CPG Ped รพ พุทธชิณ

(Clinical Practice Guideline)

2552 ...

(Clinical Practice Guideline) - - - - Preterm Infants - Febrile Convulsion - Pneumonia - ALL - Febrile Neutropenia (FN) - (Surfactant) - - - - Retinopathy of Prematurity - - Hypoglycemia

( vesicouretreic reflux) 1. - - 4-5 - , , , , - - , - - - , ( encopresis) - , , 2. - - - - costovertebralangle - lipoma , hair patch dimple , sinus tract lumbosacral - - phimosis , vaginitis , labial adhesion - neurogenic bladder

3. - 5-10 / HPF () - suprapubic aspiration ( colony/) Catheterized 103 colony/. Clean-voided 105 colony/. 1 Suprapubic aspiration Transurethral catheterization pnimosis midstream clean-voided urine 4. 4.1 dehydration 4.2 empirical antibiotics Ampicillin 50-100 ././ Gentamicin 3-5 ././ 3rd generation Cephalosporins aminoglycosides Cefotaxime 100-200 ././ Ceftriaxone 50-100 ././ / Cotrimoxazole 6-12 . trimethoprim /./. Amoxycillin-clavulanic acid 30 . amoxicillin /./ Cepholosporins 4.3 48-72 . 4.4 10-14 acute pyelonephritis 7-10 4.5 circumcision phimosis

7. (> 3 / ) prophylaxis Cotrimoxazole 1-2 . trimethoprim / 6-12 double-void perineum

(Clinical Practice Guideline) (.. 2548) 1. paracetamol ORS NSAID Aspirin 2. Prevent dehydration ORS 3. Follow up 3 Leakage Admit Warning Sign Follow up Dengue Treatment Algorithm OPD

+

Tournique + Test

Positive negative

Hx : bleed ? vomiting. PE. : VS Liver CBC. Follow Up 3 48 . admit Warning sign * .

CBC UA

Follow Up repeat tourniquet test

Hct WBC > 5,000 Plt

Hct WBC Plt

Hct WBC Plt < 100,000 / cumm

Folow Up

Force oral intake Follow Up

admit

Admit

: .... . * Warning signs - - - - - - - Leakage 2 2.1 shock admit

1. Platelet count

( Clinical Practice Guideline) . .. 2548 3 1. Paracetamol ORS NSAID Aspirin 2. IV fluid dehydration 50% Maintenance. 3. Leakage CBC Leakage 3 1. Early Detection and early treatment of SHOCK Vital signs ( BP , pulse Pressure ) 1-2 hrs , Hct q 4-6 hrs , Record intake/output Urine Sp.gr. DHF flow chart . 2. IV FLUID Replacement IV fluid Shock : 5% DAR 5% DLR 5% D/NSS Non-shock : 1 5% D/NSS IV fluid

- Hct rising >10% IV fluid M/2 24

- Hct rising >20% IV fluid M+5% D 24 1

- DHF grade III : IV fluid 10-20 ml/kg/hr. - DHF grade IV : 10 ml/kg IV push BP &

push 10 ml/kg/hr. 2

3. : 3.1 (High risk patiement) 1. Young infants

2

NSS DLR DAR IV drip free flow 10-15

10 /. IV push grade IV

BP BP

rate 10 /./. 1-2 . IV 5% D/NSS 5%DLR 5%DAR

10 /. IV bolus ( 1 )

rate 7.5 3 /./. off IV

blood sogar , blood gas , electrolyte , Ca , LFT , BUN . Cr* ()

Hct

Hct Hct

Dextran 40. 10 /./.

FWB 10 /.

( Dextran 40. 10/./.)

venous cut down CVP

dopamine , debutec Dextran 40

CVP 10 .CVP 10 .

- Vitamin K, Ca, NaHCo, - *

15 . IV fluid rate 6-7 /./. 40 . IV fluid rate 3-4 /./.

1

3-4 .

( 15-40 .) ( 100,000 /.. Hct 10-20 %) 5% D/NSS 5% DLR 5% DAR 5 /./.

vital signs 1-2 . Hct 4 .

Hct stable vital signs

Vital signs / Hct

Rate 3 /./.

rate 5-7 /./.

