COMFORT B SCORE The Comfort B score indicates a child’s level of pain and sedation. Step 1: stimulate the patient: touch to the torso or score following general nursing Step 2: watch for 5 minutes to assess how your patient responds to the stimulus and then assess them using the 6 categories. (If patient ventilated use the Respiratory Response category, if not ventilated use the Cry category) Step 3: Sum numbers in each category to produce the overall Comfort B score Alertness 1. Deeply asleep 2. Lightly asleep 3. Drowsy 4. Fully awake and alert 5. Hyper alert Calmness/ Agitation 1. Calm 2. Slightly anxious 3. Anxious 4. Very anxious 5. Panicky Respiratory Response (Ventilated) 1. No coughing/ no spontaneous ventilation 2. Minimal assistance from ventilator 3. Occasional cough, splinting or resistance to the ventilator 4. Actively breathes against the ventilator or coughs regularly 5.Fights ventilator, cough, gag or choking Cry (Non-ventilated) 1. Quiet breathing, no crying 2. Sobbing or gasping 3. Moaning Physical Movement 1. No movement 2. Occasional, slight movement 3. Frequent, slight movements 4. Vigorous movement limited to extremities 5. Vigorous movement including torso and head Muscle Tone 1. Muscles totally relaxed, no muscle tone 2. Reduced muscle tone 3. Normal muscle tone 4. Increased muscle tone and flexion of fingers and toes 5. Extreme muscle rigidity and flexion of fingers and toes Facial Tension 1. Facial muscles totally relaxed 2. Facial muscle tone normal, no facial tension evident 3. Tension evident in some facial muscles 4. Tension evident throughout facial muscles
therapy, give nasopharyngeal CPAP (NCPAP) of cm H2O. If the child is becoming tired on NCPAP, consider endotracheal intubation and mechanical ventilation using pressure support. When a child is ventilated, a pCO2 of 60-80 mmHg (pH 7.10-7.20) is often appropriate. See the advice about ventilation in the entry on Asthma. Antibiotics should not be given routinely. If the neutrophil I/T ratio is high or PCT >2ng/ml, take cultures and give penicillin (or flucloxacillin) gentamicin. Check blood glucose in an infant who presents with apnoea. If there is apnoea, fever and PCT >2ng/ml, consider lumbar puncture when safe to do so. A trial of nebulised adrenaline and dexamethasone may be useful for children with severe bronchiolitis. Give adrenaline 1% 0.05ml/kg diluted to 6ml plus dexamethasone 0.6mg/kg stat then prednisolone 1mg/kg 8 hourly. Adrenaline may worsen V:Q matching and causes tachycardia, so monitor closely and stop if worsens BRONCHOALVEOLAR LAVAGE Equipment Combicath, simple dressing set, 10ml syringe, sterile saline, drawing-up needle, sterile scissors, mask, gloves, hat. Measure the distance from the patient's xiphisternum to the tragus (ear), then to the outer end of the endotracheal tube. If the total distance is less than 35cm, use a Combicath 58223.19 (short), and if it is 35cm or more use a Combicath 58229.19 (long). Procedure 1. Use a sterile technique (scrub, gloves, mask, hat). 2. Pre-oxygenate the patient. 3. Insert the Combicath through a valved swivel connector (Bodai) and into the endotracheal tube until it is gently wedged. 4. While keeping the white outer protective sheath wedged, pull back the clear inner cannula 0.5 cm so you can remove the 5cm grooved tube that is between the end of the white protective sheath and the end of the clear inner cannula.
