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handbook.tex
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\documentclass[11pt,a4paper]{report}
\usepackage[a4paper,bindingoffset=0.2in,%
left=1.25in,right=0.75in,top=1.25in,bottom=1in,%
footskip=.25in]{geometry}
\usepackage{graphicx}
\usepackage{blindtext}
\usepackage{mhchem} % for chemical equation, e.g.: \ce{MgSO4}
\usepackage[super]{nth}
\usepackage{xcolor} %for making colored texts; List of predefined color: black, blue, brown, cyan, darkgray, gray, green, lightgray, lime, magenta, olive, orange, pink, purple, red, teal, violet, white, yellow
\usepackage{enumitem}
\usepackage{nicefrac} % for fraction in an equation
\usepackage{xfrac} % for fraction in an equation
\usepackage{mathtools} % only for \binom
\usepackage{amsmath}
\usepackage{amssymb}
%\usetikzlibrary{shapes.geometric, arrows}
\usepackage{booktabs}
\usepackage[right]{lineno} % line numbers
\usepackage{siunitx}
\usepackage{fancyhdr}
\usepackage{cite} % citation
\usepackage{listings} % for listing commands
\pagestyle{fancy}
\fancyhf{}
%\fancyhead[R]{\slshape \rightmark}
\fancyhead[L]{\slshape \leftmark}
\fancyhead[R]{\color{red}\textit{(Draft)}}
%\lhead{\textit{ICU Protocol {\color{red}(Draft)}}}
%\rhead{\textit{icddr,b Dhaka Hospital}}
\renewcommand{\headrulewidth}{0.4pt}
%\fancyfoot[L]{Draft}
\fancyfoot[R]{Page $|$ \thepage}
%\rfoot{Page $|$ \thepage}
\renewcommand{\footrulewidth}{0.4pt}
\usepackage{tikz}
\usetikzlibrary{scopes}
\usepackage{imakeidx}
%\makeindex
\makeindex[columns=3, title=Index, intoc]
\usepackage[hidelinks]{hyperref}
%\makeindex[columns=3, title=Alphabetical Index, intoc]
\usepackage{multirow}
%===============================
% BODY OF THE DOCUMENT
%===============================
\begin{document}
\setcounter{secnumdepth}{3}
\setcounter{tocdepth}{1}
%\linenumbers
%==========================
% TITLE PAGE
%==========================
\begin{titlepage}
\centering
~\\
\vspace{1.5cm}
\includegraphics[scale=0.30]{icddrb.png}
% \label{icddrb_logo}
\vspace{2.0cm}
{\color[rgb]{0.0,0.0,.55}{\Huge\textbf{The Handbook of}}} \\
\vspace{3mm}
{\color[rgb]{0.0,0.0,.55}{\Huge\textbf{icddr,b Dhaka Hospital}}} \\
\vspace{3mm}
\textit{\nth{5} edition; June, 2018}
% {\Huge\textbf{Management protocol in ICU, \\ icddr,b Dhaka Hospital}}
\vspace{1.5cm}
\textbf{{\color{red}( FINAL DRAFT )}}
\vspace{1.5cm}
{\Large icddr,b: Centre for Health and Population Research} \\
GPO Box 128 \\
Dhaka 1000, Bangladesh
\vspace{1.75cm}
{\large \textit{Approved by}} {\color{red}(pending)} \\
{\large Dr. Mohammod Jobayer Chisti, Senior Scientist}
\vspace{5.00mm}
{\large \textit{Reviewed by}} \\
{\large Dr. Farzana Afroze}, Senior Medical Officer \\
{\large Dr. Monira Sarmin}, Medical Officer \\
\vspace{5.00mm}
{\large \textit{Prepared by}} \\
{\large Dr. Visnu Pritom Chowdhury}, Clinical fellow \\
\href{mailto:pr3370m@gmail.com}{\texttt{visnu.pritom@icddrb.org}}
\end{titlepage}
\tableofcontents
\listoffigures
\listoftables
\newpage
\clearpage
\begin{flushright}
\thispagestyle{empty}
\vspace*{\fill}
\textit{Dedicated to, }\\
\vspace{7.0mm}
\textbf{\textit{ \fontsize{15}{1}\selectfont My fellow colleagues at icddr,b}}\\
\vspace{5.00mm}
\textit{Hope it helps}
\vspace*{\fill}
\end{flushright}
\clearpage
%============================================
% CHAPTER: WHEN A PATIENT COMES TO ICU
%============================================
\chapter[General approach]{General approach to a critically ill patient}
%============================================
% INITIAL ASSESSMENT
%============================================
\section[Initial assessment]{Initial assessment $\rightarrow$ follow ABCDE}
Check the followings:
\begin{enumerate}[noitemsep]
\item \textbf{A} ppearance of the patient; such as, lethargic, gasping, having convulsion, rolling of eyeball, staring and such
\item \textbf{B} reathing: Respiratory status (airway obstruction: suction, hypoxia: \ce{O2} support)
\item \textbf{C} irculation: Check pulse, BP, CRT, temperature and RBS
\item \textbf{D} ehydration status
\item \textbf{E} lse:
\begin{enumerate}
\item Abdominal distension, or any signs of electrolyte imbalance
\item Urine output, or, any history of taking concentrated ORS
\item In case of adult patient, check BP and CVP; consider an ECG as well
\item Look for other signs; for examples,
\begin{itemize}[noitemsep]
\item Pupilary reaction, jerks, planter response, features of meningism
\end{itemize}
\item For elderly patients ask for chronic diseases and drug history, especially steroid.
\end{enumerate}
\end{enumerate}
%============================
% MANAGEMENT OUTLINE
%============================
\section{Management outline}
During assessment of nutritional status, please consider dehydration status. If a baby has some dehydration please add an extra 5--7.5\% weight (equivalent to weight loss in some dehydration) with the measured weight to determine precise nutritional status.
\subsection{Antibiotic}
Please see the dedicated chapter/s.
