR score 5 < 3, acidosis,sepsis hemolysis )
(2) < 1000 g prophylactic photorherapy


1.
phototherapy , total blood
exchange
2. MB. phototherapy

3.
-

total blood exchange

phototherapy total blood exchange
phototherapy
crib 2 phototherapy
30 .
( on intensive phototherapy
bili-bed pamper )

phototherapy 20 .
On continuous phototherapy
2000 .

hyperthermia , dehydration ,
diarrhea

Hct , MB


Preterm Infants

Preterm infants ( < 35 wk ) at risk for early onset neonatal sepsis*

( Onset < 72 hr)
Signs of neonaltal sepsis**

NO

Yes

Risk 1

CBC , H/C, empirical antibiotic***

H/C positive
Yes

NO

Observe 48 hr
CBC , H/C,
empirical antibiotic***

Yes

NO

LP

Antibiotic 7-10

H/C positive

Yes

NO

LP

Antibiotic

Antibiotic
7-10 for GBS,

Abnormal CBC

NO

Yes

14 for GBS,
21 for Gram

Off ABO
Antibiotic
14 for GBS,

Antibiotic
7-10 for GBS,

ve

bacilli

* > 38 oC , prolonged

rupture of membrane > 18 hr , PROM , chorioaminionitis ,

HX of previous GBS infection

, GBS

** apnea , ,, , shock
*** PGS 100,000 m /kg/dose q 12 hr
gentamicin

bacilli

Antibiotic

21 for Gram ve 14 for Gram ve

bacilli

14 for Gram ve

bacteriuria

or ampicillin 100mg/kg/dose q 12 hr plus

term infants ( < 35 wk ) at risk for early onset neonatal sepsis*

( Onset < 72 hr)
Signs of neonaltal sepsis**

NO

Yes

Intrapartum antibiotic
Prophylaxis ( IAP) > 4

CBC , H/C, empirical antibiotic***

H/C positive
NO

Yes
Observe 48 hr

CBC , H/C,

Normal CBC

NO

LP

Antibiotic 7-10

Abnormal CBC
empirical antibiotic***

Observe 48 hr

H/C positive

LP

Antibiotic
7-10 for GBS,

14 for Gram ve

Antibiotic

Antibiotic
7-10 for GBS,

14 for GBS,
21 for Gram

NO

Yes

ve

bacilli

Yes

14 for Gram ve
bacilli

Antibiotic
14 for GBS,

21 for Gram

ve
> 38 C , prolonged rupture of membrane > 18 hr , PROM , chorioaminionitis ,
o

HX of previous GBS infection

, GBS

** apnea , ,, , shock
*** PGS 100,000 m /kg/dose q 12 hr
gentamicin

bacteriuria

or ampicillin 100mg/kg/dose q 12 hr plus


Febrile Convulsion

 Febrile Convulsion*

1.
2. ( 18 )
3. metabolic (electrolyte , calcium , magnesium ,
glucose )

4. EEG,CT scan
simple febrile seizure complex febrile seizure

1. :


2.
3. Diazepam 0.2-0.3 ./.
Diazepam 0.3-0.5 ./.
4.
CBC U/A

5.

6.
7. (intermittent prophylaxis ) Diazepam
Diazepam 0.2 ././
6-8 24
8. Phenobarbital Sodium valproate continuous
prophylaxis
2

Febrile convulsion
6 5

1.

2.

3.

18
18
*

Simple febrile seizure

diazepam

Complex febrile seizure

EEG
CT scan

*
*
1.

2. 5
3. anterior fontanel


Pneumonia

Clinical practice guideline for treatment Pneumonia

1 : Pneumonia OPD ER
+
History

Investigation ( CBC , CXR)

Physical exam

Pneumonia

Immunocompromised host
Underlying disease : CHD ,

Other disease

Notmal host
Degree of illness ( 5 )

BPD , CP , malnutrition

Admit

Not severe

Severe

Admit
OPD Case
( 3 )
2

 2 Pneumonia ( Not severe)

Pneumonia ( Not severe)
OPD case
Supportive case ( 6 )

Bacteria

Virus
No specific
treatment

2 5

5 15

Amoxycilin

Amoxycilin

Admit
Severe pneumonia

S. pneumoniae
& H. influenze
Admit
Penicillin Severe pneumonia

Amoxycillin+clavulanic acid
Cephalosporin

(2 or 3 generation)
7
nd

rd

Mycoplasma
Chlamydia
Pneumoniae
(atypical pneumonia)
Macrolide

S. pneumoniae

Amoxycillin+clavulanic acid
Amoxycillin (double dose)