the first. All aspects of DBD can be performed by the treating intensivist. Management of haemodynamic instability secondary to brain death Brain death can lead to a neuro-humoral response leading to profound circulatory instability which can last hours. Diabetes Insipidus, loss of sympathetic tone, hypothermia and lost pituitary function contribute to this. Diabetes Insipidus – Vasopressin 2-5 units in 1litre of fluid: replace urine output + 10% per hour OR 1 unit/kg in 50ml at 1-3ml/hr (0.02-0.06 units/kg/hr) Circulatory dysfunction – inotrope and vasopressor (minimum neccessay) as required. Methylprednisolone 15mg/kg. Triiodothyronine (T3) for myocardial dysfunction: based on echocardiographic findings and in consultation with the cardiac intensivist or cardiologist. Maintain normoglycaemia with infusion of 50% dextrose, or an infusion of insulin (0.05-0.1 unit/kg/hr) as needed. Treat coagulopathy with FFP. Give platelets if bleeding due to platelet count <50 x 109 Stable gas exchange (PaCO2 + PaO2 as close to normal as possible); prevent atelectasis (PEEP 5-10 cm + ETT suction); use low tidal volumes to avoid volutrauma. 2. Donation following Circulatory Death (DCD) Main considerations DCD is to be considered for all patients where withdrawal of life sustaining therapies is going to occur. The intensivist, the treating unit consultant and the family must agree on withdrawal of life sustaining therapies first before consideration of organ donation. All units involved must document this in the medical record. Designated intensivist – a second intensivist provides the donation counselling and seeks consent for DCD. Designated officer (representing the hospital) – a number of senior medical staff are registered as designated officers and their consent on behalf of the
Cyclosporine Calcineurin inhibitor Solid organ transplant, GVHD, KD, lupus nephritis, nephrotic syndrome Inhibit T cell activation Infection, malignancy, HT, nephrotoxic, liver toxic, seizure, encephalopathy, BM suppression, TMA, gum hyperplasia, hypertrichosis, GI upset Daclizumab Anti-IL-2 receptor (anti-CD25) antibody Multiple sclerosis Liver toxic, autoimmune hepatitis, immune-mediated disorder (skin, LN, colitis), seizure, anaemia, lymphopenia, allergic reaction, infection, fever Eculizumab anti-C5 monocloncal antibody PNH, atypical HUS, thrombotic microangiopathy post-BMT Binds to C5 preventing haemolysis and coagulation Major: headache, thrombocytopenia, leukopenia, haemolysis, GE complaints, infections, fever & chills, asthenia, oedema, oral herpes, URT infections, anaphylaxis, skin reactions, myalgia Etanercept Anti-TNF JIA, idiopathic pneumonia syndrome, KD, FMF Infection, malignancy, rash, allergic reaction, injection site reaction, heart failure, CNS demyelination Infliximab Anti-TNF JIA, KD, IBD Infection, malignancy, cytopenia, rash, heart failure, hepatitis, CNS demyelination, infusion reaction Mycophenolate mofetil Mycophenolate mofetil is an ester prodrug that is hydrolyzed to the active immune suppressor mycophenolic acid (MPA). MPA inhibits the activity of inosine monophosphate dehydrogenase, a key enzyme in the de novo pathway of guanosine nucleotide synthesis in B and T that slows their proliferative response Solid organ transplant, lupus nephritis hyperlipidaemia, cytopenia, GI upset, infection, malignancy