Hct .

rate 7 /./.

2 . rate 10 /./.

, pulse pressure ,

Hct Hct

Dextran 40 10 /./.

FWB 10 /./

rate IV vital signs stable, Hct , fluid 24-48 .

crystalloid rate 7,5,3 /./.

.. ( 1 13 .. 2548)

Hct , MB 3 1781 1784 24

Visible jaundice

Term infant Preterm infant

Onset < 24 hr. Onset 24-72 hr. Onset 24 hr. BW < 2000 gm BW 2000 gm

Hct,MB Hct,MB Hct,MB

MB

1. Healthy term infant Prolonged jaundice > 7 term > 14 preterm TB OB >14 thyroid screening congenital hypothyroidism

Visible jaundice

Onset < 24 hr Onset 24-72 hr Onset 72 hr

Hct,MB Hct,MB Hct,MB

MB 0.5 mg%/hr.

MB 8-13 mg MB 13mg%

F/U Hct,MB Next 12 hr

Rate of rising >0.5 mg%/hr.

MB

* (Healthy term newborn) hyperbilirubinemia

Total bilirubin (TB) (mg/dl) Age (hrs) Phototherapy Intensive ( 2) Exchange Exchange transfusion and Phototherapy transfusion intensive phototherapy If intensive Phototherapy fail( 3 ) 24( 1 ) 24-48 12 15 20 25 49-72 15 18 25 30 >72 17 20 25 30

* hemolysis exchange transfusion TB > 20 mg/dl (1) 24 (2) intensive phototherapy special blue 2 (3) intensive phototherapy failure TB 1-2 mg/dl 4-6 . TB exchange transfusion : American Academy of Pediatrics. Provisional Committee for Quality Improcement and Subcommittee on Hyperbilirubinemia. Pracice parameter : management of hyperbilirubinemia in the helthy tem newborn. Pediatricd\s 1994;94 : 558.

2. Preterm infant

Total bilirubin (TB) (mg/dl) Phototherapy Exchange 500 - 1000 g 3 - 5 Variable 1001 - 1500 g 5 - 10 Variable 1501 - 2000 g 10 - 15 Variable 2001 - 2500 g > 15 Variable (1) sick preterm phototherapy total blood exchang ( sick preterm APGAR score 5 < 3, acidosis,sepsis hemolysis ) (2) < 1000 g prophylactic photorherapy

1.

phototherapy , total blood exchange

2. MB. phototherapy total blood exchange phototherapy total blood exchange

3. phototherapy - crib 2 phototherapy

30 . - ( on intensive phototherapy

bili-bed pamper ) -

phototherapy 20 . - On continuous phototherapy - 2000 . - - hyperthermia , dehydration ,

diarrhea - Hct , MB

Preterm Infants

Preterm infants ( < 35 wk ) at risk for early onset neonatal sepsis* ( Onset < 72 hr)

* > 38 oC , prolonged rupture of membrane > 18 hr , PROM , chorioaminionitis , HX of previous GBS infection , GBS bacteriuria ** apnea , ,, , shock *** PGS 100,000 m /kg/dose q 12 hr or ampicillin 100mg/kg/dose q 12 hr plus gentamicin

Off ABO

Signs of neonaltal sepsis**

NO Yes

Risk 1 CBC , H/C, empirical antibiotic***

NO Yes

Observe 48 hr CBC , H/C, empirical antibiotic***

H/C positive

Yes NO

LP Abnormal CBC

Antibiotic 7-10 for GBS,

14 for Gram ve bacilli

Antibiotic 14 for GBS,


NOYes

Antibiotic 7

H/C positive

Yes NO

LP Antibiotic 7-10


21 for Gram ve



term infants ( < 35 wk ) at risk for early onset neonatal sepsis* ( Onset < 72 hr)

* > 38 oC , prolonged rupture of membrane > 18 hr , PROM , chorioaminionitis , HX of previous GBS infection , GBS bacteriuria ** apnea , ,, , shock *** PGS 100,000 m /kg/dose q 12 hr or ampicillin 100mg/kg/dose q 12 hr plus gentamicin