\subsection{Micronutrient}
(for chisldren with SAM)
\begin{enumerate}
\item Inj. \ce{MgSO4}: 0.1 ml/kg/day, for 5 -- 7 days (IM)
\item Tab. Folic acid: 1.25 mg, once daily, for 10 days
\item Tab. Zinc 20 mg: 1 tablet, once daily, for 10 days (age \textgreater 6 months) \\ \sfrac{1}{2} tab if age $\geq$2 months but $<$6 months
\item Cap. Vitamin A:
\begin{itemize}[noitemsep]
\item 2 months -- $<$6 months\hspace{3mm}: \hspace{2mm}50,000 IU, Stat
\item 6 months -- $<$12 months : 100,000 IU, Stat
\item 12 months -- 5 years\hspace{8mm}: 200,000 IU, Stat
\end{itemize}
{\color{red}$\star$} If measles, another dose on 2nd day \\
{\color{red}$\star$} For eye changes due to malnutrition, on day 1, 2 and 14
\item Multivitamin drops:
\begin{itemize}[noitemsep]
\item Age $<$1 year: 0.5 ml, 12 hourly, for 10 -- 15 days
\item Age $\geq$1 year: 1 ml, 12 hourly, for 10 -- 15 days
\end{itemize}
\item Syr. Potassium Chloride (KCl): 4 mmol/kg/day, in 3 divided dosage, for 3 -- 5 days (1 TSF = 7 mmol/l)\\
{\color{red}$\bullet$} for quick dispense, $\approx$1 ml/kg
\end{enumerate}
%========================
% COMPLICATIONS
%========================
\subsection{Complications}
\begin{enumerate}
\item \textbf{Hypoglycemia\index{Hypoglycemia}}: 10\% glucose, 5 ml/kg, IV Stat \& \\ 10\% glucose 50 ml orally; 25 ml for infant.\\ \\
\textbf{Correction of repeated $\downarrow\downarrow$glycemia correction in children} \\
Look for features of infection.
\begin{itemize}
\item Symptomatic child
\begin{itemize}
\item IV 10\% glucose
\item $+$ hourly glucose
\item Hourly diet
\end{itemize}
\item Asymptomatic child
\begin{itemize}
\item Oral 10\% glucose
\item $+$ hourly diet
\end{itemize}
\item If $\geq$2 episodes of hypoglycemia
\begin{itemize}
\item Send to ICU
\item Give correction
\item Repeat RBS 30 minutes later
\end{itemize}
\end{itemize}
~\\
\textbf{In ICU}:
\noindent i.e. \nth{3} episode: \\
IV + Oral correction $\rightarrow$ \sfrac{1}{2} oral diet, hourly + \sfrac{1}{2} IV (with 5\% dextrose @3ml/kg) \\
$\Downarrow$ \\
\noindent \nth{4} episode: \\
IV correction + Full IV (Fluid ration with 10\% dextrose @3--4 ml/kg) \\
$\Downarrow$ \\
\noindent \nth{5} episode: \\
IV correction + Full IV (Fluid ration with 12.5\% dextrose @3--4 ml/kg) \\
$\Downarrow$ \\
\noindent More episodes of hypoglycemia $\rightarrow$ {\color{red}\textbf{Consider referral}} \\
\textbf{***} Next step should be considered if a new hypoglycemic episode occurs within $<$24 hours of the previous one. \\
\item \textbf{Oral thrush\index{Oral thrush}}: Nystat oral drop, 0.5 -- 1 ml, 6 -- 8 hourly, 5 -- 7 days
\item \textbf{Perianal excoriation\index{Perianal excoriation}}: Apply soothing agent, e.g. vaseline; if no response, Clotrimazole ointment, apply topically (at perianal region) 8 hourly, 5 -- 7 days
\item \textbf{Rectal prolapse\index{Rectal prolapse}}: \ce{MgSO4} compression, 6 hourly, 5 -- 7 days
\end{enumerate}
\subsection{Diet}\index{Diet}
\begin{enumerate}
\item $<$6 months: Exclusive breast feeding, \\
and if non breast-fed modified infant formula (MIF): 10 ml/kg/feed; increase according to demand.
% 2 -- 4 days; then, 12 ml/kg/feed
\item $\geq$6 months:
% Milk suji, 10 ml/kg, \nth{1} 2 -- 3 days, 2 hourly \\ (in case of Kwashiorkor 9 ml/kg/feed); then 12 ml/kg/feed, 2 hourly
for non breast-fed children, 10 ml/kg 2 hourly.
\end{enumerate}
%============
% DIET
%============
\section{Dietary management}
\begin{enumerate}
\item Children with marasmus and marasmic-kwashiorkor:
\begin{itemize}[noitemsep]
\item Day 1: 10 ml/kg/feed of milk suji (120 ml, 80 kcal/kg/day)
\item Day 2 -- 3: 12 ml/kg/feed of milk suji (144 ml, 96 kcal/kg/day)
\item Day 4: 12 ml/kg/feed of milk suji 100 (144 ml, 144 kcal/kg/day), if no diarrhea
\end{itemize}
\item Children with kwashiorkor:
\begin{itemize}[noitemsep]
\item Day 1 -- 3: 9 ml/kg/feed of milk suji (108 ml, 72 kcal/kg/day)
\item Day 4: 9 ml/kg/feed of milk suji 100 (108 ml, 108 kcal/kg/day), if no diarrhea
\end{itemize}
\item Adult: Rice suji, 150 -- 200 ml, 2 hourly.
\end{enumerate}
\noindent \textbf{Energy content}:
\begin{itemize}[noitemsep]
\item Modified infant formula: 68 kcal/100 ml
\item Milk suji: 67 kcal/100 ml
\item Rice suji: 70 kcal/100 ml
\end{itemize}
\newpage
%==================================
% IV FLUID MANAGEMENT
%==================================
\section{Intravenous fluid management}\index{Fluid management}
\paragraph{Dehydration assessemnt: Dhaka method}
\begin{table}[ht]
\centering
\caption[Dhaka method dehydration assessment]{Dhaka method of assessing dehydration \cite{chisti2010influences}} ~\\
\begin{tabular}{l|l|l}
\toprule[1.5pt]
Parameters & \multicolumn{2}{c}{Clinical findings} \\
\midrule
Condition\textsuperscript{$\star$} & Irritable/less active\textsuperscript{$\star$} & Lethargic/comatose\textsuperscript{$\star$} \\
Eyes & Sunken & \\
Mucosa & Dry & \\
Thirst\textsuperscript{$\star$} & Thirsty\textsuperscript{$\star$} & Inability to drink\textsuperscript{$\star$} \\
Skin turgor\textsuperscript{$\star$} & Reduced\textsuperscript{$\star$} & \\
Radial pulse\textsuperscript{$\star$} & & Uncountable/ absent\textsuperscript{$\star$} \\
\midrule
\multirow{3}{*}{Diagnosis} & Some dehydration & Severe dehydration \\
& (If at least 2 signs, 1 key (\textsuperscript{$\star$}) sign & (If signs of some dehydration \\
& are present) & $+$ 1 of key(\textsuperscript{$\star$}) signs are present) \\
\midrule
Estimated body & \multirow{2}{*}{5--10\%} & \multirow{2}{*}{$>$10\%} \\
weight loss & & \\
\bottomrule[1.5pt]
\end{tabular}
\begin{flushleft}
% Table notes.
