HISTORY ELECTROLYTE SOLUTIONS

 General data IVF Glu Na Cl K Ca HCO3

 Chief complaint D5W 5mg/L
 PMHx D10W 100mg/L
o HPN, DM, BA, FDA, Malignancies 0.9 NSS 154 154
o Previous Hospitalization, Accidents, Surgeries, Blood Transfusion reactions D5LR 130 109 4 3 28
 FHx D5NM 40 40 13
o HPN, DM, BA, TB, CA D5NR 140 98 5
 PSHx D5 0.9
o Occupation, NANS (Non Alcoholic and Non smoker) 50 mg/L
NaCl
o Packs per year: D5NMK 50 mg/L 40 40 30
1 pack = 1 year = 20 sticks
e.g. 2 packs per day started at 18 yo (age is 26)
2 x 8 years = 16 pack years IVF Na Cl K HCO3 Ca Mg
e.g. 3 sticks per day started at 18 yo (age is 26) ECF 142 103 4 27 5 3
3/20 sticks/pack = 0.15 D5LR 130 109 4 28 5
0.15 x 8 years = 1.2 or 1-2 pack year D5 0.45 77 77
o Shots/glass per sitting, Bottles per day, days per week 3% NaCl 513 513
e.g. 8 shots of whiskey per sitting, 0.9 NaCl 154 154
5 glasses of beer per day in 3 days per week D5W Osm = 278
 OBHx D5W Osm = 556
o MIDAS (Menarche, Interval, Duration, Amount, Symptoms) D5LR Osm = 130
o Coitarche NaHCO3 = 446
o Menopause
o OCP, S/P, PAP, Intermenstrual bleeding
o Postcoital bleeding
o OB Score
o LMP, EDC, AOG
o PNCU
o HBsAg/VDRL
o TT/BT/MTV
o UTI

PHYSICAL ASSESSMENT MECHANICAL VENTILATION

Awake, coherent, ambulatory, not in CPD / wheelchair bound, stretcher bound, per Indication for Intubation
mother’s arm. 1. Impending respiratory failure, apnea
AS (anicteric sclerae) PC (Pinkish Conjunctivae) PERRLA 2. RR >35
Non hyperemic, Non-enlarged tonsils, NCLAD (No Cervical Lymphadenopathy) NNVE 3. PaCO2 > 50
(No Neck Vein Engorgement) 4. PaO2 <60
SCE (Symmetrical Chest Expansion) CBS (Clear Breath Sounds) 5. TV < 3-5 ml/kg
AP (Adynamic Precordium) NCRRR (Normal CR, Regular in Rhythm) 6. VC < 10-15 ml/kg
Soft non-tender abdomen 7. Inspiratory force < 25 cm H20
GNE (Gross Normal Extremities) CRT (Capillary Refill Time) of < 2 sec 8. FEV < 10 ml/kg
9. Vq / Vt > 0.6
DRE (DIGITAL RECTAL EXAM) FINDINGS 10. To deliver high FIO2
(-/+) External Mass 11. Absent
GST (Good Sphincter Tone) 12. pH <7.35
Full/Empty Rectal Vault (feel for fecal material or any mass) VENTILATOR SETTING
If with mass: 1. TV: 6-8 ml/kg (ARDS) 8-10 ml/kg
4x4 cm mass @ 4 o’clock position, tender/nontender, movable/non-movable, 2. Pale: 6-20
prostate enlarged/non-enlarged(for males only please), tender/nontender 3. Mode: AC (Assist Control)
(-/+) stool/blood on examining finger / blood streaked stool if both 4. SIMV (Synchronized Intermittent 1 mV)
5. FIO2
S-O-A-P 6. PEEP 5cm H20
S (Subjective):
INDICATIONS FOR WEANING
 fever, headache, , cough, DOB, abdominal pain vomiting, bowel/urinary
1. Mental status: Awake, Alert
changes, sleep, appetite
2. PaCO2 > 60 mmHg w/ FIO2 < 50%
O (Objective)
3. PEEP < 5 cm
 Vital signs, PE
4. PaCO2 < pH acceptable
A (Assessment)
5. Spontaneous TV < 5mL
 Impression, T/C, diagnosis
6. VC > 10 ml/kg
E.g. Lacerated wound, Post Appendectomy
7. MIP > 25 cm H20
P (Plan)
8. RR < 30/min
 Management, drug prescription, procedures, health teachings
9. Rapid shallow breathing index < 100 (RBI)
 Referral to other department, scheduling of operation 10. Stable vs. Ft a 1-2 hours
E.g. TT 0.5 mL deep IM R deltoid
HTIG 250 ml deep IM L deltoid Spontaneous Trial
E.g. Removal of suture with dressing FIO2 room air 21%
Advised O2 via nasal prong = # LPM x 0.4 x 20
 HISTORY ELECTROLYTE SOLUTIONS
 General data IVF Glu Na Cl K Ca HCO3
 Chief complaint D5W 5mg/L
 PMHx D10W 100mg/L
o HPN, DM, BA, FDA, Malignancies 0.9 NSS 154 154
o Previous Hospitalization, Accidents, Surgeries, Blood Transfusion reactions D5LR 130 109 4 3 28
 FHx D5NM 40 40 13
o HPN, DM, BA, TB, CA D5NR 140 98 5
 PSHx D5 0.9
o Occupation, NANS (Non Alcoholic and Non smoker) 50 mg/L
NaCl
o Packs per year: D5NMK 50 mg/L 40 40 30
1 pack = 1 year = 20 sticks
e.g. 2 packs per day started at 18 yo (age is 26)
2 x 8 years = 16 pack years IVF Na Cl K HCO3 Ca Mg
e.g. 3 sticks per day started at 18 yo (age is 26) ECF 142 103 4 27 5 3
3/20 sticks/pack = 0.15 D5LR 130 109 4 28 5
0.15 x 8 years = 1.2 or 1-2 pack year D5 0.45 77 77
o Shots/glass per sitting, Bottles per day, days per week 3% NaCl 513 513
e.g. 8 shots of whiskey per sitting, 0.9 NaCl 154 154
5 glasses of beer per day in 3 days per week D5W Osm = 278
 OBHx D5W Osm = 556
o MIDAS (Menarche, Interval, Duration, Amount, Symptoms) D5LR Osm = 130
o Coitarche NaHCO3 = 446
o Menopause
o OCP, S/P, PAP, Intermenstrual bleeding
o Postcoital bleeding
o OB Score
o LMP, EDC, AOG
o PNCU
o HBsAg/VDRL
o TT/BT/MTV
o UTI

PHYSICAL ASSESSMENT MECHANICAL VENTILATION

Awake, coherent, ambulatory, not in CPD / wheelchair bound, stretcher bound, per Indication for Intubation
mother’s arm. 1. Impending respiratory failure, apnea
AS (anicteric sclerae) PC (Pinkish Conjunctivae) PERRLA 2. RR >35
Non hyperemic, Non-enlarged tonsils, NCLAD (No Cervical Lymphadenopathy) NNVE 3. PaCO2 > 50
(No Neck Vein Engorgement) 4. PaO2 <60
SCE (Symmetrical Chest Expansion) CBS (Clear Breath Sounds) 5. TV < 3-5 ml/kg
AP (Adynamic Precordium) NCRRR (Normal CR, Regular in Rhythm) 6. VC < 10-15 ml/kg
Soft non-tender abdomen 7. Inspiratory force < 25 cm H20
GNE (Gross Normal Extremities) CRT (Capillary Refill Time) of < 2 sec 8. FEV < 10 ml/kg
9. Vq / Vt > 0.6
DRE (DIGITAL RECTAL EXAM) FINDINGS 10. To deliver high FIO2
(-/+) External Mass 11. Absent
GST (Good Sphincter Tone) 12. pH <7.35
Full/Empty Rectal Vault (feel for fecal material or any mass) VENTILATOR SETTING
If with mass: 1. TV: 6-8 ml/kg (ARDS) 8-10 ml/kg
4x4 cm mass @ 4 o’clock position, tender/nontender, movable/non-movable, 2. Pale: 6-20
prostate enlarged/non-enlarged(for males only please), tender/nontender 3. Mode: AC (Assist Control)
(-/+) stool/blood on examining finger / blood streaked stool if both 4. SIMV (Synchronized Intermittent 1 mV)
5. FIO2
S-O-A-P 6. PEEP 5cm H20
S (Subjective):
INDICATIONS FOR WEANING
 fever, headache, , cough, DOB, abdominal pain vomiting, bowel/urinary
1. Mental status: Awake, Alert
changes, sleep, appetite
2. PaCO2 > 60 mmHg w/ FIO2 < 50%
O (Objective)
3. PEEP < 5 cm
 Vital signs, PE
4. PaCO2 < pH acceptable
A (Assessment)
5. Spontaneous TV < 5mL
 Impression, T/C, diagnosis
6. VC > 10 ml/kg
E.g. Lacerated wound, Post Appendectomy
7. MIP > 25 cm H20
P (Plan)
8. RR < 30/min
 Management, drug prescription, procedures, health teachings
9. Rapid shallow breathing index < 100 (RBI)
 Referral to other department, scheduling of operation 10. Stable vs. Ft a 1-2 hours
E.g. TT 0.5 mL deep IM R deltoid
HTIG 250 ml deep IM L deltoid Spontaneous Trial
E.g. Removal of suture with dressing FIO2 room air 21%
Advised O2 via nasal prong = # LPM x 0.4 x 20
 ELECTROLYTES CUSHING’S TRIAD
a. Corrected Ca = (40-lbs) x 0.02 + s.Ca 1. Increase systolic BP
b. Corrected Na = Na + RBS mg% - 100 x 1.6 / 100 2. Widened pulse pressure
c. Na Deficit = (140 – actual) (0.6 x BW) 3. radycardia /AbN˚ respiratory pattern
d. K Deficit = (D-A) (0.4 x BW) a. Cheyne Stoke breathing
D = 3.5 cardiac
4.5 non-cardiac HEMORRHAGIC STROKE TRIAD
H20 Deficit = 0.6 x kg BW
1. Papilledema
D = 15 CKD 2. Headache
18 NCKD
3. Vomiting
Actual Na – Desired Na / Desired Na
MEIG’S SYNDROME
GLASCOW COMA SCALE 1. Pleural Effusion
2. Polycystic Ovary / Fibromatosis
EYE RESPONSE 3. Hypoalbuminemia
a. Spontaneous eye opening 4
b. Opens to verbal command 3
c. Responds to painful stimuli 2 DENGUE
d. No response 1 GRADE I
 Fever
MOTOR  Non-specific symptoms
a. Obeys with command 6 o Anorexia
b. Localizes pain 5 o Vomiting
c. Flexion withdrawal 4 o Abdominal pain
d. Decorticate / Flexion 3  (+) Torniquet test
e. Decerebrate / Extension 2
f. No response 1 GRADE II
 Grade I + spontaneous bleeding
VERBAL
a. Oriented 5 GRADE III
b. Disoriented 4  Grade II + severe bleeding + circulatory failure
c. Inappropriate 3
d. Incomprehensible 2 GRADE IV
e. No response 1  Grade III + irreversible shock + massive bleeding

FOUR SCALE ABG COMPUTATION

- Full outline of responsiveness

EYE RESPONSE
a. Eyelids open, tracking, blinking to command 4
b. Eyelids open but not tracking 3
c. Eyelids close but open to loud voice 2
d. Eyelids close but no pain 1
e. Eyelids close with pain 0

MOTOR RESPONSE
a. Thumbs up, fist or peace sign 4
b. Localizing to pain 3
c. Flexion response to pain 2
d. Extension response to pain 1
e. No response to pain or generalized 0
myoclonus

BRAINSTEM REFLEXES
a. Pupil and Corneal reflex 4
b. One pupil wide and fixed 3
c. Pupil or corneal reflex absent 2
d. Pupil and corneal reflex absent 1
e. Absent pupil, corneal and cough reflex 0

RESPIRATION
a. Not intubated, regular breathing pattern 4
b. Not intubated, Cheyne-stoke breath pattern 3
c. Not intubated, irregular breathing 2
d. Breath above ventilation rate 1
e. Breath at ventilation rate, apnea 0
 DOPAMINE COMPUTATION CLASSIFICATION OF PTB
Single strength = BW x desired dose / 13.3 Class 0 Class 1
Double strength = BW x desired dose / 16.6  NO PTB EXPOSURE  HISTORY OF EXPOSURE
 Not infected  Neg. Skin test to tuberculin
Single strength = BW x desired dose / 16.6
Double strength = BW x desired dose / 33.2 Class 2
 TB INFECTION
Cardiac Dose = 5  No disease
Renal Dose = 5-10  Positive reaction to tuberculin test
 No clinical, bacteriologic or radiographic evidence of TB
CT SCAN BLEED VOLUME
Class 3
Given: 58 mm ~ 5.8  TB CLINICALLY ACTIVE
23.3 mm ~ 2.3  Clinical, bacteriologic, or radiographic evidence of current disease

5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) Class 4

= 34.684 - (estimated bleeding volume)  TB NOT CLINICALLY ACTIVE
 History of episode of TB
DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE  Abnormal but stable radiographic findings
 No clinical or radiographic evidence of current disease
a. If the effusion are not bilateral and comparable size
b. If the patient is febrile Class 5
c. If the chest has a pleuritic chest pain  TB SUSPECT
d. If effusion persist despite the diuretics therapy  Diagnosis pending
 TB disease should be ruled out within 3 months
LOCATING MYOCARDIAL DAMAGE
Signs and Symptoms of TB
Anterior = V2-V4 (L) coronary, LAD  Fever
 Night sweats
Anterolateral = I, qV1, V3 – V6, LAD, circumflexes Anteroseptal
 Weight loss
= V1-V4, LAD  Anorexia
 Weakness
Inferior = II, III, aVF, (R) coronary artery  General Malaise

Lateral = I, aVL, V5, V6, circumflex branch of (L) coronary artery Posterior RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB
1. Isoniazid = 5 mg/kg, max 300 mg
= V8 – V9 (R) coronary artery, circumflex artery 2. Rifampicin = 10 mg/kg, max 600 mg
3. Pyrazinamide = 20-25 mg/kg, max 2 g
(R) Ventricular = V4R, V5R, V6R, (R) coronary artery 4. Ethambutol = 15-20 mg/kg

CHEST TUBE THORACOSTOMY

INDICATIONS
JONES
Major:CRITERIA OF RF
 1. Pneumothorax 4. Pleural effusion  Carditis
2. Chylothorax 5. Empyema  Polyarthritis
3. Hemathorax 6. Hydrothorax  Chorea
 Erythema marginatum
TIMING OF TUBE REMOVAL  Subcutaneous nodule
 The timing of tube removal depends on clinical and radiological evidence of
complete expulsion of all contents of pleural cavity with complete expansion of Minor:
the lung  Fever
 Minimal drainage should have occurred over the previous 24 hours (<25 ml/kg)  Polyarthralgia
 When the patient coughs or performs the valsalva maneuver no air leak should  Lab: Inc. ESR / Leukocyte count
ensue  ECG: Prolong P-R interval
 The chest radiograph should confirmed complete expansion of the lung  Elevated anti-streptolysin O, other strep antibody
 The s in the fluid in the tube in the underwater seal bottle should be minimal,  (+) throat culture
relating to the normal negative pressured in the chest during the phases of  Rapid Ag test for Group A
respiration  Strep / result: Scarlet Fever

INDICATIONS FOR CTT Criteria:

 Gross pus on thoracentesis  2 major/one minor and 2
 Presence of organism on gram stain of the pleural fluid  (+) evidence of preceding Group A strep infection
 Pleural fluid glucose < 50 mg / dL
 Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH

LIGHT’S CRITERIA
1. Pleural fluid protein / serum protein > 0.5
2. Pleural fluid LDH / serum LDH > 0.6
3. Pleural fluid LDH > 2/3 the upper limit of normal serum LDH

TRANSUDATIVE VS EXUDATIVE FLUID

Transudative Exudative
SG < 1.012 > 1.020
Protein < 3 g/dL >3 g / dL
FP / SP < 0.5 >0.5
LDH <60% >60%
FLDH/SLDH <0.6 >0.6
Cholesterol <45 mg / dL >45 mg / dL