H/C positive

Signs of neonaltal sepsis**

NO Yes

Intrapartum antibiotic Prophylaxis ( IAP) > 4

CBC , H/C, empirical antibiotic***

NOYes

Observe 48 hr CBC , H/C,

Abnormal CBC

NOYes

H/C positive

Yes NO

LP Antibiotic 7-10


21 for Gram ve



Normal CBC

Observe 48 hr empirical antibiotic***

LP




21 for Gram ve

Febrile Convulsion

Febrile Convulsion* 1. 2. ( 18 ) 3. metabolic (electrolyte , calcium , magnesium , glucose ) 4. EEG,CT scan simple febrile seizure complex febrile seizure 1. : 2. 3. Diazepam 0.2-0.3 ./. Diazepam 0.3-0.5 ./. 4. CBC U/A 5. 6. 7. (intermittent prophylaxis ) Diazepam Diazepam 0.2 ././ 6-8 24 8. Phenobarbital Sodium valproate continuous prophylaxis 2

Febrile convulsion 6 5 1. 2. 3.

* 1. 2. 5 3. anterior fontanel

- - 18 - 18

* - -

*

Simple febrile seizure Complex febrile seizure

EEG CT scan

diazepam

*

Pneumonia

Clinical practice guideline for treatment Pneumonia

1 : Pneumonia OPD ER

Degree of illness ( 5 )

Admit ( 3 )

+

Pneumonia Other disease

Immunocompromised host Underlying disease : CHD , BPD , CP , malnutrition

Admit

Notmal host

Not severe Severe

OPD Case 2

History

Physical exam Investigation ( CBC , CXR)

2 Pneumonia ( Not severe)

* : Pneumonia virus bacteria RX bacterial pneumonia : < 6 staccato afebrile pneumonia erythromycin 14 Chlamydia trachomatis : atypical pneumonia bacterial pneumonia antibiotics

Macrolide 10-14

Amoxycillin+clavulanic acid Amoxycillin (double dose)

Cephalosporin (2nd or 3rd generation)

7

Mycoplasma Chlamydia

Pneumoniae (atypical pneumonia)

7

2 Amoxycilin

Amoxycillin+clavulanic acid Cephalosporin

(2nd or 3rd generation) 7

2 Amoxycilin

No specific treatment

Pneumonia ( Not severe)

OPD case Supportive case ( 6 )

Virus Bacteria

2 5 5 15

7

Admit Severe pneumonia

S. pneumoniae & H. influenze Penicillin

Admit Severe pneumonia

S. pneumoniae

3 : Severe Pneumonia

: antibiltics hemoculture : ET- tube sputum exam culture : < 6 afebrile pneumonia macrolide 14 Chlamydia trachomatis : Pneumonia Mycoplasma pneumoniae or Chlamydia pneumoniae Bed side cold agglutinin add macrolide

S. pneumoniae

Ceftriaxone I.V Cefotaxime I.V Amoxycillin

Clavulanic acid I.V

S.aureus

Severe Pneumonia

Admit + Supportive care

< 2 2 5 5 15

PGS Ampicillin I.V* + Aminoglycoside Cefotaxime I.V Ceftriaxone I.V * cloxacillin I.V S.aureus

Ampicillin I.V

2

Ampicillin

Amoxycillin 7

oral antibiotic 7

2

Penicillin G IV

2

Pen V Amoxycillin 7

PGS high dose IV. Cefotaxime Ceftriaxone

2

oral antibiotic 7

Pneumonia ( Degree of illness) 1. Not severe pneumonia - (Tachypnea) oxygen desaturation dehydration alteration of mental status - WHO tachypnea < 2 60 / 2 1 50 / 1- 5 40 / > 5 20 / 2. Severe pneumonia - < 2 ( Pneumonia < 2 severe ) underlying disease BPD, heart disease, malnutrition immunocompromised host - > 70 / > 50 / ( > 1 ) - Marked retraction or cyanosis or apnea - Oxygen saturation < 92 % oxygen ( in room air) - dehydration , ,, - CXR complication of pneumonia pleural effusion,lung abscess,atelectasis pneumatocele pneumonia staphylococcus aureus

