BASIC - PAEDIATRICS Flashcards
Name of NSAIDs?
Ibuprofen
Indications of NSAIDs?
- PRN for mild-to-moderate pain
- Regular treatment of pain related inflammation
Mechanism of NSAIDs?
What is the selective cox inhibitor?
- Inhibit synthesis of prostaglandins from arachidonic acid by inhibiting cyclooxygenase (COX)
- COX-1 stimulates prostaglandin synthesis essential to preserve gastric mucosa, maintain renal perfusion (by dilating afferent glomerular arterioles) and inhibit thrombus formation at the vascular endothelium
- COX-2 expressed in response to inflammatory stimuli stimulates production of prostaglandins that cause inflammation and pain
- Therapeutic benefits of NSAIDs are principally COX-2 inhibition and adverse effects by COX-1 inhibition
- Selective COX-2 inhibitors (e.g. etoricoxib) developed to reduce the adverse effects
SE of NSAIDs?
- GI toxicity
- Renal impairment
- Increased risk of MI/CVA
- Fluid retention
Interactions of NSAIDs?
- GI Ulceration o Aspirin, corticosteroid - GI bleeding o Anticoagulants, SSRIs, venlafaxine - Renal Impairments o ACEi, diuretics
Contraindications of NSAIDs?
o Severe renal impairment
o Heart Failure
o Liver failure
Caution of NSAIDs in prior?
o Peptic ulcer disease
o GI bleeds
o CVD
Prescription of NSAIDs?
- Available as tablets, suspensions, gels, suppositories, injectable
- Acute pain treatment should be stopped when resolved
- Taken with food to minimise GI upset
What to warm patients on NSAID use?
- Warn patients that the most common side effect is indigestion and advise them to stop treatment and seek medical advice if this occurs
Communication when on NSAIDs?
- For patients with acute pain, explain that long-term use, e.g. beyond 10 days, is not recommended due to the risk of side effects
- Advise patients requiring long-term treatment (particularly if they have renal impairment) to stop NSAIDs if they become acutely unwell or dehydrated to reduce the risk of damage to the kidneys
What other drug should be considered?
- Can use gastroprotection for patients at increased risk
What is the general dose for NSAIDs in children?
3-4 times a day, maximum dose 30mg/kg/day
What is the dose of NSAIDs for children 10-11 years and 12-17 years?
o For Child 10–11 years
300 mg 3 times a day; maximum 30 mg/kg per day; maximum 2.4 g per day.
o For Child 12–17 years
Initially 300–400 mg 3–4 times a day; increased if necessary up to 600 mg 4 times a day
Indications for paracetamol?
- 1st line analgesic for acute and chronic pain
- Antipyretic
Mechanism of paracetamol?
- Weak cyclooxygenase (COX) inhibitor, involved in prostaglandin metabolism
- Increase pain threshold and reduce (PGE2) concentrations in thermoregulatory region, controlling fever
- Specifically, COX-2 isoform (inflammation) rather than COX-1 isoform (protecting gastric mucosa, regulating renal blood flow and clotting)
SE of paracetamol?
Describe mechanism of overdose and treatment?
- Few side effects
o Metabolised by CYP450 enzymes to toxic N-acetyl-p-benzoquinone imine (NAPQI) which is conjugated with glutathione before elimination
o NAPQI accumulation causes hepatocellular necrosis
o Treated with acetylcysteine
Interactions of paracetamol?
- CYP450 inducers increase the rate of NAPQI production and risk of liver toxicity after paracetamol overdose
Dose reduction of paracetamol?
- Dose reduced in liver toxicity
Caution of paracetamol?
o Chronic excessive alcohol use
o Malnutrition
o Low body weight
o Hepatic impairment
Prescription of paracetamol?
- Oral paracetamol can be purchased in retail outlets7
- Regular administration or PRN
- Available as tablets, caplets, capsules, soluble tablets or oral suspensions
- IV is possible
Communication to patient of paracetamol?