ACUTE RESPIRATORY FAILURE Refractory Septic Shock

 Septic shock that last > 1 hour and does not respond to fluid or pressure
TYPE I or Acute Hypoxemic Respiratory Failure
administration
 Occurs when alveolar flooding and subsequent intrapulmonary shunt
physiology occurs Multi-organ Dysfunction Syndrome
 Alveolar flooding may be a consequence of pulmonary edema, pneumonia or  Dysfunction of more than 1 organ requiring intervention to maintain
alveolar hemorrhage homeostasis
 Low pressure pulmonary edema
 Defined by diffused bilateral airspace edema BRONCHIECTASIS
 Is an abnormal and permanent dilatation of bronchi
TYPE II Respiratory Failure  Associated with destruction and inflammatory changes in the wall of the medium
 Occurs as a result of alveolar hyperventilation and results on the inability to sized airways often at the level of segmental or subsegmental bronchi
eliminate CO2 effectivity  The dilated airways frequently contain pools of thick purulent material, while
 Mechanism by which this occurs are categorized by impaired CNS drive to more peripheral airways are often occluded by secretions or obliterated and
breath, impaired strength with failure of neuromuscular function in the replaced by fibrous tissue
respiratory  As the result of inflammation it produces airway damage, impaired clearance of
 Reason for diminished CNS drive to breath including drug overdose, brainstem microorganism resulting to vascularity of the bronchial wall increases with
injury, sleep disordered breathing associated enlargement of the bronchial arteries and anastomoses between the
bronchial and pulmonary arterial circulation
Overload Respiratory System due to:
 Increase resistive loads (bronchospasms) INDICATIONS FOR INITIATING HEMODIALYSIS
 Reduced lung compliance (alveolar edema)  Failure of conservative management
 Reduced chest wall compliance (pneumothorax)  Management to relieve
 Increase minute ventilation (pulmonary embolus) a. Pulmonary congestion (unresponsive to high dose furosemide)
b. Severe metabolic acidosis
TYPE III Respiratory Failure c. Severe hyperkalemia
 Occurs as a result of lung atelectasis  BUN >100 mg/dL or creatinine >10mg/dL
 Also called perioperative respiratory failure  Note: For acute renal failure it is best to start dialysis early
 After general anesthesia, decreases in functional residual capacity of
dependent lung units RHEUMATIC ARTHRITIS
Require 4 out of 2 criteria:
TYPE IV Respiratory Failure o Morning stiffness
 Due to hypoperfusion of respiratory muscles in patients in shock, due to o Arteritis of 2 or more joints
pulmonary edema, lactic acidosis, anemic o Arteritis of hands and joints
o Systemic arthritis
o Rheumatoid nodule
o Serum Rheumatoid factor
o Radiographic changes
 DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS
Bacteremia
 Presence of bacteria in blood as evidenced by positive blood culture

Septicemia
 Presence of microbes and their toxins in the blood

SIRS
 Systemic inflammatory response syndrome
 Two or more of the following conditions:
o Fever (oral temp >38˚C) or hypothermia (<36˚C)
o Tachycardia (>90 bpm)
o Tachypnea (>24 bpm)
o Leukocytosis (>12,000/uL) or Leukopenia (<4,000/uL) or > 10% bands  Calculated by adding the score of the 5 factor and can range from 5 – 15
may have a non-infectious etiology
Sepsis CHILD-PVGH Class is either:
 SIRS that has proven or suspected microbial etiology a. Score of 5 – 6
b. Score of 7 – 9
Severe Sepsis
c. Score of 10 or Above
 Similar to sepsis “sepsis syndrome”
 Sepsis with one or more signs of organ dysfunction
Decomposition
Examples  indicate cirrhosis
1. Cardiovascular: Arterial systolic blood pressure <90 mmHg or Mean Arterial  N/A
Pressure ≤ 70 mmHg that responds to administration of IV  CHILD PVGH Score of 7 or more
2. Renal: Urine output <0.5 ml/kg/hr for 1 hour despite adequate fluid
resuscitation Class 8
3. Respiratory: PaO2/FIO2 <250 or if the lung is the only dysfunctional organ ≤ 200  Listing for liver transformation (accepted criteria)
4. Hematologic: Platelet count <80,000/uL or 50% ⭣ in platelet from highest
value recorded over the previous 3 days Hepatic Fibrogenesis
5. Unexplained metabolic acidosis: a pH ≤7.30 or a base deficit ≥ 5.0 meq/L and a  Stellate cell activation
plasma lactate level >1.5 times upper limit of normal for reporting  Collagen production
6. Adequate fluid resuscitation: Pulmonary artery wedge pressure ≥ 12 mmHg or
Central Venous pressure ≥8 mmHg

Septic Shock
 Sepsis with hypotension (arterial blood pressure of ≥ 90 mmHg or
MAP > 70 mmHg

CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY CHILD-PVGH

FRAMINGHAM CLASSIFICATION
CIRTERIA OF CIRRHOSIS
FOR DIAGNOSIS OF CHF
Factor
MAJOR CRITERIA Units 1 2 3
s. BilirubinNocturnal umol
 Paroxysmal /L
Dyspnea <34 34-51 >51
 Neck vein distention mg / dL <2 2-3 >3
s. Albumin
 Rales g/L >35 30-35 <30
 Cardiomegaly g / dL >3.5 3.0-3.5 <3
Protime
 Acute pulmonary edema sec 0-4 4-6 >6
 S3 gallop INR <1.7 1.7-2.3 >2.3
COMPLICATIONS OF ERCP
 Increased Easily Poorly
1. Infection Ascitesvenous pressure (>16 cmH20)
None
 Positive hepatojugular reflux controlled controlled
2. Perforation Hepatic
3. Pneumothorax None Minimal Advanced
encephalopathy
MINOR CRITERIA
4. Bleeding
 Extremity edema
MUSCLE STRENGTH  Night cough
O – No muscular contraction  Dyspnea on exertion
1 – Trace contraction  Hepatomegaly
2 – Active movement with gravity eliminated  Pleural effusion
3 – Active movement against gravity  Vital capacity reduced by one-third from normal
4 – Active movement against gravity & slight resistance  Tachycardia (>120 bpm)
5 – Against full resistance
MAJOR OR MINOR
PULSE VOLUME SCALE Weight loss of >4.5 kg over 5 days treatment
O – Absent
+1 – Thready/Weak
+2 – Normal
+3 – Increased
+4 – Bounding

IDEAL PEAK FLOW

Ideal peak flow: Hg (m) – 100 x 5 (+) 175 (M) (+) 170 (F)

N ≥ 80%
PEFR = Peak flow reading / Ideal peak flow x 100 = %

N ≤ 20%
PEFR variability: Highest reading – Lower x 100 = %
Highest Reading
 GRADING OF MURMURS BLOOD TRANSFUSION
MS
1 – Faint  Please transfuse available unit of patient’s blood type after proper cross
2 – Audible Euphoria, depression, mild confusion, slurred speech, matching
Stage I
disturbance in sleep
3 – Moderately Loud  Please take baseline CP status and vital signs prior to BT
Stage II Lethargy, moderate confusion
4 – Loud with palpable thrill  Initially run BT at 5-10 gtts/min for 30 mins then titrate at 15-20 gtts/min if
Stage III Marked confusion, incoherent speech, sleeping but arousable
5 – Loud with thrill, stet partially off without BT reactions
Stage IV Coma, initially responsive to noxious stimuli, response
6 – Loud with thrill, w/o stet  Mainline to KVO while on BT
 Monitor VS q15 mins while on BT
NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION  Refer for any BT reactions such as fever, chills, dyspnea, hypotension and pruritus
CLASS I  Refer accordingly
 No limitation of physical activity  Thank you.
 No symptoms with ordinary exertion
HUMAN ALBUMIN TRANSFUSION
CLASS II  Please transfuse available unit of 25% human albumin
 Slight limitation of physical activity (+20mg Furosemide) once available
 Ordinary activity causes symptoms  Please take baseline CP status and vital signs prior to transfusion
 Run each unit for 4 hours
CLASS III  Mainline IVF at KVO while on BT
 Marked limitation of physical activity  Monitor VS and CP status Q15 mins while on BT
 Less than ordinary activity causes symptoms  Refer any untoward s/sx accordingly
 Asymptomatic at rest  Thank you.
Or
CLASS IV  Please transfuse available cc of 25% human albumin to run for 4 hours
 Inability to carry out any physical activity without discomfort once available
 Symptomatic at rest
PLATELET CONCENTRATE TRANSFUSION
 Please transfuse available unit of platelet concentrate of patient’s blood
type after proper cross matching
 Please take baseline CP status and vital signs prior to BT
 Transfuse each bag after the other to run each bag by 30 minutes to 1 hour
 Mainline to KVO while on BT
 Monitor VS and CP status while transfusing
 Watchout for any untoward s/sx
 Refer accordingly
 Thank you.

OBSTETRICS & GYNECOLOGY Clearance Labs:

 ECG 12 leads
1st Prenatal Visit  Chest x-ray PA view
1. Prescribe:  CBC, ABO/RH typing, CTBT
 KY jelly #1  Urinalysis
 Surgical gloves 6 ½ #1  Protime
 Glass slides #4  Creatinine, BUM, S. Na, S. K, SGPT, SGOT, FBS, Lipid profile
 Cotton applicator #1  HBSAg

2. Prenatal record

3. Routine labs
 CBC, Plt, ABO/RH typing
 FBS
 Urinalysis, Fecalysis
 Anti-TP, HBSAg
 G/S of vaginal discharge
 UTZ
a. Transvaginal UTZ - <12 weeks AOG
b. Transabdominal UTZ - >12 weeks AOG

Indications:
<20 weeks:
Fetal viability
Fetal baseline biometry

>32 weeks:
Fetal growth monitoring

>37 weeks: Biophysical

scoring Final fetal
presentation
Placental localizatiwith BPP

Aging:
<22 wks – EARLY
>22 wks – LATE
 4. Prescribe MTV Post partum
a. All trimester 1. Iron PP
 Ca + Vit D 2. Mefenamic acid
b. <20 weeks 3. Oxytocin ampule
 Vit B complex 4. Co-amoxiclav
c. >20 weeks 5. Cefuroxime
 MTV + Iron
5. Feminine wash BID Post curette
6. Prenatal milk (PNM) 1 glass BID 1. MTV + Iron
2. Mefenamic acid MONTHS
Prenatal Follow-up 3. Clindamycin 1 January 31
2 February 28
 <28 weeks: q 4 wks
OPD 3 March 31
 28-36 weeks: q 2 wks
4 April 30
 >36 weeks: q weekly
5 May 31
6 June 30
Oral Glucose Tolerance Test: 75 grams
7 July 31
(24-28 wks)
8 August 31
Prescribe:
9 September 30
75 gms glucose solution
10 October 31
Sig: Dissolve ¾ sachet in 200 ml solution of water with 1-5 calamansi
11 November 30
NPO postmidnight
12 December 31

1/7 0.14
2/7 0.29
3/7 0.43
mmol/L to g/dL: Divide by 0.055 4/7 0.57
5/7 0.71
Counting Fetal Movement 6/7 0.86
 Within 2 hours postprandial
 At least 10 kicks
GRADING OF EDEMA
“Absent” Absent or unilateral
Grade 1 Mild: both feet/ankles
Grade 2 Moderate: both feet and lower legs hands or lower arms
Severe: generalized bilateral pitting edema, including both
Grade 3
feet, legs, arms and face

PELVIC EXAM POSTPARTUM ORDERS

 Inspection  Back to room/ward
o Grossly N external genitalia  Full diet once full awake
o Masses, discharges, bleeding  Present IVF to run at 30 gtts/min, D/C if with minimal VB
 Speculum  IVF to ff: D5LR + 10 “u” Oxy to run at30 gtts/min
o Cervix – hyperemic/nonhyperremic; fish mouth deformity/ping pong  Meds:
 IE o Antibiotics
o Cervical dilatation o MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain
o Cervical effacement o Methergin 1 tab TID x 3 days
o Station o Vitamins
o BOW (intact/leaking)  SO:
o Amniotic membrane PROM x days/hours o Monitor VS q 15 min until stable
o Presenting part o Massage uterus prn
 Clinical pelvimetry <20 wks
o Ice pack on hypogastrium >20 wks
o Inlet MTV +xIron
o Perilight 15 min OD MTV + Iron
o Midplane Folic acid
o Routine perineal care Prenatal milk
 Ischial spines o WatchPrenatal milk
out for profuse vaginal bleeding
Calcium + Vit D
 Sacrum o ReferCalcium + Vit D
accordingly
 Sidewalls Vit
o Thank youB complex
o Outlet
 EFW DISCHARGE ORDERS (Normal OB) Tetanus Toxoid Schedule
 BME 50 gms GCT 100 gms OGTT 75 gms OGTT  MGH TT1 First contact or as early as possible
o I (introitus) - admits 2 fingers with
Fasting 105ease/snugly
mg/dL  HomeTT2
Meds Atleast 4 weeks after TT1
o1hC (cervix) – open/closed,; firm, doughy
185 mg/dL TT3 on Sat Atleast
 OPD ff-up 6 months
@ OB service after
clinic withTT2 or duringofnext
photocopy D/Spregnancy
185 mg/dL TT4 IE and At
 Discharge least 1 year
summary c/o after TT3
o2hU (uterus) – level of umbilicus 155 mg/dL
>140 mg/dL 140 mg/dL TT5
 TCB anytime Atleast
if with 1 year
profuse VB,after TT4
HA, blurring of vision, Untoward s/sx
o3hA (adnexae) – firm/fullness; w/ adnexal
140 mg/dL
masses
o D (discharges) – (+) (-); scanty or minimal bleeding
o E (episiotomy) – with blood/well coaptated wound
 RVE
o Intact rectovaginal septum
o Good sphincter tone
 Abdomen
o Inspection: globular/gravid; linea nigra, striae
o Auscultation: NABS
o Palpation: Leopold’s
o FH, FHB R/L
 NSVD ADMITTING NOTES CS ADMITTING NOTES
 Please admit to ROC under the service of  Please admit to ROC under the service of
 TPR q 4 hours and record  TPR q 4 hours and record
 Full diet, NPO once in active labor  Full diet, NPO post midnight
 Labs:  Labs:
o CBC o CBC, APC, CT, BT, PT
o HBsAg o Urinalysis
o Urinalysis  Venoclysis
 IVF: D5LR + 10 “u” oxytocin to run at 10-15 gtts/min  Meds:
 Meds o Cefazolin 500mg IVTT q8H x 3 doses then shift to
o Ampicillin 2g IV ANST if PROM Co-Amox 625mg/tab, 1 tab BID
 SO: o Famotidine 20mg IVTT q8H x 3 doses
o Monitor FHB and progress of labor o Ketomed 30mg IVTT q8H x 3 doses
o Puboperineal shave please o Ketomed 10mg q8H to start if patient is on soft diet
o Inform NROD o Tramadol 50mg IVTT q6H prn
o Will inform service consultant on deck  Inform OR
o Refer prn  Secure signed consent
o Thank you  Abdominoperineal prep please
 Side notes  Request 500cc FWB of patient’s blood type as standby
o T P R BP  Dr. for anesthesia
o Wt  Inform NROD
o LMP  Refer accordingly
o EDC  Thank you
o AOG
o FH
o FHB
o CD
o Effacement
o Station
o BOW
o Leopolds
 Final Dx:
o PU FT del via NSVD/1’LTCS/Rpt CS in cephalic presentation to a live Bb
Girl/Boy with BW: BL: AS: PAOG: OB score:

POST-OP ORDERS POST OP ORDERS (TAHBSO)

 To RR  To RR
 Monitor VS q15 mins until stable  Monitor VS q 15 min, until stable
 NPO x 6 H, then may have sips of CL  Flat on bed x 6 H, then may turn to side
 O2 at 2-3 LPM via nasal prong  NPO x 6 H then may have sips of CL
 Run present IVF @ 30 gtts/min  Present IVF x 30 gtts/min
 IVF to ff:  IVF to ff:
o D5LR + 10 “u” oxytocin x 8 H o D5LR
o D5NM o D5NM + 10 “u” oxytocin x 8 H
o D5LR x 8 H o D5LR x 8 H
 Meds:  Meds:
o Antibiotics  SO:
o Ranitidine (Zantac) 50mg IVTT q8H x 3 doses o MIO q H and record
 SO: o Refer if UO is <30cc/H
o Attach px to O2 at 2-3 LPM via nasal prong o May return blood
o Attach pc to pulse ox o Remove FC @
o MIO q H and record o Apply abdominal binder
o Refer if UO is <30cc/H o Refer PRN
o Remove FC 24H post op o Thank you
o Standby available blood
o Apply abdominal binder NON-STRESS TEST
o Morphine precaution please Test of fetal condition
o Specimen for histopathology
o Watch out for profuse vaginal bleeding, hypotension, tachycardia or any REACTIVE when:
untoward s/sx  At least 2 accelerations of the FHR occurs for at least 15 bpm, lasting for 15 sec
o Refer PRN w/in 20 min period of observation
o Thank you
NONREACTIVE
 May imply that the fetus is acidotic, asleep, or drugs was administered to the
mother
A. EARLY DECELERATION
 Head compression
B. LATE DECELERATION
 Utero-placental insufficiency
C. VARIABLE DECELERATION
 Cord compression ; Fetal distress
 Most common ; Most ominous
 TRANS-OUT CONTRACTION STRESS TEST /
Side notes the ff: OCYTOCIN CHALLENGE TEST
 Stable VS  A measure of utero-placental function
 Able to flex both legs  Contraction induced by using IV oxytocin
 (-) vomiting  Record FHB
 Blurring of vision
POSITIVE
Orders  Consistent and persistent late deceleration (50%) of the FHB in the absence
 May refer back to room of uterine hypertonus or supine hypotension
 D/C O2 and pulse oximeter
 Monitor V/S q 15 min until stable NEGATIVE
 MIO q Hly (+ FC) or shift (- FC) and refer if UO <30 cc/H  @ least 3 contractions in 10 mins, each lasting 40 secs, w/o late
 Watch out for profuse vaginal bleeding, hypotension, tachycardia or any deceleration
untoward s/sx
 Refer accordingly SUSPICIOUS
 Thank you  Inconstant late deceleration patterns