\end{flushleft}
\label{dhaka-dehydration}
\end{table}
\paragraph{Indications for IV fluids}
Some dehydration correction to be given by oral G-ORS. However, in case of the followings, dehydration correction to be given with IV fluids.
\begin{enumerate}
\item Persistent/ frequent ($>$3 times/hour)/ repeated vomiting
\item Persisting dehydration even after giving repeated oral correction
\item Ileus
\item High purging ($>$15 ml/kg/hr) match
\item Diabetic ketoacidosis (NS)
\item Hyponatremia (Na\textsuperscript{+} \textless 110 mmol/l or, \textgreater 110 mmol/l with symptoms)
\item Cerebral edema (3\% \ce{NaCl} in ICU)
\item Severe dehydration
\end{enumerate}
\paragraph{Fluid calculations}
Please see the dedicated chapter.
%\begin{enumerate}
% \item Shock: 20 ml/kg/hr for 1 hour \\
% -- Acetate, if purging \\
% -- Normal saline (NS), if no purging
% \item For malnourished children:
% \begin{enumerate}
% \item Severe dehydration: \\
% -- 20 ml/kg/hr, IV (\nth{1} hour)\\
% -- 10 ml/kg/hr, IV \& 10 ml/kg/hr, oral (\nth{2} hour) \\
% \textit{Fluids}: \\
% $\circ$ \textless 2 months: \sfrac{1}{2} Acetate + 5\% dextrose + 13 mmol/l KCl \\
% $\circ$ \textgreater 2 months: Acetate \\
% {\color[rgb]{.85,0,0}{\textbf{**}}} Please always check, electrolyte, ABG and lab reports
%
% \item Some dehydration: \\
% -- 10 ml/kg/hr for \nth{1} 2 hours + purging match, then, \\
% -- 5 ml/kg/hr for next 10 hours + purging match \\
% \textit{Fluids}: \\
% $\circ$ For IV: \sfrac{1}{2} Acetate + 5\% dextrose + 13 mmol/l KCl \\
% $\circ$ For oral: G-ORS
%
% \end{enumerate}
%
% \item For well nourished children:
% \begin{enumerate}
% \item Severe dehydration: \\
% Age \textless 1 year: \\
% -- 30 ml/kg over \nth{1} hour (Acetate/ cholera saline) \\
% -- 70 ml/kg over next 5 hours (Acetate/ cholera saline) \\
% Age \textgreater 1 year: \\
% -- 30 ml/kg over \sfrac{1}{2} hour (Acetate/ cholera saline) \\
% -- 70 ml/kg over 2\sfrac{1}{2} hours (Acetate/ cholera saline)
%
% \item Some dehydration: \\
% -- 75 ml/kg over 4 hours (Acetate/ cholera saline/ G-ORS)
% \end{enumerate}
% \item Fluid ration (if patient is kept NPO):
% \begin{itemize}
% \item For children: \\
% -- 3 ml/kg/hr (fluid according to electrolyte status)
% \item For adults (421 formula): \\
% -- 4 ml/kg (\nth{1} 10 kg) + 2 ml/kg (next 10 kg) + 1 ml/kg for remainin kgs; e.g. if a patient weighs 50 kg, then his/her fluid ration will be 90 ml/hr
% \end{itemize}
%\end{enumerate}
\newpage
%============================
% ELECTROLYTE IMBALANCE
%============================
\section{Electrolyte imbalance}
Please see the dedicated chapter.
%=====================
% CONVULSION
%=====================
\section{Management of convulsion}
Please see the dedicated chapter.
%=====================
% IONOTROPPES
%=====================
\section{Regarding ionotropes}
After correction of dehydration, if patient still remains in shock, start inotropes.
%\begin{enumerate}
% \item For children:
% \begin{enumerate}
% \item Fluid bolus:
% \begin{itemize}[noitemsep]
% \item Fluid bolus 20 ml/kg for 2 times, for malnourished child
% \item 20 ml/kg for 3 times, for well nourished child
% \end{itemize}
% \item Blood transfusion:
% \begin{itemize}[noitemsep]
% \item 10 ml/kg for malnourished child
% \item 20 ml/kg for well nourished child
% \end{itemize}
% \end{enumerate}
% \textbf{*} Start inonotropes dopamine, adrenalin (if cold periphery), noradrenalin, steroid one by one.\\
% \textbf{**} Please catheterize the patient to meaure the urine output.
%
% \item For adults:
% \begin{itemize}
% \item Dehydration status should be assessed and correction should be given accordinly
% \item If severe sepsis or, septic shock is suspected,
% \begin{itemize}
% \item IV bolus with 30 ml/kg of isotonic fluid (NS or Acetate)
% \item If no response, another bolus with 7.5 ml/kg with isotonic fluid (if CVP is indicative)
% \end{itemize}
% \item If target BP is not achieved, ionotropes should be started with the targets of the followings:
% \begin{itemize}
% \item MAP:\\
% $\rightarrow$ in adults: $>$ 65 \\
% $\rightarrow$ in children: $>$ 50 \\
%
% \item Urine output: \\
% $\rightarrow$ in adults: $\ge$ 0.5 ml/kg/hr \\
% $\rightarrow$ in children: $\ge$ 1.0 ml/kg/hr\\
% \item CVP: 10 -- 12 cm of water pressure
%
% \end{itemize}
%
% \textbf{**} Please check lungs base for features of fluid overload, check CVP
% \end{itemize}
%
%\end{enumerate}
~\\
\noindent\textbf{Dosage:}
\begin{itemize}
\item Dopamine: 3 ml/kg in 50 ml fluid {\color{red}(NS)} \\
start @ 8 ml/hr $\rightarrow$ 12 $\rightarrow$ 15 (as in single strength; gradually increase the dose according to vitals)\\
{\color{red}$\star\star\star$} At single dilution, 8 ml/hr $=$ 8$\mu$g/kg/min.
\item Adrenaline: 0.3 ml/kg in 50 ml fluid {\color{red}(NS)} \\
start @ 0.5 ml/hr $\rightarrow$ 1 $\rightarrow$ 1.5 $\rightarrow$ 2 $\rightarrow$ 2.5 $\rightarrow$ 3 $\rightarrow$ up to 10 ml/min (single strength/dilution) $[$ also titratable as, 1 $\rightarrow$ 2 $\rightarrow$ 3 upto 10 $]$\\
{\color{red}$\star\star\star$} At single dilution, 0.5 ml/hr $=$ 0.05$\mu$g/kg/min.
