馬偕小兒血液腫瘤科

R1​注意事項
20130716revised

病房常規工作，秘笈和照顧病童篇
1. ​ANC <300, 則停止口服化療藥(如6-MP); ANC <200,則停止口服 Bactrim (但部份病童因
長期ANC<200,主治醫師仍會視情況決定是否繼續口服 Bactrim), 血球恢復後記得恢復
Bactrim and 6MP
2. ​注射 HDMTX,須Hold Bactar 1 week (2010.11. Dr. Pui ‘s suggestion)
3. ​不是自己開的orders必須要double-check​ 包括
a. ER及duty Dr. 之admission orders
b. Sepsis workup，尤其​dosage of antibiotics 是否正確, 或是否開了Amikin在不適合
用aminoglycosides類抗生素的病人身上
c. ​化療therapy中相關之生化monitor，止吐藥，退燒藥等premedications
4. 出院order部分
a.第一次出院的病童返院及出院之事務必須交待清楚，​出院時預約之OPD必須清楚註
明月,日,星期幾，上午or 下午 Dr. 某某某 (務必check 門診時間)
b.​絕大部份病人要帶 CBC 速件單及Bactrim回​。
c.​若病人住院打MTX 2.5g或 MTX 5g，出院時要評估是否帶 Cr單回​。
d.​若病人出院仍須打leunase，出院時帶 glucose 速件單回​。
e.口服化療藥物​Dexamethasone​或​6MP需確認帶回劑量數，剩藥帶回者請與護理師再
確認住院中給過藥物次數，不要只靠電腦藥單​。
f.若病人此次住院或出院前有neutropenic fever而使用抗生素治療,出院時,最近一次採取
血液細菌培養是在五天之內,且細菌室未主動通知結果,此時,必須打電話詢問當天此病
童是否血液培養長細菌,確定no growth,方可出院
5. IC or Port-A 不可 hold, 時間到了務必換針
6. Patients流鼻血止血方法: 須坐起，向前傾，摺衛生紙成一小塊，放在患側鼻翼上，再用
大姆指壓患側鼻翼(要用力)，10分鐘後仍不止血則 consult ENT。

檢驗檢查篇
● 血液室
1. CBC必為速件單,生化項目也儘可能以速件開出
2​貧血病童在不確定病因時輸血前請留EDTA管2管及生化管1管後才輸血
3.PT, PTT不從central line抽，盡可能從artery (or vein) 抽
4.若check PT, PTT, fibrinogen時可抽血1.8cc 置於小兒PT, PTT管，一管即可。若
check PT, PTT, fibrinogen, protein C, protein S, antithrombin III時可抽血4.5 cc 置於
大人PT, PTT管，一管即可或小兒PT, PTT管，二管即可。
5.若值班時懷疑凝血疾病時(如hemophilia A,B等)，要留檢體作factor assay時，請抽
PT, PTT管1.8cc兩管，白天聯絡血液室(3017)，晚上聯絡急診檢驗科(2290)，請將檢
體離心後置於-70℃保存。以便日後檢驗factor assay。

● 細菌室
1. Sterile sample(Ex: CSF, blood, urine)的細菌培養，請務必於醫令加註”實驗室檢查注
意事項”如下: (不能只加註在”備註”中)
小兒血液腫瘤科病人： if G(-)請加作 Cefuroxime, Tazocin, Tienam,Timentin,Rocephin,
if G(+)請加作 Cefuroxime, Claforan
2. 血液培養若長細菌，請立即通知總醫師或主治醫師，以立即做藥物review及調整; 並
 請同時通知Infection fellow​,告知細菌室請他們加作第​1​點之​sensitivity test​。
3. 當住院醫師(白班或值班)一旦知道檢體初步發報告”有長細菌”,請住院醫師(白班或值
班)務必立即告知主治醫師或總醫師.(已向各樓層護理長達成協議,請所有住院醫師配
合),並打電話給細菌室,請他們做Sensitivity test ​(ex: urine fungus culture長Candida
albicans​ 須立即打電話給細菌室,請他們Sensitivity test). 住院醫師如遇到細菌室同仁
回覆”不能做Sensitivity test”之情況,請立刻向主治醫師或總醫師反應,以期能立即和細
菌室同仁詢問/溝通/請求協助.

● 血庫及其相關檢查
1. 若病童為thrombocytopenia，小於三個月懷疑neonatal alloimmune
thrombocytopenia，要確定母親血清是否有針對父親血小板的anti-plt Ab, 要先聯絡血
庫羅君瑋醫檢師約時間, (此檢查通常為每星期二下午作), 母親安排至主治醫師門診開
立檢驗單— ​platelet antibody-screening test​ (醫令代碼:66771)

● X光科及核醫
1. 為顧及放射科要求，一般先排放射科imaging studies，再排核醫檢查
2. CT or MRI等imaging studies及bone scan等應先請教閱片醫師的意見 (X光​施​醫師)，
再與主治醫師討論，宜由主治醫師告知家屬，不要逕自直接回答家屬的詢問。
3. 影像檢查除使用power-injection (機器)打顯影劑之檢查(如CT ​angio、 heart MRI​、
renal arterial MRI等)外，其他皆可使用central lin​e；​但年紀較小的病​人，​若無法打上
22號I​C，​則須兩條line以確保顯影劑之流速
4. 轉院病人CT or MRI reading : 1. 請家屬拿外片至4F放射科上傳至PACS, 不需費用
2.若須本院放射科醫師判讀發報告, 需點選”其他” => 資源共享－二次處方醫院
CT,MRI複製片放射科醫師判讀費)
5. Anti-ds DNA 請務必選擇​核醫​檢查，不要勾免疫單​。
6. Neuro-image 請指定​Dr.黃榮貴
● 驗beta-hCG請一律開立”​Total beta-hCG​”, 而非free-beta hCG