ADMITTING ORDERS (Abdomen) HYPERSTIMULATION

 Uterine contractions occur more frequent than every 2 mins, or lasting
 Please admit to ROC under the service of Dr.
longer than 90 secs, or presence of hypertonus
 TPR q shift and record
 NPO
UNSATISFACTORY
 Labs:
 Frequency of contractions is <3 per minute
o CBC (save serum)
o Serum pregnancy test
o Urinalysis
 IVF: D5LR + 10 “u” oxytocin x 30 gtts/min
 SO:
o For completion curettage on call
o Secure consent
o Pad count at bedside
o Save specimen passed out
o Please prescribe the ff: Nubain, Benadryl, Dormicum
o Refer for profuse bleeding and other untoward s/sx
o Thank you
 HYPERTENSION PRENATAL CHECK-UPS
140/90 mmHg 0-27 wks q 4weeks
28 wks q 2weeks
Proteinuria 29-35 wks q 2weeks
 >300mg/24H urine sample 36 wks and beyond q 1week
 > 1000mg/random sample 6H apart
 1+ = mild proteinuria TETANUS TOXOID
 2+ to 4+ = heavy proteinuruia 0 20 weeks AOG
*Edema DOES NOT validate Preeclampsia 1 1 month
2 6 months
GESTATIONAL HPN
3 1 year
 HPN w/o Proteinuria (after 20 weeks gestation)
4 1 year
 Confirm 12 weeks Postpartum

PREECLAMPSIA STEROIDS
 (+) HPN, (+) Proteinuria after 20th week 1 dose 28-32 wks
3 doses q 2 wks
ECLAMPSIA OGTT at 24-28wks
 (+) convulsions, (+) Preeclampsia

CHRONIC HPN MAGNESIUM SULFATE DOSES

 140/90mmHg Loading dose:
4gms slow IV
SUPERIMPOSED PREECLAMPSIA 5gms each buttocks deep IM
 Inc diastole and systole
 Proteinuria Maintenance dose:5gmsIM/IV q 6hrs
 S/Sx of end organ damage Monitor BP, U/O, DTRs-hyporeflexia
Monitor RR
Triad for Sever Preeclampsia
 Hemolysis MgSO4 drip:
 Elevated Liver Enzyme  1-2gms/hr
 Low Platelet Count 1L = 10gm 🡒 given 100cc/hr
Hypertension Etiology (Williams)  10meq/L (about 12mg/dL)
 Exposed chorionic villi >respiratory depression
 Twin pregnancy (Multiple gestation)  12meq/L
 Vascular disease >respiratory paralysis and arrest
 Family history
Antidote: Calcium gluconate 1g IV

ABORTION FETAL DEATH

THREATENED ABORTION 1. Tobacco-stained amniotic fluid
 Bloody vaginal discharge or bleeding appears 2. Spalding’ Sign
 Closed vaginal os o significant overlapping of fetal skull bones
 Low abdominal pain 3. Robert’s sign
 Bleeding first, cramping follows o Demonstration of gas bubbles in the fetus
4. Exaggeration of fetal spinal curvature
INEVITABLE ABORTION
 Gross rupture of membrane BIOPHYSICAL SCORING PARAMETERS
 Leaking amniotic fluid 1. Fetal Breathing Movements
 Cervical dilatation 2. Gross Body Movement
3. Fetal Tone
COMPLETE ABORTION 4. Reactive FHR
 Complete detachment 5. Amniotic Fluid
 Internal cervical os closes *Perfect Score is 10/10 or 8/8

INCOMPLETE ABORTION CBC repeated at 28-32 AOG HbsAg

 Internal cervical os opens and allows passage of blood 🡒 last trimester
Alpha fetoprotein 🡒 16-18 wks AOG
Mullerian Anomalies
 Segmented mullerian agenensis or hyperplasia PLASMA GLUCOSE RESULTS
 Unicornuate uterus (Blood Glucose testing performed at 24-28wks AOG)
 Bicornuate uterus Time NDDG Coustan & Capenter (mg/dL)
 Septate uterus Fasting 105 95
 Uterus with internal ? Changes 1st Hr 190 180
2nd Hr 165 155
Induction of labor
 Oxy drip but not in labor 3rd Hr 145 140

Augmentation of Labor
 Oxy drip however in labor
 LEOPOLD’S MANEUVER DELIVERY OF PLACENTA
L1 (Fundal Grip) SHULTZE MECHANISM
 What fetal pole occupies the fundus  Peripheral
 Shiny portion
L2 (Umbilcal grip)
 Fetal back DUNCAN MECHANISM
 Central
L3 (Pawlick’s grip)  Dirty part
 (+) engagement of head or (-) engagement
DEFINE:
L4 (Pelvic grip)  Placenta increta  invades
 Side of cephalic prominence  Placenta percreta  penetrates
 Placenta accrete  attaches
FUNDIC HEIGHT
12wks – 1st felt; above the symphysis pubis Normal Rotation of Umbilical Cord:
16wks – between symphysis and umbilicus  Counter clockwise or Left-handed maneuver
20wks – umbilicus
36wks – below ensiform cartilage PLACENTA PREVIA
Types:
FHB Monitoring
o Totalis  placenta covers cervical os completely
 Every 30mins= low risk
o Partialis  internal os partially covered by placenta
 Every 15mins= high risk
o Marginal  edge of the placenta is at margin of internal os
BISHOP SCORE Etiology: (P2ALM2)
0 1 2 3 o Previous CS
Dilatation 0 1-2cm 3-4cm 5-6cm o Puerperal Endometritis
Effacement 0-30% 31-50% 51-70% >70% o Advancing age
Station -5/-3 -2 -1 +1/+2 o Multiparity
Cervical o Multiple induced abortions
Posterior Midline Anterior -----
Position Diagnosis:
Cervical o Painless third trimester bleeding
firm medium soft -----
Consistency o UTZ for placental localization
*Scoring: 3-8 difficult induction o Placental Migration (placenta close to the internal os during 2nd trimester
9-favorable induction migrate to fundus as pregnancy advances

MYOMA PLACENTA ABRUPTION

 causes soft tissue dystocia  premature separation of the normally implanted placenta after the 20th week of
 etiology: unopposed estrogen stimulation pregnancy and before birth of fetus
 types: Subserous, Intramural, Submucous
Etiology: (PECSS)
ROT – right occiput transverse o Pre-eclampsia
Montevideo Units – 200 units or pressure of > 60 o External trauma
Depoprovera – injectable CP is G1 to HPN patients o Chronic hypertension
o Short umbilical cord
EXCISION OF BARTHOLIN’S CYST o Sudden uterine decompression
 Hyperplasia (uterus) – provera
 Endocervical LACERATIONS

Endometrial
For Functional Curettage 1st Degree
 Endometrial  for D & C o Fourchette, perineal skin, vaginal mucosa but not the underlying fascia and
muscle
AUGMENTATION OF LABOR 2nd Degree
o Fascia and muscles of the perineal body but not the anal sphincter
 ↓ amniotic fluid
3rd Degree
 Oligohydramnios (causes)
o Extend from vaginal mucosa, perineal skin and fascia up to anal sphincter
o Cord compression
but not the rectal mucosa
o Macrosomia
4th Degree
o Deformations
o Encompasses extension up to rectal mucosa
o Fetal distress

HYOSCINE N-BUTYL BROMIDE (Buscopan)  for softening of the cervix BRAXTON HICKS CONTRACTION
 The uterus undergoes palpable but originally painless contractions at irregular
NST: Fetal condition “7 days” intervals from the early stages of gestation

CST: Uteroplacental contraction SIGNS OF PLACENTAL SEPARATION

 Calkin’s Sign (uterus becomes globular & firmer from discoid)
 Sudden gush of blood
 Uterus rises in the abdomen as the detached placenta drops to the lower
segment and vagina
 Lengthening of the cord
 AMONIOTIC FLUID INDEX POSTERIOR COLPORRHAPY
 Normal: 6-24 cm 1. Induction of spinal anesthesia.
 Oligohydramnios: <5 cm 2. Patient is placed in dorsal lithotomy position.
 Low normal: 9-10 3. Asepsis/Antisepsis
 Polyhydramnios: >24 4. Drapings done leaving the operative site exposed
5. Allis clamps are applied at the posterior vaginal mucosa, elevated creating a
CESAREAN SECTION triangle.
INDICATIONS FOR CESAREAN SECTION 6. A transverse incision made at the posterior fourchette. A portion of the
posterior vaginal mucosa is elevated using an Allis clamp and an index finger
 Prior CS
covered with gauze is inserted upward and laterally, dissecting the posterior
 Labor dystocia (most frequent indication for 1’ CS)
vaginal mucosa of the perirecteal fascia.
 Fetal distress
7. Vertical incision in posterior vaginal mucosa made. Perirectal fascia dissected
 Breech presentation
off the posterior vaginal mucosa. The apex of triangle held with Allis clamp. The
POST OP COMPLICATIONS OF CS DELIVERY dissection of perirectal fascia off the vaginal mucosa is started with scalpel but
 Hysterectomy is completed with blunt dissection
 Operative injury to pelvic structures 8. Kelly plication sutures with vicryl 2-0 through the margins of levator ani muscles
 Infection from apex down to posterior fourchette is done and progressively tied.
 Puerperal fever 9. The excess posterior vaginal mucosa trimmed.
 Transfusion 10. The perineal fascia closed with interrupted vicryl 2-0
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using continuous
STAGES OF LABOR interlocking stitches to posterior fourchette.
 I: Active labor to full cervical dilatation (4-10 cm) 12. Vaginal packing done with 1 os.
 II: Full cervical dilatation to delivery of baby 13. Perineal wash done.
 II: Delivery of baby to expulsion of placenta 14. End of procedure.
 IV: Delivery of placenta to 1 hour after
CARDINAL MOVEMENTS ENDOCERVICAL POLYPECTOMY
 Engagement 1. Induction of labor.
 Descent 2. Sepsis/Antisepsis/drapings done leaving operative site exposed.
 Flexion 3. Insertion of straight catheter to empty the urinary bladder.
 Internal rotation 4. Posterior vaginal retractor positioned, endocervix identified.
 Extension 5. Anterior lip of the cervix grasped with tenaculum forceps.
 External rotation 6. Endocervical polyp found.
 Expulsion 7. Polyp grasped, twisted, and removed using an ovum forcep.
8. Vaginal packing inserted.
ASYNCLITISM  such lateral deflection of the head to a more anterior or posterior 9. End of procedure.
position of the pelvis

ANTERIOR COLPORRHAPY 1’ LOW TRANSVERSE CESAREAN SECTION

1. Induction of anesthesia. 1. Induction of spinal anesthesia.
2. Patient is placed in dorsal lithotomy position. 2. Patient in supine position.
3. Asepsis/Antisepsis 3. Insertion of foley catheter.
4. Drapings done leaving the operative site exposed 4. Asepsis/Antisepsis
5. Evacuation of urine using straight catheter. 5. Drapings done, exposing operative site.
6. The lateral edges of the vaginal cuff are held with Allis. Several Allis clamps are 6. Vertical incision done from 2 FB above the symphysis pubis up to 3 FB below the
placed 3-4 cm apart up the midline of anterior vaginal wall. umbilicus. Incision deepened to subcutaneous tissues and transversalis fascia,
7. The vaginal mucosa is undermined for approximately 3-4 cm up to first Allis rectus muscle split, peritoneum cut longitudinally.
clamps placed in midline. 7. Bleeders clamped and ligated as encountered
8. The vaginal mucosa is dissected off the pubovesical cervical fascia and opened 8. Retractors applied exposing pelvic structures
with scissors in the midline. The vaginal mucosa is opened in midline up to next 9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder.
Allis clamp. This is continued until the vagina is opened to within 1 cm of 10. Bladder pushed downward and a curvilinear incision is done on the
urethral meatus. lower uterine segment using bandage scissors, bag of water ruptured.
9. The PVC fascia is separated from the vaginal mucosa. The dissection is 11. Rupture of membranes.
continued until bladder and urethra are separated from the vaginal mucosa 12. Amniotic fluid suctioned & fetal head exposed.
and clearly identified and urethral vesical angle has been ascertained. 13. Delivery of baby boy in left occiput transverse position.
10. Kelly plication done with chromic 2-0. The anterior repair is started by 14. Umbilical cord doubly clamped and cut.
placing suture in PVC fascia, starting at the level of first Kelly placation 15. Manual extraction of placenta.
suture 16. Closure of incision site done layer by layer
11. The edges of vaginal mucosa retracted laterally with Allis clamps and a. First (endometrial) layer closed by continuous interlocking
remaining PVC fascia is plicated in midline with multiple interrupted mattress stitches using Chromic 1.
sutures. The edge of vaginal mucosa are held in tension and excessive b. Second (myometrial) layer closed by continuous interlocking
mucosa trimmed. stitches using Chromic 1.
12. The vaginal mucosa is sutured in midline down to previously incised site c. Third (Vesico-uterine folds) closed by simple continuous stitches
by continuous interlocking suture using chromic 2-0.
13. Perineal wash done 17. Suction of blood and amniotic fluid and sponge done.
14. End of procedure. 18. Inspection of the ovaries, fallopian tubes and ligaments
19. Parietal peritoneum closed with continuous suture using chromic 2-0
20. Transversalis fascia sutured with continuous interlocking stitches using Vicryl
1-0
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0
23. Incision site painted with betadine
24. Top dressing applied.
25. End of procedure.
 REPEAT LOW TRANSVERSE CESAREAN SECTION TAHBSO
1. Induction of spinal anesthesia. 1. Induction of spinal/epidural anesthesia
2. Patient in supine position. 2. Patient in supine position.
3. Insertion of foley catheter. 3. Insertion of foley catheter done.
4. Asepsis/Antisepsis
4. Asepsis/Antisepsis 5. Drapings done leaving operative site exposed.
5. Drapings done, exposing operative site. 6. Midline incision done from symphysis pubis up to 2 FB below the umbilicus cutting
6. Old scar removed. Vertical incision done from 2 FB above the symphysis pubis through skin, subcutaneous tissue and fascia, rectus muscle split and peritoneum incised.
up to 3 FB below the umbilicus. Incision deepened to subcutaneous tissues and 7. Bleeders clamped and ligated as encountered.
transversalis fascia, rectus muscle split, peritoneum cut longitudinally. 8. Self retaining and bladder retractors were applied to expose pelvic structures.
7. Bleeders clamped and ligated as encountered 9. Moist pack applied.
8. Retractors applied exposing pelvic structures 10. Inspection of the pelvic structures done.
11. Abdominopelvic structures examined revealed that the uterus measures 8x7cms with
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder. smooth serosa. Both ovaries grossly normal .Both measures 3x2 cm. Left fallopian tube
10. Bladder pushed downward and a curvilinear incision is done on the lower dilated to 7x3 cm and its ampullary area containing serous fluid. Right fallopian tube
uterine segment using bandage scissors. with small cystic paratubal masses ~1x1cm.
11. Rupture of membranes. 12. Right round ligament is doubly clamped, then cut and ligated with Chromic 1. The
12. Amniotic fluid suctioned and fetal head exposed. same procedure is done on the opposite side.
13. Delivery of baby boy in left occiput transverse position. 13. Anterior and posterior leaves of the broad ligament opened. Anterior leaf of the
14. Umbilical cord doubly clamped and cut. broad ligament incised to the point of bladder reflection.
14. Infundibulopelvic ligament triply clamped, cut and doubly ligated using Chromic 1-0.
15. Manual extraction of placenta. 15. Vesicouterine folds cut transversely
16. Closure of incision site done layer by layer 16. Bladder dissected by blunt and sharp dissection.
a. First (endometrial) layer closed by continuous interlocking stitches 17. Uterine arteries triply clamped, cut and doubly ligated with Chromic 1-0 on both sides.
using Chromic 1. 18. Pubovesical fascia incised and pushed down with use of sponge
b. Second (myometrial) layer closed by continuous interlocking stitches 19. Cardinal ligaments clamped, cut and suture ligated with Chromic 1-0.
using Chromic 1. 20. Amputation of cervix at level of cervical os.
c. Third (Vesico-uterine folds) closed by simple continuous stitches using 21. Betadinized OS inserted to the vaginal stump.
22. Closure of vaginal stump with continuous interlocking suture using Vicryl 1-0. Stump angles
chromic 2-0.
are anchored to the cardinal ligaments on both sides with figure of eight stitches using
17. Suction of blood and amniotic fluid and sponge done. Vicryl 1-0.
18. Inspection of the ovaries, fallopian tubes and ligaments 23. Bleeders clamped and ligated as encountered.
19. Parietal peritoneum closed with continuous suture using chromic 2-0 24. Parietal peritoneum closed with continuous stitches using chromic 2-0.
20. Transversalis fascia sutured with continuous interlocking stitches using Vicryl 1-0 25. Transversalis fascia sutured with continuous stitches using vicryl 1-0.
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0 26. Subcutaneous tissue closed with simple interrupted stitches with Plain 2-0.
22. Skin closed by subcuticular stitches using Monocryl 4-0. 27. Skin closed by subcuticular stitches using Monocryl 3-0.
28. Operative site painted with betadine
23. Incision site painted with betadine
29. Top dressing done.
24. Top dressing applied. 30. Specimen sent for Histopath.
25. End of procedure. 31. End of procedure.