\item Noradrenaline: 0.3 ml/kg in 50 ml fluid {\color{red}(NS)} \\
start @ 0.5 ml/hr $\rightarrow$ 1 $\rightarrow$ 1.5 $\rightarrow$ 2 $\rightarrow$ 2.5 $\rightarrow$ 3 $\rightarrow$ up to 5 ml/min (single strength/dilution) $[$ also titratable as, 1 $\rightarrow$ 2 $\rightarrow$ 3 upto 10 $]$\\
{\color{red}$\star\star\star$} At single dilution, 0.5 ml/hr $=$ 0.05$\mu$g/kg/min.
\end{itemize}
%===================
% RESUSCITATION
%===================
\section{Resuscitating a patient}\index{Resuscitation}
\begin{enumerate}
\item Start with ABC, i.e. airway, breathing and circulation \\
Keep the patient in lateral position, give O-P \& N-P suction and \ce{O2} inhalation if necessary \\
Application of airway tube or nasopharyngeal tube \\
{\color{red}$\star$} for children, airway and breathing is more important \\
{\color{red}$\star$} for adult, it is circulation instead.
\item Check RBS and Sp\ce{O2}
\item If the baby is unresponsive, check heart/ pulse, and consider cardiopulmonary ressuscitation (for children 15:2 and for adults 30:2)
\item Consider drugs: Every 3 -- 5 minutes interval during resuscitation
\begin{enumerate}
\item Inj. Atropine (1 amp: 1 mg/ml)
($\star$ \textbf{maximum} 3 doses) \\
{\color{red}$\circ$} Children: 20$\mu$g/kg (\textbf{minimum}: 100$\mu$g) \\
{\color{red}$\circ$} Adult: 1 amp
\item Inj. Adrenalin (1:1000) (1 amp: 0.6 mg(600$\mu$g)/ml)
($\star$ \textbf{maximum} 5 doses, range: 3-5 doses)\\
{\color{red}$\circ$} Children: 10$\mu$g/kg \\
{\color{red}$\circ$} Adult: 1 amp
\end{enumerate}
\item Cosider ABG, check RBS again
\item Search for reversible causes like, hypothermia, hypoglycemia, hypo or hyperkalemia, pulmonary embolism, toxins. \\
-- Adrenaline nebulization in \textbf{croup dose} (ASA: adrenaline, steroid, adrenaline); nebulization with adrenaline (1:1000): 0.5 ml/kg (max: 6 ml) + 6 ml NS (usually improves with 1 nebulization) \\
-- Steroid (prednisolone 2 mg/kg single dose) \\
-- If necessary, \nth{2} nebulization with adrenaline (1:1000) \\ 0.5 ml/kg (max: 6 ml) + 6 ml NS.
\end{enumerate}
%=================================
% CHAPTER: FLUID MANAGEMENT
%=================================
\chapter[Fluid management]{Fluid management: A medical emergency}\index{Fluid management}
\section[Hypovolumic shock]{Hypovolumic shock (Severe Dehydration)}
\begin{enumerate}
\item \textbf{SAM}:
\begin{enumerate}
\item \textless2 months: (\nicefrac{1}{2} A/C + 5\% Dex + 13 mmol/L \ce{K+})
\begin{enumerate}
\item \nth{1} hr: @20 ml/kg (only IV)
\item \nth{2} hr: @20 ml/kg (10 ml/kg IV + 10 ml/kg Oral)
\item \nth{3} and \nth{4} hrs: @10 ml/kg (Oral)
\item Next 8 - 10 hrs: @5 ml/kg (Oral),
or, upto dehydration correction
\end{enumerate}
\item \textgreater2 months: (Full A/C + 5\% Dex + 7mmol/L \ce{K+})
\begin{enumerate}
\item \nth{1} hr: @20 ml/kg (only IV)
\item \nth{2} hr: @20 ml/kg (10 ml/kg IV + 10 ml/kg Oral)
\item \nth{3} and \nth{4} hrs: @10 ml/kg (Oral)
\item Next 8 - 10 hrs: @5 ml/kg (Oral),
or, upto dehydration correction
\end{enumerate}
\end{enumerate}
\item \textbf{Non-SAM}:
\begin{enumerate}
\item \textless1 yr: (Full A/C or N/S)
\begin{enumerate}
\item \nth{1} @30 ml/kg in 1 hr
\item \nth{2} @70 ml/kg in 5 hrs
\end{enumerate}
\item \textgreater1 yr: (Full A/C or N/S)
\begin{enumerate}
\item \nth{1} @30 ml/kg in \nicefrac{1}{2} hr
\item \nth{2} @70 ml/kg in 2\nicefrac{1}{2} hrs
\end{enumerate}
\end{enumerate}
\end{enumerate}
\noindent
\textbf{NB}: In every case match purging or stool output is mandatory.\\
\section{Severe sepsis and Septic Shock}
\begin{enumerate}
\item \textbf{SAM}:
\begin{enumerate}
\item \nth{1} hr: @20 ml/Kg (Isotonic fluid)
\item \nth{2} hr: @20 ml/Kg (Isotonic fluid)
\item \nth{3} hr: @10 ml/Kg (\textbf{Whole blood})
\item Next - Inotropes
\end{enumerate}
\item \textbf{Non-SAM}:
\begin{enumerate}
\item \nth{1} hr: @20 ml/Kg (Isotonic fluid)
\item \nth{2} hr: @20 ml/Kg (Isotonic fluid)
\item \nth{3} hr: @20 ml/Kg (Isotonic fluid)
\item Next - Inotropes\\
\end{enumerate}
\end{enumerate}
\noindent
\textbf{NB}: Isotonic fluids - Acetate or Cholera saline (A/C), Normal Saline (N/S) \\
\noindent \textbf{Contraindications of Cholera saline}: Hyperkalemia, metabolic and respiratory alkalosis, hypocalcemia ($\downarrow$\ce{Ca++}), severe sepsis and septic shock.
~\\
\section{Composition of several isotonic solutions}\index{Isotonic solutions}
\begin{table}[ht]
\centering
\caption[Composition of IV fluids]{Composition of Normal saline, Cholera saline and Hartmann's solution} ~\\
\begin{tabular}{l|l|l|l|l|l}
\toprule[1.5pt]
\textbf{NS} & & \textbf{AC} & & \textbf{HS} \\
\midrule
\ce{Na+} & 154 mmol/l & \ce{Na+} & 134 mmol/l & \ce{Na+} & 131 mmol/l \\
\ce{Cl-} & 154 mmol/l & \ce{Cl-} & 99 mmol/l & \ce{Cl-} & 111 mmol/l \\
& & \ce{K+} & 13 mmol/l & \ce{K+} & 5 mmol/l \\
& & \ce{C2H3O2-} & 48 mmol/l & \ce{Ca++} & 2 mmol/l \\
& & & & \ce{Cl-} & 111 mmol/l \\
& & & & \ce{HCO3-} & 29 mmol/l \\
\midrule
\textbf{Osmolarity} & 308 mOsm/l & & 294 mOsm/l & & 278 mOsm/l \\
\bottomrule[1.5pt]
\end{tabular}
\begin{flushleft}
% Table notes.
