group 1pediatric ward case prsentation-.pptx

THIS IS ABOUT SAM + ANEMIA SECONDARY TO MALARIA + SCAP

1. MIZAN TEPI UNIVERSITY COLLEGE OF MEDICINE AND HEALTH SCIENCE school of pharmacy pediatric ward case presentation on SAM+ S. MALARIA + SCAP

2. Outline Case identification Subjective findings Objective findings Physician assessment Background Pharmaceutical care plan Patient counselling References

3. Patient demographic information Name: SA Age : 7 Month Sex : male Card no: 035235/16 Date of admission : 27/11/2016 E.C Bed number : P11 Address ; Guraferda 01 kebela weight : 5.6 kg

4. Chief Compliant Fever cough Fast brething for 02day Granting

5. History of present illness This is a 7 months infant male was admited to the pediatric ward at MTUTH with a chief Complaints of fever, cough, fast breathing and granting for 02 day .

6. Past medical History No known past medical history.

7. Past medication History No known past medication history

8. Family History He has no known of family history.

9. Immunization History He has immunized on his age .

10. physical examination G/A : Acute sick looking HEENT ; pink conjunctiva RS: Fast breathing CVS : S1 and S2 well heard CNS : Alert NS: has no neuropathy Abdomen : Flat/ Soft

11. Vital signs Date R/R P/R T O C Spo2 Remark 27/11/2016 56/min 157b/mi 37 91% 28/11/2016 40b/min 164b/mi 37.9 94% 29/11/2016 32b/min 104b/mi 37.6 96% 30/11/2016 30b/min 136b/mi 36.5 96% 01/12/2016 30 b/min 150 b/mi 36.5 97%

12. Laboratory Results Laboratory test Results Reference range Remark HGB 6.7g/dl 11.0 - 16g/dl HCT 21.0% 37.0% - 54.0% MCV 64.3 fl 80.0 – 100.0fl MCH 20.4pg 27.0- 34 .0 pg MCHC 31.9g/dl 32.0 g/dl – 36 .0 g/dl ESR 21mm/h B/F P. Falciparum seen B/ group and RH .factor O+

13. Physician Assessment SAM + S.Malaria + SCAP .

14. Current medication Artesunate 3mg /kg /day 0,12,24hr then daily for 06 day F -75 milk Azithromycin 10mg/5ml po /day for 03 days Hydrocortisone 4mg/kg Iv loading dose then 2mg IV QID Ceftriaxone 75mg/kg IV BID Ampicillin 50mg /kg/dose IV QID Paracetamol 120mg /5ml po QID F-100 milk Zink 20mg po daily for 10 days Vancomycin 20/kg/dose IV TID Cefepime50mg/kg/dose IV TID Salbutamol 6puff PRN complete and DC On hand

15. Background Severe acute malnutrition is defined as the presence of oedema of both feet or severe wasting (weight-for-height/length <-3 standard deviations (SD) ) or mid upper arm circumference < 115 mm. Severe wasting is extreme thinness diagnosed by a weight-for-length (or height) < −3 standard deviations (SD) of the WHO Child Growth Standards.

16. Cont… In children ages 6-59 mon, a mid-upper arm circumference<11.5cm also denote extreme thinness which is convenient way of screening children in need of treatment. Bilateral edema is diagnosed by grasping both feet, placing a thumb on top of each, and pressing gently but firmly for 10 sec. A pit (dent) remaining under each thumb indicates bilateral edema.

17. causes/contributing factors to malnutrition Immediate causes: Diet and disease Inadequate quantity and quality of food Lack of knowledge on appropriate foods provided to children, poor food preparation Infections: reduce appetite, increase energy and nutrient utilization, and limit the ability to absorb or retain nutrients e.g. in diarrhea, intestinal parasites

18. Cont… Root causes : Food insecurity, poor health services, poor environmental sanitation, natural disasters, and excessive workload for women. poor weaning practices, culture, inadequate water supply, low literacy levels, low nutrition advocacy/education Underlying causes : poverty, corruption, poor governance, poor infrastructure.

19. Pathophysiology When a child's intake is insufficient to meet daily needs, physiologic and metabolic changes take place in an orderly progression to conserve energy and prolong life. Energy is conserved by reducing physical activity and growth, reducing basal metabolism and the functional reserve of organs, and reducing inflammatory and immune responses. These changes have important consequences:

20. Cont… The liver makes glucose less readily, making the child more prone to hypoglycaemia . It produces less albumin, transferrin, and other transport proteins. ◆ Heat production is less, making the child more vulnerable to hypothermia. excrete excess fluid and sodium, and fluid easily ac ◆ The kidneys are less able to cumulates in the circulation, increasing the risk of fluid overload .

21. Cont… The heart is smaller and weaker and has a reduced output, and fluid overload readily leads to death from cardiac failure. Sodium builds up inside cells due to leaky cell membranes and reduced activity of the sodium potassium pump, leading to excess body sodium, fluid retention, and edema. ◆ Potassium leaks out of cells and is excreted in urine, contributing to electrolyte imbalance, fluid retention, edema, and anorexia.