1’ LOW TRANSVERSE CESAREAN SECTION (PFANNENSTIEL) VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)
1. Induction of spinal anesthesia.  Allow a trial of labor under double set-up for all previous cesarean of one low
2. Patient in supine position. segment incision after excluding an inadequate pelvis and unless a new
3. Insertion of foley catheter. indication arises
4. Asepsis/Antisepsis  Selection Criteria:
5. Drapings done, exposing operative site. o 1 or 2 prior low-transverse cesarean section delivery
6. Curvilinear incision done from 2 FB above the symphysis pubis up to 3 FB below o Clinically adequate pelvic
the umbilicus. Incision deepened to subcutaneous tissues and transversalis o No other uterine scars or previous rupture
fascia, rectus muscle split, peritoneum cut longitudinally. o Physicians immediately available throughout active labor capable of
7. Bleeders clamped and ligated as encountered monitoring labor and performing an emergency cesarean section
8. Retractors applied exposing pelvic structures delivery
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder. o Availability of anesthesiologist and personnel for emergency cesarean
10. Bladder pushed downward and a curvilinear incision is done on the lower section delivery
uterine segment using bandage scissors
11. Rupture of membranes. EVACUATION CURETTAGE
12. Amniotic fluid suctioned &fetal head exposed 1. Induction of spinal anesthesia.
13. Delivery of live full term baby boy in left occiput transverse position. 2. Patient in dorsal lithotomy position.
14. Umbilical cord doubly clamped and cut. 3. Asepsis/Antisepsis.
15. Manual extraction of placenta. 4. Drapings done leaving the operative site exposed.
16. Closure of incision site done layer by layer 5. Straight Catheterization done.
a. First (endometrial) layer closed by continuous interlocking stitches using 6. Right angle retractor applied to expose cervix.
Chromic 1. 7. Anterior cervical lip grasped with tenaculum forceps at 12 0’clock position.
b. Second (myometrial) layer closed by continuous interlocking stitches using 8. Hysterometer inserted.
Chromic 1. 9. Pre-curettage uterine depth measured 9 cm
c. Third (Vesico-uterine folds) closed by simple continuous stitches using 10. Sharp and dull curettage done in a clockwise manner, evacuated ½ cup of
chromic 2-0 products of conception and placental tissues.
17. Suction of blood and amniotic fluid and sponge done. 11. Post curettage uterine depth was not measured.
18. Inspection of the ovaries, fallopian tubes and ligaments 12. Perineal washing done.
19. Parietal peritoneum closed with continuous suture using chromic 2-0 13. Specimen for histopathology.
20. Transversalis fascia sutured with continuous interlocking stitches using Vicryl 1-0
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0.
23. Incision site painted with betadine
24. Top dressing applied.
25. End of procedure.
 VAGINAL HYSTERECTOMY FRACTIONAL CURETTAGE
1. Induction of anesthesia. 1. Induction of anesthesia.
2. Patient is placed in dorsal lithotomy 2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis 3. Asepsis/Antisepsis.
4. Drapings done leaving the operative site 4. Drapings done leaving operative site exposed.
5. Evacuation of urine using straight catheter 5. Straight catheterization done.
6. Vaginal mucosa is incised with a scalpel around the entire cervix. 6. Weight-bearing retractor applied at posterior vaginal wall. Cervix smooth with
7. Downward traction is applied using tenacula, Metzenbaum used to dissect the no erosions.
bladder off the anterior lower uterine segment 7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
8. A sponge covered finger dissects the bladder all the way up to the 8. Endocervical curettage done, evacuated minimal endocervical scrapings.
vesicouterine fold, facilitates entry to anterior cul de sac. 9. Hysterometer inserted. Pre-curettage uterine depth measured 9cm.
9. Right angle retractor is placed under the vaginal mucosa and bladder, elevating 10. Endometrial curettage done. Evacuated ½ teaspoon of endometrial
the bladder. Strong downward traction is applied to the tenacula on the cervix, scrapings/tissues and placental tissues.
and the peritoneal vesicouterine fold is grasped with Allis clamps and incised 11. Post curettage uterine depth measured, approximately 8 cm.
with sharp curved mayo scissors. 12. Tenaculum and retractors removed.
10. Elevating the peritoneal vesicouterine fold with Allis clamps, definite hole can 13. Perineal wash done
be seen. Finger is inserted in the hole. 14. Specimen sent for histopath.
11. Tenacula are brought acutely up toward the pubic symphysis, exposing the cul- 15. End of procedure.
de-sac, second right angle at posterior cul-de-sac
12. The posterior vaginal retractor is removed. The broad ligament is exposed from COMPLETION CURETTAGE
the uterosacral ligaments to the tuboovarian ligament. A finger is placed in the
1. Induction of anesthesia.
posterior cul-de-sac and moved laterally revealing the uterosacral ligament as
2. Patient in dorsal lithotomy position
it attaches to the lower uterine cervix.
3. Asepsis/Antisepsis
13. With the cervix on upward and lateral retraction using the tenacula, a clamp is
4. Drapings done leaving operative site exposed
placed in the posterior cul-de-sac with one blade underneath the uterosacral
5. Insertion of straight catheter.
ligament, and the opposite blade over the uterosacral ligament. This is done
6. Speculum applied at posterior vaginal wall
to prevent possible ureteral damage from clamping the ligaments in lateral
7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
position.
8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of products of
14. Uterosacral ligament is cut using the mayo scissors.
conception.
15. Chromic 1-0 suture is used to suture ligate the uterosacral ligament.
9. Betadine wash done.
16. When tied, the suture is held with a Kelly clamp for traction.
10. End of procedure.
17. With uterus on upward and lateral retraction using the tenacula on the cervix,
11. Specimen sent for histopathology.
cardinal ligaments is clamped adjacent to the lower uterine segment and
incised.
18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture. Suture is held
with a Kelly clamp for traction

19. The remaining portion of the broad ligament attached to lower uterine cervix CRITERIA FOR TIMING OF ELECTIVE REPEAT CS DELIVERY (At least 1):
segment containing the uterine artery is clamped and ligated.
 Fetal heart sounds documented for 20 weeks by non-electronic fetoscope
20. With all the ligaments on both sides, clamped and ligated, cervix is
or for 30 weeks by Doppler
retracted upward in midline with the tenacula. Posterior uterine wall is
 It has been 36 weeks since a (+) serum/urine hCG pregnancy test
grasped, the fundus is delivered posteriorly.
was performed by a reliable laboratory
21. Two cochers clamps are applied to the tubo ovarian round ligaments, incised
 An UTZ measurement of the CRL obtained at 6-11 weeks supports
close to the fundus.
a gestational age at least 39 weeks
22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second suture ligation
 UTZ obtained at 12-20 weeks confirms the gestational age of at least 39 weeks
is tied in a fixation stitch, placing the suture in the mid portion of its pedicle.
determined by clinical history and PE
23. The anterior and posterior clamps right angle retractors are removed, and
the weighted posterior retractor is placed in the vagina. Any bleeding from
any pedicle is clamped. ADMITTING NOTES (Ectopic Pregnancy)
24. Cardinal ligaments, uterosacral ligaments and utero ovarian ligaments  Cc:
anchored at the posterior vaginal mucosa.  Imp:
25. Reperitonealization of the pelvis, carried out with purse string sutures.  Please admit pc to ROC under the service of Dr.
26. Perineal wash done.  TPR q 4 hours and record
27. End of procedure.  NPO temporarily
 Labs:
DIAGNOSTIC CURETTAGE o CBC, APC
o CT, BT, PT
1. Induction of anesthesia.
o BT w/ Rh
2. Patient in dorsal lithotomy position
o U/A
3. Asepsis/Antisepsis
o S. Pregnancy test
4. Drapings done leaving operative site exposed
 IVF: D5LR 1L X 8 Hrs
5. Straight catheter was inserted.
 Meds: None temporarily
6. Cervix dilated with Goodell’s dilator
 SO:
7. Retractor applied at posterior & anterior vaginal wall
o Monitor VS, abdominal status hourly
8. Application of tenaculum forceps at 12 o’clock position of cervical lip.
o Refer once lab result is in
9. Insertion of hysterometer to measure pre-curettage uterine depth of 3 inches.
10. Blunt curette done in a clockwise manner. Evacuated scanty endometrial o Dr. seen patient at ER
scrapings. o Watch out for any untoward s/sx
11. Perineal wash done o Refer prn
12. Specimen sent for histopath
 ANESTHESIA PEDIATRICS
Pre-meds: WATERLOW’S CLASSIFICATION
 Cefuroxime (Zegen) 1.5 gms IV Wasting Stunting
 Omeprazole 20mg IV Normal ≥90% Normal ≥95%
 Metoclopramide (Plasil) 10mg IV Mild 80-90% Mild 90-95%
Moderate 70-80% Moderate 80-90%
Anesthetic Agent: Bupivacaine 15mg + MgSO4 16mg Severe ≤70% Severe ≤80%
Formula for Wasting
𝐴𝑐𝑡𝑢𝑎𝑙 𝑤𝑡
× 100
Detailed Technique: RA-SAB

𝐼𝑑𝑒𝑎𝑙 𝑤𝑡 𝑓𝑜𝑟 ℎ𝑡
 X-LLDP, SAS
 LA w/ 2% Lidocain
 LP at L3 L4
 CSF clear and free flowing Formula for Stunting

𝐴𝑐𝑡𝑢𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑟 ℎ𝑡
 Intrathecal administration of anesthetic
× 100
SIGNS OF MALIGNANCY ON ULTRASOUND 𝐼𝑑𝑒𝑎𝑙 𝑙𝑒𝑛𝑔𝑡ℎ 𝑜𝑟 ℎ𝑡 𝑓𝑜𝑟 𝑎𝑔𝑒
 Septations
 Internal echoes AGE HR BP RR
 Ascites Premature 120-170 55-75/35-45 40-70
 Multiple daughter cysts 0-3 months 100-150 65-85/45-55 35-55
3-6 months 90-120 70-90/50-65 30-45
<5 cm cyst  in postmenopausal women expectant management 6-12 months 80-120 80-100/55-65 25-40
1-3 yr 70-110 90-105/55-70 20-30
3-6 yr 65-110 95-110/60-75 20-25
6-12 yr 60-95 100-120/60-75 14-22
12 yr 55-85 110-135/65-85 12-18

Conversion: to mg/dL
Creatinine divide by 88.4
BUN divide by 0.357
Bilirubin
divide by 17.1
(total, direct, indirect)

Hypernatremia
Water deficit = plasma Na conc. – 140 X total body water
SURGERY
140
FOLEY CATHETER CHANGE PRESCRIPTION Total body water = wt. x 0.4
(women)
Foley catheter f.16 #1
Wt. x 0.5 (men)
Urobag #1
Total divide by 8 divide by 2 = PNSS 1L x
Sterile Gloves s.7 #1
rate x 8 hrs
50 cc Sterile Water #1
Plaster #1 EXPANDED PROGRAM ON IMMUNIZATION
KY Jelly #1 Interv
Vaccine Age Dose No Route Site al
10cc syringe #2
betwe
en
TETANUS PROPHYLAXIS FOR WOUNDS doses
TT 0.5 ml/amp #1 Birth; ant time
BCG 1 0.05 ml 1 ID R deltoid
HTIG 250 cc/vial #1 after
3 cc syringe #1 or 6 weeks
Upper outer
RANSON’S CRITERIA DTaP / DTwP 6 weeks 0.5 ml 3 IM aspect of4 weeks
thigh
Objective signs of severity of acute pancreatitis
OPV 6 weeks 0.5 ml 3 PO Mouth 4 weeks
Anter
On Admission:
o
Age > 55 y.o Hepa B 6 weeks 0.5 ml 3 IM 4 weeks
lateral
Glucose > 200mg/dl aspect
WBC > 16,000/cumm of
LDH > 350 IU/L thigh
AST > 250 U/L Outer
Measles 9 months 0.5 ml 1 SC aspect
After Initial 48 hrs of
Serum Ca++ < 8mg/dl upper arm
Arterial PO2 < 60mmHg BCG 2 School entry 0.1 ml 1 ID L deltoid
Base Deficit > 4meq/L
BUN Increase > 5mg/dl
Hematocrit fall > 10%
Fluid Sequestration > 6,000ml
 1 month
Childbearing then
TT 0.5 ml 3 IM R Deltoid
women 6-12
months
IDEAL WEIGHT FOR HEIGHT
MONTHS P50 MONTHS P50 YEARS P50
15.5 75.35 42.5 92.18 13.25 145.4
16 75.8 43 92.45 13.5 146.42
16.5 76.24 43.5 92.71 13.75 147.29
17 76.69 44 92.98 14 148.03
17.5 77.63 44.5 93.25 14.25 148.64
18 77.37 45 93.51 14.5 149.14
18.5 77.71 45.5 93.78 14.75 149.54
19 78.04 46 94.04 15 149.85
19.5 78.38 46.5 94.30 15.25 150.09
20 78.71 47 94.55 15.5 150.28
20.5 79.04 94.82 15.75 150.41
21 79.37 95.08 16 150.52
21.5 79.70 AGE 16.25 150.66
22 80.03 IN 16.5 150.76
22.5 80.35 Y E A R S 16.75 150.88
23 80.67 17 151.30
23.5 80.90 ( G I R L S ) 17.25 151.00
24 81.32 4 95.08 17.5 151.05
24.5 81.60 4.25 96.00 17.75 151.10
25 81.95 4.5 98.11 18 151.15
25.5 82.23 4.75 99.12 18.25 151.18
26 82.88 5 101.03 18.5 151.20
26.5 82.99 5.25 102.48 18.75 151.22

IDEAL BODY WEIGHT

At birth 3kg
3-12mo Age (mo)+
9 /2 1-6 yrs Age
(yrs)x 2 + 8
7-12 yrs [Age (yrs)x 7 – 5 ]/2
IDEAL HEIGHT FOR AGE
BIRTH TO 2 YEARS OLD TO
IDEAL BODY WEIGHT GIVEN BIRTH WIEGHT
2 YEARS OLD 18 YEARS OLD <6mo Age (mo) x 600 +
LENGTH WEIGHT HEIGHT WEIGHT BW in gm 6-12 mo Age
(CM) (Kg) P50 (CM) (Kg) P50 (mo)x 500 + BW in gm
45-46 2.51 71-72 8.82
47-48 2.90 73-74 9.15
49-50 3.33 75-76 9.49
51-52 3.78 77-78 9.84
53-54 4.27 79-80 10.21
55-56 4.77 81-82 10.59
57-58 5.27 83-84 10.99
59-60 5.84 85-86 11.40
61-62 6.32 87-88 11.82
63-64 6.81 89-90 12.26
65-66 7.26 91-92 12.72
67-68 7.68 93-94 13.20
69-70 8.16 95-96 13.69
71-72 8.58 97-98 14.20
73-74 8.95 99-100 14.73 EXPECTED BODY WEIGHT
75-76 9.34 101-102 15.28 Term: EBW= (Age in days - 10) x 20 + BW
77-78 9.75 103-104 15.85 in gm Preterm: EBW= (Age in days - 14) x
79-80 10.18 105-106 16.45
15 + BW in gm
81-82 10.61 107-108 17.06
 Where 10: # of days to recover over
83-84 11.06 109-110 17.70
85-86 11.47 111-112 18.36 physiologic weight loss 20: g/day gained
87-88 11.96 113-114 19.05
115-116 19.76 CARDIAC OUTPUT
117-118 20.50 Newborn: 180-240ml/kg/min or 4ml/beat
119-120 21.26
121-122 22.06
123-124 22.88
125-126 23.73
127-128 24.62
129-130 25.54
131-132 26.49
133-134 27.48
135-136 28.51
137-138 29.58
139-140 30.68

MONTHS P50 MONTHS P50 YEARS P50

0 48.8 27 83.21 5.5 103.8
0.5 50.50 27.5 83.52 5.75 105.16
1 52.20 28 83.82 6 106.51
1.5 53.74 28.5 84.13 6.25 108.83 Exchange Exchange
Conside
2 55.27 29 84.44 6.5 109.49 Age Photo transfusio transfusio
r
2.5 56.62 29.5 84.74 6.75 110.43 n if n if
Photo
extensive photo intensive photo
3 57.97 30 85.04 7 111.72
</=24d
3.5 59.15 30.5 85.34 7.25 113.00
>/=12 >/=15 >/=20
4 60.32 31 85.64 7.5 114.27 25-48 >/=25 (430)
(170) (260) (340)
4.5 61.34 31.5 85.94 7.75 115.54
>/=15 >/=18 >/=25 >/=30
5 62.35 32 86.24 8 116.80 49-72
(260) (310) (430) (510)
5.5 62.23 32.5 86.53 8.25 118.07
>/=17 >/=20 >/=25 >/=30
6 64.10 33 86.93 8.5 119.34 >72
(290) (340) (430) (510)
6.5 64.85 33.5 87.12 8.75 120.62
7 65.60 34 87.41 9 121.91
7.5 66.30 34.5 87.70 9.25 123.21
8 67.00 35 87.99 9.5 124.54
8.5 67.79 35.5 88.28 9.75 125.84
9 68.38 36 88.57 10 127.15
9.5 68.94 36.5 88.85 10.25 128.56
10 69.50 37 89.13 10.5 129.94
10.5 70.09 37.5 89.42 10.75 131.35
11 70.71 38 89.70 11 132.79
11.5 71.25 38.5 89.98 11.25 134.25
12 71.8 39 90.26 11.5 135.76
12.5 72.35 39.5 90.54 11.75 137.29
13 72.9 40 90.81 12 138.86
13.5 73.43 40.5 91.09 12.25 140.47
14 73.95 41 91.36 12.5 141.90
14.5 74.43 41.5 91.63 12.75 143.40
15 74.90 42 91.91 13 144.28
 DEHYDRATI NEW ADMISSION
ON 1. Instruct folks “kadto sa ADMITTING SECTION, ihatag ni para

[] cc
Pedia
75 𝑥
matagaan kamo
ORS (Mix 1 sachet𝑘gin
ER:
4
ER chart”
water a. Fill-up!