\end{flushleft}
\label{NS}
\end{table}
%=======================================
% CHAPTER: CONVULSION MANAGEMNT
%=======================================
\chapter[Convulsion \& Consciousness level]{Convulsion management \& Assessing level of consciousness}
\section{Management of convulsion}\index{Convulsion}
When a patient has convulsion, administer \nth{1} dose Inj.Lorazepam/ Diazepam 0.1mg/kg/dose (Inj Lorazepam 0.1 mg/kg/dose) Stat, \\
and wait for 5 min for convulsion to resolve, \\
if convulsion persists, \\
$\Downarrow$ \\
\nth{2} dose Inj.Diazepam 0.2mg/kg/Dose (Inj Lorazepam 0.1 mg/kg/dose) slowly over 3--5 min, \\
and wait for another 5 min for convulsion to resolve, \\
if convulsion persists, \\
$\Downarrow$ \\
Inj. Phenobarbitone 20mg/kg/dose Stat loading dose @1 mg/kg/min (over 20 -- 30 minutes) \\
followed by 12 hrly maintenance @5mg/kg/day (2.5 mg/kg/dose), \\
if convulsion persists, \\
$\Downarrow$ \\
Inj. Phenytoin 20mg/kg/dose Stat loading dose @1 mg/kg/min (over 20 -- 30 minutes) \\
followed by 12 hrly maintenance @5mg/kg/day (2.5 mg/kg/dose), \\
if convulsion persists, \\
$\Downarrow$ \\
Syr. \ce{Na+}Valproate 20mg/kg/dose Stat loading dose \\ followed by 8 hrly maintenance @5mg/kg/day (1.67 mg/kg/dose), \\
if convulsion persists, \\
$\Downarrow$ \\
Inj. Midazolam /Inj. Diazepam, \\
bolus @0.1 mg/kg over 2--3 minutes, then maintenance @0.1mg/kg/hr over 6-8 hrs\\ (if apnoea then \textbf{NO DIAZEPAM})
~\\
\noindent {\color{red}\textbf{$\star\star\star$}} \textit{If apnea after Loazepam}, \\
Inj. \textbf{Flumazenil} (@0.01 mg/kg/dose, can be repeated every 1 minute interval, maximum 4 times) may be given. \cite{appletan1995lorazepam}
\newpage
\section[Level of Consciousness]{Determining level of consciousness: GCS, AVPU}
\begin{enumerate}
\item \textbf{Adult}: \\
The Glasgow Coma Scale (GCS\index{GCS}) is used to describe the general level of consciousness in patients with traumatic brain injury (TBI\index{TBI}) and to define broad categories of head injury. \\
The GCS is divided into 3 categories, eye opening (E), motor response (M), and verbal response (V). The score is determined by the sum of the score in each of the 3 categories, with a maximum score of 15 and a minimum score of 3, as follows: \\ \\
GCS score = E + M + V
\begin{enumerate}
\item \textbf{Eye opening scores}:
\begin{itemize}
\item 4: Spontaneously
\item 3: To verbal command
\item 2: To pain
\item 1: No response
\end{itemize}
\item \textbf{Best motor response scores}:
\begin{itemize}
\item 6: Obeys command
\item 5: Localizes pain
\item 4: Flexion withdrawal
\item 3: Flexion abnormal (decorticate)
\item 2: Extension (decerebrate)
\item 1: No response
\end{itemize}
\item \textbf{Best verbal response scores}:
\begin{itemize}
\item 5: Oriented and converses
\item 4: Disoriented and converses
\item 3: Inappropriate words; cries
\item 2: Incomprehensible sounds
\item 1: No response
\end{itemize}
\end{enumerate}
\textbf{Interpretation}: Patients who are intubated are unable to speak, and their verbal score cannot be assessed. They are evaluated only based on eye opening and motor scores, and the suffix ``T'' is added to their score to indicate intubation. In intubated patients, the maximum GCS score is 10T and the minimum score is 2T. \\
The GCS is often used to help define the severity of TBI: \\
$\bullet$ Mild head injuries are generally defined as those associated with a GCS score of 13-15, and \\
$\bullet$ moderate head injuries are those associated with a GCS score of 9-12. \\
$\bullet$ A GCS score of 8 or less defines a severe head injury/coma. \\
These definitions are not rigid and should be considered as a general guide to the level of injury. \cite{jennett1975}
\newpage
\item \textbf{Children}:
The {\color{teal}\textbf{AVPU}} scale (acronym from ``alert, voice, pain, unresponsive'') is a system by which a health care professional can measure and record a patient's responsiveness, indicating their level of consciousness. \index{AVPU}
\begin{enumerate}
\item \textbf{Alert}: The patient is fully awake (although not necessarily oriented). \\
-- This patient will have spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function.
\item \textbf{Verbal}: The patient makes some kind of response when they are talked to, which could be in any of the three component measures of eyes, voice or motor. \\
-- For example, patient's eyes open on being asked ``Are you OK?''. The response could be as little as a grunt, moan, or slight move of a limb when prompted by the voice of the rescuer.
\item \textbf{Pain}: The patient makes a response on any of the three component measures on the application of pain stimulus. \\
-- Such as a central pain stimulus like a sternal rub or a peripheral stimulus such as squeezing the fingers. A patient with some level of consciousness may respond by using their voice, moving their eyes, or moving part of their body (including abnormal posturing).
