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ANATOMY AND PHYSIOLOGY DEFINED

Posted by sammy on August 7, 2018 at 6:00 PM Comments comments (1)

Define anatomy and physiology, and name several subspecialties of these sciences.

Two branches of science—anatomy and physiology—provide the foundation for understanding the body’s parts and functions.

Anatomy (a-NAT-o¯-me¯; ana- up; -tomy process of cutting) is the science of body structures and the relationships among them. It was first studied by dissection (dis-SEK-shun; dis- apart; -section act of cutting), the careful cutting apart of body structures to study their relationships. Today, a variety of imaging techniques (see Table 1.3 on page 21) also contribute to the advancement of anatomical knowledge. Whereas anatomy deals with structures of the body, physiology (fiz-e¯-OL-o¯-je¯; physio- nature; -logy study of) is the science of body functions—how the body parts work. Table 1.1 describes several subspecialties of anatomy and physiology.

Because structure and function are so closely related, you will learn about the human body by studying its anatomy and physiology together. The structure of a part of the body allows performance of certain functions. For example, the bones of the skull join tightly to form a rigid case that protects the brain. The bones of the fingers are more loosely joined to allow a variety of movements. The walls of the air sacs in the lungs are very thin, permitting rapid movement of inhaled oxygen into the blood.

The lining of the urinary bladder is much thicker to prevent the escape of urine into the pelvic cavity, yet its construction allows for considerable stretching as the urinary bladder fills with urine.

C H EC K P O I N T

1. What body function might a respiratory therapist strive to improve? What structures are involved?

2. Give your own example of how the structure of a part of the body is related to its function.

Introduction to Anatomy and Physiology

Posted by sammy on August 7, 2018 at 5:40 PM Comments comments (0)

AN INTRODUCTION TO THE HUMAN BODY

T H E H U M A N B O D Y A N D H O M E O S T A S I S

Humans have many ways to maintain homeostasis, the state of relative stability of the body’s internal environment. Disruptions to homeostasis often set in motion corrective cycles, called feedback systems, that help restore the conditions needed for health and life. •

Our fascinating journey through the human body begins with an overview of the meanings of anatomy and physiology, followed by a discussion of the organization of the human body and the properties that it shares with all living things. Next, you will discover how the body regulates its own internal environment; this unceasing process, called homeostasis, is a major theme in every chapter of this book. Finally, we introduce the basic vocabulary that will help you speak about the body in a way that is understood by scientists and health-care professionals alike.


Hypoglycemia

Posted by sammy on February 18, 2013 at 8:15 AM Comments comments (0)

A clinical condition due to reduced levels of blood sugar (glucose).

Causes

Overdose of insulin or anti-diabetic drugs

Excessive alcohol intake

Starvation

Operations to reduce the size of the stomach (gastrectomy)

Tumours of the pancreas (insulinomas)

Certain drugs, eg. quinine

Hormone deficiencies (cortisol, growth hormone)

Clinical features

Profuse sweating

Nervousness

Fainting

Palpitations

Poor sight

Weakness

Hunger

Abdominal pain

Vomiting

Convulsions

Loss of consciousness

Differential diagnosis

Other causes of loss of consciousness

Investigations

Blood sugar

Specific investigations

- to exclude other causes of hypoglycemia

Management

Oral glucose or sugar (before coma sets in) 10-20g in 200mL water (2-4 teaspoons) is usually taken initially and repeated after 15 minutes if necessary or if patient is unconcious, glucose 50% 2050mL IV, followed by 10 % dextrose solution by drip at 5-10 mg /kg/min until patient regains conciousness, then encourage oral sugary drinks. HC3

Where possible, treat the cause of the hypoglycemia.

Prevention

Educate patients at risk of hypoglycaemia e.g. Diabetics, patients who have had a gastrectomy, on recognition of symptoms of hypoglycemia.

Advise patients at risk to have regular meals and always to have glucose or sugar with them for emergency treatment of hypoglycaemia.

 

FEBRILE CONVULSIONS

Posted by sammy on February 18, 2013 at 8:10 AM Comments comments (0)

A disorder mainly affecting children between 6 months and 6 years characterised by generalized tonic-clonic seizures in a febrile illness

Cause 

Malaria fever

Respiratory tract infections

Urinary tract infections

Other febrile conditions

Clinical features

Elevated temperatures (>38°C)

Convulsion is usually brief (<15 minutes) but may recur if temperature remains high

No CNS infection or neurological abnormality in the period between convulsions

Differential diagnosis

Epilepsy

Meningitis

Encephalitis

Brain lesions

Trauma

Hypoglycaemia

Hypocalcaemia

Investigations

Blood: slide for malaria parasites; haemogram LP and CSF examination

Full blood count

Random blood glucose

Urinalysis , culture and sensitivity

Chest xray

Management HC2

Treat the cause

Lie prone

Use tepid sponging to help lower the temperature

Give an antipyretic:

paracetamol 10mg/kg every 8 hours prn

Give diazepam 500 micrograms/kg rectally

- maximum dose: 10mg

- repeat prn after 10 minutes

-if diazepam rectal dose-form is not available use diazepam injection solution and give the same dose rectally using the syringe after

removing the needle

 

DEHYDRATION

Posted by sammy on February 18, 2013 at 8:10 AM Comments comments (0)

A condition brought about by the loss of significant

quantities of fluids and salts from the body

Cause

 Diarrhoea

Vomiting

Excessive sweating as in high fever Respiratory distress

Management in children HC2

Management with Plan A, B or C is based on an

assessment of the degree of dehydration according

to key clinical signs - see table below. Refer to

Management of Childhood Illness MoH 2000 for

further details.

 

Clinical features of dehydration in children

Signs

Degree of dehydration

None/Mild

Some Severe

General

condition

Well,

Alert

Restless,

irritable

Lethargic or

unconscious or very drowsy Eyes

Not sunken

Sunken Sunken

Fontanelle

Not sunken

Sunken Sunken

Ability to drink

Drinks normally

Drinks eagerly

thirsty

Drinks poorly or not able to drink

Skin pinch Goes back quickly

Goes back slowly

Goes back very slowly

Treatment Plan A Plan B Plan C

 

Plan A (No dehydration and for prevention):

Counsel the mother on the 3 rules of Home

Treatment

 - extra fluids, continue feeding, when to return

Give extra fluids - as much as the child will take Advise the mother to:

Continue/increase breastfeeding: -if child exclusively breastfed, give ORS or clean water in addition to milk

-if child not exclusively breastfed, give one or more of:

ORS, soup, rice-water, yoghurt drinks, clean water

In addition to the usual fluid intake, give ORS after each loose stool or episode of vomiting: <2yrs: 50-100mL; 2yrs and over: 100-200mL

- give the mother 2 packets to use at home

- giving ORS is especially important if the child has been treated with Plan B or Plan C during current visit

- give frequent small sips from a cup

-if child vomits, wait 10 minutes, then give more slowly

In a child with high fever or respiratory distress, give plenty of fluids to counter the increased fluid losses in these conditions

Continue giving extra fluid as well as ORS until the diarrhoea or other cause of dehydration stops

Counsel the mother on:

Correct breastfeeding and other feeding during sickness and health Increasing fluids during illness

How to maintain her own health

When to return to the health worker

Plan B (Some dehydration):

Give ORS in the following approximate amounts during the first 4 hours: Age (mths) < 4 4-12 13-24 25-60

Weight (kg) < 6 6-9.9 10-11.9 12-19

ORS (mL) 200-400 400-700 700-900 900-1400

.Only use child’s age when you don’t know the weight

.You can also calculate the approx. amount of

ORS to give a child in the first 4 hours as weight (kg) x 75mL

Show the mother how to give the ORS

- give frequent small sips from a cup

-if the child wants more than is shown in the table, give more as required

-if the child vomits, wait 10 minutes, then continue more slowly

For infants <6 months who are not breastfed, also give 100-200mL of clean water during this first 4 hours

Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment Plan

After 4 hours:

Reassess the patient

Reclassify the degree of dehydration Select the appropriate Treatment Plan A, B or C

Begin feeding the child in the clinic

If the mother must leave before completing the child’s treatment:

Show her how to prepare ORS at home and how much ORS to give to finish the 4-hour treatment

Give her enough packets to complete this and 2 more to complete Plan A at home

Counsel the mother on the 3 rules of home treatment

- extra fluids, continue feeding, when to return

Plan C (Severe dehydration):

a) If you are able to give IV fluids:

Set up an IV fluids line immediately

-if the child can drink, give ORS while the drip is set up

Give 100ml/kg of compound sodium lactate infusion (Hartmann’s solution or Ringer’s Lactate solution) or half-strength [HS] Darrow’s solution in glucose 2.5% or sodium chloride infusion 0.9%

-divide the IV fluid as follows:

Age

First give 30mL/kg in:

Then give 70mL/kg in:

Infants (<12 months) 1 hour* 5 hours*

Children (12 mths-5yrs) 30 minutes* 2½ hours*

* Repeat once if radial pulse still very weak/undetectable

Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment Plan If the patient is not improving:

Give the IV drip more rapidly

As soon as the patient can drink- usually after 3-4 hours in infants or 1-2 hours in children:

Also give ORS 5mL/kg/hour.