* : Pneumonia
10-14
Cephalosporin
virus bacteria RX bacterial pneumonia
(2nd or 3rd generation)
: < 6 staccato afebrile pneumonia
7
erythromycin 14 Chlamydia trachomatis
: atypical pneumonia bacterial pneumonia antibiotics

 3 : Severe Pneumonia
Severe Pneumonia
Admit + Supportive care

2 5

< 2

Ampicillin I.V
S.aureus

PGS Ampicillin I.V*

+ Aminoglycoside
Cefotaxime I.V

5 15

Penicillin G IV

Ceftriaxone I.V
* cloxacillin I.V
S.aureus

Ampicillin

Ceftriaxone I.V
Cefotaxime I.V

Amoxycillin
Clavulanic acid I.V

Amoxycillin
2
7
oral antibiotic
7

Pen V S. pneumoniae

Amoxycillin

7
PGS high dose IV.
Cefotaxime

Ceftriaxone
2
oral antibiotic
7

: antibiltics hemoculture
: ET- tube sputum
exam culture
: < 6 afebrile pneumonia macrolide 14
Chlamydia trachomatis
: Pneumonia Mycoplasma pneumoniae or Chlamydia
pneumoniae Bed side cold agglutinin add macrolide

 Pneumonia ( Degree of illness)

1. Not severe pneumonia
- (Tachypnea) oxygen
desaturation dehydration alteration of mental status
- WHO tachypnea
< 2
60 /
2 1
50 /
1- 5
40 /
> 5
20 /

2. Severe pneumonia
- < 2 ( Pneumonia < 2
severe ) underlying disease BPD, heart disease,
malnutrition immunocompromised host
- > 70 / > 50 / ( > 1 )
- Marked retraction or cyanosis or apnea
- Oxygen saturation < 92 % oxygen ( in room air)
- dehydration , ,,
- CXR complication of pneumonia pleural
effusion,lung abscess,atelectasis pneumatocele
pneumonia staphylococcus aureus

General supportive care for Pneumonia

1.

2.
3. antihistamine
4. bronchodilator wheezing
5. Tepid sponge paracetamol
6. ( chest physiscsal therapy)

(vibration)

7. , 70 /
50 / (> 1 ) , ,
apnea ET tube ICU

 Viral Pneumonia / Bacterial Pneumonia

1. Virus > Bacteria
2. breath sound virus pneumonia wheezing
Bacterial pneumonia wheezing
3. CBC : Virus Pneumonia
WBC ,
lymphocyte
: Bacterial pneumonia
WBC 15,000 cells /
cu.mm , neutrophil Band
4. ESR ( 30 mm. /hr.) bacterial pneumonia
5. CXR : interstitial infiltration perihilar infiltration
Viral pneumonia
: alveolar infiltration consolidation lobar
infiltration bacterial pneumonia

: Virus Pneumonia Bacterial

pneumonia bacterial pneumonia
: reference Update on Pediatric infectious disease
2005

Antibiotics Pneumonia

(././)

Amoxycillin
Amoxycillin

40-50
80-100

Erythromycin

30-40

Amoxycillin+clavulanic
acid*
Clarithromycin

40-50

Azithromycin

10 ./. 1

15

5 ./.
4

S.pneumonia
Drug resistant S.pneumonia
(DRSP)
S.pneumonia , Chlamydia ,
Mycoplasma
S.pneumonia , H.influenzae
S.pneumonia , H. influenzae ,
Chlamydia , Mycoplasma
S.pneumoniae , H.influenzae ,
Chlamydia , Mycoplasma

Cefprozil
Cefdinir

30-40
14

S.pneumonia , H.influenzae
S.pneumoniae , H.influenzae

(././)

Ampicillin
Amoxycillin+clavulanic
acid
Penicillin G sodium
(PGS)
Cloxacillin**
Gentamicin
Amikacin
Cefotaxime
Ceftriaxon

100-200
40-50

S.pneumoniae
S.pneumoniae , H.influenzae

1-2 /.