輸血篇
1. 備血除開單外，需自己與血庫(分機2230)聯絡， W​5 或假日前要考慮是否先備 platelet (因
備減白PLT需時較久), 以利假日之用，platelet儘量於12:00 am前聯絡
2. 一般輸血 criteria如下:
Hb <8 or Hb <7 g/dL for aplastic anemia
Hb <10 g/dL for R/T patient
Platelet <10×10​3​ /uL for aplastic anemia
Platelet <20×10​3​ /uL for AML or refractory ALL
Platelet <50×10​3 ​/uL有 bleeding 時
1st CSF tap and IT,要儘可能keep platelet ​>​100x10​3​/uL
If UGI bleeding, keep Platelet >75×10​3​/uL
If ICH, keep Platelet >100×10​3​/uL
3. 若是白血病及再生不良性貧血病患需要輸血，因為他們輸血有特殊的處置碼(40326)，所
以請在文字醫囑加上:”​白血病/再生不良性貧血病患需輸血​”，不需要key處置碼，護士就
會知道。(注意！只有​白血病​和​再生不良性貧血​才適用，其他像Lymphoma, solid tumor
等都不需要) (可以copy ​4855快速鍵​：​BT​)
4. 輸血前請記得打Chlorpheniramine(CTM) 1amp/40kg ​or/and Solu-cortef(100) 1amp/40k
以避免輸血反應(一般CTM即可，除非曾經輸血打CTM仍有過敏反應，不確定的話可以
查一下過去輸血的紀錄)。輸完血仍有過敏反應者(skin rash, lasryngospasm)續打CTM,
 or Solu-cortef, or 加Bosmin
5​. ​Suspect acute leukemia的病患未確定診斷前, 若有需要輸血(PRBC or PLT), 輸血前只打
CTM​，​勿打solu-cortef (因用過steroid會影響到ALL診斷。)
6. 備輸Pack RBC ​(1U ≒ 135cc)​原則為：
　 (1) 體重15kg (或接近15kg) 可輸 1U
(2) 體重<10kg者, 則輸 15cc/kg
(3) 計算病人需要輸多少PRBC ：​15cc/kg 預期可使H​b↑3.4單位
　 (4) 輸注時間為​3~4 hrs
(5) 備血時要開​Filter RC-50 (51057)
7. 備輸Platelet 之原則為：
　 (1) 備血小板以​減白血小板為優先​，其次為​分離術血小板(Apheresis PLT)​；
若備不到或緊急要輸，則考慮傳統單袋血小板
(2) 減白血小板以cycle (即PH)為單位，1 cycle = 12 Units 之單袋血小板
(3) 備減白血小板​不需​開filter , 備分離術血小板或傳統單袋血小板則須開​filter:
PL-50 (51058)
(3) 體型較小之病人(BW​≤​10kg) 血小板備法為: ​減白1PH ​雙連袋​，每次輸1/2 PH
(4) 輸血小板需要​full run​ (輸太慢Platelet活性會減低)
8.​ 輸血通常是​扣iv不打Lasix​，需輸血前打lasix以避免fluid overload之情況一般為：
​(1)​ ​HB <7.0 g/dL (需輸血量會較大)
(2) 病人體型較小(BW<15kg)
9. 一般若Hb < 5~6 g/dL，若不是因為急性出血所導致的嚴重貧血，宜先予5cc/kg輸3~4hrs
，可repeat 1~2次，至hemodynamic狀況較穩定，urination ok後，再考慮予較大量之輸
血，同時可併用Lasix，可有效避免heart failure之發生。
10. 原則上輸血後不必常規 recheck Hb and platelet count
11.​ ​注意已備血品之到期日​:
♦ Washed RBC 備血以後24hr到期 (1袋約600元),
♦ Platelet (減白or捐中移除plasma) 3天到期(減白血小板1PH約 7000元)
♦ 血庫移除plasma的血小板是24hr到期
12. 注意病童輸血之特別需求
♦ Washed RBC / 移除plasma的PLT (for 輸血反應嚴重之病人)
♦ 經放射處理(irradiated)之RBC/PLT (for severe aplastic anemia,日後可能需接受移植
之病人)
♦ 血庫目前有raiation 機器，備血時順便問一下是否可放射楚處理。除非emergent輸
血，儘可能放射電血完再輸血

Port-A之使用及照顧
1. 目前使用之Port-A有valve可避免血液回流​，故通常不可抽血。
2. On Port-A 時確認圓盤位置，角針需插到底
3. 病房角針有四種大小：1吋22號(黑,長),1吋20號(黃,長), 0.75吋22號(黑,短), 0.75吋20號
(黃,短)
4. ​Heparin​ lock: 5 cc sterile heparinized saline = 0.1 cc heparin + 4.9 cc Normal saline
5. Occlusion of port-A catheter的處理:
開藥一支​urokinase (60000U)​, 註明for central occlusion, 健保有給付, 取12 cc的N/S將
一支urokinase稀釋成12 cc，抽出2 cc (即10000 u)，然後以緩慢動作打入catheter後，留
置syringe，把silicone clamping sleeve, 用smooth -edged clamp (catheter本身即有)夾住
，保留15分鐘後打開clamp，使用上述heparin solution flash。
若仍不通: 若platelet > 20,000​ ​/uL，此步驟可以在4小時內重複3次
若platelet < 20,000​ ​/uL，此步驟可以在4小時內最多可再重複1次
若通了，則將clamp夾住，馬上用heparin flush來keep catheter通暢。
再不通: 借放射科顯影劑打入port-A, 照CXR確認port-A位置
6.​CT scan & MRI可從port-A給顯影劑​, 不需要特別打一條周邊line (已與放射科施主任討論
確定), 病人下去做檢查前請先接點滴, 確保port-A順暢, ​不要on cap下去做檢查。
7.​CT angiography​ ​&​ ​dynamic MRI不可從port-A給顯影劑​, 需要特別打一條周邊line​。
8.可copy ​4855快速鍵：portao
化療處方及化療藥物篇