General supportive care for Pneumonia 1. 2. 3. antihistamine 4. bronchodilator wheezing 5. Tepid sponge paracetamol 6. ( chest physiscsal therapy) (vibration) 7. , 70 / 50 / (> 1 ) , , apnea ET tube ICU

Viral Pneumonia / Bacterial Pneumonia 1. Virus > Bacteria 2. breath sound virus pneumonia wheezing Bacterial pneumonia wheezing 3. CBC : Virus Pneumonia WBC , lymphocyte : Bacterial pneumonia WBC 15,000 cells / cu.mm , neutrophil Band 4. ESR ( 30 mm. /hr.) bacterial pneumonia 5. CXR : interstitial infiltration perihilar infiltration Viral pneumonia : alveolar infiltration consolidation lobar infiltration bacterial pneumonia : Virus Pneumonia Bacterial pneumonia bacterial pneumonia : reference Update on Pediatric infectious disease 2005

Antibiotics Pneumonia

(././) Amoxycillin 40-50 S.pneumonia Amoxycillin 80-100 Drug resistant S.pneumonia

(DRSP) Erythromycin 30-40 S.pneumonia , Chlamydia ,

Mycoplasma Amoxycillin+clavulanic acid*

40-50 S.pneumonia , H.influenzae

Clarithromycin 15 S.pneumonia , H. influenzae , Chlamydia , Mycoplasma

Azithromycin 10 ./. 1 5 ./. 4

S.pneumoniae , H.influenzae , Chlamydia , Mycoplasma

Cefprozil 30-40 S.pneumonia , H.influenzae Cefdinir 14 S.pneumoniae , H.influenzae (././) Ampicillin 100-200 S.pneumoniae Amoxycillin+clavulanic acid

40-50 S.pneumoniae , H.influenzae

Penicillin G sodium (PGS)

1-2 /. S.pneumonia

Cloxacillin** 100-150 S.aureus Gentamicin 5-7 Gram negative bacilli Amikacin 15-30 Gram negative bacilli Cefotaxime 100-200 S.pneumonia , H.influenzae Ceftriaxon 50-100 S.pneumonia , H.influenzae * DRSP double dose ( 80-100 mg/kg/day Amoxycillin) ** empyema pneumatocele dose 200 mg/kg/day.

Pedriatric department Buddhachinaraj Hospital Multidisplinary Carepath

( ALL on Siriraj ALL-03A protocol for Induction of remission phase)

Plan of care

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

.. .. ..

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

Expected of outcome

- LOS - cost

- LOS - cost

- LOS - cost

- LOS - cost

- LOS - cost

- LOS - cost

Plan of care

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 .. .. ..

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Assessment anxiety,fear,pain,v/s

physical exam anxiety,fear,pain,v/s N/V, stomatitis Phepbitis tissure necrosis physical exam

anxiety,fear,pain,v/s N/V, stomatitis Phepbitis tissure necrosis physical exam




Plan of care


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

Test CXR CBC plt2/week G/M, BUN,Cr,E'lyte,uric,C aMg,P,LFT () H/C,U/A,U/C, stool exam,stool c/s BMA ()

CBC plt

CBC plt

CBC plt

CBC plt

CBC plt

B M A

Treatment PRC if Hct < 25% Plt conc if

Plan of care Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

.. .. .. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

Medication Albendazole prednisolone sodamit zyloric V C R

V C R

If febrile neutropenia* guideline

V C R

If febrile neutropenia* Stomatitis**

guideline

V C R


guideline

V C R


guideline

V C R

A D R

A D R

If febrile neutropenia* guideline

A D R


guideline

A D R


guideline

A D R


guideline

A D R

L A S P

L A S P

L A S P

L A S P

L A S P

L A S P

IT IT IT I f pain guidelin Consult Activity *** ( ) Diet ANC , stomatitis ******** ( cryotherapy )

Plan of care


1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

Education Counseling Pretest bleedingactivityN/V

coping techning,support group

bleedingactivityN/Vcoping techning

T E S T

bleeding activity N/V coping techning

T E S T

bleeding activity N/V coping techning

T E S T

D/C plan

education education education education education

Febrile Neutropenia (FN)

Febrile neutropenia (FN)(1)