Continue to reassess the patient frequently, classify the degree of dehydration and select appropriate Plan A, B or C to continue treatment

b) If you are unable to give IV fluids but IV treatment is available nearby (i.e. within 30 minutes):

Refer urgently for IV treatment

If the child can drink:

Provide the mother with ORS and show her how to give frequent sips during the trip to the referral facility

c) If you are unable to give IV fluids and this therapy is not available nearby (i.e. not within 30 minutes ORS) but you can use a nasogastric tube (NGT) or the child can drink:

 

 

Start rehydration with ORS by NGT or by mouth: give 20mL/kg/hour for 6 hours (total = 120mL/kg)

Reassess the child every 1-2 hours:

-if there is repeated vomiting or increasing abdominal distension, give the more slowly

-if hydration status is not improving within 3 hours, refer the child urgently for IV therapy

 After 6 hours, reassess the child

Classify the degree of dehydration

Select appropriate Plan A, B or C to continue treatment

Note:

If possible, observe the child for at least 6 hours after rehydration to ensure that the mother can correctly use ORS to maintain hydration Management in Older Children & Adults HC3 & HC4

Assess the level of dehydration using the table below: linical features of dehydration older children and adults

Clinical feature

Degree of dehydration -Mild, Moderate, Severe

General appearance

Thirsty, alert

Thirsty, alert

Generally conscious, anxious, cold extremeties, clammy, cyanosis, wrinkly skin of fingers, muscle cramps, dizzy if standing

Pulse Normal Rapid

Rapid, thready, sometimes absent

Respiration Normal Deep, may be rapid

Deep and rapid Systolic BP Normal Normal Low, may be unmeasurable

Skin pinch

Returns rapidly

Returns slowly

Returns very slowly (>2 seconds)

Eyes Normal Sunken Very sunken

Clinical feature

Degree of dehydration

Mild Moderate Severe

Tears Present Absent Absent

Mucous membranes -Moist, Dry, Very dry

Urine output Normal

Reduced, dark urine

Anuria, empty bladder

•at least 2 of these signs must be present

Rehydrate the patient as follows

Degree of dehydration

Rehydration fluid

Route

Volume to give in first 4 h (1) Mild ORS (2) Oral 25mL/kg

Moderate ORS Oral 50mL/kg (3)

Severe SLC inf (4) IV 50mL/kg (5)

Notes on table

 1. Volumes shown are guidelines only – if necessary volumes can be increased or the initial high rate of administration maintained until clinical improvement occurs.

2. As well as ORS, other fluids such as soup, fruit juice and clean water may be given.

3. Initially adults can usually take up to 750mL ORS/hour.

4. If sodium lactate compound IV infusion (Ringer-Lactate) is not available:

use half-strength [HS] Darrow’s solution in glucose 2.5% or sodium chloride infusion 0.9%

-however, both of these are less effective

5. In severe dehydration, give IV fluids as rapidly as possible at first until radial pulse can be felt then slow down the rate of administration.

Volumes which may be given over the first 24 hours (60kg adult) are as follows:

Time period Volume of IV fluid

First hour                               1L

Next 3 hours                          2L

Next 20 hours                        3L

After 4 hours, evaluate rehydration in terms of clinical signs (and not in terms of volumes of fluid given).

As soon as signs of dehydration have gone (but not before) start fluid maintenance therapy with as much alternating ORS and water (to avoid hypernatraemia) as the patient wants

Continue this for as long as the cause of the original dehydration persists Note:

Continued nutrition is important – there is no physiological reason to discontinue food during treatment for dehydration

 

RHEUMATIC HEART DISEASE

Posted by sammy on February 5, 2013 at 4:55 PM Comments comments (0)

A valvular complication of rheumatic fever.

 

The valves commonly involved are:

 

z

Mitral valves leading to stenosis, incompetence

or both

 

z

Aortic valve leading to stenosis and incompetence

 

Cause

 

z

As for acute rheumatic fever

 

Clinical features

 

z

Heart failure

 

z

Arrythmias

 

z

Thromboembolic problems eg. stroke

 

z

Palpitations

 

z

Heart murmurs depending on valves affected and

nature of effect caused

 

z

The patient may be asymptomatic and the

valvular lesion discovered as an incidental finding

 

z

Increased cardiac demand as in pregnancy and

anaemia may lead to congestive cardiac failure

as a presentation

 

UCG 2010

207

 

 

 

9. Cardiovascular diseases

Differential diagnosis

 

z

Other causes of cardiac failure

 

Investigations

 

¾

Chest X-ray

¾

ECG where available

¾

Echocardiography

 

Management

 

f

Treat heart failure if present

 

f

benzathine penicillin 2.4 MU IM once monthly

or phenoxymethylpenicillin (Penicillin V)

750mg every day

 

Child:

 

f

benzathine penicillin <30kg: 0.6 MU once

monthly

>30kg: 1.2 MU once monthly

-

continue either medicine up to 30 years of

age

-

If allergic to penicillin give

erythromycin 250 mg per day

 

 

PULMONARY OEDEMA

Posted by sammy on February 5, 2013 at 4:55 PM Comments comments (0)

Congestion of the lung tissue with fluid

 

Cause

 

z

Cardiogenic: CCF

z

Inflammatory diseases, eg. cancer, TB

z

Fibrotic changes

 

Clinical features

 

z

Dyspnoea, breathlessness

z

Rapid breathing rate

z

Cough with frothy blood stained sputum

 

Differential diagnosis

 

z

Pneumonia

z

Plural effusion

z

Foreign body

z

Trauma

 

Investigations

 

¾

Chest X-ray

¾

ECG

¾

Echocardiography

 

Management H

Acute

 

f

Find cause of left ventricular failure & treat

 

accordingly

f

Give high concentration oxygen

f

plus furosemide 40-80mg IM or slow IV

 

- repeat prn up to 2 hourly according to response

- doses >50mg should be given by IV infusion

child: 0.5-1.5mg/kg daily (max: 20mg daily)

f

plus glyceryl trinitrate 500mcg sublingually

every 4-6 hours

 

UCG 2010 206

 

 

 

9. Cardiovascular diseases

f

Give morphine 5-15mg IM or 2-4mg slow IV

child: 0.1mgs/kg slow IV single dose

 

f

plus prochlorperazine 12.5mg by deep IM

 

- avoid in children

f

Repeat these every 4-6 hours till there is

improvement

 

Caution

 

U

No digitalization if patient has had digoxin within

the past 14 days but give maintenance dose

 

Prevention

 

z

Early diagnosis and treatment of cardiac

conditions, respiratory tract infections

 

z

Avoid (narcotic) medicine abuse

PERICARDITIS

Posted by sammy on February 5, 2013 at 4:55 PM Comments comments (0)

Inflammation of the heart membrane (pericardium)

which may be:

z

Acute and self-limiting, sub-acute or chronic

z

Fibrinous, serous, haemorrhagic or purulent

 

 

UCG 2010

204

 

 

 

9. Cardiovascular diseases

Causes

 

z

Viral, eg. Coxsackie A & B, influenza A & B,

Varicella

 

z

Bacterial, eg. mycobacterium, staphylococcus,

meningococcus, streptococcus, pneumococcus,

gonococcus

 

z

Fungal: histoplasmosis

 

z

Mycoplasma

 

z

Uraemia (less common)

 

z

Hypersensitivity such as acute rheumatic fever,

myocardial infarction

 

z

Radiation

 

z

Trauma

 

z

Neoplasms

 

Clinical features

 

z

Pericardial inflammation: retrosternal pain

radiating to shoulder and much worse on deep

breathing, movement, change of position or

exercise

 

z

Pericardial rub is a diagnostic sign

 

z

Pericardial effusion: reduced cardiac impulses,

muffled heart sounds, acute cardiac compression

 

z

Effects on cardiac function: chronic constrictive

pericarditis, acute cardiac compression (cardiac

tamponade), dyspnoea, restlessness, rising

pulmonary and systemic venous pressure, rapid

heart rate, pulsus paradoxus, low BP and low

output cardiac failure.

 

Differential diagnosis

 

z

Any cause of central retrosternal chest pain eg.

pneumonia, ischaemic heart disease, peptic ulcer

 

Investigations

 

¾

ECG

¾

X-ray: chest

¾

Echo cardiography

 

UCG 2010

205

 

 

 

9. Cardiovascular diseases

Management H

 

f

According to cause and presenting clinical features

f

If there is fluid, perform tapping

 

Prevention

 

z

Early detection and treatment of infections

SCHAEMIC HEART DISEASE (Coronary heart disease)

Posted by sammy on February 5, 2013 at 4:55 PM Comments comments (0)

A condition in which there is insufficient blood flow

through the coronary arteries of the heart thus

leading to ischaemia and/or infarction

 

Cause/risk factors

 

z

Deposition of fatty material (cholesterol plaques)

inside the coronary arteries

z

Enlarged heart following hypertension

z

Diabetes mellitus, obesity and hypertension

z

Smoking

z

Hyperlipidemia

z

Family history of heart disease

 

Clinical features

 

z

Chest pain which may be localised on the left or

central part of the chest ranging from mild to

severe deep pain

 

z

Tightness in the chest or a sense of oppression

worsening on exertion and relieved by rest and

lasting only a few minutes

 

UCG 2010

203

 

 

 

9. Cardiovascular diseases

z

There may be associated anxiety, vomiting and

sweating

 

z

Signs of sympathetic activation

eg. pallor and tachycardia

 

z

Low BP

 

z

shortness of breath

 

z

Arrythmias - may cause sudden death

 

Differential diagnosis

 

z

Indigestion

z

Peptic ulcers

z

Pleurisy

z

Pericarditis

z

Severe anaemia

z

Dissecting aneurysm

 

Management HC4

f

Give aspirin 150mg single dose (to be chewed)

f

glyceryl trinitrate 500 micrograms sublingually

 

Repeat after 5 min if no response

 

f

give propranolol 10-40mg daily for as long as is

required

 

- ensure close observation of the pulse rate and

circulatory status

´

avoid in patients with shock or hypotension

¾

Refer to higher level of care.