#ALL or lymphoma 打MTX 5g/m2 or 2.5g/m2, ​只依照開始打MTX後30hr level 調

整dose, 之後一直打到MTX<0.1μmol/l為止, 中間不再調整leucovorin dose
MTX​ ​Leucovorin
<0.1 normal, MBD
<1.5 15mg/m​2​ q6h
1.5~5.0 30mg/m​2​ q6h
>5 100mg/m​2​ q6h
#Osteosarcoma 打MTX 12~20g/m2, 只依照開始打MTX後24hr & 48hr 的level 調
整dose, 之後一直打到MTX<0.1μmol/l為止, 中間不再調整leucovorin dose
a. Instituted every 6 hours for a minimum of 10 doses beginning 24 hours after
the initiation of MTX infusion.
b. Dosage of leucovorin are adapted to the dose of MTX
​MTX​ ​Leucovorin​ ​minimum dose
12gm/㎡ 15mg/㎡ 10
14gm/㎡ 20mg/㎡ 10
16gm/㎡ 35mg/㎡ 12
18gm/㎡ 50mg/㎡ 14
20gm/㎡ 100mg/㎡ 14
Leucovorin dose一旦往上調整之後,就不再往下調降,直到DC為止.
c. Increase dose of leucovorin in case of delay elimination of MTX
(greater than ​20μmol/l at 24 hr ​and ​2μmol/l at 48hr​)
Dose formula:
​usual leucovorin dose ×observed abnormal level
upper limit of normal MTX level for that day
= 24hrs dose of leucovorin delivered by continuous infusion
e.g.,MTX 12 gm/㎡with a MTX level of 40 μmol/l at 48hr
= ​60mg × 40 ​ = 1,200 mg leucovorin
2
1. 所有neutropenic fever之新病童，入院要check是否有化療藥在化療藥局中未打,若
有請先取消​。
2. 臨時取消C/T或出院時若有未打完的C/T要聯絡退藥
3. 白班與值班醫師均須注意：​加化療藥物時，請務必再check醫囑上的化療劑量和施打
時間。若值班醫師、護士或藥局對用法、dose有疑問時，則務必聯絡總醫師或主治
醫師再做確認。
4. 注射Vincristine之case須 QW1,4 check Na (monitor SIADH)​。
5. 注射Leunase之case QW1,4 check sugar or Dex (monitor hyperglycemia ), 腹
痛要注意acute pancreatitis的可能性 (check Amylase, Lipase), 注意anaphylaxis
及前次注射處是否紅腫​。
6. 注射high dose MTX之case需check Creatinine​。​需注意Leucovorin
dose調整
7. 注射high dose MTX予regular ACT and antihistamine預防過敏反應
8. 注射high dose MTX, 須Hold Bactar for 1 week (2010.11. Dr. Pui ‘s suggestion)
9. 注射Vincristine, Epirubicin, Idarubicin, Mitoxantron, Actinomycin-D​絕不可外漏​,
也不可使用PUMP (詳見化療藥物介紹)
10. 注射Endoxan and Ifosfamide 須注意Hematuria,處理方法參照兒癌血液(II)-I p.44
Management of Hemorrhagic Cystitis​ – 參照11F兒癌血液(II)-1. p44
Microscopic hematuria
1. Transient microscopic hematuria (no more than 2 abnormal urinalyses on 2 separate
days during a course of therapy); no modification of the oxazaphosphorine or Mesna
2. Persistent microscopic hematuria (>2 abnormal urinalyses during a course of therapy)
2-1. Do not modify the oxazaphosphorine dose.
2-2. Change the Mesna to a continuous infusion: 360mg/m​2​ during oxazaphosphorine,
followed by 120mg/m​2​/h for 24hrs

Gross hematuria
Evaluate all episodes of gross hematuria by cystoscopy. Also consider further testing,
such as urine culture, excretory urogram, and voiding cystogram, and perform as
indicated.
1. Transient gross hematuria during or after a course of therapy (only one episode, which
clears to less than gross hematuria)
1-1. Do not modify the oxazaphosphorine dose.
1-2. Change the Mesna to a continuous infusion: 360mg/m​2​ during oxazaphosphorine,
followed by 120mg/m​2​/h for 24hrs. plus hydration​ ≧​ ​ 3000cc/m​2​/day
2. Persistent gross hematuria after completion of a course of therapy
2-1.Hold subsequent oxazaphosphorine until the urine shows less than gross
hematuria.
Reinstitute oxazaphosphorine at full dose, with the Mesna changed to a continuous
​
infusion: 360mg/m​2​ st, followed by 120mg/m​2​/h for 24hrs. plus hydration​ ≧
2​
3000cc/m​ /day
2-2. If gross hematuria dose not resolve to microscopic hematuria or less, withhold
further oxazaphosphorine therapy.
3. Persistent gross hematuria occurring during a course of oxazaphosphorine
3-1. Interrupt the oxazaphosphorine.
3-2. Withhold further oxazaphosphorine until the next course of therapy.
3-3. If the gross hematuria resolves to microscopic hematuria or less, subsequent
courses of oxazaphosphorine may be administered at full dose, with Mesna
changed to a continuous infusion: 360mg/m​2​ during oxazaphosphorine, followed by
120mg/m​2​/h for 24hrs. plus hydration​ ≧​ ​ 3000cc/m​2​/day
4. Occurrence of a second episode of gross hematuria or persistence of microscopic
hematuria on the continuous infusion regimen.
4-1. Continue the oxazaphosphorine when the urine shows less than gross hematuria.
4-2. Double the loading dose of Mesna to 720mg/m​2 ​and the subsequent hourly dose to
240mg/m​2​/h. plus hydration​ ≧​ ​ 3000cc/m​2​/day
4-3. Continue to give Mesna by continuous infusion for 48 hours after the last dose of
oxazaphosphorine.
5. Persistent gross hematuria in the face of the “double dose, continuous infusion”
regimen. Discontinue oxazaphosphorine.
Note: 1. Mesna 可泡在D5W, D5S, N/S or 0.33% G/S 中
2.以上治療gross hematuria 必須配搭至少hydration 3000cc/m​2​/day