standard nasal prong therapy, or mask oxygen if preferred. There is no need for a prolonged weaning process, either be on humidified high flow, or standard low flow. PERTUSSIS Pertussis (whooping cough) usually presents as episodes of severe, prolonged coughing, but may present as apnoea in young infants. A whoop (loud stridor on inspiration after a paroxysm) is rare in children <6 mo old. Patients often appear well between paroxysms; persistent respiratory distress suggests that there is pneumonia. Mortality is highest in very young infants, and with a white cell count >100,000 (especially neutrophils >50,000). Diagnosis is by immunofluorescence or PCR of nasophayngeal aspirate. Severe illness may be associated with circulatory failure (from pulmonary hypertension), respiratory failure (often pneumonia), and encephalopathy with coma or convulsions (probably from hypoxic-ischaemic injury). 1. Give clarithromycin 7.5 mg/kg/dose 12H for 7 days oral or NG. If parenteral treatment is required, give azithromycin 15 mg/kg (max 500 mg) IV day 1, then 5 mg/kg (max 200 mg) daily for 7 days. Treat contacts if they are not fully immunised and either <12 mo old, or chronic cardio-respiratory illness, or in last month of pregnancy. 2. Oxygen therapy is often indicated even though the child is well oxygenated between paroxysms; reduces cyanosis during paroxysms of coughing. 3. There are copious thick secretions, and effective suctioning is very important (particularly after intubation). 4. In severe disease, consider giving methylprednisolone. 5. Humidified high flow or Nasal CPAP may be helpful for apnoea (but may stimulate coughing paroxysms). 6. Pulmonary hypertension may cause severe circulatory or respiratory failure; it may be caused by leukocyte aggregates in pulmonary vessels. If there is
Proliferation signal inhibitors (MTOR inhibitors) Inhibit T cell activation via a different pathway to Calcineurin inhibitors Not commonly used immediately post transplant due to poor wound healing Sirolimus 3 mg/m2 stat then 1mg/m2 daily oral, Poor wound healing Oral ulcerations Dyslipidaemia Oedema Lung toxicity Pleural effusions Cytopaenias Nephrotoxicity Everolimus Dependent on trough Blood levels Usual Adult dose 1.5mg-3mg BD Heart: No cyclosporin No Tacro: With cyclosporin With Tacro: Levels after 4 days of dose ∆ Poor wound healing Acne Mouth ulcers Pleural effusions Corticosteroids Methylprednisolone Heart: starting 10mg/kg/dose BD Liver:: starting 2.5mg/kg/dose (max 25mg) IV 6 hourly tapering to 1mg/kg/dose (max 10mg) IV 12 hourly. Then: None Weight gain Hypertension Hyperlipidaemia Osteopenia Hyperglycaemia Poor healing Salt/water retention Prox. myopathy
Azathioprine, 143, 190 Bernoulli, 32 Bicarbonate, 94 Bidirectional shunt, 31 Bites, animal or human, 16 Blalock shunt, 31 Blood culture, 180 Blood gas, 40 Blood groups, 115 Blood transfusion, 115 Brain injury, hypoxic, 124 Brain injury, traumatic, 117 Bronchiolitis, 26, 163 Bronchoalveolar lavage, 27 Burns, 163 Bypass, 31 Calcium, 179 Carbon monoxide, 29 Cardiac Admission, 34 Arrhythmia, 50 Atelectasis, 44 Fluids, 36 High risk, 34 Muscle relaxants, 38 Post-op, 34 Pump blood, 39 Cardiac arrest, 124, 163 Cardiac index, 32 Cardiac, 34 Cardiomyopathy, 68, 143 Cardiopulmonary bypass, 31 Catecholamines, 128 Catheter gauges, 144 Catheters, intravascular, 70 Cavo-pumonary shunt, bidirectional, 31 Cellulitis, 16 Cellulitis, orbital, 15 Cellulitis, periorbital, 