Give𝑘g[4 ] solution per hour x5 4

#
75 𝑥
b. Ask the px before giving this if they are willing to
Sig. stay in the ER to complete the work-up
hours 2. Fill-in the ER chart with concise hx, PE, admitting dx, plan
a. Have the ER chart checked by the ROD
DEGREE OF DHN
(WHO) b. Fill up the lab request forms & prescription papers of the
patient –
have ROD sign the prescription
NO DHN SOME DHN SEVERE DHN
c. Instruct the px on where to go next:
Activity Active Irritable Lethargic
i. Labs & dx forms: “ kadto sa cashier para sa billing”
Eyeballs Not sunken Sunken Sunken
ii. Prescription: “ kadto sa botica, bakal ka amo ni nga bulong”
Skin turgor
Good Slow Very slow 3. Follow-up the dx and labs:
(abdomen)
a. CXR – pre-read after 30min-1H; make sure to bring
Drinks eagerly, Cannot/ unable
Thirst Not thirsty the ER chart with you and narrate to the radiologist
very thirsty to drink
LABORATORIES (include in the plan) pertinent Hx & PE before prereading
To be taken post hydration (6H): b. CBC, platelet – after 6H
 CBC, plt c. S. electrolytes, urinalysis, fecalysis – after 2H
 S. Na, K
Separate form; instruct folks to buy specimen cup:
 Urinalysis
 Fecalysis Fontanels
- Anterior closes at 18 months (as early as 9=12 months)
TREATMENT - Posterior 6-8 weeks
No DHN: feeding, fluid, follow-up
Some DHN: ORS 75ml/kg divided into 4 solutions; give 1 Colostrum – 1st 2-4 days postpartum ↑ CHON, vitamins, salt, Ig
solution q1h x 4h Severe DHN: PLR/D5LR ↓ fat and sugar

Absolute Contraindications to BF
 Galactosemia Age 70ml/kg 70ml/
kg  Tyrosinemia
*Repeat once if radial≤12mo 1 hr*very weak
pulse is still 5 hrs or
not detectable s Relative Contratindications to BF
Hypotension:  Psychosis
 PNSS 10cc/kg fast drip  Active TB

Fever > 2 days

 Perform tourniquet test MultiVitamins:
 Ascorbic acid
Chest pain Drops 100mg/mL: Syrup: 100mg/ml
 Order xray, ECG 15 <3mos:
leads Seizure 2-6y/o:
0.3ml/day 3-
 CBC, platelets, electrolytes, 5ml/day 7-
12mos:
12y/o:
 Start IV: D5 0.3 NaCl KV0 0.6ml/day
10ml/day
 O2 at 1-2 LPM 1-2y/0: 1.2ml/day

O2 sat < 92  Vit. B complex + hysine + beclizine

 O2 @ 1-2 LPM, then refer (Appebon syrup) 2-6y/o: 1-2tsp OD
*Always have the ROD countersign 7-14y/o: 2-4tsp OD

Paracetamol dose:  Iron (weight x 5/elem Fe)

6-28 (hosp/pedia protocol: 10) mg/kg/mkdose for 1mkday OD- prophylactic Hemarate 30/5
fever > 37.8 C 3-6mkday BID-therapeutic Iberet 26.25/5
Zinc RD – 10-20mg/day Incremin 30/5
REMEMBER!!! 10mgdrops- infant Sangobion 12/10
 ROD makes rounds usually @ 8,12,4 20mg- >2yo Ferlin 30/15
 Monitor v/s q1h
 Ask for urine frequency and BM q4h especially  Folic acid
for AGE 2.5g/ml
 Pedia office: 134 0.2 mkday

 Vitamin A
 6-11mos: 100,000IU – 1 dose
 12-71mos: 200,000IU
<2yrs: dropsAge10mg/ml=1mlRange (%) Mean (%)
2 weeks 42-66 50  >2yrs:
3 months 31-41 36 syrup
6 months – 6 33-42 37 20mg/5ml=
yrs 5ml
7 yrs – 12 yrs 34-40 38
Adult: Nelson textbook of Pediatrics, 15th
Source:
edition Male
p. 1379 42-52 47
Female 37-47 42
 Analgesics/ Anti-emetic/ Anti-spasmodic
AntipyreticParacetamol (Q4h) Mefenamic Acid (q6-8hr) Metoclopramine Nifuroxide (Ercefuryl)
RD: 5-8 RD: 0.5mkdose PO <6mos- 10ml
RD: 10- mkdose Susp: 0.2mkdose IV >6mos- 5ml
15mkdose PO 50mg/5ml Amp: 10mg/2ml, Adult: 1cap
10mkdose IV 125mg/5ml 5mg/2ml Syr: Q6H Susp:
15mkdose-BFC Cap: 5mg/5ml 220mg/5ml
Drops: 250mg/500 Tab: 10mg Cap: 200mg
100mg/ml Aspirin (Q4-6H) Dicycloverine HCL (Q8h) Hyosciene N-Butyl (Bromide)
60mg/0.6mk RD: 10-15mg/kg/dose Q6-8h
Syrup: upto RD:
120mg/5ml 60-80mg/kg/24h 2.5-5mg/kg/day
RD:
125mg/5ml Anti-inflam:60- 6mos-2y.o: 0.5-
0.15mkdose
350mg/5ml 100mg/kg/24hPO 1ml 2y.o-5y.o:
Amp:
Tab: Kawasaki: 80- 2.5-5ml
20mg/ml
325mg/tab 100mkday Drops: 5mg/ml,
Tab: 10mg
250mg/tab Nimesulide (BID) 15mg/ml Syr:
500mg/tab 2mg/ml, 10mg/ml
RD: 2.5-
Amp: Tab: 10mg
5mkdose Domperidone (Motilium) Q8h*15
150mg/ml
300mg/ml 100mg/tab
RD: 0.3mkdose
Ibuprofen Dyspepsia: Adult: 1tab/2tsp Q8h
RD: 5-10 Children: 2.5ml Q8h Suspension: 1mg/ml
mg/kg/dose PO Tab: 10mg N/V: Adult: 2tab/4tsp Q6-8h
Q6-8H Children: 5ml
Q6-8h

Antihelminthics
Antaci Ranitidine (Q8h-12h) Famotidine (Q12h/IV- Mebendazole
ds Q8h) 500mg/tab single dose
RD: 100mg/tab or 5ml BIDx3 consecutive days
RD:
0.75mkose 20mg/ml susp: 5ml BIDx3 consecutive
0.2mkdose
PO 0.8- days 50mg/ml susp: 10ml SD
Amp:
1mkdose IV Enterobiasis (100mg or 5mg SDrpt 2 or 4
25mg/2ml
Amp: 25mg/ml, 50mg/5ml weeks) Susp: 20mg/ml, 50mg/ml
Tab:
Tab: 150mg/300mg Tab: 100mg; 500mg
20mg/40
Cimetidine (Q4-6h) Omeprazole *deworm @2-4 yrs old
RD: 10-15mkday Pyrantel Pamoate
<1y.o: 20mkday RD: 10-20 mkdose
1-12y.o: 20- Susp: 125mg/5ml
1mgkday Tab: 125mg; 850mg
25mkday Liquid:
100mg/5ml Albendazole
Amp: 150mg/ml, RD: 75mkday
100mg/ml Susp:
Tab: 200mg, 400mg 200mg/5ml
AlMg (Maalox) (Q6h) Ursofalk Tab: 400mg
2-4 tabs max: 16tabs
*take 30 minutes 1 hr Quinolones
after meal at bedtime Ciprofloxacin - BID
Vial: 100mg/50ml, 200mg/100ml, 400mg/200ml
Anti-
Paroromycin (Humagel)
Amebicide
Diarrheals Erceflora – Bacillus
clausii Metronidazole Q6h Furazolidone
>1mos: 1-2 vials/day RD: 30-50 mkday PO
RD: 20-30mkday 3-4 dived
2-11y.o: 1-2 vials/day 7.5 mkdose IV
dose 150mg/cap, 150
Adult: 2-3 vials/day 15mkdose – loading RD: 4-7 mkday
mg/5ml
Racecadotril (Hidrasec) Nifuroxamide (Ercefuryl) dose Vial: 5mg/ml Liquid: 16.7
1 mos onwards IV: 500mg/100 mg/5ml Susp:
RD: 1.5mg/kg/day Q8h Susp: 50mg/ml
125mg/5ml
BW Hidrasec Sachet 200mg/5ml
<6mos: 1tsp BID Paramomycin Etofamide (Kitnos)
<9kg 10mg 1
>mos: 1tsp TID RD: 15-20mkayX3 days
sachet 9-13kg
RD: 20-30 mkday
10mg 1 sachet Q12H Susp: 100mg/5ml
Susp:
13-27kg 30mg 1 sachet Tab: 200mg; 500mg
150mg/15ml
>27kg 30mg 2 sachet
 Antihistami Cephalosporins
ne Hydroxyzine Hcl (Iterax) Desloratadine (Aerius) 1st Generation 2nd Generation
6-11 mos: 2ml Cefaclor Q8h
Q12h x 5 days
1-5 y.o: 2.5 RD: 20-
RD: 1mg/kg/day or
ml 6- 40mkday
wt/4 Syrup: 2mg/ml
11y.o: 5ml Drops:
Tab: 10mg;
>/=12y.o: 50mg/ml
25mg Amp:
10ml Syr: Susp:
5mg/ml
2.5ml/5ml 125mg/5ml
Tab: 5mg 250mg/5ml
Chlorphenamine Maleate Diphenhydramine Hcl Tab: 315mg;
Q8h 750mg Cap:
RD: 500mg
RD: 3-5 mkdose PO
0.2mkdose Cefuroxime Q6-8h
1mkdose IV
Amp: RD: 20-40mkday PO; 50-
Syr:
10mg/ml Cefalexin Q6h
12.5mg/5ml 100mkday IV
Vial: RD: 30-50
Cap: 25mg, 50
10mg/ml mkday PO 50-
mg IV/IM: Cefamandol
Syrup: 100mkday IV
50mg/ml RD: 50-100mkday
2mg/5ml Drops: 100mg/ml
Tab: 4mg Susp: 125mg/ml Cefprozil
*20kg-1/2 amp IM 250mg/ml RD: 20-4-mkday
>20kg-1amp IM Cap: 250mg; Powder: 125mg/5ml;
Cetirizine diHCL-OD-BID Levocetirizine 500mg 250mg/5ml Tab: 250mg;
RD: 0.25-0.27
500mg
mkdose Drops: Cefazolin
RD: 50-100mkday IV x Cefotiam
3dose Vial: 250mg RD: 50-
Inj: 500mg; 1g 100mkday
Tab: 200mg
Vial: 0.5g; 1 gm
Cefixime Q12h UTI: 8
TF: 20 RD: 3-6mkday
PO, 15mkday Drops:
20mg/ml
Susp:
100mg/5ml
Cap:

Mucolyt 3rd Generation 4th Generation

ic Cefoperazone Cefepime OD-
RD: 100-150mkday IV BID RD: 50-
Vial: 1.5g 100
Ceftriaxone BID Vial: 500mg; 1g; 2g
RD: 50-
100mkday
Carbocysteine (Q8- Erdosteine (Q12h) Vial: 500mg; 1
12h) g;
RD: 30-50 mkday 250m
Drops: 50mg/5ml g
Syr: 100mg/5ml RD: 10mkday Ceftazidi
Cap: 500mg 10-20kg, 2-6y.o: 2.5ml me
<3mos: 0.25ml 21-30kg, 7-12y.o: 5ml RD: 30-50mkday
3-5mos: 0.5ml >30kg, >12y.o: IV Vial: 250mg;
5mlTID/7.5ml BID 500mg;
6-8mos: 0.75ml Susp: 115mg/ml; cap: 1g; 2g
300mg Cefpodoxi
9-12mos: 1 ml me
5y.o: 5ml 3-10mkday
Bronchodilat Ambroxol (Q8h) Susp:
ors D: 1.2-1.8 mkday 50mg/5ml
Liq: 15mg/5ml; 30mg/ml Tab: 100mg
Co-Amoxiclav: 228.5g/5ml;
Soln for inhalation:457/5ml
15ml/2ml
Aminoglycosides Antihypertensives
Furosemide
Salbutamol TID Procaterol RD: 0.5-
>/6: 5ml 1mkdose
</=5y.o: 2.5ml Amp:
RD: 0.13-0.15 Gentamycin 20mg/2ml
mkdose Sry: Aminophylline/Theophyline OD-BID 5- Tab: 40mg
2mg/5ml 8mkday
100mg/ Hydralazine
3-5mkdose
5ml Amp: Amikacin OD-BID RD: 0.1-
80mg/5ml;
1mg/ml RD: 12-15mkday – 15 0.2mkdose
125mg/tab,
Tab: 2mg mkdose OD Amp: 20mg/ml
175mg/tab
Tab: 10mg; 15mg;
Terbutaline BID TID Bambuterol
Vancomyci 50mg
1-15y.o: 2.5ml
6-12y.o: n RD:
<3y.o: Aspirin
5mkdose Oral 15mkday
0.075mkdose 75-100mkday
soln: 1mg/ml
Steroids
Antifung
al Nystatin Q6h Fluconazole – Prednisone – BID Dexamethasone
Adult & children: 4- OD RD: 3- RD: 1mkday BID; RD: 0.5 – 1mkdose
6ml Infant: 2ml 6mkday 2mkday OD Susp: 0.3mkdose initial,
Tab: 500,000 U Vial: 3mg/ml 10mg/5ml then 0.1 mkdose 1-
Susp:100, 000 U/ml Cap: 50, 150, 300mg Syr: 5mg/5ml; 20mg/5ml 2mg/kg Q6h x 4
Griseofulvin Tab: 1, 5, 10, 20, 30, *xtubate on 3rd dose
Amphothericin Tab: 125mg/500mg 50mg
B RD: 0.3- Hydrocortisone
Procaterol (Meptin) BID-
0.7mkday Ketoconazole x 5 RD: 5mkdose
TID RD: 0.25mkdose or
Slow in days OD Adult: Q6-8h LB:
0.25xwt Syr: 5meq/ml
Infusion 200mg/tab 10mkdose
Tab: 25meq, 50meq
*250mcg/kg/day-1mg/ 5-12y.o: 100mg/tab MD: 5(max 100)
Isoprinosine: 50- 50mg/5ml;
kg/day Vial: 1-4y.o: 50mg/tab Vial inj: 100mg; 250mg;
100mkday 500mg
Erdosteine Aminophyllin
Macrolides Azithromycin (Ectrin/Zertin) e LD: 5-
OD-BID RD: 15- IVIG 175mg/5ml- 7mkdose
Erythromycin q8h 20mkday Susp: Dose: 2g/kg in 12H or 400mg/kg/dose x 5d
RD: 35-50mkday 200mg/5ml 2.5g/vial, dilute w/ 50ml diluents to make 50mg/ml administer the
Granules: Tab: 250mg; ffL
200mg/5ml; 500mg Vial:
400mg/5ml 500mg Test dose:
Drops: 0.1 0.5ml/kg/H x 15min
100mg/2.5ml Chloramphenicol 0.2 1ml/kg/H x 15min
Tab: 250-500mg q6h RD: 50- 0.4 1.5ml/kg/H x 15min
100mkday;
0.8 2ml/kg/H x 15min
Clarithromycin Q12h 75mkday (enteric
2.5ml/kg/H x 15min
RD: 7.5mkdose; fever) FT
3ml/kg/H x 15min
15mkdose Susp: infant>/=2week: 25-
3.5ml/kg/H x 15min
125mg/5ml 50mg/kg/day
4ml/kg/H x 15min
Tab: 250; 500mg
Cotrimoxazole BID *if tolerated in fuse the rest at cc/h for 10hr watch out for
Roxithromycin OD-BID RD: 5-8mkday; 8 UTI; 10 BPN headache, flushing, hypotension, fever and chills
Adult: 150mg/tab; Susp:
300mg/tab Q12h 200mg/40mg/ NaHCO3
5ml-
BE x wt x 0.3 or 1meq/kg can be given IV push or drip 50mcg/kg NA>1-2 meq/kg
(40mg/5ml)