- Effects should be felt around half an hour after taking it
- Warn them not to exceed the recommended maximum daily dose because of the potential risk of liver poisoning
- Advise them that many medicines purchased from the chemist (e.g. cold and flu preparations) contain paracetamol
- Warn them to check the label
General dosage of paracetamol in children 10-15 years and 16-17 years?
o Child 10-15 years
480-750mg every 4-6 hours, max 4 doses
o Child 16-17
0.5-1g every 4-6 hours, max 4 doses
Indication for oxygen?
- Hypoxaemia
- Accelerate reabsorption in pneumothorax
- Reduce half-life of carboxyhaemoglobin in carbon monoxide
Mechanism for oxygen?
- Supplemental oxygen therapy increased the PO2 in alveolar gas, driving more rapid diffusion into blood
- Increases delivery of oxygen to the tissues
- In pneumothorax, oxygen reduces nitrogen fraction in alveolar gas to accelerate nitrogen diffusion out of body
- Oxygen competes with CO to bind with haemoglobin and thereby shortens the half-life of carboxyhaemoglobin
SE of oxygen?
- Discomfort of facemask
- Dry throat
Any interactions in oxygen?
None
Contraindications of oxygen?
- Caution in Type 2 Respiratory failure (COPD)
- Avoid around naked flames, heat sources or smoking
Prescription of oxygen?
Different deliveries for different indications?
Doses?
- Target oxygen saturation 94-98%
- Initial delivery device, use reservoir (non-rebreathe) mask in critical illness, use nasal cannula for everyone else
- Reservoir mask allows highest oxygen concentration and flow rate should be 15L/min
- Nasal cannula delivers variable oxygen concentrations between 24-50% at flow rates of 2-6L/min
Communication in oxygen?
- Should be kept in place continuously but may briefly be removed for eating and drinking
Monitoring of oxygen?
o SpO2 monitoring
o ABG
Names of common beta-2 agonists?
- Short-Acting
o Salbutamol, Terbutaline - Long-Acting
o Salmeterol, formoterol
Indications of beta-2 agonists?
- Asthma – short acting as step 1, long-acting as step 3 (must be given with inhaled corticosteroids)
- Hyperkalaemia – nebulised salbutamol (in addition to insulin, glucose, calcium gluconate) in emergency treatment
Mechanism of beta-2 agonists?
What happens in high doses?
Specific long acting SE?
- Beta2-receptors found in smooth muscle of bronchi, GI tract, uterus, blood vessels
- Stimulation of GPCR leads to smooth muscle relaxation – improves airflow
- Stimulate Na/K/ATPase pump causing K+ to move into cells – treat hyperkalaemia in addition to insulin
SE of beta-2 agonists?
- ‘Fight-or-flight’ effects
o Tachycardia, palpitations, anxiety, tremor - Gluconeogenesis, may increase serum glucose
- High doses
o Serum lactate levels increased - Long-acting
o Muscle cramps
Interactions of beta-2 agonists?
- Beta-blockers reduce effectiveness
- Hypokalaemia
o Concomitant use with theophylline, corticosteroids
Contraindications of beta-2 agonists?
- Long-acting only prescribed in asthma with inhaled corticosteroid
o As associated with increased asthma deaths
Caution of beta-2 agonists?
o CVD – tachycardia promote angina, arrhythmias
o Hypokalaemia
o Diabetes
Prescription of beta-2 agonists?
- PRN prescription
o Use 2 puffs every 4 hours, up to 10 if needed
o If more, then hospital - Can be administered aerosol (MDI), dry powder, nebulised, in combination with steroid (Symbicort, Seretide)
- Spacer provided to improve airway deposition and treatment efficacy
Communication of beta-2 agonists?
- Medicine will make their airways relax and therefore improve their breathing
- Treats the symptoms, not the disease
- Clear on how and when to take the inhaler (e.g. for acute symptoms, pre-emptively before exercise or regularly for long-acting medication)
Monitoring of beta-2 agonists?
- Monitored via peak expiratory flow rate (PEFR)
Name of antimuscarinics?
Ipratropium, tiotropium, glycopyrronium
Indications of antimuscarinics?