S.pneumonia

100-150
5-7
15-30
100-200
50-100

S.aureus
Gram negative bacilli
Gram negative bacilli
S.pneumonia , H.influenzae
S.pneumonia , H.influenzae

* DRSP double dose ( 80-100 mg/kg/day Amoxycillin)

** empyema pneumatocele dose 200 mg/kg/day.

 ALL

Pedriatric department Buddhachinaraj Hospital Multidisplinary Carepath

( ALL on Siriraj ALL-03A protocol for Induction of remission phase)

Plan of care

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

..

..

..

Expected
outcome

of

- LOS cost

10

11

12

13

14

LOS - cost

15

16

17

18

19

20

21

LOS - cost

22

23

24

25

26

27

28

LOS - cost

29

30

31

32

33

34

35

LOS - cost

36

37

38

39

40

41

42

- LOS - cost

43

Plan of care

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

..

..

..

Assessment

10

11

12

13

anxiety,fear,pain,v/s anxiety,fear,pain,v/s
physical exam
N/V, stomatitis
Phepbitis
tissure necrosis
physical exam

14

15

16

17

18

19

20

anxiety,fear,pain,v/s
N/V, stomatitis
Phepbitis
tissure necrosis
physical exam

21

22

23

24

25

26

27

anxiety,fear,pain,v/s
N/V, stomatitis
Phepbitis
tissure necrosis
physical exam

28

29

30

31

32

33

34

anxiety,fear,pain,v/s
N/V, stomatitis
Phepbitis
tissure necrosis
physical exam

35

41 42 43
anxiety,fear,pain,v/s
N/V, stomatitis
Phepbitis
tissure necrosis
physical exam
36

37

38

39

40

Plan of care

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

..

..

..

Test

Treatment

10

11

12

13

CXR
CBC plt
CBC plt2/week

G/M,
BUN,Cr,E'lyte,uric,C
aMg,P,LFT
()
H/C,U/A,U/C,
stool exam,stool c/s
BMA ()

PRC if Hct < 25%

Plt conc if <20,000
Alkalinization
Hydration
(Fluid 3,000 ml/m3 day

5%D/N/5 1,000ml +
7.5% NaHCO3 40 ml iv
drip....ml/hr)

PRC if Hct < 25%

Plt conc if < 20,000

14

15

16

17

18

19

CBC plt

20

21

22

23

24

25

26

CBC plt

27

28

29

30

31

32

33

CBC plt

34

35

36

37

38

39

40

CBC plt

41

42

43

B
M
A

Plan of care

Week 1
..
1

Medication

Week 2
..
8

10

11

12

13

14

Week 3

15

16

17

18

19

21

22

23

24

25

26

27

Week 5

28

29

30

31

32

33

34

Week 6

35

36

37

Albendazole

V
C
R

prednisolone
sodamit
zyloric
V If febrile neutropenia* V If febrile neutropenia* V
C Stomatitis** C
C guideline
guideline
R
R
R

If febrile neutropenia*
Stomatitis**
guideline

V If febrile neutropenia* V
C Stomatitis** C
guideline
R
R

A
D
R

A If febrile neutropenia* A If febrile neutropenia* A

D
guideline
D Stomatitis** D
guideline
R
R
R

If febrile neutropenia*
Stomatitis**
guideline

A If febrile neutropenia* A
D Stomatitis** D
guideline
R
R

L
A
S
P
IT
Consult

20

Week 4
..

L
A
S
P

L
A
S
P

IT
I f pain guidelin

L
A
S
P

L
A
S
P
IT

Activity

*** ( )

Diet

ANC , stomatitis ******** ( cryotherapy )

L
A
S
P

38

39

40

41

42

43

Plan of care

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

..

..

..

Education

D/C plan

Counseling
Pretest

bleeding
activity
N/V

coping techning,support
group

10

11

12

13

21

22

23

bleedingactivityN/V
coping techning

T
E
S
T

bleeding activity

N/V
coping
techning

education

14

15

16

17

18

19

20

education

24

25

26

27

education

28

29

30

31

32

33

34

T
E
S
T

bleeding activity

N/V
coping
techning

education

35

36

37

38

39

40

41

42

43

T
E
S
T

education


Febrile Neutropenia (FN)

...................................................................................... HN...........................................................
Febrile neutropenia (FN)(1)

CBC , U/A , Stool exam

Hemoculture (Bactec) 1 specomen , Urine culture

High risk (2)

Low risk
1st regimen (3)
___/___/___

Modification of regimen (3)

___/___/___

2nd regimen (4)

___/___/___

72 .