Anti- TB AMINOSTERIL COMPUTATION

drugs 1-10; R-15; S-20; E-35; P-30
Weight x 1gm x 100 = cc to run for 22hrs,
Isoniazid Rifampicin: rest for 4hrs 6
RD: 5-10 RD: 10- Ex.
Syr: 100mg/5ml; 15mkday Weight: 900g 0.9x 1gm x 100 = 15cc
200mg/5ml Drops: 6
Tab: 100mg; 200mg; 100mg/ml 1. Order: Aminosteril 6% 15cc to run for 22 Hrs; rest for 4
300mg Cap: 300; 45mg
Hrs x 2 cycles (TFI 150- 1gm AA - FFP)
Pyrazinamide Ethambutol ex: FFP x 2 units 18cc/unit
RD: 15-30mkday RD: 12-
Susp: 25mkday Syr: 150-15cc-15cc-18cc+18cc x weight = 84 ÷ 24 = 3-
250mg/5ml 125mg/5ml 4cc/Hr IVF rate 24H
Tab: 500mg Tab: 400mg
Amantadine HCL Aminosteril
Streptomycin 0.5 /kg - increase until 3g/kg
RD: 4.4-
RD: Weight x RD x 100/6%/24 or Weight x RD/0.694
8.8mkday Syr:
15-20mg/kg/day *start 1g x 48H then resume at 2g
50mg/5ml
Vial: 1gm Tab: 100mg Conversion of
Ribavirin Hyponatremia
Anticonvulsants/ 1ml=2.5 mEqs NaCL
Sedatives Weight: 1.8 kg
S.Na: 131.4 Midazolam
Phenobarbit
D-A x wt x 0.6 (140-131.4 x 1.8 x 0.6 = 9.2 mEqs)+ wt x 3= maintenance (1.8 x 3=5.4)
RD:
al LD:
0.2mkdose
10mkday ½ - 4.6 – 1.8 – 6.4
Tab: 15mg HYPONATREMIA
MD: 5mkdose (max ¼ - 2.3 – 1.8 – 4.1
Amp: 5mg/ml, 5/5, 15/3 D-A x wt x 0.6 ÷ (2-3)
25mkdose) ¼ - 2.3 – 1.8 – 4.1
Phenytoin maintenance
1st
LD:
Diazepam Shift HYOPCALCEMIA
10mkdose
RD: 0.2-0.8 mkdose D5W- K/K (?) – 0.1 to 0.3
MD: 5mkday
6.6 meqs/k/H NK of Body=
Susp: 30/5,
D5IMB- 50 50meqs
NaCl- 2.5 (?)
Hypokalemia
D-A x Weight x 0.3 + (Weight x 2) ?

Weight x 0.2 x 8 x 3 x 2 x Weight

Sk- <3-5% -0.05
<2.5-10%-0.10
Wt X 0.05 x 50 /wt x (2/maintenance)
 DRIPS EPINEPHRINE DRIP
Weight x 0.6 mg = mg added to
DOPAMINE DRIP
100mgD5W 1cc/H = 0.1 ug/kg/min
(200mg/250-800conc) 0.0375/26.6
5cc/H = 0.5 cc/min ml/H= weight x dose x 60
(400mg/250ml-1600conc)
10cc/H = 1mg/kg/min concentration
0.075/13.3 Wt x RD x 60
0.1mkd/0.1cc/kg/
(0.075)
dose
SHORT CUT: wt x RD WT X 3(50) X dose (10mg/kg)
6 X Wt in Kg x mcg/K/min = mg in
100ml of D5W/NS mL/Hr
13.3 (800-conc) 6 (100)
 Set your own rate: ex: 4ml/hr
Rate (1cc/hr)
6 x wt x 0.1
Wt x RD 1.6 mcg/kg/min 4ml/h
26.6 (1600-conc) If weight is 40 kg: 6 x 40 x 0.1 = 6mg in
100ml D5W 4
To check: AD: Order: Start epinephrine drip: 6mg epinephrine + 100cc D5w x
dose given x 4cc/Hr
Prep/60/wt
(0.1 mcg/k/min)
or
WT x RD X 140D/ 1600/24
INSULIN DRIP
Prep: 1U/ml amp
Max: 20
Dose: Infant and Child 0.1Ukg/H (titrate to clinical
effect) Glucose drop: 80-110mg/dl/H

LEVOPHED Weight (kg) x dose x 24 = U in

4mg/4ml; 2mg/ml 24ml NS or
e.g 2ml/ml Weight (kg) x dose x 24 x 5 = U in 120ml of NS
*to make: 5ml/H= 0.1U/kg/H
2/100 x 1000= 20 conc

(WT x dose x 60)= MIDAZOLAM DRIP

ml Conc Prep: 5mg/ml amp
To check: ml x conc/60/15= dose Dose: intermittent: 0.05 –
0.15mg/kg/dose Continuous: 1-
DRIP FORMULA 2mcg/kg/dose
6 x wt (kg)x mcg/kg/min – mgin100ml of
D5NSS MI/H 6 x wt (kg) x mcg/kg/min = mg in 100ml of
D5W/NS mL/H
ISOPROTERENOL/EPINEPHRINE/NOREPINEPHRINE Max total dose: 10mg (intermittent)
0.6 x wt (kg) = mgin100ml O Can cause respiratory depression, hypotension, bradycardia
*1ml/H will deliver 0.1 mcg/kg/min
DOPAMINE/ DOBUTAMINE/ AMRINONE/ NITROPRUSSIDE AMIODARONE DRIP
6 x wt (kg)= mg in 100ml Prep: 50mg/ml amp
Dose: infant and child: 5mg/kg over 30 min ff by infusion starting
*0.1 ml/H will deliver 1mcg/kg/min
at 5mcg/kg/min Max dose: 10mcg/kg/min or 20 mg/kg/H must be
DOPAMINE/ DOBUTAMINE diluted in D5W
6 x wt (kg) = # mg to add to diluents to make 100ml volume
Infusion concentration should not exceed 2
DOBUTAMINE DRIP
Dobu-premix
2.5 – 15mcg/kg/min (max: 40mcg/kg/min) mg/ml Weight (kg) x dose x 60 x 50
0.06-1000=250/250 D
Peak effect: 10-20min
%W
Prep: 0.03- = mg in 50mlD5W
12.5 mg /ml x 20ml/vial= 250mg/250ml (vial)
2000 1000
Premix: Wt x dose x To make: 1ml/H= 1mcg/kg/min
1000mcg/ml in 250= 250/250 (1mg/ml)
0.06/0.03
NICARDIPINE DRIP
2000mcg/ml in 250 ml= 500mg/250 (2mg/ml) Prep: 2.5mg/ml= 5mg/10ml ampule
Dose: Child: 0.5-5mcg/kg/min (titrate to
Wt x RD x 60 or wt x RD x 1400/12500 or 6 x wt in kg=
clinical effect) Adult: start with 5mg/H,
mg in increase dose as needed by
100ml 2000 2.5mg/H Q 5 -15 min (Max dose: 15mg/H)
decreased by 3mg/H as needed to maintain
(1mcg/kg/min) desired response
Ex: 250mg in D5W 250cc(1mg/ml) 500mg in
D5W250cc(2mg/ml) Mcgtt/min= (Wt x DD)/16.6 MINOPHYLLINE DRIP
ugtts/min=(wt x DD)/33.2 LD: 5mg/kg BW in 30cc 5W in a soluset (if px is not maintained on
= Wt x DD x 0.06 = Wt x DD X 0.03
*to check: 7.5 – actual x
oral theophylline) or
2000/ 60 /wt actual x 25mg/vial dilute 1ml + 4ml NSS to make 5 mg/ml solution.
conc/60/wt
Aspirate mL give per IV infusion for 30 min as
FUROSEMIDE DRIP LD (5mg/kg) D5W250cc + Aminophylline
20 mg/2ml 250mg/amp at ugtts/min
**4ml + 20cc PNSS to run
@ 1cc/h (weight) 15 x Main drip: 0.4 –
(dose) 0.1 x 24 0.8mg/kg/H Formula
ugtts/min = dose x BW
36 x 2/20 = 3.6
3.6/4ml = 0.9 or 1cc Note: maintenance infusion rate must be induced to 0.2 – 0.3 mg
/kg/H for elderly patient, pregnant patient and those in CHF. Liver
Prep: 10mg/ml amp (2m) disease or cor pulmonale watch out for hypoglycemia and
Dose: infant and child: 0.05 mg/kg/H (titrate to tachycardia.
 clinical effect) Adult: 0.1 mg/kg/H (max: 0.4
mg/kg/H)
 Weight (kg)x dose x 24 = mg in 24 ml of NS to make: 1ml/H =
0.1mg/kg/H
 Weight (kg) x dose x 24 x 5= mg in 120ml NS to make
5ml/H=0.1mg/kg/H

*20mg furosemide + 20cc distilled water to make concentration

of 1mg/ml Infusion rate: 0.05 x weight
eg: 0.05 x mg x 1 = 4 cc
DUET (Double Volume Exchange Laryngoscope Blade Size
Transfusion) Blood volume: 80cc/kg Term/Newborn Size 1
ABC: no correction if <10
E.g wt: 3kg 2-11 yrs Size 2
B.D
3 x 80 x 74-60/74 = 3360/74 >12yrs Size 3
45cc to be
exchanged 160- ET Tube Size & Depth
180cc/kg/FWB Weight Size Depth
Mother’s Blood type – wt 80 x 2 500-1000 2.5 7.0
1000-1400 3.0 7.5
INDICATIONS: Corrected WBC: 1400-1900 3.0 8.0
Sepsis e.g RBC = 7500= 1900-2200 3.5 8.5
S. Bilirubin 75000/500-15 2200-2600 3.5 9.0
>20mg/dl Hypoxia for every RBC = 1 WBC 2600-3000 3.5 9.5
and acidosis
WBC = 37-15=22 corrected 3000-3400 3.5 10
Hemolytic dose of
3400-3700 3.5 10.5
NB ABO
3700-4100 4.0 11.0
incompatibility
Prematurity 4100-4500 4.0 11.5
>4500 4.0 12.0
COMPLICATIONS:
Vascular BELL CLINICAL STAGING OF NEONATAL NECROTIZING
embolism ENTEROCOLOTIS (NEC)
Infection 1. Suspect ,
Cardiac arrhythmia vol Infant with suggestive clinical signs but x-ray non diagnostic
overdose CP arrest 2. Definitive
Electrolyte imbalance Infant w/ pneumatosis
intestinalis 2a: mildly ill
FIO2: 100% target FiO2 X TRF (S) 2b: moderately ill (acidosis, thrombocytopenia/ ascites)
79
3. Advanced
GUIDELINES FOR PEDIATRIC PLATELET TRANSFUSION 3a: critilac w/ impending
Children/Adolescents perforation 3b: critical w/
<50 x 109/L and bleeding proven perforation
<50 x 109/L and invasive procedure
<20 x 109/L and bone marrow failure with age risk factor
<10 x 109/L and bone marrow failure w/o age risk factor

Infants within the 1st 4mos of life

<100 x 109/L and bleeding
<50 x 109/L and invasive procedure
ELECTROLYTE COMPUTATIONS
WATERLOW
CLASSIFICATION I. Potassium
> 90 no PEM WT for Age: Actual WT x  N= 4-5.6 meq
75-90 MILD 100%  N K deliuence: 0.1-
60-74 MODERATE Wt at P50 0.4meq/kg Deficit = (KD - KA)x
<60 SEVERE wt x 0.6 Maintenance K: 2 x wt
Total K deficit: deficit + maintenance
HT for Age= Actual HT X 100 Full Incorporation: 40meq/L or 20
mEq/500cc K infusion rate:
Ht at P50
N= 0.2meq – 0.4meq/kg
Wt for HT = Actual wt X 100 IV rate x amt of K (meq)
Vol of IVF x
Wt at P50 of HT at P50
Wt Deficit: Wt x 50 x K
Height WT Maintence – 2 x wt
>95 – no >90 – no
stunting 90- wasting 80- II. Sodium 135-145 meq
95 –mild 90- mild Maintence Na= 3 x Wt Na: 1 meq=
85-89 – 70-80- 2.3mg/dl Max target/day: 10 meq
moderate moderate K= 1 meq=
<70- severe 3.91mg/dl

NaHCO3= gr x = 650mg = 7.7meq gr v = 325

ET Tube Size AOG SIZE
<1000 <28 2.5 III. Calcium: 8-10 meq
1000-2000 28-34 3.0 IV. Chloride: 98-106 meq
2000-3000 34-38 3.5 V. CO2 15meq
>3000 >38 3.5-4.0
Rate x 24 = ÷ 100= ET SIZE BY AGE x4
Premature 2.5mm
0-3 mo 3.0mm MAXIMUM K that can be in cooperated per Liter IVF:
3-7 mo 3.5mm  Parenteral: 40meqs
7-15 mo 4.0mm  Central: 60-80meqs
15-24 mo 4.5mm
2-10 yrs Age (yrs)+16/4 or Age(yrs)+ 4/4 DEFICITS
10-20 yrs 6-8mm Na= 135-150/3-4meq/kg/day
Na deficit= (Desired 140 – actual)
X TBW TBW (L) = 0.6 x BW (kg) +
ET level: size of Maintenance
tube x 3
 CREATININE PHOTOTHERAPY
CLEARANCE Indication: PT 10mg%
(140-age) (wt in kg) x 0.85 (F) Bilirubin PT 15mg%
1(m) Creatinine (mg/dl) x 72 Bilirubin
* ÷ 88.4 → mg/dl
Complication: Osmotic diarrhea, Rashes Bronze baby syndrome, Dehydration
STAGING
1 Kidney damage with >90 Kramer’s Classification
NGFR ZONE JAUNDICE EST. LEVELS
2 Mild ↓ GFK 60-90 1 Head/neck 6-8mg/dl
3 Moderate ↓ GFK 30-59 2 Upper trunk 9-10mg/dl
4 Severe ↓ GFK 15-24 3 Lower trunk to thigh 12-14mh/dl
5 Kidnet failure <15 4 Arms/legs/elbow/knees 15-18mg/dl
1. Based on Height 5 Hands/feet >18mg/dl
*0.33 = pretem; lbw, <1 yr B1 – uncongugated/ indirect
0.45 = term, infant, <1yr B2 – conjugated/ direct Bilirubin
0.55 = children, adolescent
female RESPONSE TO PHOTOTHERAPY
0.7 = adolescent male
* X ht (cm) *check rebound B2 for 12-24H after discharge
Serum creatinine (mg/dl)
Bilirubin Age Action
2. Adult <18 - Wean to single
photo
*Male: 72
</=18 - D/C home
Female: 85
</=14 49-7/2 D/C photo
140-age x wt
</=15 >72’ D/C photo
* x Creatinine
Age in hours TSB (mg/dl)
(mg/dl)
24-48H <15 15-<20 20-<25 >/=25
49-72H <18 18-<24 25-<30 >/=30
Values:
>72H <20 20-<25 25-</=30 >/=30
80-120: normal
50-80: renal impairment INTENSIVE PHOTO/
Tx/rec OPD PHOTO
PHOTO exctrans
20-50: renal insufficiency
5-20: renal failure
<5: uremia

GFR: 125ml/min (75-150)