- Acute exacerbation (short-acting)
- Added in step 4 of chronic asthma (long-acting)
Mechanism of antimuscarinics?
- Bind to muscarinic receptor, competitive inhibitor of acetylcholine
- Stimulation of muscarinic receptor causes ‘rest and digest’ effects
- Blockage has opposite effects:
o Reduced smooth muscle tone
o Reduced secretions
o Relaxation of pupillary constrictor and ciliary muscles – pupil dilatation and preventing accommodation – blurred vision
SE of antimuscarinics?
- Little systemic absorption
- Blurred vision, urinary retention, constipation, dry mouth
Interactions of antimuscarinics?
- None
Cautions of antimuscarinics?
o Angle-closure glaucoma
o Arrhythmias
Contraindications of antimuscarinics?
o Hypersensitivity to atropine or derivatives
Prescription of antimuscarinics?
- Short-acting used QDS or PRN
- In acute asthma
o 0.25mg in 4mL saline
o Every 20-30 mins for 1st 2 hours then every 8 hours if needed - Can be inhaled or nebulised liquid
Communication of antimuscarinics?
- Treatment to make their airways relax, which should therefore improve their breathing
- Treats the symptoms, not the disease
- Ensure they are clear on how and when to take the inhaler (e.g. for acute symptoms, pre-emptively before exercise or regularly for long-acting medication)
- Discuss possible side effects, such as dry mouth, and advise them to chew gum or suck sweets or bottle of water
Monitoring of antimuscarinics?
- Monitor PEFR
Names of inhaled corticosteroids?
Beclomethasone (Clenil Modulite 50mcg lower-potency, Clenil 200mcg)
Indications of inhaled corticosteroids?
Step 2 of therapy in chronic asthma – not controlled by short-acting B2 agonists
Mechanism of inhaled corticosteroids?
- Pass through plasma membrane and activate receptor which:
o Upregulation of anti-inflammatory proteins
o Downregulates pro-inflammatory interleukins, cytokines, chemokines - Effects
o Reduces mucosal inflammation
o Widens the airways
o Reduces mucus secretion
SE of inhaled corticosteroids?
- Occur locally in the airway
o Oral candidiasis
o Hoarse Voice - Few systemic effects unless at very high dose which may cause adrenal suppression, growth retardation and osteoporosis
Interactions of inhaled corticosteroids?
- None
Contraindications of inhaled corticosteroids?
- Caution of long-term high-dose corticosteroids as potential for growth suppression
Prescription of inhaled corticosteroids?
- Inhalation of powder (circle one) o Child 5-11 years 100-200mcg BDS o Child 12-17 years 200-400mcg BDS, can be increased - Inhalation of aerosol (normal puffer) o Child 12-17 years 50-200mcg BDS, can be increased to 400mcg - Prescribe brand name - May need steroid card - Drugs are delivered in aerosol (metered dose inhaler [MDI]) or dry powder form
What should be prescribed with inhaler?
- Spacer with metered dose inhalers improves airway deposition and treatment efficacy and reduce oral adverse effects
- Inhaler and technique should be checked and corrected at every consultation
Communication of inhaled corticosteroids?
- Explain that you are offering a steroid inhaler to ‘dampen down’ inflammation in the lung
- Reassure them that hardly any of the steroid is absorbed into the body so, except in very high-dose treatment, there are unlikely to be any serious side effects (or weight gain)
- Advise them to rinse their mouth and gargle after taking the inhaler to prevent development of a sore mouth or hoarse voice
- Show your patient how to use the device
Monitoring of inhaled corticosteroids?
- Review after 3–6 months
Name of osmotic laxatives?
Lactulose, Macrogol (Movicol), phosphate enema
Indications of osmotic laxatives?
Constipation and faecal impaction – 1st line Movicol in paediatrics
Bowel preparation prior to surgery or endoscopy
Hepatic encephalopathy
Mechanism of osmotic laxatives?
