Case presentation on paediatrics

The branch of medicine that involves the medical care of infants, children, and adolescents.
THIS PPT IS A CASE PRESENTATION

1. Case presentation on paediatrics Presented By Meraj Fatima, PharmD 4 th Year. Sultan- ul - Uloom College of Pharmacy Hyderabad, India. Guided by Dr. S P Srinivas Nayak , Assistant Professor Dept. of Pharmacy Practice, SUCP

2. Case: A 7year old male patient weighting 16kg Presented in the emergency department with a 2-day history of worsening groin and hip pain. Could not bear weight. Patient was febrile with a temperature of 39.2°C, vomiting and dehydrated. There was no history of injury. There is no previous medical history, No known drug allergies, no drug history Differential diagnosis : Septic arthritis, Osteomyelitis Dept. of pharmacy practice, SUCP, HYDERABAD 2

3. Test results : Bone scan revealed right pubic osteomyelitis CRP = 56mg/L (normal range 0–10mg/L) ESR = 34mm/h (normal range 1–10mm/h) Blood culture revealed - Staphylococcus aureus sensitive to flucloxacillin Dept. of pharmacy practice, SUCP, HYDERABAD 3

4. Medication prescribed : Flucloxacillin i.v. 800mg four times a day for 2 weeks. To be followed by oral flucloxacillin 800mg four times a day for 4 weeks. Progress : Temperature settled and ESR/CRP decreased following initiation of antibiotic therapy. Dept. of pharmacy practice, SUCP, HYDERABAD 4

5. On the third day of treatment the patient developed a raised red rash which was suspected of being an allergic reaction to flucloxacillin . Treatment was changed to i.v. Clindamycin 160mg three times a day (10mg/kg/dose) for 2 weeks followed by oral clindamycin 160mg three times a day for a further 4 weeks. Dept. of pharmacy practice, SUCP, HYDERABAD 5

6. Comments on drug therapy and monitoring required: •Body weight appears low for age; therefore, need to check if the weight is correct (expected weight for a 7-year old to be approx. 23kg). If incorrect, doses of medication will need to be recalculated. •Recommended i.v. Dose of flucloxacillin of 50mg/kg/dose is correct. However, usual maximum oral dose of flucloxacillin is 25mg/kg/dose. This is because of the increased risk of gastric side effects with high oral doses of flucloxacillin . • There is a need to consider compliance with oral flucloxacillin therapy due to poor palatability of the suspension formulation (if the child would not take capsules) and the frequent dosingregimen . Dept. of pharmacy practice, SUCP, HYDERABAD 6

7. • Whilst the risk of flucloxacillin -induced hepatotoxicity is low in children, there is a need to consider measuring baseline and repeat liver function tests because of the prolonged course (more than 2 weeks) of flucloxacillin therapy . • Clindamycin has good oral bioavailability, so i.v. Therapy may be unnecessary . • The recommended dose of clindamycin by i.v. Infusion is up to 10mg/kg dose 6 hourly in severe infection. The infusion should be diluted to 6mg/mL with sodium chloride 0.9% or dextrose 5% (or a combination) and administered over 30–60min at a maximum rate of 20mg/kg/h. Consider 160mg in 27mL sodium chloride 0.9% over 30min . • The recommended standard oral dose of clindamycin is 3–6mg/ kg/dose four times a day. This may contribute to problems with adherence to long-term therapy. A three times daily dosing regimen is to be preferred, particularly as this child may return to school, and four times daily dosing would require a dose to be administered at school which may be problematic. Dept. of pharmacy practice, SUCP, HYDERABAD 7

8. • Consideration should be given to how to administer ­clindamycin. Clindamycin palmitate suspension, which was palatable, is no longer available as a licensed preparation in the UK. Whilstextemporaneous formulations are available that use clindamycin - hydrochloride capsules, the palatability of the resultan suspension is a major concern, particularly given the prolonged course of therapy. A 75mg/5mL suspension, licensed in Belgium, can be imported. From a safety and efficacy perspective it is preferable to use such a product, which has been through a regulatory process similar to that of the UK, than to compound an extemporaneous preparation, which has not undergone appropriate pharmaceutical/pharmacokinetic evaluation. Dept. of pharmacy practice, SUCP, HYDERABAD 8

9. •Consideration could be given to decreasing the dose of clindamycin to 150mg three times a day to accommodate capsules, although the child may have difficulty taking these. •The most serious adverse effect of clindamycin is antibiotic associated colitis. Therefore, it is important to monitor for diarrhoea. If this arises treatment should be discontinued. Dept. of pharmacy practice, SUCP, HYDERABAD 9

10. 18 months old female patient, weighting 10 kg is presented with Severe right-sided abdominal pain, Vomiting and loss of appetite, Increased temperature 38.2°C No previous medical history, no known drug allergies. Test : ultrasound Provisional diagnosis : Appendicitis Appendicectomy was performed. The appendix was noted to be perforated. Dept. of pharmacy practice, SUCP, HYDERABAD 10

11. Medications : Morphine 50mg in 50mL to run at 1–4mL/h (10–40mcg/kg/h) Paracetamol 200mg four times a day as required orally or per rectum Diclofenac 12.5mg twice a day as required per rectum. or Ibuprofen 100mg four times a day as required orally when tolerating milk Five days of i.v. Antibiotic therapy with: Gentamicin 70mg daily Ampicillin 250mg four times a day Metronidazole 75mg three times a day Dept. of pharmacy practice, SUCP, HYDERABAD 11

12. Comments on the patient’s drug therapy : • The morphine dose is incorrect. If the infusion is prepared as directed, 1mL/h will actually provide 100μcg/kg/h. This is a 10-fold overdose which is a medication error frequently seen in children. • There is a need to consider how to administer the appropriate rectal dose of paracetamol to this child. Often post appendicectomy patients will need to be nil by mouth for several days. Rectal bioavailability is lower than oral bioavailability and there may be a need to consider giving a larger rather than smaller paracetamol dose, that is, possibly 250mg/rectum 8 hourly rather than 125mg 6 hourly, for up to 48h, but not exceeding 90mg/kg/day. Dept. of pharmacy practice, SUCP, HYDERABAD 12

13. • Suggest that paracetamol and NSAID are administered regularly in addition to the morphine for at least the first few days post-surgery. Multimodal analgesic therapy is recommended. • There will be a need to monitor CS for side effects. Nausea, vomiting and pruritus all occur frequently with morphine but can be treated/prevented. • Young children are particularly susceptible to developing myoclonic jerks with morphine. These are often worrying for parents but resolve on withdrawal of the morphine. Dept. of pharmacy practice, SUCP, HYDERABAD 13

14. • NSAIDs are well tolerated by children and the risk of adverse events is much lower in children than the adult population. However, it is important to ensure adequate hydration status postoperatively, particularly when using NSAIDs. Acute renal failure has been reported in children who have been treated with NSAIDs and not adequately hydrated . • The choice of antibiotics for CS is appropriate. High-dose (7 mg/kg) once-daily aminoglycoside (gentamicin/tobramycin) therapy is now routinely used in children. It is administered by short infusion over 20 min. Plasma drug levels should be monitored to achieve a 18–24 h trough level of <1 mg/L. Monitor urea and electrolytes and serum creatinine . Ampicillin can be given as a bolus injection over 3–5 min. Metronidazole should be given as a short infusion over 20 min. Dept. of pharmacy practice, SUCP, HYDERABAD 14

15. Thank you Dept. of pharmacy practice, SUCP, HYDERABAD 15