15 Cerebral oedema, diabetes, 95 Cervical spine, 73, 121 Chest drain, 73 Child abuse, 145 Cholangitis, 15 Coma, 75 Convulsions, 76 Cooling blanket, 108 Coroner, 85 Cross-clamp time, 31 Croup, 78 Cryoprecipitate, 115 Culture, blood, 180 Cyanide, 29 Cyclosporin, 143, 190 31 Death, 81 Dexamethasone, 78 Diabetes, hyerosmolar nonketotic, 96 Diabetes, ketoacidosis, 92, 163 Diphtheria, 127 Disaster, 97 Diuretic therapy, 101 Dobutamine, 179 Donor coordinator, 85 Drowning, 124, 163 ECMO, 102, 104, 179 Ejection fraction, 32 Electrolytes, 111
Endotracheal tubes, 106 Epiglottitis, 107 Escharotomy, 29 Eucalyptus oil, 171 External disaster, 97 Extracorporeal membrane oxygenation, 102 Feeding, 149 Fever, 108 Filtration, 109 Fluid therapy, 111 Fontan procedure, 31 Foreign body, 163 Fractional shortening, 32 Fractures, compound, 16 Fresh frozen plasma, 115 Frusemide, 101 Gastric lavage, 170 Gauges – catheter, needle, 144 Giardiasis, 15 Haematology, 115 Haemofiltration, 179 Head injury, 117 Heart transplant, 190 Heart valve donation, 89 Heparin, 37, 71, 136, 180 Hepatitis b, 127 Herpes simplex, 15 Hydrochlorothiazide, 101 Hydrocortisone, 179 Hyperosmolar nonketotic diabetes, 96 Hypoglycaemia, 95 Hypoplastic left ventricle, 57 Hypothermia, 118 Hypoventilation, 45 Hypoxic brain injury, 124 I/T ratio, 115 ICP catheter, 119 Immature to total neutrophil ratio, 115 Immunization, 127 Immunoglobulin, 143, 179 Impetigo, 16 Infant feeding, 149 Inotropes, 128 Intracranial pressure catheter, 119 Intravenous fluids, 111 Ipecac, 170 Ipratropium, 23 Iron poisoning, 171 Kawashima, 31 Ketamine, 25 Konno, 32 L- transposition, 65 Lactate, 34 Laryngeal mask, 106 78 Lavage, bronchoalveolar, 27 Left ventricle, hypoplastic, 57 Lipid emulsion rate, 151 Liver failure, 163 Liver transplant, 191 Lumbar puncture, 134, 136 Magnesium, 24 Measles, 127 Meningitis, 134, 136 Meningococcal infection, 136 Meningococcus, 15, 127, 136 Methylprednisolone, 23, 24 Midazolam, 76 Mumps, 127
Myocarditis, 143 Neutrophil ratio, 115 Non-accidental injury, 145 Nonketotic diabetes, 96 Normal values, 146 Norwood operation, 32 Nutrient solution rate, 151 Nutrition, 149 Nutriton, requirements, 160 Orbital cellulitis, 15 Organ donation, 83 Osteomyelitis, 16 Otitis media, 16 Oxygen dissociation, 154 Oxygen satn, venous, 34 Oxygen shunt diagram, 154, 155 PA band, 59 Paediatric emergency transport, 160 Paediatric index of mortality, 167 Paracetamol, 108 Paracetamol poisoning, 171 Periorbital cellulitis, 15 Peritoneal dialysis, 112 Peritonitis, 15 Pertussis, 16, 127, 158 PETS, 160 Phenobarbitone, 76 Phenytoin, 76 PIM, 167 Plasmafiltration, 180 Platelets, 115 Pneumococcus, 127 Pneumonia, 16 Pneumothorax, 73 Poisoning, 163, 170 Poisoning, snakebite, 183 Polio, 127 Post-op cardiac patient, 34 Potassium, 35, 94 Prednisolone, 78, 143 Primene amino acid soltn, 151 Pulmonary atresia, 60 Pulmonary hypertension, 158 Purpura fulminans, 136 Pyridoxine, 76 Quality of care, 167 Rastelli, 32 Registrars, 178 REV procedure, 32 Rhabdomyolysis, 145 Ross, 32 Rubella, 127 Salbutamol, 23 Salicylate poisoning, 171 Seizures, 76 Senior registrars, 178 Sepsis, 136, 179 Septic shock, 163 Septicaemia, 16 Shunt diagram, oxygen, 154 Shunt, Blalock, 31 SIDS, 124 Snakebite, 163, 183 Somatosensory evoked potentials, 123, 125 Spironolactone, 101 Splenectomy, 187 Standardised mortality rate, 167 Status epilepticus, 76 Stroke index, 33