止吐藥原則: ​健保目前給付參照(11C網芳小兒血液腫瘤科資料夾/健保規範)
1. Zofran​ (較短效) ：針劑三種劑型(健保8mg/vial、兒癌4mg/vial、兒癌8mg/vial)
Dosage為 ​0.15 mg/kg/dose​ 30 min before C/T, IV infusion 15min
口服則只有8 mg (健,兒癌)
2. Kytril ​(較長效)：針劑四種劑型(健保1mg/vial、健保4mg/vial、兒癌1mg/vial、
 兒癌4mg/vial)
Dosage 為20-40 μ​g/kg qd 30 min before C/T, IV infusion 15 min
口服則只有1 mg (健,兒癌)
3. 一般使用劑量：
Kytril: <15kg: 1mg；15~30kg: 2mg；> 30kg: 3mg
Zofran: < 15kg: 4mg；15~30kg: 6mg；>30kg: 8mg
4. Zofran 在大小孩最高可使用至12mg ivd q6h, Kytril在大小孩最高可使用至4mg ivd
q12h, 打化療中仍嘔吐可互換Zofran or Kytril, 或加上​Decadron ivd (5mg/40mg, q6h )
加強止吐。
5. 使用 Primperan之病童須告知家屬EPS之S/S及處理
6. 兒癌捐贈藥物須勾選”​兒癌​”。常用的為G-CSF, Zofran, Kytril, EMLA等
7. Aloxi (Palonosetron) (0.25mg/5ml) (3164元/vial):
Dosage: 只有成人劑量: 0.25mg/dose 30 min before C/T
8. 化療藥Cisplatin制吐極強，請記得加Decardron。

Tumor lysis 用藥
1. Rasburicase (Urate oxidase) (1.5mg) ​0.1-​0.2mg/kg/dose qd in N/S 50 cc iv drip
30 minutes (扣iv) (健保給付最多3​次​)
# 健保之 indications:​ Uric acid > 8mg/dl in patients undergoing tumor lysis
syndrome(acute leukemia, high-grade lymphoma,請參考中央健保局之”健保給
付規範”)​, 但​不可用於G6PD deficiency病患​因為​Rasburicase​將尿酸氧化成​allantoin​的
過程中，會出現過氧化氫​（H2O2）​的副產物，因此​G6PD​缺乏患者禁止使用此藥品
，以避免引起嚴重溶血反應。
# 若因特殊需要，需增加注射次數，則為自費，盡可能以整支開立處方，以免浪費(開
立此藥務必事先和主治醫師或總醫師check)
2. Ulcerin (Aluminum hydroxide, and Homatropine; 233mg) 100mg/k/day,
(Max:20tab/day) (需搭配食物服用，效果不好)
3. Allopurinol (100mg) 100-500 mg/m​2​/day (oral max: 800mg/day, IV max: 600mg/day)
其他用藥
1. Hypomagnesemia: ​MgSO​4​ (10%, 16meq/20cc, 200mg/cc)
0.2-0.4meq/kg/dose (25-50mg/kg/dose) q4-6hr for 3-4 doses,
Max single dose: 2g(16meq)
Dilute to a concentration of 0.5meq/ml (60mg/ml of MgSO4),
Bolus infusion over 2-4hours : do not exceed 1mEq/kg/hr.
Continuous infusion rate: do not exceed 150mg/min
(Bolus​補法: ​20kg 可補1amp , diluted in MgSO4 cc數10倍的D5W or NS or
0.33%GS 中IV drip 4 hours；目前較常用加在點滴裡continuous drip​ )
*​MgSO4可加在Taita No.5裡drip
2. Potassium phosphate K3PO4​ (​20cc/amp, each ml: K+4.4meq, Phosphate 3mM​):
dilute to max concentration of 0.05mM/ml, max infusion rate: 0.06mM/kg/hr.
不可使用於含Ca溶液
Serum P level 2-2.5mg/dl: 0.08mM/kg/do, run 6hrs
Serum P level 1-2mg/dl: 0.16mM/kg/do, run 6hrs
Serum P level <1mg/dl: 0.24mM/kg/do, run 6hrs
(通常一次只會補1-2cc, 注意單位不是amp)
(通常本科作法為1cc QBT加在點滴裡慢慢補，驗血追蹤調整)
3. Hypokalemia之補充：Max conc. 80 meq/L in peripheral line and 150 meq/L in central
line (Ref：Ped Dosage Book)(08/2010); 可與NaHCO3 or MTX 一併使用
4. Interferon (Intron-A): (自費,一支筆針1800萬U) 5-10萬U/kg/dose qd sc (or equivalent to
300萬U/m​2​/day),但每次須以30萬U為單位,要先請總醫師寫​急用藥申請單
 -->已缺藥; 將改為Roferon-A(300萬U)單次劑型 (08/2010)
5. Cyclosporin (口服水劑soln: 50ml/BT, 100 mg/ml,​ ​9774元) (100mg/cap, 157元)
(25mg/cap, 51元) 8mg/kg/day, div bid, po, 顆粒不用急用藥申請單, ​水劑要先寫急用藥申
請單+急用藥非法定適應症同意書+團隊會議記錄​,
6. VAHS(virus associated hemophagocytic syndrome)之treatment:
依據TPOG HS 2003 之Initial therapy:
(1.) IVIG 1g/m​2​/day for 2 days
(2.) Prednisolone 60mg/m2/day, for 28 days (D1-D28)
(3.) CsA (Cyclosporin) 3mg/kg/day (144元/1 amp), for 21 days (D1-D21)
CsA 泡製法: 每1ml之Cyclosporin稀釋至20~100 ml之D5W或0.9% N/S的玻璃瓶溶液中,
緩慢滴注約2~6小時​。
(4.)​必要時再加上​VP-16​。
7. Glivec(100) 340mg/kg/day PC ​不需​寫事前審查單和急用藥申請單
8. Enoxaparin (LMWH) 20mg/2000u/0.2cc, 60mg/6000u/0.6cc
<2m/o: 1.5mg/k/do q12h, >2m/o: 1mg/k/do q12h
8. 注射排鐵劑Desferal (500) ~50 mg/kg/day in N/S 100 cc iv drip >4hrs (If the infusion time
can be longer, it is much better. ex 24 hrs continuous infusion)
9. 口服排鐵劑
● Deferiprone (L1) (500) ~75 mg/kg/day divided to 3 doses
● Exjade (125) 15-40 mg/kg/day in one single dose
10. As2O3(10) 0.15mg/kg/day in D5W 200cc iv drip >4hrs qd
11. Penicillin V (40萬u) 5萬u/kg/day
12. Slow K (600) (8 mEq) 2-3 mEq/kg/day bid
13. ​Mesna​暴露到氧氣,會形成disulfide form, ​打開後應立即使用, 沒用完的藥品應丟棄​。長期
儲存mesna在plastic syringe室溫12hr後,會形成暗色顆粒且黏稠度改變。