\item \textbf{Unresponsive}: Sometimes seen noted as ``Unconscious'', this outcome is recorded if the patient does not give any eye, voice or motor response to voice or pain. \cite{hoffmann2016}
\end{enumerate}
\end{enumerate}
%========================================
% CHAPTER: ELECTROLYTE IMABALANCE
%========================================
\chapter[Management of Electrolyte Imbalance]{Management of electrolyte imbalance}\index{Electrolyte imbalance}
\section[Sodium imbalance]{Sodium imbalance ({\color{red}$\uparrow\downarrow$\ce{Na+}})}
% \item Sodium:
\begin{enumerate}
\item \textbf{Hyponatremia\index{Hyponatremia} ($\downarrow$\ce{Na+})}: \\
Na\textsuperscript{+} \textless 110 mmol/l or, \textgreater 110 mmol/l with symptoms: 3\% NaCl, 12 ml/kg over 4 -- 6 hours (Maximum: 500 ml in adults) \\
~\\
\textit{Clinical features}
\begin{itemize}
\item Headache
\item Lethargy
\item Nausea
\item Depression of sensorium
\item Stupor
\item Seizures
\item Coma
\end{itemize}
\item \textbf{Hypernatremia\index{Hypernatremia} ($\uparrow\uparrow$\ce{Na+})}: \\
~\\
\textit{Clinical features}
\begin{itemize}
\item Thirst
\item Irritability
\item Confusion
\item Seizures
\item Coma
\end{itemize}
% \begin{itemize}[noitemsep]
% \item G-ORS (if, oral feed allowed), or,
% \item \sfrac{1}{2} Acetate or, \sfrac{1}{2} NS + 5\% Dextrose (depending on electrolyte status)
% \end{itemize}
\textit{Classification}
\begin{enumerate}
\item Mild: $>$145 -- $\leq$150 mmol/l (no need for correction)
\item Moderate: $>$150 -- $<$170 mmol/l (need correction, manageable at LCU)
\item Severe: $\geq$170 mmol/l (send to ICU)
\end{enumerate}
{\color{red}$\star$} Please add salt 1 gm/l in feed, if the baby has significant hypo (expect for SAM) or, hypernatremia \\
{\color{red}$\star$} 25\% diet to be curtailed at baseline, i.e. at the time when hyper\ce{Na+} correction starts. \\
{\color{red}$\star$} If there is $\geq$10\% weight gain in absence of dehydration, 50\% diet to be curtailed to prevent iatrogenic cerebral or pulmonary edema.
\textbf{** Na\textsuperscript{+} content}:
\begin{itemize}[noitemsep]
\item G-ORS: 75 mmol/l
\item \sfrac{1}{2} NS: 77 mmol/l
\item \sfrac{1}{2} Acetate: 66 mmol/l \\
\end{itemize}
\textbf{Formula for fluid volume calculation}:
\begin{equation}
\frac
{10}
{\frac
{| (\text{ serum } \ce{Na+}) - (\ce{Na+} \text{in given fluid }) |}
{(0.6 \times \text{body weight}) + 1}
} \text{ l/day}
\end{equation}
\end{enumerate}
\newpage
\section[Potassium imbalance]{Potassium imbalance ({\color{red}$\uparrow\downarrow$\ce{K+}})}
\begin{enumerate}
\item \textbf{Hypokalemia\index{Hypokalemia} ($\downarrow$\ce{K+})}:
\begin{enumerate}
\item No clinical symptoms: \\
Oral KCl, 4 mmol/kg/day in 2 -- 3 divided dosage for 5 days
\item Clinical symptoms present:\\
(e.g. ileus, head lag, bradycardia, ECG changes, or patient is NPO) \\
\begin{itemize}[noitemsep]
\item K\textsuperscript{+} \textless 2: 40 mmol/l KCl fluid
\item K\textsuperscript{+} 2 -- 2.5: 30 mmol/l KCl fluid
\item K\textsuperscript{+} 2.5 -- 3.5: 20 mmol/l KCL fluid
\end{itemize}
\end{enumerate}
\begin{figure}[htp]
\centering \includegraphics[scale=.94]{ecg-hypok.png}
\centering \caption[Hypokalemia]{ECG in hypokalemia \\ $\bullet$ U -- prominent in chest leads (most common), Others -- ST depression, T is small or inverted, prolonged PR interval \cite{abdullah_ecg}}
\label{ecg-hypoK}
\end{figure}
\newpage
\item \textbf{Hyperkalemia\index{Hyperkalemia} ($\uparrow\uparrow$\ce{K+})}: \\
Serum \ce{K+} \textgreater5.5 mmol/L, but prompt treatment is required when \textgreater6.5 mmol/L
\paragraph{Classification} ~\\
$\bullet$ Mild: \textgreater5.6 - 6.5 mmol/L \\
$\bullet$ Moderate: \textgreater6.6 - 7.0 mmol/L \\
$\bullet$ Severe: \textgreater7 mmol/L
\paragraph{Cause} ~\\
\begin{figure}[htp]
\centering \includegraphics[scale=0.44]{hyperk.png}
\centering \caption[Hyperkalemia diagnostic decision tree]{Diagnostic decision tree for hyperkalaemia. Creatinine of 500 $\mu$mol/L = 5.67 mg/dL. \cite{walker2010davidson}}
\label{HyperK}
\end{figure}
\paragraph{Clinical features} ~\\
$\diamond$ Cardiovascular: Arrhythmia (bradycardia)\\
$\diamond$ Neuromuscular: Muscle weakness, paralysis, paraesthesia.\\
$\diamond$ Gastrointestinal: Nausea, vomiting, ileus. \\
\noindent \textit{\color{red}Note}: The clinical features results from net decrease in membrane excitability occur because of persistent depolarization that inactivates sodium channels in the cell membrane.
\paragraph{ECG findings}
Look for the followings in ECG,
\begin{itemize}
\item {\color{blue}P wave}: Loss of P wave
\item {\color{blue}PR interval}: Prolongation (\textgreater0.2 second)
\item {\color{blue}QRS complex}: Widening gradually leading to ``sine wave'' (usually in severe hyperkalaemia, duration \textgreater0.1 second)
\item {\color{blue}ST segment}: Depression
\item {\color{blue}T wave}: Tall, peaked (usually seen in mild hyperkalaemia; best seen in chest leads)
\end{itemize}
\begin{figure}[htp]
\centering \includegraphics[scale=.9]{ecg-hyperk.png}
\centering \caption[Hyperkalemia]{ECG in hyperkalemia \\ $\bullet$ T -- tall, peaked and tented (in chest leads), P -- wide, small, ultimately absent, PR interval -- prolonged, QRS -- wide, slurred and bizarre \cite{abdullah-ecg}}
\label{ecg-hyperK}
\end{figure}
\paragraph{Management}
\begin{enumerate}
\item Stop all extraneous potassium, except potassium containing food (it is possible to give \ce{K+} free diet) and drugs, which may go unrecognized. (Active intervention might not be required if serum potassium level in between 5.5 to 6.0 mmol/l which may be corrected by rehydration therapy itself)
\item If serum \ce{K+} is \textgreater6.5mmol/l: \\(If serum \ce{K+} is \textgreater6.0 to 6.5mmol/l only Salbutamol could be given)
\begin{enumerate}
\item \textbf{Calcium gluconate (10\%)}: 0.5ml to 1.0 ml/kg over 2 to 5 minutes intravenously\\
Note: It counteracts cardiac toxicity (counteracts the membrane effect of hyperkalaemia, and thereby stabilizes myocardium and prevents arrhythmias). The protective effect of calcium begins within minutes, but it is effective only for an hour. It should be used even in mild form of hyperkalaemia (ECG should be monitored while it is being administered)
\item \textbf{Salbutamol (nebulisation or spray)}: 2.5 to 5 mg of salbutamol solution mixed with 2.5 ml of distilled water for nebulisation is very effective in lowering \ce{K+} levels for up to 2 to 4 hours.\\
Note: It increases potassium movement into the cells by increasing the activity of Na-K-ATPase).