24 urinary Creatinine
M: 15- IV FLUIDS
ACTUAL RETICULOCYTE
IVF: D10 – 1st24hrs of life
𝑥
COUNT (ARC)
𝐴𝑐𝑡𝑢𝑎𝑙 𝐻𝑐𝑡
𝐷𝑒𝑠𝑖𝑟𝑒𝑑
D10IMB – after 24 hours of life
𝑅𝑒𝑡𝑖𝑐𝑢𝑙𝑜𝑐𝑦𝑡𝑒
𝐻𝑐𝑡 How to replace fluids: 1st 24HDL weight x 80cc/kg – if NPO
Reticulocyte Index: ARC ÷ 2 Day 1 90 cc/kg
= HCT/Ret Count x 2 2 100 cc/kg
3 110 cc/kg
>2= hemolysis 4 120 cc/kg
<2= BM suppression 5 130 cc/kg
6 140 cc/kg
IDEAL TRACHEAL 7 150 cc/kg
ASPIRATE 8 160 cc/kg (max)
EC < 25 D10IMB = Desired – Actual x
PMNS> 10 volume Highest –
Lowest
BLOOD Available: D5IMB; D50W,
TRANSFUSION D10W D10IMB = 10-5 x
1 “U” – increase Hgb by 2: Hct volume (100)
by 3 FWB 20cc/k (max) 50-5
PRCB 10-15cc/K (15cc/k in neaonates) = 5 x 100
45
FWB: 11ccD50W 11→ D50W (subtract from the volume 100)
Volume = desired – actual HB x 6 x wt + 89ccD5IMB 89→ D5IMB
= desired – actual Hct x D10IMB
wt Rate = volume x 12
gtts/ml = gtts/min COMPOSITION OF AVAILABLE PARENTERAL FLUIDS
60min x 4H IV Na Cl K Mg Ca HCO3
0.9NSS 154 154 - - - -
PRBC: 0.3NSS 51 51 - - - -
Volume = desired – actual Hgb x 2 x Weight LR 130 109 4 - 1.5 Lactate
= desired – actual Hct x NR 140 98 5 1.5 - Acetate/
Weight Desired Hct = Gluconate
volume/weight + actual Hct NM 40 40 13 1.5 1.5 Acetate
IMB 25 22 20 1.5 - Acetate
Platelet Count: 1U /6KBW Serum Anion Gap (AG)= Na – (Cl +
1U=30-50 (raises platelet count by 10K) HCO3) Urine Anion Gap= (Na + K)
– Cl
Delta Gap= Actual
AG – 10 24-
Actual HCO3
 How to Adjust IVF rate once on Feeding H. Influenzae: 7-10days
Example: IVF: D5IMB S. pneumonia: 10-14 days
(90) WT: N. meningitides: 7 days
2840gms E. coli, citrobacter, Senatia: ≥
21 days Enterococcus: ≥ 14
Computations: 90 x 2.84kg ÷ 24H = 10-11cc/hr IVF rate days
 Advance feeding to 10ccq 3 hrs x 3 feedings
If tolerated, increase to 20cc every feeding until MENINGITIS
30cc is reached.
 <1mo: GBS, enterobacteriaceae, listeria,
 Adjust IVF rate accordingly
monocytogenes Tx: Ampicilin &
↓ to 8cc/hr at 10cc feeding
Cefotaxime
↓ to 6cc/hr at 15cc feeding Alt: Ampicilin & gentamycin
↓ to 5cc/hr at 20cc feeding (nosocomial – Ampi +
↓ to 1cc/hr at 30cc feeding gentamycin)
10x 8 ÷ 24 = 3 [IVF – 3 = 8]  1mo-3mo: GBS, S. Pneumoniae, Hi. Influenza, N.
15x 8 ÷ 24 = 5 [IVF – 5 = 6] meningitides, Enterobacteriaceae
20x 8 ÷ 24 = 6 [IVF – 6 = 5] Tx: Ampiciliin, Cefotaxine
30x 8 ÷ 24 = 10 [IVF – 10 = 1]
feeding q3H → 24h ÷ 3h = 8  >3mo & children – S. Pneumoniae, N. meningitides, H.
 DC CBG monitoring once 20cc feeding is tolerated. influenza, neonatal pathogens
Tx: Cefotaxime/Ceftiaxone, Vancomycin added for possible
BICARBONATE CORRECTION penicillin resistant S. Pneumoniae

UMBILICAL CATHETERIZATION
Serum HCO3 level (meq/L) Volume of Distribution (Vol) Wt x 3 + 9 = answer
>10 0.5 + 1.2 cm 2
5-10 0.75
Allowable
TOTAL BloodSPILLAGE
PROTEIN loss
<5 in Preterm:
(TPS) 10% of BW 1.0
Allowable
TPS= Blood loss
Total Protein in infants/neonates: 20% of BW
(mg) BSA (m2) x
24H EPINEPHRINE
1:10, 000 (0.1mg/ml)
FLUID LIMITATION
Volume in 24H = 400-500ml x BSA + Urine
Recommended IV does: 0.1-0.3 mg/kg of 1:10, 000 solutions via
output in 24H Length: inches to cm, multiply
umbilical vein 0.5–1mg/kg via ET
by 2.54

> 5 years old

(>20kgs)D5LR
> 3 years old KAWASAKI DISEASE
(<15kg)D50.3Nacl/
 Febrile, examthematous, multisystem vasculitis
 Fever for at least 4 days
+ clinical features
Deficit(at least 4/5) <10 kg >10kg
1. Bilateral bulbar
Mildconjuctival injection
50 w/o exudates w/
30 lumbar sparing
Moderate 100 60 2. Erythematous mouth & pharynx, strawberry tongue and red,
Severe 150 90 cracked lips
Maintenance 3. Polymorphous, generalized erythematous rash
(24 H) (morbilliform, maculopaular or scarlatiniform )
4. Changes in peripheral extremities (induration of hands and feet w/ erythematous palm & soles later w/periungual desquamation)
5. Acute, nonsuppurative, unilateral cervical lymphadenopathy at least
0-3 kg 75cc/kg 1.5cm in diameter or if w/ coronary actery aneurysims
3-10 kg 100cc/kg
10-20kg 75cc/kg ATYPICAL KD – common in <12 mo old
20-30kg 60cc/kg  Coronary artery ectasia/dilatation: confirms diagnosis (1-4 wks DOI)
30-40kg 50cc/kg  Labs: CRP > 3.0mg/dl 1st 2
Newbor
n >40kg 40cc/kg weeks of illness ESR >
40mm/h
↑ PLT ct >450 on days 10-12 of illness
0-1 day old 80cc/kg/hr
“without aspirin & IVIg, fever can last upto 2 weeks or longer. After fevr resolves, pt can remain notablefor 2-3 weeks. Desquamation of
2 90cc/kg/hr
groin, finger, toes after 2-3 weeks may occur. ”
3 100cc/kg/hr
4 110cc/kg/hr Treatment
5 120cc/kg/hr  IVIg high dose within 10 days
6 130cc/kg/hr  Aspirin
7 140cc/kg/hr  IVIg: 2g/kg as single dose over 10-12hrs
Mild Dehydration 8 150cc/kg/hr  Aspirin: 80-100mg/kg/day x 4 doses
30-50cc/kg/6h D50.3Nacl  After fever is controlled, ↓ Aspirin to 3-5 mg/kg/day,
discontinue after 6-8 weeks if no heart problems
Moderate
Dehydration 60- Recommended Dosage and Drip Rate for
90cc/kg/6h Kawasaki Patient Dosage: 2g/kg/12hrs
¼ of computed deficit give D5LRX2hrs then ¾ to be given for the EX: Pt: 10kg
next 6hrs D50.6Nacl
Patient total needs: 20g of Immunorel
Severe Dehydration Total Volume need: 400ml to be divide by 12 hrs
>100cc/kg/6h = 33.33ml Initial Test drip: 33.33ml/4=
8.33ml for 1st hour
 Succeeding Drip Rate CEFEPIME
2nd hour: 8.33ml x 16.67ml  Term and preterm infants greater than 28 days of age:
Total Volume left: 375ml/10hrs=37.5ml/hr 50mg/kg per dose every 12 hrs
 Term and preterm infants 28 days of age and younger: 30
MGH orders for KD mg/kg per dose every 12 hrs
 Repeat CBC, Plt, ESR, after 2 weeks  Meningitis and severe infections due to Pseudomonas
 Repeat 2D echo after 6 weeks aeruginosa or Enterobacter spp: 50mg/kg per dose
 Home meds: ASA 80mg/tab 1 tab OD x 6 weeks take every 12 hrs
on full stomach  Administer via IV infusion by syringe pump over 30 minutes or IM.
 No live attenuated vaccine for at least 11 months  To reduce pain at IM injection site, cefepime may be mixed
with 1% Lidocaine without epinephrine
OXYGEN THERAPY
CEFOTAXIME
Nasal Cannula
50 mg/kg Oxygen
dose IV Flow
infusion
rateon syringe pump
Est. over 30%minutes, or IM.
FIO2 in
1 24% Dosing Interval Chart
2 28% PMA (Weeks) PostNatal (day) Interval (hours)
3 32% 0 to 28 12
≤29
4 36% > 28 8
5 40% 0 to 14 12
30 to 36
6 44% > 14 8
0 to 7 12
37 to 44
> 7 8
Simple Face
Mask ≥45 All 6
5-6 40%
Disseminated Gonococcal Infections: 25 mg/kg per dose IV over 30 minutes or IM every 12 hrs for 7 days with a duration of 10 to 14 days if
6-7 50%
meningitis is documented.
7-8 60%

SCLEREMA NEONATORUM
In an infant, fat has higher saturated-to-unsaturated fatty acid
ration compared to adult fat and thus a higher melting point.
Prematurity, hypothermia, shock and metabolic abnormalities have
been postulated to further increase this ratio, possibly as a result of
enzymatic alteration allowing precipitation of fatty acid crystals
within the lipocytes. This condition has been suggested to result in
the dramatic clinical findings in affected skin. X-ray diffraction
techniques have confirmed that infants with sclerema neonatorum
have an increase in saturated fats and that the crystals within the

CEFTAZIDIME
RESPIRATORY DISTRESS SYNDROME  30 mg/kg per dose IV infusion by syringe pump over 30 minutes or
IM.
- Deficiency of pulmonary surfactant, a phospholipid protein
 To reduce pain at IM injection site, Ceftazidime may be
mixture that decreases surface tension & prevent alveolar
mixed with 1% Lidocaine without epinephrine.
collapse.
Dosing Interval Chart
- Type II alveolar cells from 32 weeks AOG
PMA (Weeks) PostNatal (day) Interval (hours)
- Risk of RDS is decreased in babies born >24hrs and <7days
0 to 28 12
after maternal steroid administration ≤29
> 28 8
APNEA – respiratory pause >20sec or a shorter pause assoc. w/ 0 to 14 12
30 to 36
cyanosis, pallor, hypotonia or bradycardia > 14 8
Causes: Thermal instability, prematurity, infection (NEC, meningitis, 0 to 7 12
37 to 44
neo sepsis), metabolic disorders, CNS problems (Seizures, > 7 8
malformations), drugs (maternal/fetal), decreased O2 delivery ≥45 All 6
Primary
FLUCONAZOLE
Disturbance PH Compensatory Response
Change
 Invasive Candidiasis: 12 to 25 mg/kg loading dose, then 6 to 12 mg/kg per dose IV infusion by syringe pump over 30 minutes or orally.
Acute resp. ↑ HCO3 by 1 meq/l for
↑PaCO2↓ ↓pH  Consider the higher doses for treating severe infections or
Acidosis each 10mmhg rise in Candida strains with higher MICs (4 to 8 mcg/ml). Extended
PaCO2 dosing intervals should be considered for neonates with renal
Acute Resp. ↑ ↓ HCO3 by 1-3meq/L for insufficiency (serum Creatinine greater than 1.3 mg/dl)
↓ PaCO2
Alkalosis pH each 10mmhg fall in  NOTE: the higher doses are based on recent
PaCO2 pharmacokinetics data but have not been prospectively
Chronic Resp. ↓ ↑ HCO3 by 4meq/L for tested for efficiency or safety
↑PaCO2↓
Acidosis pH each 10mmhg rise in  Prophylaxis: 3 mg/kg per dose via IV infusion twice weekly or
PaCO2 orally. A dose of 6 mg/kg twice weekly may be considered if
Chronic Resp. ↑ ↓ HCO3 by 2-5meq/L for Candida strains with higher MICs (4 to 8mcg/ml). Consider
↓ PaCO2 prophylaxis only in VLBW infants at high risk for invasive
Alkalosis pH each 10mmhg fall in
PaCO2 fungal disease.
 Thrush: 6mg/kg on day 1 then 3mg/kg per dose every 24 hrs orally.
Metabolic ↓
↓ HCO3 ↓ PaCO2 by 1 – 1.5 x fall in
INVASIVE CANDIDIASIS DOSING INTERVAL CHART
PIP – 8 – 10 (Pacterm 12) Gestational age
Post Natal (Days) Interval (hours)
PEEP – 4 (weeks)
100-FIO2 ÷ 79 x PEEP = level of 0 to 4 48
compressed air PEEP – compressed ≤29
>14 24
air – level of pure air 0 to 7 48
30 and Older
>7 24
 OXACILLIN MEDICAL PROPHYLAXIS
 Usual Dosage: mg/kg per dose IV over at least 10 Diphtheria – update DPT immunization status for all age
minutes groups and Erythromycin 4-050mkd in 4 days divided
 Meningitis: 50 mg/kg per dose doses X 10 days (max 2g/day).
 Alternative: Benzathine Pen G IM single dose
PMA (Weeks) PostNatal (day) Interval (hours)
 <30kg – 600,000 units DOSING INTERVAL CHART
0 to 28 12  >30kg – 1.2 Million units
≤29
> 28 8
0 to 14 12 NOTE: Close contact should be observed for 7 days for evidence
30 to 36
> 14 8
0 to 7 12 of the disease. Endocarditis – prophylaxis given 30-60 mins after
37 to 44
> 7 8
≥45 All 6 procedure
 Oral: Amoxicillin 50mg/kg
RANITIDINE  Unable to tolerate PO
 Oral: 2mg/kg per dose every 8 hrs.  Ampicillin 50mkdose IM/IV or
 IV: Term: 1.5 mg/kg per dose every 8 hours slow push  Cefazolin/Ceftriaxone 50mg/kg
 Preterm: 0.5 mg/kg per dose every 12 hours slow push  Allergic to Penicillin
 Continuous IV infusion: 0.0625 mg/kg per hour; dose range. 0.04  Cephalexin 50mg/kg or
to 0.1 mg/kg per hour  CLindamycin 20mg/kg or
 Azithromycin/Clarithromycin 15mg/kg
MEROPENEM  Allergic & unable to tolerate PO:
 Sepsis: 20mg/kg per dose IV  Cefazolin/ceftriaxone 50mg/kg IM or IV or
 Less than 32 weeks GA: less than or equal to 14 days PNA,  Clindamycin 20mg/kg IM or IV
every 12 hrs, greater than 14 days PNA, every 8 hrs NOTE: No prophylaxis for procedures Respiratory, GIT or GUT
 32 weeks and older GA: less than or equal to 7 days PNA,
every 12 hours; greater than 7 days PNA, every 8 hours Hepatitis B
 Meningitis and infections caused by Pseudomonas species,  Newborn with HBsAg (+) mother
all ages: 40mg/kg per dose every 8 hours. - HBIG 0.5mL and Hep B vaccine 0.5ml IM at birth or w/in 12 hrs
 Give an IV infusion over 30 minutes, longer infusion times followed
(up to 4 hrs) may be associated with improved therapeutic
by Hep B vaccine at 6 weeks after and after 6 months.
efficacy.
 Premature & HbsAg (-) mother
- Hep B vaccine delayed until child ≥ 2000 gm
 Sexual contact with HBsAg (+) partner, exposure to blood/ body
fluids
- Hep B vaccine + HBIG 0.06ml/kg IM (not later than 14
days from exposure from sexual contact and with in 7
days for percutaneous exposure)
METRONIDAZOLE  Household/Sexual Contact with Chronic Causes
 Loading dose: 15mg/kg orally or IV infusion by syringe punp over - Hap B vaccine only
60 minutes
 Maintainance dose: 7.5 mg/kg per dose orally or IV infusion Malaria
over 60 minutes. Begin one dosing interval after dose.  Mefloquine (250mg/tab) to start 1 week before travel then
weekly until 4 weeks after leaving endemic area as ff:
DOSING INTERVAL CHART  < 45kg = 5mg/kg (max: 250mg)
 >45kg = 1 tab once a week
 Doxycycline daily to start 2-3 days before travel then daily until 4 weeks after leaving endemic area
PMA
 (Weeks) PostNatal (day) Interval (hours) 8 years old = 2mg/kg up to adult dose of
0 to 28 12
≤29
>
100mg/day NOTE: Contraindicated for28 8
< 8years and pregnant women
0 to 14 12
30 to 36
> 14 8 Meningococcemia
0 to 7 12  Rifampicin in 2 divided doses X 2days
37 to 44
> 7 8 ≤ 1 month – 5mkdose every 12 hrs
≥45 All 6 ≥ 1 month – 10mkdose every 12 hrs (max 600mg)
 Alternative: Ceftriaxone single IM dose
< 15 years old – 125mg
≥ 15 years old – 250mg or

Ceprofloxacin (not for ≤18 years old)

≥ 18 years old: 20mk PO as SD (max 500mg)