22. Cont… ◆ Loss of muscle protein is accompanied by loss of potassium, magnesium, zinc, and copper. ◆ The gut produces less gastric acid and enzymes. Motility is reduced, and bacteria may colonize the stomach and small intestine, damaging the mucosa and deconjugating bile salts. Digestion and absorption are impaired

23. Cont… Cell replication and repair are reduced, increasing the risk of bacterial translocation through the gut mucosa. Micronutrient deficiencies limit the body's ability to deactivate free radicals, which cause cell damage. Edema and hair/skin changes are outward signs of cell damage.

24. CLINICAL FEATURES Non oedematous (Marasmus): Severe wasting, old man’s face, eyes are sunken Apathetic or irritable, appetite is fairly good, Oedematous (Kwashiorkor): hair changes, presence of bilateral pitting oedema , moon face Skin changes (dermatosis, flaky paint dermatitis) Hair changes: Silky, straight, sparsely distributed. Organomegaly

25. Cont… Marasmus - Kwashiorkor : Wasting with edema

26. Diagnosis The main diagnostic features are: Weight-for-length/height < -3SD (wasted) or Mid-upper arm circumference < 115 mm or Oedema of both feet (kwashiorkor with or without severe wasting).

27. Treatment General treatment involves 10 steps in two phases: initial stabilization and rehabilitation.

28. Cont… Hypoglycaemia Treatment Give 50 ml of 10% glucose or sucrose solution (one rounded teaspoon of sugar in three tablespoons of water) orally or by nasogastric tube, followed by the first feed as soon as possible. Give the first feed of F-75 therapeutic milk, if it is quickly available, and then continue with feeds every 2 h for 24 h; then continue feeds every 2 or 3 h, day and night.

29. Cont… If the child is unconscious , treat with IV 10% glucose at 5 ml/kg or, if IV access cannot be quickly established, then give 10% glucose or sucrose solution by nasogastric tube. Continue with 2 h r oral or nasogastric feeds to prevent recurrence. Start on appropriate IV or IM antibiotics

30. Cont… Hypothermia Treatment Feed the child immediately and then every 2 h r if dehydrated, rehydrate first. Re-warm the child Keep the child away from draughts.

31. Cont… Dehydration treatment Give 5 ml/kg of ReSoMal rehydration fluid orally or by nasogastric tube, every 30 min for the first 2 h r . Then give 5–10 ml/kg per h r for the next 4–10 h r on alternate hours, with F-75 formula. If not available then give half strength standard WHO ORS with added potassium and glucose as per the ReSoMal recipe below.

32. Cont… If rehydration is still required at 10 h r , give starter F-75 instead of ReSoMal, at the same times. Use the same volume of starter F-75 as of ReSoMal. If in shock or severe dehydration but cannot be rehydrated orally or by nasogastric tube, give IV fluids, either Ringer’s lactate solution with 5% dextrose If not is available, 0.45% saline with 5% dextrose should be used

33. Cont… Electrolyte imbalance Treatment Give extra potassium (3–4 mmol/kg per day). Give extra magnesium (0.4–0.6 mmol/kg per day). When rehydrating, give low sodium rehydration fluid (ReSoMal). Prepare food without added salt.

34. Cont… Infection Treatment If the child has uncomplicated severe acute malnutrition, give oral amoxicillin (25mg/kg BID for 5 days). If there are complications, give parenteral antibiotics: – Benzylpenicillin (50 000 I U/kg IM or IV every 6 h) or Ampicillin (50 mg/ kg IM or IV every 6 h) for 2 days, then oral Amoxicillin (25–40 mg/kg every 8 h for 5 days) plus gentamicin (7.5 mg/kg IM or IV) once a day for 7 days.

35. Cont… If there is evidence of worm infestation , treatment should be delayed until the rehabilitation phase. Give albendazole 400mg as a single dose or mebendazole 100 mg (grater than 2year) orally twice a day for 3 days. In countries where infestation is prevalent, also give mebendazole to children with no evidence of infestation 7 days after admission.

36. Cont… Micronutrient deficiencies Treatment Give vitamin A on day 1 and repeat on days 2 and 14 only if child has any signs of vitamin A deficiency like corneal ulceration or a history of measles < 6 months, 50 000 IU 6–12 months, 100 000 IU > 12 months, 200 000 IU

37. Cont.. Although anaemia is common, do not give iron initially, but wait until the child has a good appetite and starts gaining weight (usually in the second week), because iron can make infections worse. Multivitamins including vitamin A and folic acid, zinc and copper are already present in F-75, F-100 and ready-to-use therapeutic food packets. When premixed packets are used, there is no need for additional doses.