Supportive Care篇
病童有發燒，而經判斷可能有neutropenia，或雖無發燒，但有腹痛及腹部signs，或有循環
不良之癥狀，如cyanosis，則往往可能比有發燒的更為凶險，均應​立即抽血做檢查 (blood
culture, CBC等），並​立刻給予廣效適當之抗生素，不要等CBC驗出來才給抗生素，以免延
誤治療的最佳時機。切勿為了開電腦醫囑而延誤抽血檢查與打抗生素的時間，可先口頭告知
護理人員需要抽的血與抗生素劑量，以在抽完blood culture的同時也可以馬上給予抗生素
，若病房沒有抗生素公藥也務必要求緊急借藥。

Criteria of Neutropenic fever

Neutropenia ：　Absolute Neutrophil Count < 1000/mm3
[​ANC= total WBC X (% of Band + Seg. form)​]
1. 發燒的定義：​耳溫超過39℃或6小時內有兩次耳溫超過38.5℃
2. 若是ANC<200，​耳溫超過38.5℃或6小時內有兩次耳溫超過38℃​，就要進行發燒處理。
3. 若是年齡小於3個月(通常為NBC case)。​耳溫超過38.5℃或6小時內有兩次耳溫超過38℃
，就要進行發燒處理。年齡1個月以上先不要做CSF，1個月以內請call VS決定是否做
CSF。
4. 兒科耳溫槍=腋溫+0.5℃; 耳溫=肛溫,但本科​禁​量肛溫

Orders of Sepsis workup

 1.如當日有CBC data, 則可不用再驗, If mild fever 未達 septic workup 標準, 勿用退燒藥
2.Blood culture X 2 (​原則上為左、右手各一套,必須在檢驗單上註明左手或右手，若有
central line如CVC line，則一套由central line抽，但是含有valve之新型Port-A則通常
無法抽血​)
3.Sterile sample(Ex: CSF, blood, urine)的細菌培養，請務必於醫令加註”實驗室檢查注意事
項”如下:
小兒血液腫瘤科病人： if G(-)請加作 Cefuroxime, Tazocin, Tienam,Timentin,Rocephin,
if G(+)請加作 Cefuroxime, Claforan
4. ​血液培養若長細菌，請立即通知總醫師或主治醫師，以立即做藥物review及調整; 並​請同
時通知Infection fellow​,告知細菌室請他們加作第​1​點之​sensitivity test​。
5.​CBC, DC, RBC, PLT QW1,4 check
6.​Urinalysis (必要時加urine culture), U/C請註明「​為小兒血液腫瘤病人, mix菌種請加作鑑
定​」
7.BP monitoring stat & q4h
8. ​(remission and ANC<500時) 給予G-CSF，或再請教CR及VS
9.視臨床狀況,必要時做Chest X-ray, plain abdomen imaging studies
10.​一般退燒只用 ACT​，勿用voltaren塞劑及Clofon im，並少用Ibuprofen (影響血小板功能)
11.若需要做​Stool culture 不可用 swab 只用 fresh stool
12.所有培養檢驗單,包括blood culture, urine and stool culture, fungal culture,診斷欄上都必
須註明病童之診斷如leukemia, lymphoma, neuroblastoma, etc…
13.詢問主治醫師是否停止化療
14.抗生素選擇: ​第一線: Cefuroxime + Amikin (ANC<200者再加Tazocin) ,
#fever有超過三天者, 可另加 Tazocin,
#fever 持續4-7 days應重新作sepsis workup, 加抽F/C, 加antifungal agents.
# Poor renal function or nephrectomy者打Cefuroxime + Tazocin, 勿打
Aminoglycoside
#使用antifungal agents須加驗GOT/GPT, BUN/Cr, Bil D/T, Na/K/Ca, 原則上為st
check, then QW1,4 F/U
15. ​Prophylaxis篇​ (一律自費，會consult social worker補助)
兒癌病童有以下幾種情況必須投予口服​預防性抗生素​和口服​預防性抗黴菌藥物​,以達到有效
預防​菌血症​及​黴菌血症​之風險.
*一旦開始給治療用抗生素,則prophylaxis antibiotics (即Ciprofloxacin, Vancomycin)須DC
*​q14 check BUN/Cr, GOT/GPT, Bil T/D, Na/K/Ca​ (for antifungus agent and Vancomycin)

使用條件
Ciprofloxacin Voriconazol
Disease Indication + e/ Duration
Vancomycin Micafungin
AML Chemotherapy後
ANC​≤​500 + +
預期>7days
Relapsed
ALL, AML, Chemotherapy後
用到ANC自
lymphoblast ANC​≤​500 + + 谷底上升
ic 預期>7days
>300/uL才可
lymphoma DC
 ANC​≤​500
只使用於Re- 預期>7days
+ -
ALL induction結
束前之階段
ANC<500/uL
已達7天 + +
ANC​≤​500
Relapsed 預期>7days
+ -
tumor ANC<500/uL
已達7天
+ +

Dosage
vancomycin 400mg/m2/dose q12​h
ciproxin 300mg/m2/dose q12​h
micafungin 1mg/kg/day with max. of 50mg/day
voriconazole 4mg/kg/dose q12h。

出
Prophylactic antibiotics Dosage Maximal dose
處
Ciprofloxacin​(250mg/tab), 7
45元/tab., 需避免與含重金屬之 250 to 350 mg/m​2 ​q12h 1.5g/day
藥物如MgO, Ulcerin等併用