Prevention

 

z

Low-fat, low-cholesterol diet

 

z

Stop smoking

 

z

Effective control of hypertension and diabetes

mellitus

HYPERTENSION

Posted by sammy on February 5, 2013 at 4:55 PM Comments comments (0)

Persistently high resting blood pressure (>140/90mm Hg

at least two measurements five minutes apart with

patient seated).

 

Classification of Blood pressure (BP)*

 

Category SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120-139 or 80-89

Hypertension,

stage 1

140-159 or 90-99

Hypertension,

stage 2

=160 or =100

 

key: SBP=systolic blood pressure DBP=diastolic

blood pressure

 

Causes

 

z

In the majority of cases the cause is not known

(essential hypertension)

 

Secondary hypertension is associated with:

 

z

Kidney diseases

z

Endocrine diseases

z

Eclampsia

z

Medicines (steroids and decongestants containing

 

caffeine and pseudoephedrine)

z

Others

 

Clinical features

 

z

The majority of cases are symptomless and are

only discovered on routine examination

 

May present as a complication affecting:

 

z

Brain (stroke)

z

Eyes (impairment of vision)

z

Heart (heart failure)

z

Kidney (renal failure)

 

UCG 2010

200

 

 

 

9. Cardiovascular diseases

General symptoms include:

 

z

Headache

z

Palpitations, dizziness

z

Shortness of breath

 

Differential diagnosis

 

z

Pre-eclampsic toxaemia (PET)

z

Eclampsia

z

Other causes of stroke

 

Investigations

 

¾

Urine analysis

¾

Blood sugar

¾

Plasma urea and electrolytes

¾

Chest X-ray

¾

ECG

 

Management: Treat to maintain optimal

blood pressure

 

Mild hypertension (stage 1)

 

f

Do not add extra salt to cooked food

f

Increase physical activity / exercise

f

Reduce body weight

f

Stop smoking

f

Decrease alcohol intake

 

If all the above fail (within 3 months) initiate

medicine therapy:

 

 

f

Give bendrofluazide 2.5mg-5mg each morning

 

- avoid in pregnancy and breastfeeding

Moderate and Severe hypertension (stage 2)

 

f

bendrofluazide 2.5-5mg each morning

 

f

plus ACE inhibitor (e.g. Captopril, Lisinopril or

enalapril) or CCB (e.g. Nifedipine or amlodipine)

or ARB (e.g.Lorsatan or Candesartan) or Beta

blockers (e.g. Atenolol or propranolol)

 

see table on the next page for dosages.

 

UCG 2010 201

 

 

 

9. Cardiovascular diseases

Hypertensive emergencies

 

f

Treatment depends on whether there is acute

target organ damage e.g. encephalopathy,

unstable angina, myocardial infarction,

pulmonary oedema or stroke.

 

f

If acute end target organ damage present admit

and give parenteral medicnes. Give IV

furosemide 40-80 mg stat.

 

f

Plus IV Hydralazine 20mg slowly over 20

minutes. Check blood pressure regularly at least

3 hourly.

 

f

If without acute target organ damage treat with

combination oral antihypertensive therapy as

above for severe hypertension.

 

f

Special Considerations.(Compelling

indications)

Patients with hypertension and other

comorbidities require special attention and

medicine therapy may differ from that above.

The table below indicates the suitable medicines

for such patients.

 

 

UCG 2010 202

 

 

 

9. Cardiovascular diseases

Caution

 

U

Propranolol, atenolol: do not use in heart failure

 

or asthma

U

Diuretics: do not use in pregnancy or

breastfeeding except in case of pulmonary

oedema or pre-eclampsia

Note:

 

.

Bendrofluazide: potassium supplements are

seldom required - only use in susceptible patients

.

Methyldopa: use in hypertension with renal

failure and in pregnancy and breastfeeding

 

Prevention

 

z

Regular physical exercise

z

Reduce salt intake

CONGESTIVE HEART FAILURE

Posted by sammy on February 5, 2013 at 4:50 PM Comments comments (0)

Inadequate cardiac output for the body’s needs

despite adequate venous return - may be due to

failure of both left and right ventricles.

 

Causes

 

z

Hypertension

z

Valvular heart disease, eg. rheumatic heart disease

z

Anaemia

z

Myocarditis

z

Prolonged rapid heart beat (Arrythimias)

z

Thyroid disease

z

Cardiomyopathy

z

Myocardial infarction

z

Congenital heart disease

 

Clinical features

 

Infants and young children

 

z

Respiratory distress with rapid respiration,

cyanosis, subcostal, intercostal and sternal

recession.

 

UCG 2010

197

 

 

 

9. Cardiovascular diseases

z

Rapid pulse, gallop rhythm

z

Excessive sweating

z

Tender hepatomegaly

z

Difficulty with feeding

z

Cardiomegaly

z

Wheezing

 

Older children and adults

 

z

Palpitations, shortness of breath, exercise in tolerance

z

Rapid pulse, gallop rhythm

z

Raised jugular venous pressure (JVP)

z

Dependent oedema

z

Enlarged tender liver

z

Fatigue, orthopnea, exertional dyspnoea

z

Basal crepitations

z

Wheezing

 

Differential diagnosis

 

z

Severe anaemia

z

Protein Energy Malnutrition (PEM)

z

Nephrotic syndrome

z

Asthma

z

Severe pneumonia

 

Investigations

 

¾

Chest X-ray

¾

Blood: haemogram

¾

Urea and electrolytes

¾

Echocardiogram

¾

ECG

 

Management HC4

 

f

Bed rest with head of bed elevated

f

Prop up patient in sitting position

f

Reduce salt intake

f

furosemide 20-40mg IV or oral increasing as

 

required to 80-160mg daily or every 12 hours

according to response

child: 1mg/kg IV or IM repeated prn according to

response (max: 4mg/kg daily)

 

UCG 2010 198

 

 

 

9. Cardiovascular diseases

f

ACE inhibitors start with small dose captopril

 

6.25 mg 8 hourly aiming for a maintainance dose

of 50 mg 8 hourly. Child: 1mg/kg daily. (Avoid if

systolic BP is less than 90 mmHg.)

Plus

 

f

Spironolactone for heart failure 25-50mg once

a day

child: initially 1.5-3mg/kg daily in divided doses

 

For acute pulmonary oedema:

 

f

morphine 5-15mg IM (0.1 mg/kg for children)

f

plus prochlorperazine 12.5mg IM

f

Repeat these every 4-6 hours till there is

 

improvement

f

Beta-blockers like carvedilol at specialised centers.

 

In urgent situations:

 

f

digoxin injection loading dose 250 micrograms

IV 3-4 times in the first 24 hours

Maintenance dose: 250 micrograms daily

child: 10 micrograms/kg per dose as above

 

In non-urgent situations:

 

f

digoxin loading dose 0.5-1mg orally daily in 2-3

divided doses for 2-3 days

maintenance dose: 250 micrograms orally daily

 

- elderly patients: 125 micrograms daily

child: loading dose: 15 micrograms/kg orally 3-4

times daily for 2-4 days

maintenance dose: 15 micrograms/kg daily for 5

days

Note

 

.

Ensure patient has not been taking digoxin in the

past 14 days before digitalizing, because of risk

of toxicity due to accumulation in the tissues

 

Prevention

 

z

Early diagnosis and treatment of the cause

z

Effective control of hypertension

INFECTIVE ENDOCARDITIS

Posted by sammy on February 5, 2013 at 4:50 PM Comments comments (0)

An infection of the heart valves and lining of the

heart chambers by microorganisms which is difficult

to diagnose and treat. It is classified into 3 types:

 

.

Sub-acute endocarditis: caused by low virulence

organisms such as Streptococcus viridans

.

Acute endocarditis: caused by common pyogenic

organisms such as Staphylococcus aureus

 

.

Post-operative endocarditis: following cardiac

surgery and prosthetic heart valve placement.

The commonest organism involved is

 

Staphylococcus albus

 

UCG 2010

195

 

 

 

9. Cardiovascular diseases

Clinical features

 

z

Acute or chronic illness

 

z

Fatigue

 

z

Weight loss

 

z

Low grade fever and chills

 

z

Embolic phenomena affecting various body organs

 

z

Congenitally abnormal or previously damaged

heart valve predisposes to this condition

 

z

Heart failure may occur

 

z

The disease may be of short duration if due to

acute endocarditis and the patient may be

critically ill

 

z

Prominent and changing heart murmurs may occur

 

z

Splenomegaly, hepatomegaly

 

z

Anaemia

 

z

Finger clubbing

 

Note:

 

.