- Osmotically active substances (sugars/alcohol) that remain in gut lumen
- Hold water in stool
- Maintain volume and stimulate peristalsis
- Lactulose
o Reduces ammonia absorption by increasing gut transit rate and acidifying stool
o Inhibits proliferation of ammonia-producing bacteria
o Useful in hepatic encephalopathy
SE of osmotic laxatives?
- Flatulence
- Abdominal cramps
- Nausea
- Diarrhoea
- Phosphate enema
o Local irritation, electrolyte disturbances
Interactions of osmotic laxatives?
- Effects of warfarin may be slightly increased
Contraindications of osmotic laxatives?
o Intestinal obstruction (risk of perforation)
When would you use phosphate enema in caution?
o Heart failure, ascites, electrolyte disturbances
Prescription of osmotic laxatives?
- Orally used prescribed regularly
- May take a few days for an effect to be seen, as need to pass through GI tract
- Phosphate enema PRN or once only
- Taken with or without food
- Can have solutions which can be diluted in another liquid (squash) to improve compliance
- Enemas administered with patient lying on side and stay in position for a few minutes
Communication of osmotic laxatives?
o Explain treatment with a laxative
o Will hopefully make their stool softer and easier to pass
o To work, it requires them to drink plenty of water: they should aim to have at least 6–8 glasses of liquid per day
o Mention that side effects can occur, but these may get better over time
o Advise that the dose should be adjusted to maintain comfort
o If regularly passing >2/3 soft stools per day, dose should be reduced, or stopped
Name of stimulant laxatives?
Senna, Bisacodyl, glycerol suppositories
Indications of stimulant laxatives?
Constipation – 2nd line in paediatrics
As suppositories for faecal impaction
Mechanism of stimulant laxatives?
- Stimulant laxatives increase water and electrolyte secretion from the colonic mucosa
- Increasing volume of colonic content and stimulating peristalsis
- Direct pro-peristaltic action, although the exact mechanism differs between agents
o Bacterial metabolism of Senna in intestine produces metabolites that have a direct action on the enteric nervous system, stimulating peristalsis
o Rectal administration of glycerol suppositories, provokes a similar but more localised effect and can be useful to treat faecal impaction
o Docusate sodium has both stimulant and faecal softening actions
SE of stimulant laxatives?
- Abdominal pain/cramps
- Diarrhoea
- Prolonged use
o Melanosis coli (reversible pigmentation of intestinal wall)
Interactions of stimulant laxatives?
- None
Contraindications of stimulant laxatives?
o Intestinal Obstruction
o Haemorrhoids
o Anal Fissures
Prescription of stimulant laxatives?
- Regular oral administration, usually BDS
- When rectal, PRN or once only
Communication of stimulant laxatives?
- Explain offering treatment with a laxative that will help stool to pass
- As with other laxatives, ensuring good oral fluid intake will also help, 6–8 glasses of liquid per day
- Stimulant laxatives do not work immediately and may need a few doses before a sustained effect is noticed
- Dose can be adjusted if necessary to maintain comfort
- If they are regularly passing >2/3 soft stools per day, dose should be reduced or stopped
- Mention side effects but these may get better over time
Name of emollients?
Aqueous cream, liquid paraffin
Examples - E45, Aveeno (colloidal oatmeal)
Indications of emollients?
- Topical treatment for all dry or scaling skin disorders
- Used alone or in combination with topical corticosteroids in the treatment of eczema
Mechanism of emollients?
- Emollients replace water content in dry skin
- Contain oils or paraffin-based products that soften skin and reduce water loss by protecting against evaporation
- Many preparations used as soap substitute (as soap is drying to the skin) and also bath or shower emollients
SE of emollients?
- Greasy on skin but this is part of therapeutic effect
- Exacerbate acne and folliculitis by blocking pores and hair follicles
Interactions of emollients?
- Space out topical emollients – usually apply emollient 15 minutes before application of steroid cream
Contraindications of emollients?
- Fire hazard when oil content high
Properties of different types of emollients?