出
Prophylactic antifungal agents Dosage Maximal dose
處
Voriconazole​(200mg/tab) 1685元/tab 2,
# AC or PC 1 hr (空腹吸收最好) 4mg/kg/dose 4,
200mg q12h
# Renal impairment​不需​調整劑量 q12h 6
#和Vincristine併用時Vincristine須減量以減少毒性
Micafungin ​2100​元/​vial
泡法:1 vial 先以N/S or D5W 5ml稀釋成10mg/ml,再
泡在100ml N/S or D5W中iv drip > 1 hour
2mg/kg/day IV 50mg qd
輸注前後均要以N/S沖過IV管路
#​ Renal impairment​不需​調整劑量
# ​Severe hepatic impairment​ :​建議調整劑量
出處:​1.Pizzo 6​th​, 2.Pediatric dosage book 15​th​, 3.藥物圖像, 4.Harriet lane 17​th​, 5.Micromedex, 6.藥物仿
單7. Prophylactic antibiotics reduce morbidity due to septicemia during intensive treatment for pediatric
acute meyeloid leukemia, Cancer 2008, St. Jude Children’s Research Hospital

Antibiotics
請注意病人有無正在使用prophylactic 口服ciprofloxacin 需要DC

Antibiotics Dosage Max dose 出

處
Amikin​ (250) 20mg/kg/day, IV drip, div q12h 1.5g/day 2, 4
Contraindication: Nephrectomy, impaired
renal function, 最近一個月內曾使用數次.
( “Neuroblastoma” alone is not a
contraindication.)
Cefuroxime​ (750) 150 mg/kg/day, slow IV push, div q6h Child: 6g/day, 2, 4
Adult: 9g/day
Claforan ​(250mg, 2g) 150-200mg/kg/day, div q6h 12g/day 2
(Meningitis: 200mg/kg/day)
Colistin ​(Colistimethate Dose is based on​ CMS ​component 3
sodium)(CMS) Pediatric : 4-6mg/kg/day q8h, IV or IM
160mg/vial Adult: 80-160mg q8h
(Colimycin 66.8mg/vial) Liver impairment:不需調 dose
*注意開order時的單位, Renal impairment:​ ​Clcr 50-90mL/min: 160mg q12h
電腦上mg指的是 Clcr 10-50mL/min: 160mg q24h
Clcr <10mL/min: 160mg q36h
Colimycin, 但計算是以
CMS為主, 所以單位請
用vial比較方便!
Tazocin​ (piperacillin 2g 本科用法: 400mg/kg/day, div q6h 18g of 2, 4
+ tazobactam 0.25g) Doses based on piperacillin: Tazocin/day
(2.25g) <6m/o: 150-300mg/kg/day
>6m/o: 300-400mg/kg/day
IV drip 30分, div q6h
Oxacillin ​(500) 150-200mg/kg/day, IV drip, div q6h 12g/day 2
Targocid​ (teicoplanin) 10mg/kg/dose q12h X 3 doses, then 400-600 6
(200) 10mg/kg/dose qd, IV drip 30分 mg/dose,
>60kg者以
600mg
Tigecycline​(50mg/vial) Adult : 100mg stat , then 50mg q12h iv drip 3
Liver impairment :
Mild不需調 dose
Severe : Initial 100mg, then 25mg q12h
Renal impairment 不需調 dose
Vancomycin​ (500) 60mg/kg/day, IV drip 1 hour, div q6-8h Child: 1g/dose 1,
Adult: 4g/day 2, 4
Tienam​ (Imipenem 60mg of imipenem/kg/day IV drip 30分, div 4g/day 2
500mg + Cilastatin q6h
500mg) (500)
Meropenem​(500) 40mg/kg/dose q8h, IV drip 30分 2g/dose 2
Adjust in renal impairment:
1. CCr 26-50: administer every 12 hours
2. CCr 10-25: one- half dose , administer every 12
hours
3. CCr <10: one-half dose, administer every 24
hours
Metronidazole​ (SABS) 15mg/kg/dose loading , then 30mg/kg/day, 4g/day 2,
(500mg/100cc) div q6h, IV drip 30分 4, 5
Ceftazidime (Fortum) 150mg/kg/day IV drip div in q8h 6g/day 2, 4
(1g) Adjust in renal impairment:
1. CCr 30-50: administer every 12 hours
2. CCr 10-30: administer every 24 hours
3. CCr <10: administer every 24-48
 hours
Cleocin​ (300mg/amp, 30-40mg/kg/day, IV drip, div q8h IV: 4.8g/day 2, 4
150mg/cap) 15-30mg/kg/day, po, div q6-8h PO: 1.8g/day
Cefepime​ (500) 150mg/kg/day div q8h, slowly IV drip 6g/day 2, 4
30min
Cefpirome(1g) Child:60mg/kg/day, iv q12h 4g/day 3
Adult:1-2g per dose iv q12h
Adjust dose in renal impairment:
CCr>50: normal dose
CCr20-50: LD 1g, then 50% dose
CCr<20: LD 1g, then 25% dose
Ciprofloxacin​ (100) 30mg/kg/day divided in q8-12h, slowly IV 1.2g/day 2
drip 60分
Linezolid ​(600/300ml) IV infusion over 30-120mins 600mg/dose 3, 5
1. Uncomplicated skin and skin-structure
infections:
< 5yrs: 10mg/kg q8h for 10-14 days
5~11yrs: 10mg/kg q12h for 10-14
days
≧12yrs: 600mg q12h for 10-14 days
Adult: 400mg q12h for 10-14 days
2. Pneumonia, complicated skin and
skin-structure infections:
0-11yrs: 10mg/kg q8h for 10-14 days
≧12yrs: 600mg q12h for 10-14 days
Adult: 600mg q12h for 10-14 days
3. Vancomycin-resistant Enterococcus
faecium infections(VRE):
0-11yrs: 10mg/kg q8h for 14-28 days
≧12yrs: 600mg q12h for 14-28 days
Adult: 600mg q12h for 14-28 days
Renal impairment: no adjustment
Hepatic impairment: no adjustment
H/D, CVVH: no adjustment