Any unexplained fever in a patient with a heart

valve problem should be regarded as endocarditis

 

Differential diagnosis

 

z

Cardiac failure with heart murmurs

z

Febrile conditions associated with anaemia

 

Investigations

 

¾

Blood cultures: these are usually positive and all

efforts should be made to identify the responsible

pathogen and obtain sensitivity data before

starting treatment

 

¾

At least 3 sets of blood cultures 8 mls each

should be obtained (each from a separate

venepucture) at least one hour apart.

 

¾

Blood: haemogram, ESR

 

¾

Urinalysis for microscopic haematuria, protenuria

 

¾

Echocardiography

 

¾

ECG

 

UCG 2010

196

 

 

 

9. Cardiovascular diseases

Initial empirical therapy HC4

f

benzylpenicillin 4 MU IV every 4 hours

 

plus gentamycin 1mg/kg IV every 8 hours

child: Benzyl Penicillin 50,000 IU/kg per dose

every 6 hours and Gentamycin 2.5mg/kg per

dose every 8 hours

´

gentamycin is contraindicated in pregnancy

 

Once a pathogen has been identified:

 

f

Amend treatment accordingly

 

Prevention

 

z

Prophylactic Amoxicillin 2g (50mg/kg for

children) plus gentamycin 1 hour before plus

500 mgs 8 hourly for 48 hrs after dental

extraction and tonsillectomy in individuals with

cardiac valve defects.

 

z

Prompt treatment of skin infections

DEEP VEIN THROMBOSIS (DVT)

Posted by sammy on February 5, 2013 at 4:50 PM Comments comments (1)

Clot formation within the deep venous system

usually of the calf, thigh or pelvic veins. The clot

can cause a local problem at site of formation or

dislodge leading to thromboembolism in various

parts of the body, particularly the lungs.

 

Causes

 

z

Venous stasis (immobilization, prolonged bed

rest, surgery, limb paralysis)

 

z

Heart failure, myocardial infarction

 

z

Blunt trauma

 

z

Venous injury including cannulation

 

z

Increased coagulability states such as those

associated with some medicines – oral

contraceptive pills, chemotherapy

 

z

Malignant disease of pancreas, lung, stomach,

prostate

 

z

Pregnancy and postpartum

 

z

Polycythaemia

 

z

Anaesthesia – general

 

z

Stroke

 

z

Long distance air travel

 

Clinical features

 

z

50% of cases may be clinically silent

 

z

Painful swelling of the calf, thigh and groin with a

positive Homans’ sign (unreliable for diagnosis)

 

z

Dislodgment of the thrombus may lead to a

greater risk of pulmonary embolism characterized

by fever, pleuritic chest pain, haemoptysis,

dyspnoea.

 

Differential diagnosis

 

z

Cellulitis

z

Myositis

z

Contusion

 

UCG 2010

193

 

 

 

9. Cardiovascular diseases

z

Sarcoma of the underlying bone

z

Phlebitis

z

Karposis sarcoma of the leg

 

Investigations

 

¾

Blood: haemogram, clotting/bleeding time,

fibrinogen degredation products. Prothrombin time

(PT) and International Normalised Ratio (INR).

 

¾

In case of pulmonary embolism: ECG, chest X-ray,

 

echo cardiogram.

¾

Venogram

¾

Ultrasound (at specialised centres)

 

Management

HC4

f

Fibrinolysis at specialised centers

f

Unfractionated heparin given as: IV bolus

5000 IU stat then 250 IU units per kg

subcutaneuosly12 hourly for 5 days adjust dose

according to APTT maintain INR between 2 - 3.

 

f

Low molecular weight heparin (enoxaparin)

 

1mg/kg daily (LMWH) for 5 days can be used as

an alternative

 

f

plus warfarin

 

5mg single dose given in the evening,

commencing on day 3.

-

maintenance dose: 2.5-7.5mg single dose

daily, adjusted according to the INR 2 -3.

f

Check for bleeding and monitor Prothrombin

Time (PT) and INR.

 

f

Starting therapy with warfarin alone

increases the risk of thrombus progression

and embolisation.

 

Antidotes for anticoagulants HC4

 

For heparin:

 

f

protamine sulphate: 50mg slow IV (over 10

minutes) will neutralise the action of 5,000 IU of

heparin when given within 15 minutes of heparin

 

UCG 2010 194

 

 

 

9. Cardiovascular diseases

-

1mg protamine neutralises approx 80-100 IU

heparin (max dose: 50mg)

 

-

if protamine is given longer than 15 minutes

after heparin, less is required as heparin

is rapidly excreted

 

For warfarin:

 

f

phytomenadione (vitamin K) usually 2-5mg

SC, or oral

-

in severe haemorrhage transfusion with fresh

frozen plasma (15mls/kg) or fresh whole

blood.

-

dose depends on INR and degree of

haemorrhage; large doses may reduce

response to resumed warfarin therapy for a

week or more

 

Note:

 

.

Check for bleeding and monitor INR and PT

 

Prevention:

 

.

Early ambulation

 

.

Prophylaxis with Heparin in any acutely ill

medical patient and prolonged admission.

VITAMIN A DEFICIENCY

Posted by sammy on February 5, 2013 at 4:45 PM Comments comments (0)

Lack of vitamin A which is required for proper

functioning of the retina & of epithelial cells. More

common in children

 

Causes

 

z

Malnutrition

z

Severe childhood illness, eg. measles, whooping

cough

 

Clinical features

 

z

Night blindness

z

Conjunctival dryness - see Xerophthalmia,

z

Corneal ulceration (keratomalacia)

z

Dry, rough and thickened skin (‘toad skin’)

 

 

Differential diagnosis

 

z

Other causes of blindness, eg. glaucoma,

trachoma, onchocerciasis, gonococcal

ophthalmia, accidents, cataract

 

Investigations

 

¾

Diagnosis is based on clinical presentation

¾

Serum vitamin A

 

Management

HC2

 

f

vitamin A: give 3 doses (days 1, 2 and 14)

< 6 months: 50,000 IU

6-12 months: 100,000 IU

over 12 months: 200,000 IU

 

UCG 2010

191

 

 

 

 8. Nutrition

Note

 

.

Give prophylactic vitamin A to children with

measles, malnutrition, chronic respiratory

infections, persistent diarrhoea and to lactating

mothers

Protein Energy Malnutrition ([PEM) of Early Childhood

Posted by sammy on February 5, 2013 at 4:40 PM Comments comments (0)

Malnutrition in childhood.

 

The term malnutrition is derived from two French

 

words (mal = bad) and (Nutriture = nutrition) and

 

it literally means ‘bad nutrition’, and technically

 

includes under nutrition and over nutrition.

 

f

Malnutrition is a significant contributor/cause of

morbidity and mortality among children less than

five years of age in sub-Saharan Africa (SSA).

 

f

Malnutrition (PEM), singly or in combination with

other disease, is a significant contributor/cause

of morbidity and mortality among children less

than five years of age in Uganda as well.

 

f

PEM underlies two-fifth (. 40%) of childhood

deaths in Uganda.

 

f

Thus, protein energy malnutrition (PEM) is a

significant public health problem, mainly of the

under developed world.

 

f

Current accurate statistics on the magnitude of

the problem, both on the global and the local

level are scanty:

Examples:

-

850 million people are chronically hungry in

the world

 

UCG 2010

177

 

 

 

 8. Nutrition

-

4-6 million Ugandans suffer from chronic

energy deficiency.

-

20% Ugandans live in abject poverty and

suffer from chronic hunger.

 

-

About 39%, 22.5% and 4.0% of the under-five

year old children are stunted, underweight and

wasted respectively in Uganda.

 

f

In the under-five year old children, the most

prevalent form of malnutrition is protein energy

malnutrition (PEM).

 

f

Protein energy malnutrition (PEM) describes a

broad spectrum of clinical conditions ranging

from Marasmus (dry malnutrition) on one

extreme end to Kwashiorkor (wet malnutrition)

on the other extreme end with intermediate

forms, such as Marasmic – Kwashiorkor (mixed

malnutrition).

 

f

The intermediate forms constitute the majority of

cases.

 

Forms of PEM:

 

Primary PEM – Inadequate diet is the

primary cause;

Secondary PEM – disease or other medical

condition is the

primary cause;

diet is secondary.

Acute malnutrition – Is an indictor of current

nutritional status,

reflecting recent

weight changes or

disruption in nutrient

intake.

-

Acute malnutrition is the most appropriate

indicator of the current nutritional status and

appropriate indicator to use in an emergency

 

UCG 2010

178

 

 

 

 8. Nutrition

setting. The children are thinner than the

normal ones of same height.

 

-

Chronic malnutrition – Is an indicator of the

nutritional status overtime. Chronically

malnourished children are shorter (stunted)

than their comparable age group.