___/___/___

.....................

___/___/___

H/C : NG
___/___/___

__/__/__

__/__/__

___/___/___

___/___/__

___/___/__

3-4

Hemoculture
___/___/__

2nd regimen
high risk
ANC < 100

Low risk
ANC > 100

___/___/___
3
generation oral
cephalosporin(6)

5-7

rd

regimen
5
repeat CBC

ANC > 100

ANC < 100

3rd generation oral

___/___/___

cephalosporin 5-7

1st regimen

antifungal(7) FN>7
___/___/___

(6)

3-4

____/____/____

5-7
ATB 2 wks Antifungal 3-2
wks

CBC U/A,H/C,MUC
CXR,U/S abdomen eye exam

( 1) Febrile neutropenia : > 38.3 oC > 38.0oC 4 ANC < 500 mm3
(2) High risk : shock , hypotension , poor perfusion , ARDS , S&S of sepsis
(3) 1st Regimen antibiotic
3.1 Ceftazidime 100-150 mg/kg/ day IV q 8 hr + Gentamicin 5 mg/kg/day IV q 8 hr
3.2 Piperacillin /tazobactam (400-500 mg/kg/day IV q 8 hr
3.3 4 th gen cephalosporin Add Modification instruction
(4) 2 nd Regimen antibiotic
4.1 Imipenem 80-100 mg/hg/day+Aminogiycosid Amikacin (15 mg/kg/day q 8 hr)
Netilmycin
4.2 Meropenem Add Modification instruction
(5) Modification instruction
5.1 , ,,thrombophlebitis Add cloxacillin
5.2 Add vancomycin VP shunt central line Hx of previous colonization with MRSA
within 1 yr
5.3 perianal abscess intraabdominal infection add Metronidazole
imipenem Meropenem
5.4 gerprtic-like pral ulcer Tzanck smear add Acyclovicr
5.5 diarrhea Pseudomembranous colitis add Metronidazole imipenem
Meropenem
5.6 oral thrust oral Fluconazole 3-5 mg-kg/day OD
5.7 severe mucositis add Penicillin Imipenem ,Meropenem
Piperacilln/tazobactam
5.8 diffuse bilateral infilteation CXR PCP Co-trimoxazole 20
mg/kg/dsy/
(6) Oral 3 rd generation cephalosporin step down therapy
Cefdinir 14 mg/kg/day OD or BID
Cefixime 6 mg/kg/day OD or BID
(7) Antifungal for systemic infection
7.1 Amphotericin B test dose 0.1 mg/kg 0.5 mg/kg, 1 mg/kg 1224
maintain dose 1 mg/kg

Mix with 5% D/W to concentration 0.1 mg/ml (peripheral administration) or 0.25 mg/ml (central line
only)
Infuse over 4-6 hr.
7.2 side effect Amphotericin B Premedication
Paracetamol,Chlorpheniramine Hydronortisone 1 mg/kg (max 25 mg)

- (Surfactant)

- Retnopathy of
Prematurity
-
- Hypoglycemia

Surfactant
Indication
- moderate severe RDS On mechanical ventilator
FiO2 > 0.4 2 6 hrs.
- retreatment 6-12 hrs. dose FiO2 > 0.3 On
mechanical ventilator MAP > 7 8 cmH2O
Dose survanta 4 ml/kg/dese intratracheal ( Survanta)
4 1 ml/kg
Slight Trendelenburg
Reverse Trendelenburg
2
- check ET-tube suction clear
secretion
- montor O2 saturation heart rate
dose Bag 30 O2 sat > 92%
dose
- : suction ET-tube 2 hrs.
clinical Indication
: setting weaning protocol
: F/U CXR
Adverse reaction ; Hypoxia ,Apnea , Bradycardia