Antibiotics Dosage Max dose 出

處
Augmentin​ (Amoxicillin Adult: 1.2g q6-8h 7.2g/day 3
500 + Clavulanic acid Child: 30mg/kg/dose q6h IV drip
100) (600)
Bactrim​(​Sulfamethoxazol For PCP prophylaxis, doses based on 320mg 2,
e[SMX] 400mg & TMP: 5-10mg/kg/day or 150mg/m2/day div TMP/day 4
Trimethoprim[TMP] 80mg​), bid qW1,3,5 (4#/day)
Trimerin​ (10cc= 1# 1#/16kg/day bid or tid in leukemia induction
Bactrim) (​SMX200mg & 1#/16kg/day, qw1, 3, 5 bid or tid in remission
TMP40mg /5ml Susp,
60ml/Bot )​
Septrin​ (1 vial = 1# 15-20mg TMP/kg/day div q6-8h for PCP 2,
Bactrim) (​SMX400mg & infection for 14-21days 5
TMP80mg, 5ml/Amp​) 1vial(5cc) dilute in D5W to 75-125 cc; run 1.5 hr,
Timentin​ (Ticarcillin 300-400mg ticarcillin/kg/day div q4-6h 18-24g 2
disodium1.5g+Clavulan ticarcillin /day
ate0.1g) (1.6g)
Ertapenem​ (Invanz) 3m/o-12y/o: 15mg/kg/dose q12h 1g/day 2
(1g) Adolescents and adults: 1g qd

出處:1.Pizzo 6​th​, 2.Pediatric dosage book 15​th​, 3.藥物圖像, 4.Harriet lane 17​th​,
5.Micromedex, 6.藥物仿單

Antifungal agents
*一旦使用antifungal agent, 要​qw14 check BUN/Cr, GOT/GPT, Bil T/D, Na/K/Ca

Antifungal agents Dosage Max dose 出

處
Ampheterin-B 0.5-1.5mg/kg/day​ dilute in D5W to 1.5mg/k/day 1,2
(50mg/vial) concentration 0.1mg/ml run 2-6 hrs, qd
708元/vial (for Aspergillus spp. and other
filamentous fungi)
*Ibuprofen syrup 10mg/kg po 30 min
before Ampho-B => prevent chillness
*monitor GOT, GPT, BUN, Cr, Na, K, Ca
QW1,4
AmBisome 3-5mg/kg/day​ dilute in D5W or D10W to 10mg/kg/day 1,2​(
(50mg/vial) 7305元/vial concentration 2mg/ml(大小孩) or p.11
5​)
0.5mg/ml(小小孩), infusion >2 hrs, qd
*Ibuprofen syrup 10mg/kg po 30 min
before AmBisome => prevent chillness
*monitor GOT, GPT, BUN, Cr, Na, K, Ca
QW1,4
Diflucan ​(50mg/cap) 本科用法：300mg/m​2​/day or pediatric dose 1,
90元/cap, 10mg/kg/day div q12h or bid 12mg/k/day 2,
(100mg/50ml/vial) 733 震盪療法: 450mg/m​2​ one dose once daily 3
元/vial =============================== equivalent to
口服和IV dose一樣 # Esophageal candidiasis: 6mg/kg/day on adult doses of
# Oral: with or without day1, then 3mg/kg/day (up to 400mg/day
food 12mg/kg/day) qd at least 3wks; continue
# Parenteral: IV 2wks following resolution symptoms
infusion over 1-2hr # Oropharyngeal candidiasis:6mg/kg/day
(rate: <200mg/hr), on day1,then 3mg/kg/day qd at least
concentration 2mg/ml; 2wks
if doses> 6mg/k/day, # Systemic candidiasis: 6-12mg/kg/day
IV infusion over 2 hrs (minimum duration of therapy:28 days)
# Dose equivalency: # Cryptococcal meningitis:12mg/kg on
pediatric 3mg/kg = day1,then 6mg/kg/day(up
adults 100mg to12mg/kg/day) for 10-12wks after CSF
# Ccr < 50, 減50% is sterile
dose
#和Vincristine併用時
須減少Vincristine劑
量, 因為Azole類會延長
Vincristine代謝 ;
Voriconazole​(200mg/t 2-12 y/o: No Data 2,
ab) LD: 6mg/kg/dose q12h x 2doses, day 1 4,
1685元/tab MD: 4mg/kg/dose q12h​ (​may be increased 6
# AC or PC 1 hr (空腹 to 5mg/kg/dose q12h if needed or reduced to
吸收最好) 3mg/kg/dose q12h if patient unable to tolerate​)
#腎功能異常不需調整 ===============================
劑量  >12y/o​:
#口服生體可用率極高
(96%), 臨床需要時,可 # Invasive aspergillosis / Fusarium /
將IV和PO互換 Scedosporium / and other serious
#和Vincristine併用時 infections:
須減少Vincristine劑 < 40 kg: 200mg q12h x 2 dose
量, 因為Azole類會延 then 100 mg q12h (​may be increased to
長Vincristine代謝; 如 150mg q12h if response is inadequate​)
果DC Voriconazole > 40 kg: 400mg q12h x 2 dose
後,​則至少須間隔5天以 then 200 mg q12h (​may be increased to
上才可給Vincristine  300mg q12h if response is inadequate​)

# Esophageal candidiasis​ (treat for a

minimum 14 days and until 7 days after
resolution of symptoms):
< 40 kg: 100mg q12h
> 40 kg: 200mg q12h
Voriconazole LD: 6mg/kg/dose q12h x 2doses, day 1 No Data 2,
(200mg/vial) 5385元 MD: 4mg/kg/dose q12h 4,
/vial # 1amp 以D/W 19cc 稀釋成10 mg/cc then 6
# Ccr < 50 不建議用iv dilute with NS or D5W (final
form,但可改口服 concentration 0.5-5mg/ml)
#和Vincristine併用時 # IV infusion over 1-2 hr at a rate <
須減少Vincristine劑 3mg/kg/hr
量, 因為Azole類會延長
Vincristine代謝
Posaconazole 大小孩10cc (400mg) po bid 2
(40mg/ml, 105ml/bt) 小小孩 2.5cc (100mg) po bid
# Renal or hepatic # Shake suspension before use
impairment: no # With a full meal or with a liquid
adjustment necessary nutritional supplement
Caspofungin 本科用法：​大小孩50mg/day qd ​(1 vial先 LD: 70mg/day, 2,
(50mg/vial) 10450元 以D/W 10.5cc dilute to 5mg/ml, then in MD: 50mg/day 3,
/vial N/S 100cc run 1hr) (>12y:70mg/da 4
# Do not use diluents 小小孩: 2mg/kg/day y has been
containing dextrose =============================== used in patient
# liver function 2-11 y/o​: not clinically
impairment: decrease # loading dose (LD): 70mg/㎡/day responding to
daily dose to 35mg # Maintenance dose (MD): 50mg/㎡/day 50mg/day)
qd
>12 y/o:
# LD: 70mg/day
# MD: 50mg/day qd
#藥物圖像Aspergillosis: LD:1.4mg/kg/day,
MD: 1mg/kg/day
Micafungin ​2100​元
/​vial 2mg/kg/day IV 50mg qd
泡法:1 vial 先以N/S or
 D5W 5ml稀釋成
10mg/ml,再泡在
100ml N/S or
D5W中iv drip > 1
hour
輸注前後均要以N/S
沖過IV管路
#​ Renal impairment​不
需​調整劑量
# ​Severe hepatic
impairment​ :​建議調整
劑量
出處:1.Pizzo 6​th​, 2.Pediatric dosage book 15​th​, 3.藥物圖像, 4.Harriet lane 17​th​,
5.Micromedex, 6.藥物仿單