 

Aetiology/Causes of PEM:

 

Causes/contributing Factors to Malnutrition:

 

- Immediate causes: diet

 

 

disease

 

- Basic causes: Food Insecurity

Poor health services

Poor environmental

sanitation

 

 

- Underlying causes: Poverty

(4P’s) Politics

Policies

 

 

Programs

 

Food Factors:

-

Food insecurity

-

Balanced diet (6 principles of diet design)

-

Organoleptic characterisitics of food (e.g.

colour, taste, consistency, flavour)

-

Food preparation

-

Food taboos

Non-Food Factors

-

Infections and infestations

-

Poverty and corruption

-

Poor governance

-

Human rights and the right to food

UCG 2010

179

 

 

 

 8. Nutrition

-

Poor infrastructure

-

Poor marketing and distribution system

-

Underdeveloped Agro-Industry

-

Inter-sectoral nature of nutrition

-

Loan facilities

-

Nutrition education/advocacy

-

Political economy

-

Saving culture

 

Some of the factors responsible for

malnutrition include:

-

Excessive workload for women; No time to

 

prepare nutritious meals for the children.

 

-

Poverty

 

-

Inadequate food intake

 

-

Presence of disease

 

-

Poor weaning practices

 

-

Food insecurity

 

-

Poor maternal and child rearing practices

 

-

Inadequate water supply.

 

-

Harmful cultural practices/institutions

 

-

Poor environmental sanitation

 

-

Family instability

 

-

Low family incomes

 

-

Low education/or illiteracy

 

-

Lack of nutrition education (IEC component of

 

PHC)

 

(IEC = Information, Education,

 

Communication; PHC = Primary Health

 

Care)

 

Consequences of PEM

 

Several consequences of PEM in children

include:

-

Impaired growth and development

-

Impaired mental development.

-

Impaired body resistance/immune system.

-

Increased risk of adult chronic diseases

 

UCG 2010

180

 

 

 

 8. Nutrition

-

Increased risk for the cycle of inter-

generational malnutrition

 

 

-

Contributes a lot to the loss of millions of

dollars to the national economy and overall

development.

 

Clinical Features of PEM

 

Marasmus:

-

Severe wasting (severe weight loss of

muscle tissue and subcutaneous fat).

-

Wasting is less than 60% (= - 3SD) of the

expected weight for age (% Harvard

Standard)

 

-

Absence of bilateral pitting oedema of both

feet.

 

-

“Old man’s face” – because of severe

wasting of muscles and subcutaneous fat on

the face.

 

-

The ‘excess skin’ hangs/gathers around the

buttocks (baggy pants)

-

The ribs are prominent, so are the zygoma

 

bones.

-

Scapular blades and extremities (the limbs)

-

Eyes are sunken (due to loss of orbital fat).

-

Apathetic/or at times irritable in case of

 

medical complications

-

Appetite is fairly good

-

Skin is almost normal

-

Hair demonstrates some changes – Not as

 

dramatic as in Kwashiorkor.

-

Organomegaly is rare (liver, spleen –

enlargement)

 

Kwashiorkor

-

Presence of bilateral pitting oedema

(oedema of both feet)

-

Miserable

-

Apathetic

 

 

UCG 2010

181

 

 

 

 8. Nutrition

-

Moon face

-

Appears adequately nourished due to

excess extra cellular fluid.

-

Skin changes (dermatosis) (flacky paint

dermatitis)

-

Hair changes . silky, straight, sparsely

distributed, easily, painlessly pluckable.

-

Severe pallor of the conjunctiva, mucous

membranes, palms and soles.

-

Loss of skin turgor (dehydration) +

malnutrition

-

Organomegaly (Liver, spleen) is common.

 

Marasmic – Kwashiorkor

Presents with features of both Marasmus and

Kwashiorkor, such as:

-

Oedema of both feet

-

Marked wasting (due to loss of muscles +

 

 

fat)

-

Apathy/Misery

-

Skin changes (Dermatosis)

-

Hair changes (silky, pluckable)

-

Some degree of organomegaly (Liver,

 

Spleen)

 

UCG 2010 182

 

 

 

 8. Nutrition

Biochemical and Immunological Features

 

Variable Marasmus Kwashiorkor

 

•Total protein .

..

•Serum Albumin .

..

•Serum Globulin .

.. or

Normal

•Serum Transferrin .

..

•Serum Immunoglobulins . or .

.. or .

(IgG, IgM, IgA)

•Serum complement ..

•Cortisol .

..

•Insulin ..

•Glucagon ..

•Serum Electrolytes . or Normal . or

Normal

•Serum Sodium . or Normal . or

Normal

•Serum Potassium ..

•Serum magnesium ..

•Serum Zinc ..

•Serum Selenium ..

•Serum Iron . or .. or .

•Serum Copper ..

Differential Diagnosis

 

-Nephrotic syndrome (Nephritis)

 

-Liver disease

 

-Heart disease

 

-Malabsorption syndrome

 

-Malignancy (e.g. Gastro intestinal tract

 

cancer,

 

-Liver Cancer/Hepatocellular carcinoma).

 

UCG 2010 183

 

 

 

 8. Nutrition

Investigations:

The following investigations are useful in

establishing a diagnosis of PEM and

differential diagnoses.

 

 

History: - especially Dietary history

Blood: - Complete Blood count (Full

Haemogram) (e.g. Hb, ESR, white blood cells

(WBC) (total and differential)

Red blood cells (RBC), Haematocrit

Blood sugar, serum electrolytes, serum protein

(total and Albumin, globulins), serum

complement, transferin immunoglobulins (IgG,

IgM, IgA); haemoparasites, Malaria, HIV/AIDS

Urine:

 

Urinalysis – Urine sugar, protein, casts

(granular, hyaline), electrolytes, amino acids/

or amino acid metabolites, microorganisms,

cells (WBC or RBC).

Stool

 

Stool microscopy – for ova and cysts, occult

blood, parasites.

Chest x-ray

 

Look for evidence of Tuberculosis or other chest

abnormalities.

The Management of Protein Energy

 

Malnutrition of Early childhood

 

Assessment of the Nutritional status:

-

Histories

-

Physical examination

-

Anthropometric measures

-

Biochemical indicators

-

Immunological indicators

-

Clinical features.

UCG 2010

184

 

 

 

 8. Nutrition

Dietary history:

-

Obtain a detailed history on food intake of

the child, especially the 24-hour dietary

recall.

-

History on breast-feeding and

weaning/complementary feeding should

also be sought.

-

History of both present and past

infections/illness and their management.

 

-

History of immunization against the six

common immunizable diseases (Measles,

Tuberculosis, Whooping cough/Pertussis,

diphtheria, Polio, Tetanus) and now also

against influenza and meningitis plus

hepatitis B in adults.

 

Clinical Examination

Anthropometry (physical body dimensions)

-

Weight for age (W/A)

-

Height for age (H/A)

-

Weight for Height (W/H)

-

Mid upper arm circumference (MUAC)

-

Quack stick Index (MUAC/Ht)

SYSTEMS REVIEW (SYSTEMIC EXAMINATION)

 

 

Examination should be systematic; from head to toe.

 

CNS:

-evidence of mental retardation

 

EENT:

-

Symmetry of eyes, ears and relation to nose

-

Evidence of infection (e.g. otitis media,

conjunctivitis)

-

Evidence of nutrient deficiency (e.g. bitot

spot, angular stomatitis, cheilosis, magenta

tongue).

 

-

Pallor of mucous membranes

-

Mouth ulcers

 

 

UCG 2010

185

 

 

 

 8. Nutrition

R/S:

-

Evidence of chest infection (e.g. cough,

dyspnoea)

-

Increased respiratory rate (RR)

 

CVS:

-Increased heart rate (HR); increased pulse

rate(PR)

 

P/A:

-

Bowel movements

-

Abdominal distension – Ascites,

organomegaly (e.g. enlarged liver, spleen)

 

-

Bowel sounds (e.g. Alterations in paralytic

ileus/dehydration, obstruction

(constipation/worms)

 

Urinary system/Urogenital System

(UGS)

-

Painful micturition/crying on passing urine

-

Blood in urine

-

Pain around public area – evidence of

 

cystitis (bladder infection)

-

Pus in urine (Pyuria)

 

 

Integumental System:

-

Skin turgor (malnutrition, dehydration)

-

Skin lesions/dermatosis, flaky paint

dermatitis, ulcers

 

Musculoskeletal System

-

Wasting (loss of muscle tissue and

subcutaneous fat)

-

Bilateral pitting oedema of both feet –

(may present in grades 0 up to 3)

-

Flabby muscles.

 

General examination

-

Temperature

-

Cyanosis

-

Jaundice/icterus

UCG 2010

186

 

 

 

 8. Nutrition

General Principles of Initial Treatment

 

Management

a) Treatment/Prevention of Hypoglycaemia

(blood sugar <3mmol/l or <55mg/dl)

Give 2ml/Kg of 25% glucose/dextrose solution IV

-

Prepare by diluting 50% glucose/dextrose

solution with an equal volume of saline or

Ringer’s Lactate infusion or – give 10%

glucose solution – 2ml/Kg by mouth.

-

Use common table sugar/sucrose if glucose

is not available or 5mls/Kg/hr of Glucose

5% (50g sugar in 1 litre of water).

- Prepare by dissolving 2 teaspoonful of

sugar in half a mug (18 teaspoonful

=100mls) of clean water.

-

Begin feeding quickly upon admission.

- Provide frequent and regular small feeds

(3 hourly day and night)

-

Treat infections promptly

- If the patient can drink, give a small feed

of an intensive therapeutic diet (F75,

SENUSU, DISCO 150).