Rheumatic Fever
 Benzathine Penicillin 1.2 Million U IM every 4 weeks
- <27kg (60lbs)- 600,000 U IM or
- Penicillin V 250mg PO twice daily for patients allergic to
Penicillin: Erythromycin 250mg PO BID
 Duration:
 RF, (-) carditis: 5 years since last episode ao ARF or
until 21 years old whichever is longer
 RF, (+) carditis w/o residual heart disease (no valvular
disease): 10 years or until 21 years old whichever is
longer
 RF, (+) carditis, (+) residual heart disease:
10 years since last episode or at least until 40 years old

whichever is longer NOTE: Consider lifelong prophylaxis for people

with severe valvular disease
 VACCINATION SPECIAL ORDERS
Absolute Contraindications Preterm
 Severe anaphylactic/allergic reaction to previous vaccine  Please admit
 Moderate – severe illness ± fever  TPR q15 minutes until stable
 Encephalopathy within 7 days of vaccine (pertussis)  NPO
 Immunodeficiency (Congenital – all live vaccines ) or households  D10W 250ccx7cc/hr
contact (OPV)  Labs:
 Pregnancy (MMR, OPV/IPV )  CBC, APC @24HDL
 Blood & RH typing
Relative Contraindications  Na, K, Ca
 Immunosuppressive therapy (all live vaccines)  BUN, Creatinine 24HDL
 Egg allergy (MMR)  NBS
 Seizure w/in 3 days of last dose (Pertussis)  ABG, Blood C/S, CBG q6H
 Shock w/in 48 hrs of last dose (Pertussis)  CXR, APL
 Fever >40.5°C w/in 48hrs of last dose (Pertussis)  Vit. K 1mg IM now
 Hep B 0.5 ml Im now
Not Contraindications  Terramycin/Erythromycin ophthalmic ointment
 Mild illness ± low grade fever  Ampicillin – q12h
 Current antibiotic therapy  Oxygen
 Positive PPD  Attach to pulse oximeter
 Prematurity
HBsAg Reactive Mother
- Give HBIg 0.5ml deep IM w/in 12HOL
- CRP at 24HOL
- Blood C/S anytime after birth
 Normal CBG: 60-140
 Bilirubin: B1B2: ÷ 17.1 (start phototherapy if ≥15)
 WBC: ≥20,000 start meds
 IT Ratio- stabs/juvenile/total neutrophils = ≥0.2 (+) infection
 Reticulocyte – actual Hct/0.40 (desired Hct)X Reticulocyte = N
1-1.5
≥ 1.0 = hemolysis
≤ 1 = bone marrow failure (CRT ÷ 2)

NURSERY Seizure Disorder

 Please admit to NICU under the service of Dr.  Please admit
 TPR Q15minutes until stable  TPR q4h and record
 Breastfeeding  NPO temporarily
 Labs: CBC, APC, BT, RH typing, NBS at 24h old  Labs: CBS, APC, Urinalysis, fecalysis, CBG now then q6h while
on NPO
Medications:  IVF: D50.3Nacl 500cc+2meq KCL/150ccIVF post voiding
1. Terramycin ophthalmic ointment OU  Meds:
2. Vit. K 1mg IM  S/O:
3. Hep B vaccine 0.5mL IM  MIO qshift & record
 Monitor VS q4h & NVS qhour & record
S/O:  Seizure precaution at bedside
 Routine newborn care  Standby O2, padded tongue depressor at bedside
 Gastric lavage  Replace GI loses volume/volume w/ PLR as sidedrip
 Suction secretion PRN  Refer PRN
 Thermoregulate at 36.5-37.5°C
 Daily cord care w/70% IPA Benign Febrile Seizure
 Watch out for tachypnea, tachycardia, alar flaring, retractions  Please admit
 Refer PRN  TPR q4h & record
 NPO temporarily
Newborn Final Diagnosis:  Labs: CBC, APC, Urinalysis, Fecalysis, CBC now then q6h while
Fullterm ( wks), AGA, BW= kg, cephalic via NSVD, Live, on NPO
Bb.Girl/Boy AS 9,10; Neonatal sepsis; Uninvestigated physiologic IVF: D50.3Nacl 50cc+ 2meq
jaundice KCl/100cc IVF IVF post voiding
 Meds: Paracetamol, Ibuprofen, Diazepam (0.2mkdose)
IVF:  S/O:
 TFR x wt/24h/20% (if with phototherapy)  MIO qshift & record
 TFR x wt/24h-fdg-Aminosteril (use formula if w/ Aminosteril & fdg)  Monitor VS q4h, neuroVS qhour & record
 Seizure precaution
eg: wt: 3kg TFR: 80  Standby O2, tongue depressor at bedside
80x3/24/20%= 20 or  Replace GI losses V/V w/ PLR as sidedrip
80x3=240x0.2= 48,
 Refer PRN
next 240/48=
288/24h= 12cc/hr

1st 24h D10w,

then D10IMB
D5IMB
Status Post Lumbar Puncture Orders CRANIAL NERVE EXAMINATION LIST
 Flat on Bed x 4h Rapport with patient  Introductions
 NPO x 4h Sit on edge of bed
 Diagnostic facies  IVC  NGT
 Send the following specimen to lab as ff:  IDC
 TT#3 – CSF cell count, diffount count  Facial asymmetry
 TT#2 – CSF, sugar & protein inspection
General  Pupil symmetry
 TT#1 – CSF GS/CS, AFB, KOH  Scars  Ptosis  eye patch
 eye glasses  Hearing aide
 RBS now
1. Ask for change in smell
 Monitor VSq15min until stable
2. Test visual acquity  Snellen chart  Left eye  Right eye
 Refer patient for any untoward s/sx Test visual fields  Hat pin  Left eye  Right eye
Test light reflexes  Direct  Consensual  Swinging torch
Status Post Extubation Orders Test accommodation  Hat pin
 Nebulizer with Racemic epinephrine now Fundoscopy  Optic disc  Retinopathy
 Extubate patient now  Dysconjugate gaze (MLF)
3, 4, 6. Test ocular movements ;  H pattern testing  Diplopia
 Nebulize w/ Racemic epinephrine q15minx3doses ask if diplopia occur  Nystagmus  Vertical  Horizontal
 Nebulize w/ Salbutamol 1nebule q6h  Test Intorsion (if CN3 palsy)
 NPO x 6h  Pin prick testing V1 V2 V3
 CXR, APG 6h post extubation  Light touch testing  Corneal reflex
 O2 6-10LPM 5. Trigeminal Sensory & Motor  Clench teeth &
palpation of masseter muscle
 Watch out for secretions,  Open jaw & ptyerygoid resistance
tachypnea, etc. Note: Racemic Epi:  Jaw jerk
PNSS: 4.7ml Epi: 0.3ml  Forehead wrinkling  Eye closure
7. Test Facial Muscles  Blowing of cheeks  Smiling
 Ear  Mastoid  Parotid  Palate
 Inspection of ear and tympanum
 whisper  High tone 68
8. Test Hearing and Balance  Low tone 100 
Rinne’s  R  L
 Weber’s (256Hz)  Nystagmus
 Hallpike’s +/- Epley’s
 Dysphonia  Swallowing
9, 10. Deviation to Normal side  Coughing  Uvual
deviation
 Gag reflex
11. test shoulder & neck  Trapezius mm: Shoulder shrug
movements  SCM mm: Head turning
12. Tongue Protrusion; deviation  Wasting  Fasiculation
to affected side  Dysarthria
Ask for BSL
If relevant assess other  Peripheral nervous system
neurological system  Cerebellar system
Summary & interpretation
 DRUGS
DRUG RD Preparation
Tab:
1.2-
Ambroxol 30mg
1.6mkdo
Syr.
se (BID-
15mg/ml
TID) Infant drops:6mg/ml
Amp/Vial
10mkdose
Amikacin 50mg/mlx2
(LD)
(Amikin, ml
15mkdose
Amikacide, 125mg/mlx
(MD)
Onikin) 2ml
15mg/kg/day
250mg/mlx
(BID)
2ml
Cap:250mg;
500mg
Amoxicillin Syr:250mg/5ml
30-50 mkday
(Pediamox) Ped.drops:
(TID)
125mg/1.25ml
100mg/ml
Vial:500mg
50-100 mkday(IV)
30-50
Amphotericin B Vial:50mg/10ml
mkday(oral)
1mg/kgBW
(alternate day)
Cap:250mg;500
50-100 mkday
mg
Ampicillin (IV) 30-
Syr:125mg/5ml
(Ampicin, 50mkday
Forte
Pensyn) (oral)
Syr:250mg/5ml
1mg/kg/BW
Ped drops:
(alternate
125mg/1.25ml
day)
Vial:500mg
Tab: 4mg
0.2-0.3 Amp:
Antamin
mkdose 5mg/ml
(TID) Vial:5mg/ml x 10ml
 DRUG
RD Preparation DRUG RD Preparation
Tab:250mg;50 Ethambutol 15 mkday Tab: 400mg;200mg
ASA 75-100 0mg Enema: Cap:250mg
1mkday
mkday(TID) 4g Ferrous sulfate Syr:220mg/
Supp:250mg (MDR) 4-
5ml
Aztreonam 30-50 mkday 6mkday
Drops: 75mg/0.6ml
(txc)
3-5 mkdose Cap:25mg;50mg
Benadryl (oral TID- Syr:12.5mg/5ml Tab:100mg
Furazolidone 4-7mkday
Inj:50mg/ml Amp:50mg/5ml
QID)
1 mkdose (IV,OD) Tab:20mg; 40mg
Furosemide 0.5-1 mkdose
0.01 mkdose Tab:10mg Amp: 10mg/ml
Buscopan Vial: 40mg/ml
Q6h Amp:20mg Gentamycin 5-8 mkday
0.02-1.5 80mg/2ml
mkday 0.15 mkdose Tab: 25mg
Hydralazine
10-20 mkday Cap:500mg (IV) Amp: 20mg/2ml
Carbocisteine (infant)(TID- Syr:100mg/ 0.75 mkdose
QID) 5ml (oral)
30-50 mkday Susp:250mg/5ml Hydro Vial:259mg
5 mkdose
(child) cortisone Amp:100mg;250mg;500
Tab: 10mg/tab OD HS mg
Ceterizine 0.25 mkday
Syr: 5mg/5ml 0.01 mkdose Tab: 100mg
Hyoscine
Cap:250mg;500mg 0.02-0.15 Amp: 20mg
Cefaclor 20-40 mkday Susp:125mg/5ml mkday
(TID) 250mg/5ml Tab: 200mg; 400mg;
Ibuprofen 5-10 mkdose
Cap:500mg 600mg
Cefadroxil 25-50 mkday Syr: 100mg/5ml
Syr:125mg/5ml
(TID) 5-10 mkday Tab: 300
Cefetamet 20 mkday (BID) INH
(premeals) Syr:100mg/5ml
50- Tab: 500mg
Cefotaxime Vial: 1g Isoprinosine 50mkday
100mkday(BID- Syr: 250mg/5ml
TID) Meclizine 12.5-50 mkday
Cefepime 50 mkday q8hrs Vial: 500mg; 2g Cap:250mg;500mg
Ceftazidime 50-100mkday Vial: 500mg; 1g Mefenamic acid 6.5 mkdose
Susp:50mg/5ml
Cefazolin 50-100mkday Vial: 500mg; 1g (q6hrs)
50-100 mkday Vial:250mg; 500mg; 6 mkday
Ceftriaxone Meperidine
(TID- 1mg plus 0.5 mkdose
QID) 10ml diluents Syr:5mg/5ml
0.25 mkdose
Tab: 500mg/500mg Metoclopromide Amp:5mg/ml;
(IV,IM) 10mg/2ml
1 mkday (0ral)

DRUG RD Preparation DRUG RD Preparation

50-100 Nafcillin 50-100 mkday
Cephalotin (TID)
mkday
Nalbuphine 0.1-0.2 mkdose 10mg/ml
25-100
Cephradine Cap: 500mg Tab: 5mg; 10mg;
mkday 0.25
Nifedipine 20mg;
Cap:250mg;50 Mkdose
50-100 30mg;60mg
Chloramphenicol 0mg
mkday TID Susp:125mg/5 400,000 U/day
Nystatin Oint: 5g
ml NB: 1.2M U/day
Vial: 1g Tab: 200mg; 400mg
Ofloxacin 20-30mkday
Tab:200mg; 400mg IV soln:
20 200mg/100ml
Cimetidine Syr:100mg/5ml
mkday Tab: 500mg
Amp: 200mg/2ml;
300mg/2ml Susp:120mg/
Paracetamol 5-25 mkdose
Tab:250mg;50 5ml;
(q4hrs)
0mg IV 250mg/5ml
Ciprofloxacin 20-30mkday infusion: Drops: 100mg/ml
100mg/50ml 50-100,000
200mg/100ml Penicillin U/mkday
1.2M “U”
400mg/200ml G 200,000-400,000
Clarithromycin Tab: 250mg;500mg (Penadu U/mkday
7.5mkday (BID) r)
(Klaricid) Susp: 125mg/5ml (meningitic
Cloxacillin Cap: 250mg; 500mg dose)
50-100 mkday
(Pharex) Oral soln Tab:15mg;30mg;
(QID) 10mkdose
powder:125mg/5ml Phenobarbital 60mg; 90mg
(LD)
Tab: 400mg/80mg; Amp: 130mg/ml
5mkdose
Cotrimoxazole 8-12 mkday (BID) 800mg/160mg
(MD)
Susp: 200mg/40mg/5ml
Piperacillin 100-300mkday Vial: 2.25g; 4.5g
Tab: 2mg; 5mg (Tazocin)
Diazepam 0.2 mkdose
Amp: 10mg/2ml Tab:5mg; 10mg;
Cap: 50mg; 150mg; Prednisone 1-2 mkday (BID)
Diflucan 6-13 mkday 20mg
250mg Susp: 10mg/5ml
Vial:2mg/ml Tab:500mg
Tab: 500mg Pyrazinamide 15-30mkday (BID) Susp:500mg/5ml;
Diloxanide 20mkday (TID)
Susp: 125mg/5ml 250mg/5ml
1-2mkdose (BID) Tab:150mg; 300mg
Ranitidine
Q 8-12hrs Amp:25mg/ml;
 DRUG
Neurotoxicity RD Preparation
Spirono  Cisplatin – ototoxocity, p. neuropathy
1-3mkday Tab: 25mg; 50mg; 100mg
lactone  Paclitaxel – p. sensory, neuropathy
Streptomycin 20-40mkday Vial: 1g  Vinca Alkaloids – motor , sensory, autonomic neuropathy,
Sucralfate adynamic ileus, urinary bladder atony
1g/dose (QID) Tab: 1g
(Iselpin)
Cardiac Toxicity
Tab: 2.5mg;
0.075  Doxorubicin, Daunomycin – cardiomyopathy
Terbutalline 5mg Syr:
mkdose
1.5mg/5ml Pulmonary Toxicity
(BID-TID)
Neb: 5mg/2ml  Bleomycin – interstitial
Tetracycline 20-50 mkday Cap: 250mg
 Alkylating agent pneumonistis with pulmonary fibrosis
(QID)
Tab: Gastrointestinal Toxicity
Theophylline 20mkday (q6hrs) 125mg SR  Mathotraxate – hepatic fibrosis
tab: 250mg  Vinca Alkaloids – adynamic ileus, urinary bladder atony
Syr: 80mg/15ml
Genitourinary Toxicity
 Cisplatin – azotemia, Mg wasting
 Methotrexate – oliguria RF
 Cyclophosphamide/ Ifosfamide – chronic hemorrhagic cyctitis
Dermatologic Toxicity
 Doxorubicin Skin necrosis, sloughing from
 Actinomycin – D drug extravasation
 Vincristine
Gonadal Dysfunction
 Azospermia recovery is uncommon
Hematologic Toxicity
 Granulocytopenia/neutropenuia
- 6-12 days after administration
- Recovery in 21-24 days
ANC= (WBC count)(%segmenters)
- Must be ≥ 1500 for chemo to proceed
 Thrombocytopenia
- Recovers 4-5 days later than granulocytes
- ≥ 100,000/mm3 for chemo to proceed

DRUG RD Preparation HEMODIALYSIS PRESCRIPTION

Blood Flow Rate:
5ml/kg/min Dialyzer: F4:
BSA 0.7
F5: BSA 1.0
F6: BSA 1.3

NSS Flushing 100ml q 15min or Heparin LD: 10-20IU/kg

MD: 10-20IU/kg
Ultrafiltrate 0.2ml/kg/min x

hrs Duration: initial 1.5 – 2

hrs
2nd day: 3hrs
3rd day: maintemance – 4hrs

Bicarbonate bath: prime solution with NSS 120ml

 Weigh patientt pre & post HD and record

 Monitor VS q15mins while on HD
 Watch out for Headache, nausea, disorientation, hypotension,
seizure, muscle cramps & vomiting
 Labs: pre & post HD
 Intradialytic transfusion (if any )
 Initial HD: Mannitol 0.5-1.0g/kg to decrease disequilibrium
syndrome in pt w/ elevated BUN (>35mmol/L)
 Refer accordingly.