CBC , U/A , Stool exam

Hemoculture (Bactec) 1 specomen , Urine culture

3-4

__/__/__ __/__/__

Low risk

1st regimen (3) ___/___/___

2nd regimen (4) ___/___/___

High risk (2)

Modification of regimen (3) ___/___/___

72 . ___/___/___

..................... ___/___/___

H/C : NG

___/___/___

Low risk ANC > 100

___/___/___

2nd regimen high risk ANC < 100

___/___/___ 3 rd

generation oral cephalosporin(6)

5-7

regimen 5

repeat CBC

___/___/__

___/___/__

Hemoculture ___/___/__

1st regimen

3-4

ANC > 100 ANC < 100

___/___/___

3rd generation oral cephalosporin(6) 5-7

antifungal(7) FN>7

___/___/___

____/____/____

5-7 ATB 2 wks Antifungal 3-2 wks CBC U/A,H/C,MUC

CXR,U/S abdomen eye exam

...................................................................................... HN...........................................................

( 1) Febrile neutropenia : > 38.3 oC > 38.0oC 4 ANC < 500 mm3 (2) High risk : shock , hypotension , poor perfusion , ARDS , S&S of sepsis (3) 1st Regimen antibiotic 3.1 Ceftazidime 100-150 mg/kg/ day IV q 8 hr + Gentamicin 5 mg/kg/day IV q 8 hr 3.2 Piperacillin /tazobactam (400-500 mg/kg/day IV q 8 hr 3.3 4 th gen cephalosporin Add Modification instruction (4) 2 nd Regimen antibiotic 4.1 Imipenem 80-100 mg/hg/day+Aminogiycosid Amikacin (15 mg/kg/day q 8 hr) Netilmycin 4.2 Meropenem Add Modification instruction (5) Modification instruction 5.1 , ,,thrombophlebitis Add cloxacillin 5.2 Add vancomycin VP shunt central line Hx of previous colonization with MRSA within 1 yr 5.3 perianal abscess intraabdominal infection add Metronidazole imipenem Meropenem 5.4 gerprtic-like pral ulcer Tzanck smear add Acyclovicr 5.5 diarrhea Pseudomembranous colitis add Metronidazole imipenem Meropenem 5.6 oral thrust oral Fluconazole 3-5 mg-kg/day OD 5.7 severe mucositis add Penicillin Imipenem ,Meropenem Piperacilln/tazobactam 5.8 diffuse bilateral infilteation CXR PCP Co-trimoxazole 20 mg/kg/dsy/ (6) Oral 3 rd generation cephalosporin step down therapy Cefdinir 14 mg/kg/day OD or BID Cefixime 6 mg/kg/day OD or BID (7) Antifungal for systemic infection 7.1 Amphotericin B test dose 0.1 mg/kg 0.5 mg/kg, 1 mg/kg 12-24 maintain dose 1 mg/kg

Mix with 5% D/W to concentration 0.1 mg/ml (peripheral administration) or 0.25 mg/ml (central line only) Infuse over 4-6 hr. 7.2 side effect Amphotericin B Premedication Paracetamol,Chlorpheniramine Hydronortisone 1 mg/kg (max 25 mg)

- (Surfactant)

-

-

-

- Retnopathy of Prematurity

- - Hypoglycemia

Surfactant Indication

- moderate severe RDS On mechanical ventilator FiO2 > 0.4 2 6 hrs.

- retreatment 6-12 hrs. dose FiO2 > 0.3 On mechanical ventilator MAP > 7 8 cmH2O

Dose survanta 4 ml/kg/dese intratracheal ( Survanta) 4 1 ml/kg Slight Trendelenburg Reverse Trendelenburg 2

- check ET-tube suction clear secretion

- montor O2 saturation heart rate dose Bag 30 O2 sat > 92% dose

- : suction ET-tube 2 hrs. clinical Indication : setting weaning protocol : F/U CXR Adverse reaction ; Hypoxia ,Apnea , Bradycardia