 

Classification of Malnutrition (PEM)

Biochemical Classification

-

Macro-nutrient malnutrition (PEM in children)

-

Micro-nutrient malnutrition (Hidden Hunger)

 

Public Health Classification

-

Stunting (height/age - 2SD)

-

Underweight (weight/age - 2SD)

-

Wasting (weight/height -2SD)

Clinical Classification Underweight

-

Mild

-

Moderate

-

Severe

UCG 2010

187

 

 

 

 8. Nutrition

Severe Underweight

-

Kwashiorkor (wet malnutrition)

-

Marasmus (Dry malnutrition)

-

Marasmic –Kwash (Mixed malnutrition)

 

Overweight/obesity

-

In children

-

Majority cases are adults

 

 

b) Treatment/Prevention of Hypothermia

 

-

Measure body temperature twice daily

-

Ensure that the patient is well covered

with cloths, hats and blankets.

-

Ensure enough covering/blankets are

provided at night.

 

-

Encourage caretaker/mother to sleep next

to her child (body to body contact,- direct

heat/warmth transfer from mother to

child).

 

-

Keep the ward closed during the night

and avoid wind drafts inside.

 

-

Quickly clean the patient with a warm wet

towel and dry immediately. Avoid

washing the baby directly in the first few

weeks of admission.

 

-

Provide frequent and regular small feeds

(3 hourly day and night).

-

Hypothermia is axillary temperature

<35oC and rectal temperature <35.5oC.

 

c)

Treatment of Dehydration

 

Dehydration is a clinical condition

brought about by the loss of significant

qualities of fluids and salts from the

body.

Common causes of dehydration include:

-

Diarrhoea

-

Excessive sweating as in high fever

UCG 2010

188

 

 

 

 8. Nutrition

-

Vomiting

-

Respiratory distress

 

 

Management of dehydration is with

plans A, B, C.

This dehydration treatment modality is

based on the degree of dehydration.

Plan A

 

-

There is no clinical dehydration yet

-

It is meant to prevent clinical dehydration

 

1.

Advise the mother/Caretaker on

the 3 rules of home treatment (i.e.

extra fluids, continue feeding,

appointment to come back for review)

Give extra fluids – as much as the child

can/will take.

2.

Advise mother to:

-

Continue/increase breast feeding

 

-

If the child is exclusively breastfed

give oral rehydration solution (ORS)

or clean water in addition to milk.

 

-

If the child is not exclusively breast

fed, give one or more of:

 

• ORS

• Soup

• Rice-water

• Yoghurt drinks

• Clean water

-

In addition to the usual fluid intakes

give ORS after each loose stool or

Episode of vomiting.

 

• < 2yrs . give 50 –100ml

• > 2 yrs . give 100 – 200ml

-

Give the mother 2 packets of ORS to

use at home

-

Giving ORS is especially important if

the child has been treated with Plan B

or Plan C during current visit.

 

UCG 2010

189

 

 

 

 8. Nutrition

-

Give small but frequent sips of ORS from

a cup.

 

-

If the child vomits, wait for 10 minutes,

then give more ORS slowly.

 

-

In a child with high fever or respiratory

distress, give plenty of fluids to counter

the increased fluid losses in these

conditions.

 

-

Continue giving extra fluid as well as ORS

until the diarrhoea or other cause of

dehydration ceases.

 

3. Advise the mother on:

-

Correct breastfeeding and other feeding

 

during sickness and health

 

-

Increasing fluids during illness

 

-

How to maintain her own health

 

-

When to return to the health

 

worker/health facility for review.

 

Plan B

-

There is some clinical dehydration

-

Give ORS in the following amount during

the first 4 hours:

 

Age (Mo) <4 4-12 13-24 25-60

 

Weight (Kg) <6 6-9.9 10-11.9 12-19

 

ORS (ml) 200-400 400-700 700-900 900-1400

 

Notes:

 

1.

Only use the child’s age when the weight is not

known.

2.

Yuo can also calculate the approximate amount

of ORS to give a child in the first 4 hours as:

Weight (KG) x 75ml

-

Show the mother how to give the ORS:

Give frequent small sips from a cup.

If the child wants more than is shown in the

table, give more as required.

UCG 2010

190

 

 

 

 8. Nutrition

If the child vomits, wait 10 minutes, then

continue more slowly

-

For infants <6 months who are not

breastfed, also give 100-200ml of clean

water during the first 4 hours.

 

-

Reassess the patient frequently (every

30-60 minutes) for the classification of

dehydration and the selection of the

treatment plan.

Policy guidelines on infant and young child feeding, January, 2009

Posted by sammy on February 5, 2013 at 4:40 PM Comments comments (0)

All mothers should be counselled and supported

to initiate breastfeeding within an hour of

delivery and to exclusively breastfeed their

infants for the first six months of life unless

medically contra-indicated.

2.

Parents should be counselled and support to

introduce adequate, safe and appropriately fed

complimentary foods at six months of age and

continue breast feeding for two years.

3.

Pregnant women and lactating mother should

be appropriately cared for and encouraged to

consume adequate nutritious foods.

4.

Health service providers should establish HIV

status of all pregnant women and lactating

mothers.

5.

All pregnant women and lactating mother

should encourage to confidentially share there

HIV status with service providers and key

family members in order to get appropriate

IYCF services.

6.

Exclusive breastfeeding should be

recommended for infants of HIV infected

women for the first six months irrespective of

the infants HIV status, unless replacement is

acceptable, feasible, affordable, sustainable and

safe (AFASS).

7.

Infants borne to mothers with HIV should be

tested for HIV infection from six weeks of age,

appropriate feeding, counselling given to the

mother based on her personal situation.

UCG 2010

176

 

 

 

 8. Nutrition

8.

Malnourished children should be provided with

appropriate medical care, nutritional

rehabilitation and follow-up.

9.

Mother of infants who are borne with Low Birth

Weight but can suckle should be encouraged to

breastfeed and those who cannot, be assisted

to express breast milk and feed the baby.

10. Mothers care

taker and families should be

counselled and supported to practice optimal

IYCF in emergencies and other exceptionally

difficult/special circumstances.

Cryoprecipitate Transfusion Guidelines:

Posted by sammy on February 5, 2013 at 4:35 PM Comments comments (0)

Major Products Available:

 

Cryoprecipitated AHF (Cryoprecipitate)

Cryoprecipitated AHF, Pooled

 

Description/Contents:

 

The cold insoluble portion of plasma that

precipitates when fresh frozen plasma is thawed at

1-6oC. The supernatant (cryo-poor plasma) is

removed and the residual volume of cryoprecipitate

(approximately 15 ml) is refrozen and stored at -18

oC. Cryoprecipitate provides therapeutic amounts of

Factor VIII:C, Factor XIII, von Willebrand factor,

and fibrinogen. Each bag of cryoprecipitate contains

80-100 units of Factor VIII:C and 150-200 mg of

fibrinogen (Factor I).

In addition, significant amounts of Factor XIII

(fibrin-stabilizing factor) and von Willebrand factor

(vWF), including the high molecular weight

multimers of vWF, are also present.

 

Indications:

 

1.

Fibrinogen levels less than 115 mg/dl

2.

Cases of disseminated intravascular coagulation

where both fibrinogen and Factor VIII may be

depleted.

3.

Platelet count greater than 100,000 with

evidence of platelet dysfuntion and no response

to DDAVP

4.

Prophylaxis or treatment of significant Factor

XIII deficiency.

Historically, patients with von Willebrand’s disease

(vWD) and Hemophilia A are treated with

Cryoprecipitate.

 

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7. Guidelines for appropriate use of blood

Cryoprecipitate should not be used in the treatment

of Hemophilia B (Factor IX deficiency, Christmas

disease).

 

Cryoprecipitate has also been used in the

production of “fibrin glue” with the addition of

thrombin to form an insoluble clot for application to

surgical margins and other surgical applications.

Such use is not Food and Drug Administration FDA-

approved, although widespread. The safety of this

procedure, including the risk of the thrombin

source, has not been established.

 

Dosage and Administration:

 

For fibrinogen replacement, ten bags of

cryoprecipitate will increase the fibrinogen level of a

70-kilogram recipient approximately 70 mg/dl.

Cryoprecipitate is administered after pooling.

Compatibility testing is not necessary, but the

product should be ABO plasma compatible. Rh type

is not important.

 

Alternative Therapy:

 

Factor VIII concentrates that are made with

recombinant DNA technology or have been

pasteurized are safer and are the treatment of

choice for patients with hemophilia A and von

Willebrand’s disease. DDAVP (desmopressin) causes

the release of Factor VIII and vWF in most patients

with mild-moderate Hemophilia A and vWD.

Therefore, DDAVP may be used instead of

cryoprecipitate or factor concentrates in these

patients.

 

Autologous blood transfusion

 

Autologous blood transfusion is the collection and

re-infusion of the patient’s own blood or blood

components. Autologous blood transfusion allows

you to donate blood for own use. After collection,

blood is clearly marked with your name and

 

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7. Guidelines for appropriate use of blood

reserved for your use only. Documentation carefully

monitored. Autologous blood donation is possible by

the following:

 

Those who are not anaemic (starting

haemoglobin must be at least 11 g/dl, slightly

lower than required of a regular blood donor i.e.

12 g/dl)

Those who have no medical condition that could

cause problems during or after the blood donation

process

Those who are having planned surgery that

routinely requires a blood transfusion (except in

cases where long term storage is desired)

For planned surgery Autologous blood must be

tested for transfusion transmissible infections,

even if it is going to be transfused to the same

patient.