Antiviral agents

Antiviral agent Dosage 出處

Acyclovir HSV​: 2, 3,
(250mg/vial) 1046 # Oral: children: 1000mg/day (Max: 80mg/kg/day) div 4
元/vial, 3-5doses/day for 7-14days, adult: 400mg pid for 7-14days
(200mg/tab) 31元 # IV: <12y, 30mg/kg/day div q8h for 7-14 days
/tab >12y, 15mg/kg/day div q8h for 7-14 days
# Oral absorption: (本科用法:1500mg/m​2​/day div q8h for 7–14 days)
15%–30%  HSV prophylaxis:
# Dilute with N/S,
concentration  # IV: 750 mg/m​2​/day div q8h during risk period
less than 5
mg/ml, IV # PO: 600–1000mg/day div 3–5 times/day during risk period
infusion for 1 hr (Max: 80mg/k/day not to exceed 1g/day)
#​滴藥前bag須充分 VZV or Zoster:
搖勻,注意結晶  # PO: 250–600mg/m​2​/dose, 4–5 times/day
#要IV hydration, # IV: <1y, 30mg/kg/day div q8h for 7-10 days
不可on cap >1y, 30mg/kg/day (or 1500mg/m2/day) div q8h for 7-10
days
Tamiflu # Children>1y, <12y: 2
(75mg/cap) 103元 <15kg: 2mg/k/dose (Max 30mg) bid for 5 days
/cap >15-23kg: 45mg bid for 5 days
>23-40kg: 60mg bid for 5 days
>40kg:75mg bid for 5 days
# Children >12y: 75mg/dose bid for 5 days
Ganciclovir Congenital CMV infection (neonate and infant): 12mg/kg/day 1, 2,
(500mg/vial) div q12h for 6wk 4
1808元/vial Other CMV infection (children and adult): Induction:
#要IV hydration, 10mg/kg/day div q12h x 14-21 days, Maintenance: 5mg/kg qd
不可on cap for 7days/wk or 6mg/kg qd for 5days/wk
(1.)先加D/W 10ml dilute to 50mg/ml (只置室溫可保存12hr), (2)
再以N/S,LR, D5W dilute to 10 mg/ml iv drip > 1hr (請放在冰箱
 下層可保存24hrs)
Valganciclovir 15-18 mg/kg/day bid po with meal 1,2
(450)
Ribavirin​ (6g) 1 BT dilute in D/W 300 cc inhalation 18 hr qd​ x 3 days or
1 BT dilute in 100 cc D/W inhalation dividing to 3 doses (
30 cc, 30 cc , 40 cc )每次inhalation 2 hrs qd​ x 3 days
出處:1.Pizzo 6​ , 2.Pediatric dosage book 15​th​, 3.藥物圖像, 4.Harriet lane 17​th​,
th​

5.Micromedex, 6.藥物仿單

※RSV infection治療:
Palivizumab (Synagis, 50mg/vial) 治療用法: 25~30mg/kg/dose, repeated in 10~21 days
(泡法: in 10cc distilled water ​ivd​ for 10 mins, 泡好後靜置至少20分中等泡沫消失)
參考資料: (1) St. Jude Children’s Research Hospital, Sept. 2006, “​Guidelines for RSV
Prevention, Prophylaxis and Treatment in Immunocompromised Patients”​ ; (2) Pediatric
dosage book 17​th

※CMV infection治療:
*Retinitis: Ganciclovir + Cytotec (CMV-IVIG):
Cytotect (5g/50cc), 自費34,526元, 用法: 250-500 mg/kg/day qd x 5 days, then qod 至多5
doses
其他CMV infection: Ganciclovir為主

常用公式

√​
​Body surface (m​2​) ​=​ 〔BH (cm) x BW (kg)/3600〕

GFR = ​δ​ x height (cm)​/​ Cr (plasma)

​Proportionality Constants (​ δ ​) :
Age Group δ
Low birth weight infants, age < 1 yr 0.33
Term infants, age < 1 yr 0.45
Children, ages 2-12 years 0.55
Girls, ages 13-21 years 0.55
Boys, ages 13-21 years 0.70

Lab data: normal range:

NB Child Reference
P 4.2-9 6w/o-19m/o:3.8-6.7 2
19m/o-3y/o:2.9-5.9
3y/o-15y/o:3.6-5.6
>15y/o:2.5-5
Uric acid <7 Male:3-7 2,3
Female:2-6
Cr <0.7 ≦​1y/o: ​≦​0.6 1,2
1y/o-15y/o:0.5-1.5
 LDH 290-501 units/L 110-144 units/L 3

References from​ http://www.hosp.uky.edu/Clinlab/report.pdf

4855的快速鍵(參考用):
1. BMAF: fresh case bone marrow aspiration (leukemia !)
2. BMAB: fresh case bone marrow biopsy
3. GSedation: dormicum ketamine anexate
4. PortAO: port A occlusion
5. B/CG: green patient blood culture (including fungus culture)
6. GFever: green patient fever
7. AMLSTAIN: Combined esterase and peroxidase stain
8. IVFALT: 0.45G/S + 2*D50W / Taita No.5交替run