\item \textbf{Insulin and glucose}: Intravenous administration of dextrose 0.5 gram/kg body weight + insulin 0.3 (0.15 IU/kg bodyweight) unit per gram of dextrose over 30 minutes.\\
\textbf{e.g.} For a child with a body weight of 5.0 Kg- 2.5 grams of glucose (25 ml of 10\% or 10 ml of 25\% dextrose) plus 0.75 unit (5$\times$0.3) insulin. \\
\textbf{Note}: Glucose with insulin facilitates entry of potassium into cells by activating the Na-K-ATPase in the cell membrane. Onset of action occurs in approximately 5 to 10 minutes and duration is 4 to 6 hours.
\item \textbf{\ce{NaHCO3}}: {\color{red}\textit{(Not routinely practiced)}} 1 to 2 mEq/Kg body weight over 3 to 5 minutes intravenously.\\
Note: It increases the pH and shifts \ce{K+} into the cells. The effect begins in 5 to 15 minutes and lasts for 1 to 2 hours. It is generally not effective in patients with end-stage renal disease\\
(\textbf{Caution}: Calcium gluconate solution is not compatible with \ce{NaHCO3}. Thus, the IV line should be flushed between these two infusions. ({\color[rgb]{.85,0,0}{\textbf{It should not be given in lobar pneumonia and/or alkalosis}}}).
\end{enumerate}
\item \textbf{Other treatment option} (if above all measures fail)
\begin{enumerate}
\item \textbf{Kayexalate\index{Kayexalate}} (sodium polystyrene resin): In the absence of contraindication (please see below) it can be given in a dose of 1g /Kg orally or rectally in 20\% to 30\% sorbitol or 10\% glucose. \\
(Note: It binds \ce{K+} in the gut and thereby permanently removes \ce{K+}).\\
\textbf{Caution/contraindication}: Patients with GI motility disorder (e.g. diarrhoea), hypovolaemia or uraemia since it may precipitate colonic necrosis.
\item \textbf{Dialysis}: When the above measures fail. \\
(Note: If needed referral is mandatory)
\end{enumerate}
\item Should check renal function along the way.
\end{enumerate}
\end{enumerate}
\newpage
\section[Hypocalcemia]{Hypocalcemia ({\color{blue}$\downarrow$\ce{Ca++}})}\index{Hypocalcemia}
% \item Calcium:
IV bolus calcium with calcium gluconate 0.5 -- 1 ml/kg, followed by oral calcium supplement. \\
{\color{red}\textbf{$\star\star$}} Intravenous calcium should be given slowly after diluted with normal saline (NS). And, keep an eye on ECG monitor to avoid iatrogenic bradycardia/ arrhythmia.\\
{\color{red}$\star$} For symptomatic patients, IV can be repeated for 3 -- 4 times.
\section[Hypomagnesemia]{Hypomagnesemia ({\color{blue}$\downarrow$\ce{Mg++}})}\index{Hypomagnesemia}
Correction is given if \ce{Mg++} is very low. \\
Bolus with 50 mg/kg \ce{MgSO4}, diluted with NS (not more than 2 gm), IV slowly over 20 -- 30 minutes. Then, maintenance with 30 mg/kg \ce{MgSO4} over 6 -- 8 hour, which could be continued for a day. \\
{\color{red}$\star\star$} Please monitor ECG, BP and tendon reflexes and postpone bolus if the patient is in shock.\\
{\color{red}$\star$} 1 ampule contains, 5 ml = 2.5 gm.
%=======================================================
% CHAPTER: ANTIBIOTICS IN SEPSIS, PNEUMONIA, HAI
%=======================================================
\chapter[Choice of Antibiotics]{Antibiotics choice in Sepsis, Penumonia and HAIs}
% SEPSIS, S. SEPSIS, S. SHOCK
\section[Sepsis, Severe Sepsis \& Septic Shock]{Diagnosis and management of sepsis, severe sepsis and septic shock}
\textit{by Dr. Mohammod Jobayer Chisti}\index{Sepsis}\index{Severe sepsis}\index{Septic shock}
\subsection{Definition}
\subsubsection{Sepsis}
(Diagnosis should be done in absence of dehydration)
\begin{itemize}
\item Presence of signs and symptoms of inflammation and infection \textbf{plus},
\item Hyperthermia or hypothermia (temperature $>$38.5\si{\celsius} or $<$35.0\si{\celsius} respectively) \textbf{plus},
\item Tachycardia (HR: neonate 180/min, infant $>$160/min, 1-5 years $>$140/min, $>$5 years $>$90/min) \textbf{plus},
\item Either bounding pulses \textbf{or}, \\
altered mental status \textbf{or}, \\
hypoxemia in absence of pneumonia \textbf{or}, \\
abnormal WBC count ($>$12 x10\textsuperscript{9}/L* or, $<$4 x10\textsuperscript{9}/L \textbf{or}, \\
band and neutrophil ratio $\geq$0.1) \textbf{or}, \\
increased serum lactate level.