Five categories of autologous transfusions

recognized:

1.Preoperative autologous blood donation,

 

 

transfusion and storage: units of blood are drawn

from a patient usually starting (in short term

case) 3-5 weeks before elective surgical

procedure and stored for transfusion at the time

of the surgery

 

2.Intra-operative heamodilution: blood is collected

at the start of surgery and the fluid volume lost is

replaced with appropriate IV solutions, then

finally stored blood is re-infused after surgery

 

3.Intra-operative blood salvage: blood is salvage

from the surgical area during the operation for re-

infusion during or after the surgical procedure

 

4.Postoperative blood salvage: blood is collected

after surgical procedure is complete by drainage

of the operative area and re-infused

 

5.Autologous self stored blood (blood banking):

your own blood is preserved in a frozen state for

 

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7. Guidelines for appropriate use of blood

use by you in case your need of a blood

transfusion arises. The safest blood you can

receive is your own! This process eliminates

donor-transmitted diseases. If you have a rare

blood type or if your blood contains rare

components, this process my mean the difference

between life and death. Autologous blood is

always a perfect match. It will be there when you

need it regardless of the general blood shortage.

 

Adverse reactions to transfusion

 

Key points

 

1.

Report all suspected acute transfusion reactions

immediately to the hospital blood bank

laboratory that handles with the clinician after

getting pre-transfusion sample, post –

transfusion sample, patients urine and the

transfused unit. Attention is made to the blood

bank when suspected contamination by bacteria

or heamolysis is from the blood bank.

Regrouping and testing are done on both

patient and transfused samples.

2.

Acute reactions may occur in 1-2% of patients

Rapid recognition and management of these

may save the patient’s life.

3.

Errors and failure to follow correct procedures

are the commonest cause of life threatening

acute haemolytic reactions.

4.

Bacterial contamination of red cells or platelet

concentrates is an under-recognized cause of

acute haemolytic transfusion reactions.

5.

Patients who receive regular transfusions are at

particular risk of acute febrile reactions. With

experience, these can be recognized so that

transfusions are not delayed or stopped

unnecessarily.

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7. Guidelines for appropriate use of blood

6.

Transfusion-transmitted infections are the most

serious delayed complications of transfusions.

Since these may occur long after the infusion,

the association with them may be missed.

Therefore record all transfusions accurately in

the patient’s case notes and consider

transfusion in the differential diagnosis.

7.

Infusion of large volumes of blood and IV fluids

may cause haemostatic defects or metabolic

disturbances.

Recommendations:

 

1.

The blood used for the compatibility testing

must be stored for 7 days at 2-8 oC for possible

investigation on transfusion reactions.

2.

A nurse should observe the patient during the

first 5-10 minutes after starting of each unit. At

the end of the period, the vital functions must

be registered. It should be documented which

parameter and at what frequency (pulse,

temperature, BP).

3.

The clinician handling the patient must be

involved in the differential diagnosis of

transfusion reactions. Also a quick and clear

investigation should be started in the hospital

blood bank laboratory.

4.

Prior to disconnecting, the unit must be closed

to avoid reflux of patient blood into the donor

blood.

5.

Systematic teaching and training of nursing

staff to prevent recognize and treatment of

transfusion reactions is indicated.

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7. Guidelines for appropriate use of blood

Recognition and management of acute

 

transfusion reactions (occurring within 24

 

hours of transfusion)

 

Category 1: mild reactions

 

Signs and symptoms:

 

Localized cutaneous reactions, e.g. urticaria,

rash

Pruritis

Management:

 

X

Slow the transfusion

 

X

Give antihistamine, e.g. promethazine

hydrochloride 25-50 mg by deep IM or slow IV

-

give <25 mg/min as a diluted solution

 

containing 2.5 mg/ml in water for

injections(max: 100mg)

child: 1-5 yrs: 5 mg by deep IM

5-10 yrs: 6.25-12.5 mg by deep IM

 

If no clinical improvement within 30 minutes or if

condition worsens:

 

X

Treat as category 2

 

Category 2: moderately severe reactions

Sign and symptoms:

 

Flushing

Urticaria, pruritis

Rigors

Fever

Restlessness, palpitations

Tachycardia

Mild dyspnoea

Headache

Management:

 

X

Stop the transfusion

X

Replace the infusion set and keep the IV line

open with sodium chloride 0.9 % infusion

 

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7. Guidelines for appropriate use of blood

X

Notify the medical officer in charge and the

blood bank immediately

 

X

Send blood unit with infusion set, freshly

collected urine and new blood samples (one

clotted and one anticoagulated) from the vein

opposite the infusion site together with the

appropriate request form to the blood bank for

laboratory investigations.

 

X

Give antihistamine IM (see category 1 above)

 

X

Give antipyretic: paracetamol 15 mg/kg (adult:

1g)

 

X

If there are anaphylactic features (e.g.

bronchospasm, stridor): give hydrocortisone 4

mg/kg IV and aminophylline 6 mg/kg IV

 

X

Collect urine for the next 24 hours for volume

output and evidence of haemolysis and send to

the hospital laboratoryif there is clinical

improvement.

 

X

Restart transfusion slowly with a new blood unit

and observe carefully if no clinical improvement

within 15 mins of restarting or condition

worsens.

 

X

Treat as category 3

 

Category 3: life-threatening reactions

Signs and symptoms:

 

Rigors

Fever

Anxiety, restlessness

Hypotension (fall of >20% in systolic BP)

Tachycardia (rise of >20% in heart rate)

Haemoglobinuria

Unexplained bleeding (DIC)

Pain in chest, or near infusion site, or in

loin/back, headache

Respiratory distress, shortness of breath,

dyspoea

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7. Guidelines for appropriate use of blood

Management:

 

X

Stop the transfusion

 

X

Give sodium chloride 0.9% IV infusion 20-30

ml/kg over 5 minutes to maintain systolic BP

 

X

Raise patient’s legs

 

X

Maintain airway and give high flow oxygen by

mask

 

X

Give adrenaline (epinephrine) injection 1 mg/ml

 

0.01 mg/kg slow IM

X

If there are anaphylactic features (e.g.

bronchospasm, stridor): give hydrocortisone 4

mg/kg IV and aminophylline 6 mg/kg IV.

 

X

Give diuretic: furosemide 1 mg/kg IV

 

X

Notify the medical officer in charge and blood

bank immediately

 

X

Send blood unit with infusion set, freshly

collected urine and new blood samples (one

clotted and one anticoagulated) from the vein

opposite infusion site with appropriate request

form to blood bank laboratory investigations.

 

X

Check fresh urine specimen for haemoglobinuria

 

X

Start a 24 –hour urine collection and fluid

 

balance chart and record all intake and output

X

Maintain fluid balance

X

Refer for further management where necessary

 

Notes:

 

If an acute transfusion reaction occurs, stop the

transfusion immediately and remove the giving

set. Check the blood pack labels and patient’s

identity. If there is a discrepancy consult the

blood bank.

In an unconscious or anaesthetized patient,

hypotension and uncontrolled bleeding may be

the only signs of transfusion problem.

In a conscious patient with a severe haemolytic

transfusion reaction, signs/symptoms may

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7. Guidelines for appropriate use of blood

appear within minutes of infusing only 5-10 ml

of blood

-

close observation at the start of infusion of

 

each unit is therefore vital

 

For all category 2 & 3 reactions, record the

following in the patient’s notes:

-

type of reaction

-

time from start of transfusion that reaction

occurred

-

volume, type and pack numbers of blood

products transfused

Plasma Transfusion Guidelines

Posted by sammy on February 5, 2013 at 4:30 PM Comments comments (0)

Plasma

Major Products Available:

 

Fresh Frozen Plasma (FFP)

 

Plasma Frozen Within 24 hours After Phlebotomy

(FP24)

 

FFP Thawed

 

Plasma, Cryoprecipitate Reduced

 

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7. Guidelines for appropriate use of blood

Description/Contents:

 

All plasma products are prepared by separation

from whole blood by centrifugation. The volume of

plasma varies and appears on the label. Fresh

Frozen Plasma contains all soluble clotting factors

and contains the plasma from one unit of whole

blood, approximately 250 ml, separated and frozen

within 8 hours of collection. FFP Thawed should be

transfused within 24 hours. Plasma Frozen Within

24 hours After Phlebotomy has somewhat reduced

levels of Factor VIII (65-80%). Thawed Plasma is a

unit of FFP or FP24 thawed at 30-37 oC and

maintained at 1-6 oC for up to 5 days. Levels of

Factors V and VIII in Thawed Plasma are reduced

and Thawed Plasma should not be used to treat

patients with deficiencies of these factors. Plasma,

Cryoprecipitate Reduced is prepared by thawing FFP

at 4 oC and removing the Cryoprecipitate, which

yields plasma that is depleted in Factor VIII, von

Willebrand factor (vWF), fibrinogen, Factor XIII,

and fibronectin. Other proteins such as albumin,

Factors II, V, VII, IX, X, and XI are unaffected.

 

Indications*:

 

Bleeding, preoperative, or massively transfused

patients with a deficiency of multiple

coagulation factors.

Patients with bleeding and/or urgent invasive

procedures on warfarin therapy. Vitamin K will

reverse the warfarin defect in about 12 hours.