Severe Respiratory Distress Syndrome

Initial setting :
- FiO2 Protocol FiO2 1.0
(Flow cycle AC)
- Flow > 3 minute ventilation
- Back up rate ~ 40 60 /min
- PEEP 4 5 cmH2O
- PIP 12-20 cmH2O
- Ti 0.3 -0.4 sec
-TV 4-6 ml/kg
Blood Gas targets (arterial blood gas)
pH
7.25 7.35
PaO2
50-70
mmHg
PaO2
45-55
mmHg
Weaning
1. continuous O2 monitoring pulse oximetry O2 sat 9295% FiO2 0.05 protocol ()
2. FiO2 < 0.6 PIP 1 2 cmH2O
Tidal colume chest movement keep TV 4-6 ml/kg
3. PEEP Aeration aeration 8
(posterior rib) 1 cmH2O hypoaeration 1
desaturation PEEP 1 cmH2O
4. 60 / min mode SIMV rate
5 / min
5. 24 48 blood gas setting
target > 48 check
blood gas setting
6. setting FiO2 < 0.4 PIP 12 PEEP
4 Rate 20 extubate On NCPAP 3 PEEP 5 - 6
cmH2O

Red Blood Cell Transfusion Guidelines

1. Hct 20% Hb 7 g/di
2. Hct 25% Hb 8 g/di
- Apnea/Bradycardia 10 episodes/24 hrs. 2 episodes
requiring bag mask centilation
- Sustained tachypnea > 180 BPM
Sustained tachypnea > 80 BPM
- Poor weight gain (10 g/day adequate caloric intake )
- Mild RDS with Fio2 0.25 0.35
Nasal canula 0.125 0.25 LPM
IMV NCPAP with MAP < 6 cmH2O
3. Hct 30% Hb 10 g/dl Moderate RDS FiO2 >
0.35 IMV with MAP 6 8 cmH20
4. Hct 40% Hb 13 g/dl with severe RDS requiring
mechanical ventilation MAP > 8 cmH20 FiO2 > 0.4 0.5
severe congenital heart disease cyanosis heart failure
5. acute blood loss with shock keep Hct 40%
6.
guideline
lron Supplement, Reticulocyte count


1)
10% Phenylephine E.D. 1% Mydriacyl E.D. 1 : 9
1
2)
-
3)
- 5 4 15 21
: 15
3)
- Indirect ophthalmoscope
- Lens 20 diopter
- Eye speculum
- Cotton tip applicator
- : 0.5% Tetracaine E.D.:
- : Poly-oph E.D.:
4)
-
- 1
- Eye speculum
-
- 1
5)
-
- , , ,
/

 Retinopathy of prematurity

Retinopathy of prematurity ( ROP)
20 2545 ROP
1. 35 ( 1)

2. 36 2,000

3. 35 OPD 35

4. 12.00 .
5.
OPD
OPD
6. ROP


1. HBsAg Positive
2,000
- hepatitis B vaccine 1 HBIG 12

- hepatitis B vaccine 2 1-2 3 6

1.2 < 2,000

- hepatitis B vaccine HBIG 12
1
- hepatitis B vaccine 1 1
( )
- hepatitis B vaccine 2 1-2 3
6
2. HBsAg
2.1 2,000
- hepatitis B vaccine 1 12 HBsAg
HBIG ( 7 )
- hepatitis B vaccine 2 1-2 3 6
2.2 < 2,000
- hepatitis B vaccine 12 HBsAg
12 HBIG
- hepatitis B vaccine 1,2,3 1,2
3. HBsAg Negative
3.1 2,000
- hepatitis B vaccine 1
- hepatitis B vaccine 2 1-2 3 6-18

3.2 < 2,000

- hepatitis B vaccine 1 1
()

- hepatitis B vaccine 2 1-2 3 6-18

(31/01/50)

Hypoglycemia
Patient at risk
Check DTX at 1-2hr

DTX>45mg/dl

DTX>45mg/dl

Early feeding

asymptomatic

Check DTX
Before next feeding

DTX30-45 mg/dl

symptomatic

DTX<30mg/dl

10%DW2-4ml/kg IV
Then GIR 4-8mg/kg/min

>45mg/dl

<45mg/dl

early feeding

check DTX I hr later

check DTX I hr later

Routine care

< 45mg/dl

< 45mg/dl

>45mg/dl

Feed+IV GIR
4-8 mg/kg/min

adjust GIR +
10%DW2mL/kg

check DTX
before next feed

< 45mg/dl

Check DTX q I hr
Until euglycemia

>45mg/dl

Routine care

*Patient at risk : IDM,LBW ,SGA,LGA,preterm,asphyxia (apgar at 5 minutes < 7)

*Symptomatic : apnea,jitteriness, tremors
*adjust GIR + 2 mg/kg/min

>45mg/dl

continue same
IV&check DTX
2hr later