Severe Respiratory Distress Syndrome Initial setting : - FiO2 Protocol FiO2 1.0 (Flow cycle AC) - Flow > 3 minute ventilation - Back up rate ~ 40 60 /min - PEEP 4 5 cmH2O - PIP 12-20 cmH2O - Ti 0.3 -0.4 sec -TV 4-6 ml/kg Blood Gas targets (arterial blood gas) pH 7.25 7.35 PaO2 50-70 mmHg PaO2 45-55 mmHg Weaning 1. continuous O2 monitoring pulse oximetry O2 sat 92-95% FiO2 0.05 protocol () 2. FiO2 < 0.6 PIP 1 2 cmH2O Tidal colume chest movement keep TV 4-6 ml/kg 3. PEEP Aeration aeration 8 (posterior rib) 1 cmH2O hypoaeration 1 desaturation PEEP 1 cmH2O 4. 60 / min mode SIMV rate 5 / min 5. 24 48 blood gas setting target > 48 check blood gas setting 6. setting FiO2 < 0.4 PIP 12 PEEP 4 Rate 20 extubate On NCPAP 3 PEEP 5 - 6 cmH2O

Red Blood Cell Transfusion Guidelines 1. Hct 20% Hb 7 g/di 2. Hct 25% Hb 8 g/di - Apnea/Bradycardia 10 episodes/24 hrs. 2 episodes

requiring bag mask centilation - Sustained tachypnea > 180 BPM Sustained tachypnea > 80 BPM - Poor weight gain (10 g/day adequate caloric intake ) - Mild RDS with Fio2 0.25 0.35 Nasal canula 0.125 0.25 LPM IMV NCPAP with MAP < 6 cmH2O 3. Hct 30% Hb 10 g/dl Moderate RDS FiO2 >

0.35 IMV with MAP 6 8 cmH20 4. Hct 40% Hb 13 g/dl with severe RDS requiring

mechanical ventilation MAP > 8 cmH20 FiO2 > 0.4 0.5 severe congenital heart disease cyanosis heart failure

5. acute blood loss with shock keep Hct 40% 6. guideline lron Supplement, Reticulocyte count

1) 10% Phenylephine E.D. 1% Mydriacyl E.D. 1 : 9 1 2) - 3) - 5 4 15 21 : 15 3) - Indirect ophthalmoscope - Lens 20 diopter - Eye speculum - Cotton tip applicator - : 0.5% Tetracaine E.D.: - : Poly-oph E.D.: 4) - - 1 - Eye speculum - - 1 5) - - , , , /

Retinopathy of prematurity Retinopathy of prematurity ( ROP) 20 2545 ROP

1. 35 ( 1)

2. 36 2,000

3. 35 OPD 35

4. 12.00 . 5.

OPD OPD

6. ROP

1. HBsAg Positive

2,000 - hepatitis B vaccine 1 HBIG 12 - hepatitis B vaccine 2 1-2 3 6

1.2 < 2,000 - hepatitis B vaccine HBIG 12 1 - hepatitis B vaccine 1 1 () - hepatitis B vaccine 2 1-2 3 6 2. HBsAg 2.1 2,000 - hepatitis B vaccine 1 12 HBsAg HBIG ( 7 ) - hepatitis B vaccine 2 1-2 3 6 2.2 < 2,000 - hepatitis B vaccine 12 HBsAg 12 HBIG - hepatitis B vaccine 1,2,3 1,2 3. HBsAg Negative 3.1 2,000 - hepatitis B vaccine 1 - hepatitis B vaccine 2 1-2 3 6-18 3.2 < 2,000 - hepatitis B vaccine 1 1 ()

- hepatitis B vaccine 2 1-2 3 6-18

(31/01/50)

Hypoglycemia

Patient at risk

Check DTX at 1-2hr DTX>45mg/dl DTX>45mg/dl

Early feeding asymptomatic symptomatic Check DTX DTX30-45 mg/dl DTX45mg/dl 45mg/dl

Routine care < 45mg/dl >45mg/dl adjust GIR + 10%DW2mL/kg continue same IV&check DTX Feed+IV GIR check DTX 2hr later 4-8 mg/kg/min before next feed < 45mg/dl >45mg/dl Check DTX q I hr Routine care Until euglycemia *Patient at risk : IDM,LBW ,SGA,LGA,preterm,asphyxia (apgar at 5 minutes < 7) *Symptomatic : apnea,jitteriness, tremors *adjust GIR + 2 mg/kg/min

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CPG Ped รพ พุทธชิณ