Thrombotic thrombocytopenic purpura and

related syndromes.

Congenital or acquired coagulation factor

deficiency when no concentrate is available.

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7. Guidelines for appropriate use of blood

Specific plasma protein deficiencies. Examples

include Anti-thrombin III deficiency and C-1

esterase deficiency (hereditary angioedema).

Specific treatment protocols for these rare

conditions should be referenced.

Disseminated Intra-vascular coagulation (DIC)

such as in disseminated septaecimia following

surgery, abruptio placenta and post abortion

sepsis.

* Not all plasma products are suitable for all the

above indications. The choice of plasma

product should be based on the underlying

deficiency and the contents of the available

plasma products (see description/content).

Plasma product transfusion for coagulopathies is

not indicated unless the Prothrombin Time (PT) or

Partial Thrombin Time (aPTT) is >1.5 times the

midpoint of the normal values.

 

Do not transfuse plasma products for volume

expansion, for prophylaxis following

cardiopulmonary bypass, or as a nutritional

supplement. Dosage and Administration:

 

Plasma product transfusions should be ABO

compatible. Crossmatching and Rh compatibility are

not required for plasma product transfusions. The

usual starting dose is 10-15 mL/kg (i.e. 3-4 units

for a 70-kg patient). An assessment of the effect of

the product on the bleeding problem should be

made before continuing therapy.

 

Alternative Therapy:

 

For volume expansion, saline, other electrolyte

solutions, albumin, or synthetic colloids are safer,

cheaper and more effective. When appropriate, a

specific coagulation factor concentrate should be

used for treatment. Treatment with vitamin K can

 

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7. Guidelines for appropriate use of blood

avoid the need for plasma transfusion in patients

with vitamin K deficiency or on warfarin.

Platelet Transfusion Guidelines:

Posted by sammy on February 5, 2013 at 4:30 PM Comments comments (0)

Platelets

Major Products Available:

 

Platelets concentrate (Random donor platelets -

RDP)

 

Platelets Pooled

 

Description/Contents:

 

RDP are separated from whole blood by differential

centrifugation. One unit of RDP contains at least

5.5x1010 platelets, typically 7.5x1010 platelets.

Pooled RDP are typically prepared from 4-6 units of

RDP. Platelets are suspended in donor plasma,

unless washed.

 

Indications:

 

Prevention/treatment of non-surgical bleeding

due to thrombocytopenia

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7. Guidelines for appropriate use of blood

If possible, prior to transfusion the reason for

thrombocytopenia should be established. When

thrombocytopenia is caused by marrow failure,

the following transfusion triggers are considered

appropriate: If platelet count is <10,000/µL

and no additional abnormalities exist. If

platelet count is between 10,000 and 20,000/µL

and coagulation abnormalities exist or there are

extensive petechiae or ecchymoses. If the

patient is bleeding at sites other than skin and

platelet count is <40-50,000/µ L.

 

Patients with accelerated platelet destruction

with significant bleeding (such as autoimmune

thrombocytopenia or drug-induced

thrombocytopenia).

The endpoint should be cessation of bleeding,

since an increment in platelet count is not likely

to be achieved. Prophylactic transfusion is not

indicated in these disorders.

Prior to surgical and major invasive procedures

when the platelet count is <50,000/ µL.

During neurosurgical and ophthamologic

procedures some authorities recommend that

the platelet count be maintained between

70,000 and 100,000/µL.

Bleeding with qualitative platelet defect

documented by history and/or laboratory tests.

The cause should be identified and corrected, if

possible, prior to surgery. Platelet transfusion is

indicated only if the defect cannot be otherwise

corrected: for example, a congenital platelet

abnormality. Consultation with the blood bank

physician is recommended in these situations.

Diffuse microvascular bleeding after

cardiopulmonary bypass or massive transfusion.

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7. Guidelines for appropriate use of blood

Platelet count and coagulation studies should be

performed prior to thetransfusion to guide

subsequent therapy. During surgery on patients

with quantitative or qualitative platelet defects,

the adequacy of hemostasis in patients should

be evaluated by the assessment of

microvascular bleeding.

Platelet transfusion should be avoided in

thrombotic thrombocytopenic purpura,

heparininduced thrombocytopenia, and post-

transfusion purpura, except in cases of life

threatening hemorrhage.

 

Issue of platelet concentrates

 

1.

It is advised to give as much as possible ABO

blood groups compatible platelets.

2.

Due to the short shelf life of platelets, they

should be kept in the laboratory as short as

possible, and must be transfused as soon as

possible.

3.

They must be stored at 20 – 24degrees under

continuous agitation.

4.

Because of the risk of bacterial contamination,

platelets must be administered via the infusion.

5.

The storage of platelets under uncontrolled

conditions e.g. at the ward should be avoided.

Dosage and administration:

 

Compatibility testing is not required. Platelet

concentrate products should be ABO identical where

possible because platelet increments may be

higher. If not possible, good clinical results are

usually obtained with ABO mismatched platelets. In

this case, transfusion of large quantities of ABO

incompatible plasma may lead to a positive direct

antiglobulin test and, rarely, clinically significant red

cell destruction. Rh compatibility is important but

 

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7. Guidelines for appropriate use of blood

not always possible. Post exposure prophylaxis with

anti-Rh immune globulin should be considered

following Rh-positive platelet product transfusions

to Rh-negative women who may have children in

the future.

4-5 pooled RDP. This should raise the platelet count

of a typical 70 kg man approximately 30,00050,000/

µL. Platelet count increments after

transfusion may be lower than expected in the

presence of certain medications, fever,

splenomegaly, infection, or alloimmunization to HLA

or specific platelet antigens.

 

Alternative Therapy:

 

DDAVP (Desmopressin) may improve the platelet

functional defect in uremia. It also raises von

Willebrand factor levels in mild-moderate von

Willebrand’s disease, which may improve platelet

function. Pharmacologic agents such as Aprotinin

may reduce major surgical bleeding and thereby

avoid the dilutional thrombocytopenia characteristic

of massive transfusion. Some of these agents may

also have a direct effect on improving platelet

function.

Red Cell Transfusion Guidelines:

Posted by sammy on February 5, 2013 at 4:30 PM Comments comments (0)

Major Products Available: Red Blood Cells (pediatric pack/red cell concentrate)

 

Description/Contents:

 

Red Blood Cells (RBCs) are prepared from Whole Blood

(WB) by the removal of most of the plasma. RBCs are

stored in one of several saline-based anticoagulant/

preservative solutions, yielding a haematocrit (Hct)

between 55-80%.

 

Indications:

 

The major indication for RBC product transfusions is

prevention or treatment of symptoms of tissue hypoxia

by increasing the oxygen-carrying capacity of blood.

The transfusion requirements of each patient should be

based on clinical status rather than on predetermined

Hct or hemoglobin (Hgb) values.

 

1.

haemorrhagic shock due to:

Surgery

Trauma

Invasive procedure

Medical conditions (e.g. Gastro-intestinal

hemorrhage)

2.

Active bleeding with:

Blood loss in excess of 20% of the patients

calculated blood volume or

Blood loss with 20% decrease in blood

pressure and or 20% increase in heart rate

3.

Symptomatic anemia with

Heamoglobin less than 8 g/dl

Angina pectoris or Central Nervous System

(CNS) symptoms with heamoglobin less

than 10 g/dl

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7. Guidelines for appropriate use of blood

4.

Asymptomatic aneamia

Preoperative heamoglobin less than 8 g/dl

AND

Anticipated surgical blood loss greater than

500 ml

5.

Sickle cell disease:

When general anesthesia is anticipated, when

signs and symptoms of anemia are present, or

for exchange transfusion when indicated (e.g.

pregnancy, stroke, seizures, priapism, or acute

chest syndrome).

Anemia due to renal failure/hemodialysis

refractory to erythropoietin therapy.

Red blood cells products should not be

transfused for volume expansion only or to

enhance wound healing.

 

Dosage/Administration:

 

Red Cells require compatibility testing and should

be ABO and Rh compatible. One unit of RBCs should

increase the hemoglobin of a 70 kg adult by

approximately 1 gm/dL in the absence of volume

overload or continuing blood loss. Clinical signs and

symptoms should be assessed after every unit of

red blood cell transfusion so that the need for

additional transfusion and the patient’s blood

volume status can be assessed. Patients with

chronic anemia, who are volume expanded, and

other patients susceptible to fluid overload should

be transfused slowly. The initial transfusion period

should be carefully monitored with a slow

transfusion rate to allow the early detection of a

transfusion reaction. Transfusion should be

completed within 4 hours per unit. Alternatively the

unit may be divided by the Blood Bank in advance

and administered in two or more aliquots.

 

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7. Guidelines for appropriate use of blood

Alternative Therapy:

 

Diagnosis and treatment of nutritional anemias

(iron, B12, and folate deficiencies) will usually avoid

the need for transfusion. Erythropoeitin has been

shown to reduce transfusion needs in patients with

chronic renal failure and other patients with chronic

anemia. Autologous transfusion (pre-operative

donation, isovolemic hemodilution, perioperative

blood recovery, and post-operative blood salvage)

has been shown to reduce red cell requirements in

carefully selected patients. DDAVP, aprotinin, and

other pharmacologic agents have been shown to

reduce blood loss during some surgical procedures.


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