- Properties o Emulsions of oil and water to make creams, lotions and ointments o Lotions (less oil, more water) and creams (50% oil and water) spread further o Ointments (80% oil, 20% water) are more occlusive and potent - If find greasy and unpleasant, consider a cream or lotion instead of ointment and apply more often
Directions for emollients?
- Directions
o Applied BDS/TDS in active disease
o Give sufficient supply for frequent use
o Continue after improvement to prevent recurrence
o Apply emollients in the direction of hair growth
Communication of emollients?
- Encourage use as often as possible
Names of topical corticosteroids?
Potency of each example?
Mild – Hydrocortisone 0.5-2.5%
Moderate – Eumovate (Clobetasone butyrate 0.05%)
Potent – Betnovate (betamethasone valerate 0.1%)
Very Potent – Dermovate (Clobetasol propionate 0.05%)
Indications of topical corticosteroids?
- Inflammatory skin conditions, e.g. eczema, psoriasis where emollients are ineffective
Mechanism of topical corticosteroids?
- Upregulate anti-inflammatory genes and downregulate pro-inflammatory genes (e.g. cytokines, tumour necrosis factor alpha)
- Suppression of circulating monocytes and eosinophils
- Increased gluconeogenesis from increased circulating amino and fatty acids, released by catabolism of muscle and fat
- Mineralocorticoid effects, stimulating Na+ and water retention and K+ excretion in the renal tubule
- Because topical, effects limited to site – need prolonged use of potent topical steroids for systemic effects
SE of topical corticosteroids?
- Skin thinning
- Telangiectasia
- Contact dermatitis
- When used on face:
o Perioral dermatitis
o Exacerbate acne - Rarely, systemic effects:
o Adrenal suppression
o Immunosuppression
o Diabetes
o Osteoporosis
Interactions of topical corticosteroids?
- None when topical
Contraindications of topical corticosteroids?
- Contra-indications
o Infection present - Avoid potent on face and course should be short
Prescription of topical corticosteroids?
- Use as mild as possible for as short a time
- < 2 weeks (1 week for facial lesions)
- Prescription
o Name, strength, formulation, amount - BDS applied thinly on affected area
- Wash hands after application
Communication of topical corticosteroids?
- Warn them of the risk of skin damage if the treatment is applied to the wrong areas or for too long
- BNF advise finger-tip of cream or ointment should cover two palms worth
Indications of benzylpenicillin?
- Meningitis - 1st line community
- CAP – Secondary Care Neonates
Indications of amoxicillin?
- CAP – Primary Care 1st line
- CAP – Secondary care Children
- HAP – IV amoxicillin
- UTI - < 3months IV
- UTI - > 3months oral
- Otitis Media
Indications of co-amoxiclav?
- Alternatives in CAP and HAP
- > 3 months UTI and pyelonephritis
- Otitis Media
Indications of tazocin?
- HAP >5 days in hospital
Indications of ampicillin?
- < 3 months UTI
Indications of phenoxymethylpenicillin?
- Tonsillitis
Indications of flucloxacillin?
- Otitis Externa, etc
General mechanism of penicillins?
- Contain B-lactam ring responsible for antimicrobial activity
- Inhibit enzymes responsible for cross-linking peptidoglycans in bacterial cell walls
- Preventing osmotic gradient being maintained and leads to cell swelling, lysis and death
SE of penicillins?
- GI upset
- Allergy (1-10%)
o Skin rash 7-10 days after 1st exposure or 1-2 days after repeat
o Anaphylaxis - CNS toxicity
- Antibiotic-Associated colitis
o Tazocin, clindamycin, cephalosporins, fluoroquinolones, co-amoxiclav, ampicillin and amoxillin - Cholestatic Jaundice
o Co-amoxiclav
Interactions of penicillins?
- Reduce renal excretion of methotrexate
- Broad-spectrum antibiotics enhance anticoagulant effect of warfarin by killing normal vitamin K flora
Warnings in penicillin use?
o Dose reduction in renal impairment
o Avoid amoxicillin in sore throat as can give rash if EBV
Names of cephalosporins?
Ceftriaxone
Cefotaxime
Indications of cephalosporins?