\end{itemize}
\subsubsection{Severe Sepsis}
(Diagnosis should be done in absence of dehydration)
\begin{itemize}
\item Sepsis \textbf{plus},
\item Presence of poor peripheral perfusion (cold periphery and weak/absent peripheral pulses and capillary refill time \textgreater3 second) \textbf{or},
\item Hypotension (MAP \textless50 mm Hg in children and MAP \textless65 mm Hg in adults)
\end{itemize}
\subsubsection{Septic shock}
(Diagnosis should be done in absence of dehydration)
\begin{itemize}
\item Sepsis - induced hypotension (MAP \textless50 mm Hg in children/ \textless65 mm Hg in adults) persisting despite adequate fluid resuscitation
\end{itemize}
\textbf{[*abnormal WBC count for infancy \textgreater15$\times$10\textsuperscript{9} ⁄ L; \\
MAP: (DBP$\times$2 + SBP)/3]}
\subsection{Antibiotics management}
\subsubsection{Sepsis with Pneumonia}
\begin{itemize}
\item \textbf{Children}: $\beta$-lactam [ceftriaxone 100mg/kg (max: 4gm)] \\
+ fluroquinolones [levofloxacin 10 mg/kg (max:500 mg)] daily \\
$[$ If s. sepsis/ s. shock: + metronidazole (7.5 mg/kg; max:400 mg/dose) 8 hrly $]$
\item \textbf{Adult}: $\beta$-lactam (ceftriaxone: 4gm) \\
+ fluroquinolones (levofloxacin 500 mg) daily \\
$[$ If s. sepsis/ s. shock: + metronidazole (400 mg I.V) 8 hrly $]$
\end{itemize}
\subsubsection{Sepsis without Pneumonia}
\begin{itemize}
\item \textbf{Children}: $\beta$-lactam [ceftriaxone 100mg/kg (max: 4gm)] \\
+ aminoglycocide [gentamicin 7.5 mg/kg once daily (max:80 mg)] \\
$[$ If s. sepsis/ s. shock: + metronidazole (7.5 mg/kg 8 hrly; max:400 mg/dose) $]$
\item \textbf{Adult}: $\beta$-lactam (ceftriaxone: 4gm) \\
+ aminoglycocide (gentamicin: 80 mg I.V) 8 hrly \\
$[$ If s. sepsis/ s. shock: + metronidazole (400 mg I.V) 8 hrly $]$
\end{itemize}
\subsection{Fluid management}
\begin{itemize}
\item \textbf{Goal}: Rescue from organ dysfunction.
\begin{itemize}
\item \textbf{MAP}: \textgreater50 mm Hg in children/ \textgreater65 mm Hg in adults and
\item \textbf{UO}: \textgreater1.0 ml/kg per hour in children/ UO \textgreater0.5 ml/kg per hour in adults)
\end{itemize}
\item \textbf{Fluid choice}: IV infusion of isotonic solution (Ringer`s lactate/normal saline)
\begin{itemize}
\item \textbf{Non-SAM children}: 20ml/kg within \nicefrac{1}{2} hour (can be repeated for the \nth{3} time if goal is not achieved)
\item \textbf{SAM children}: 20ml/kg within 1 hour (can be repeated for the \nth{2} time if goal is not achieved; blood transfusion should be given if goal is not achieved after \nth{2} bolus; if blood is not available or blood transfusion is delayed manage the child as septic shock; however when blood is available transfuse blood even the patient is getting inotrope)
\item \textbf{Adults}: 30 ml/kg within \nicefrac{1}{2} hour; if goal is not achieved please open CV line and consider 7.5 ml/kg if CVP \textless10 cm \ce{H2O})
\end{itemize}
High-flow oxygen supplementation, even if Sp\ce{O2} saturation is normal
\item \textbf{Management of septic shock}:
\begin{itemize}
\item \textbf{Inotrope(s)}:
\begin{itemize}
\item for Children:
\begin{itemize}
\item Start dopamine and titrate; if goal is not achieved;
\item \nth{2} line: Adrenaline,
\item \nth{3} line: Nor-adrenaline
\end{itemize}
\item for Adults:
\begin{itemize}
\item Start with Nor-adrenaline and titrate; if goal is not achieved;
\item \nth{2} line: Adrenaline
\end{itemize}
\end{itemize}
\end{itemize}
If all the inotropes fail (inotropes resistant septic shock), start steroid: hydocortisone.
\end{itemize}
\subsection{Summary}
Summary of progression of sepsis and its consequences and management.\\
\textbf{Goal}: Survive from organ dysfunction \\
\textbf{$\star$} MAP: \textgreater50 mm Hg in children, and \textgreater65 mm Hg in adults and \\
\textbf{$\star$} UO: \textgreater1.0 ml/kg per hour in children, and \textgreater0.5 ml/kg per hour in adults \\
\begin{figure}[htp]
\centering \includegraphics[scale=0.21]{sepsis_cascades.png}
\centering \caption[Summary of sepsis]{Summary of progression of sepsis and it's consequences and management}
\label{Sepsis}
\end{figure}
\newpage
%===========================================
% ANTIBIOTICS: SEPSIS, S. SEPSIS
%===========================================
\subsection{Antibiotics outline in sepsis \& severe sepsis}\index{Outline sepsis}
\subsubsection{Age $>$2 months -- 5 years}
\begin{enumerate}
\item \textbf{Sepsis only}:
\begin{enumerate}
\item \textbf{\nth{1} line}:
\begin{enumerate}
\item \textbf{Non-SAM}: Inj. Ampicillin (200 mg/kg) + Gentamycin (7.5 mg/kg)
\item \textbf{SAM}: Inj. Ceftriaxone (100 mg/kg) + Gentamycin (7.5 mg/kg)
\end{enumerate}
\end{enumerate}
\item \textbf{Severe sepsis}: %\nth{1} IV fluid then following $\rightarrow$
\begin{enumerate}
\item \textbf{\nth{2} line}: Inj. Ceftriaxone + Gentamycin
\item \textbf{\nth{3} line}: Inj. Ceftazidime + Amikacin
\item \textbf{\nth{4} line}: Inj Imipenem / Meropenem
\end{enumerate}
$+$ Inj. Metronidazole (in case of severe sepsis)
\end{enumerate}
\subsubsection{Age $\leq$2 months}
\begin{enumerate}
\item \textbf{Sepsis only}:
\begin{enumerate}
\item \textbf{\nth{1} line}:
\begin{enumerate}
\item \textbf{SAM \& Non-SAM}: Inj. Ampicillin (200 mg/kg) + Gentamycin (7.5 mg/kg)
\end{enumerate}
\end{enumerate}
\item \textbf{Severe sepsis}: \nth{1} IV fluid then following $\rightarrow$
\begin{enumerate}
\item \textbf{\nth{2} line}: Inj. Ceftazidime + Amikacin
\item \textbf{\nth{3} line}: Inj. Imipenem / Meropenem
\end{enumerate}
\end{enumerate}
\noindent \textbf{NB}: \nth{2}, \nth{3} or \nth{4} line will be considered if clinical deterioration \textbf{after at least} $\geq$24 hrs, \\
or, no improvement \textbf{after} $>$72 hrs.
\newpage
\section[Pneumonia \& Severe Pneumonia]{Management of Pneumonia in icddr,b Hospital}\index{Pneumonia}\index{Severe pneumonia}
\subsection{Definition}
\begin{enumerate}