38. Cont… Start iron at 3 mg/kg per in the stabilization phase , and do not give iron if the child is receiving ready-to-use therapeutic food (RUTF). If child is not on any of the pre-mixed therapeutic foods, give the following micronutrients daily for at least 2 weeks: folic acid at 5 mg on day 1; then 1 mg daily multivitamin syrup at 5 ml zinc at 2 mg/kg per day, copper at 0.3 mg/kg per /day

39. Cont… Initial re-feeding In the initial phase, re-feeding should be gradual. The essential features of initial feeding are: Frequent (every 2–3 h) Nasogastric feeding if the child is eating ≤ 80% of the amount offered at two consecutive feeds

40. Cont… calories at 100 kcal/kg per day protein at 1–1.5 g/kg per day liquid at 130 ml/kg per day or 100 ml/kg per day if the child has severe oedema

41. Cont… Catch-up growth feeding Make a gradual transition from starter F-75 to catch-up formula F-100 or ready to-use therapeutic food over 2–3 days, as tolerated. Give a milk-based formula, such as catch-up f-100 containing 100 kcal/100 ml and 2.9 g of protein per 100 ml or ready-to-use therapeutic food

42. Cont… On the third day if on F-100, increase each successive feed by 10 ml until some feed remains uneaten. The point at which some feed remains unconsumed is likely to be when intake reaches about 200 ml/kg per day. After a gradual transition, give: frequent feeds, unlimited amounts 150–220 kcal/kg per day 4–6 g of protein/kg per day.

43. Cont… If on ready-to-use therapeutic food: Start with small but regular meals of RUTF and encourage the child to eat often (first 8 meals per day, and later 5–6 meals per day).

44. Cont… If the child cannot eat the whole amount of RUTF per meal in the transition phase, top up with F-75 to complete the feed, until is able to eat a full RUTF meal. If the child cannot take at least half of recommended amount of RUTF in 12 h, stop RUTF and give f-75.

45. Cont… Try introducing RUTF again in 1–2 days until the child is able to take adequate amounts. If still breastfeeding, offer breast milk first before every RUTF feed. After the transition phase , refer the child for rehabilitation in outpatient care or to a community feeding programme.

46. Pharmaceutical care assessment Patient Info: A 7-month-old baby was misdiagnosed with SAM. Current Therapy: The baby was given therapeutic feeding and antibiotics. Diagnosis Check: The diagnosis was re-evaluated and confirmed that SAM was incorrect. Therapy Check: Therapeutic Feeding: It was stopped since the SAM diagnosis was incorrect. Antibiotics: They were continued as they were necessary.

47. Cont... Risks: Unnecessary therapeutic feeding could have caused side effects and extra costs. Recommendations: Unnecessary therapeutic feeding was stopped. Antibiotics were continued as needed. Alternative care was provided based on the accurate diagnosis. Documentation: Findings were recorded and shared with the healthcare team. Follow-Up: The baby’s progress was monitored with the new care plan.

48. PHARMACEUTICAL CARE PLAN Medical condition Medication DTP GOAL Recommendation Recommendation Status Monitoring Outcome SAM - F-75 -F-100 milk - Zinck 20mg po daily for 10days Unnecessary drug therapy (In appropriate indication ) Correct Dx stop unnecessary therapeutic foods Accepted Anthropometric measurement SCAP -Cefpime50mg/kg/dose IV TID -Vancomycin 15/kg iv TID -Salbutamol 6puff Q20min -Hydrocortisone 4mg/kg loading then 2mg/kg QID -Azithromycin 200mg/5ml 1.5ml po daily for 3day (10mg/kg/day) -Ampicillin 50mg/kg/dose IV QID -Ceftriaxone 75mg/kg iv bid Azithromycin 200mg/5ml 1.5ml is dose to low -Resolve infection Continue -V/S -Auscultation Worsen MALARIA Artesunate 3mg /kg /day ,0,12,24hr then daily for 06 day Cure Repeat BF Accepted BF V/S Improve ANEMIA whole blood 20ml/kg for 3hr Non compliance Correct Anemia Refer Not Accepted HCT & Hgb Un improve

49. patient counselling Keep the child away from wet and cover h is with warm cloth. Feed him through the night. Encourage mothers to watch for any deterioration, help feed and keep the child warm. Breast feeding engagement. Appropriate application salbutamol

50. Reference STG 4 TH edition 2021. National Guideline for the Management of Acute Malnutrition in Ethiopia 2019. National Guidelines for the Management of Acute Malnutrition Republic of Lebanon Ministry of Public Health.2016 Clinical Reference Manual for Advanced Neonatal Care in Ethiopia Ministry of Health 2021 .

51. Group member Tadele Bekele ………….HSS/152/10 Wondaferahu wondimu …..HSS/195/10 Mubarek Habib ……..…HSS/138/10 Asteray Belay ………. …HSS/036/10 Daniel Birhanu ….......... HSS/062/10 Abeba yikunom ……........HSS/002/10 Adugenet markos ……. HSS/014/10 Yonas endayehu …………..HSS/187/10 Ermias Tadesse ……….. .HSS/073/10 Tsedeke lara …………….HSS/173/10 Hailu Bekuma ……….. HSS/095/10 Mathyos T/ mariam ……….. HSS/119/10

52. Thank you!