Ceftriaxone - 1st line hospital meningitis - Sepsis - UTI < 3 months IV with amoxicillin - UTI > 3months oral - Upper UTI >3 months Cefotaxime - Add on meningitis - Severe CAP
Prescription of cephalosporins?
- Usually given 6-12 hourly given orally, IV or IM
Names of macrolides?
Clarithromycin
Erythromycin
Azithromycin
Indications of macrolides?
Clarithromycin
- Secondary care child CAP alternative
- Tonsillitis, Otitis media and externa if penicillin allergic
Erythromycin
- Primary care CAP alternative to amoxicillin
Azithromycin
- Primary care CAP alternative to amoxicillin
Mechanism of macrolides?
- Inhibit bacterial protein synthesis
- Bind to 50s subunit of ribosome and block translocation
- Bacteriostatic which assists immune system in killing and removing bacteria from body
- Synthetic macrolides (clarithromycin and azithromycin) have increased activity against Gram-negative
Prescription of macrolides?
- Can be given orally as tablets, suspensions with or without food
- IV must be diluted
Indications of trimethoprim?
1st line in UTI for >3 months
Mechanism of trimethoprim?
nhibit bacterial folate synthesis, slowing bacterial growth (bacteriostatic)
- Effective against Gram-positive and Gram-negative bacteria
- Widespread bacterial resistance
- Excreted unchanged into urine so used for UTIs
SE of trimethoprim?
- GI upset (nausea, vomiting and sore mouth)
- Skin rash (3-7%)
- Haematological disorders – megaloblastic anaemia, leukopenia and thrombocytopenia
- Hyperkalaemia
- Competitively inhibits creatinine secretion by the renal tubules which commonly leads to a small reversible rise in serum creatinine concentration during trimethoprim treatment
Contraindications of trimethoprim?
- 1st trimester of pregnancy
Cautions of trimethoprim?
o Folate deficiency
o Dose reduction in renal impairment
Prescription of trimethoprim?
- Oral use only usually 12 hourly for 3 days
- Communicate as with other antibiotics
Indications of nitrofurantoin?
Lower UTI in > 3 months
Mechanism of nitrofurantoin?
- Metabolised (reduced) in bacterial cells by nitrofuran reductase
- Active metabolite damages bacterial DNA and causes cell death (bactericidal)
- Active against relevant bacteria, reaches therapeutic concentrations in urine through renal excretion and most bactericidal in acidic environments such as urine
- Bacteria with reduced nitrofuran reductase activity are resistant to nitrofurantoin
SE of nitrofurantoin?
- GI upset (nausea and diarrhoea)
- Turn urine dark yellow or brown
- Chronic treatment
o Chronic pulmonary reactions
o Hepatitis
o Peripheral neuropathy - Neonates cause haemolytic anaemia
Interactions of nitrofurantoin?
- None
Contraindications of nitrofurantoin?
o Pregnant women towards term
o Babies <3 months
o Renal impairment
Cautions of nitrofurantoin?
o Long-term use associated with adverse effects
Prescription of nitrofurantoin?
- Oral use only usually 3-days
- It should be taken with food or milk to minimise gastrointestinal effects
- Explain as with previous antibiotics
Fluids resuscitation dose for children?
0.9% saline – 20mls/kg
Oral rehydration fluids in children?
o 50mls/kg over 4 hours orally
How to work out fluid deficit in children?
Mild (5%)
o Dry mucous membranes, skin turgor, decreased urine output
Moderate (10%)
o Decreased skin turgor, oliguric, high pulse, >CRT, lethargy
Severe (15%)
o Shock, anuric, hypotension
Calculation
• % dehydration x weight(kg) x 10
• Give as 0.45% saline over 48h
• Add K+ (20mmol/500ml) once child passed urine
How to work out maintenance fluids for children?
o Maintenance Fluids (0.9% saline with 5% dextrose with 10mmol KCL)
1st 10kg 100mls/kg/day
2nd 10kg 50mls/kg/day
3rd & subsequent kg 20mls/kg/day
