Kawasaki disease Kawasaki disease (mucocutaneous lymph node syndrome ~ ~3 1

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1 Kawasaki disease. 1 DIC 6 Meropenem 10 Q&A

2 Kawasaki disease Kawasaki disease (mucocutaneous lymph node syndrome ~ ~3 1

3 AST ALT ESR CRP GOT/AST (IU/L) 10~35 23 GPT/ALT (IU/L) 3~30 10 WBC (*10^3/uL) 3.8~ Hgb (g/dl) 13~ Hct (%) 38~ PL (*10^3/uL) 120~ ESR (mm/h) 0~10 60 CRP (mg/dl) < /15 12/16 12/17 12/18 12/19 12/20 Triprolidine &Pseudoephedrine (Peace ) 0.25 # QID Aspirin (Docodon ) 100 mg 2.5 # QID Cough Mixture (Antica ) 3 ml QID Hydrotalcite (Nacid ) 500 mg 0.5 # QID Acetylcysteine (Acetin ) 1.5 g/pk 1/4 pk QID Nako #1 500 ml 500 ml QD IVIG 50 mg/ml 10 gm QD Brompheniramine & Phenylpropanolamine & Phenylephrine (Mitapp elixir 3 ml QID ) 60 ml/bot Aspirin 100 mg 0.5 # QID Diclofenac (Voren ) supp 0.5 # PRN Triamcinolone (Kenalog ) PRN 38.2 C nako#1 500 ml cough mixture peace voren supp. prn C 2

5 # QID Cough Mixture (Antica ) 3 ml QID Hydrotalcite (Nacid ) 500 mg 0.5 # QID Acetylcysteine (Acetin ) 1.

4 kenalog 37.3 C / Aspirin 100 mg/tab Acetylcysteine (Acetin ) 1.5 g/pk Hydrotalcite (Nacid ) 500 mg/tab Cough Mixture (Antica ) Brompheniramine & Phenylpropanolamine & Phenylephrine (Mitapp elixir ) 60 ml/bot 50 mg QD 1/4 pk QID 250 mg QID 3 ml QID 3 ml QID aspirin 80~100 Aspirin mg/kg/day 1100 mg/day aspirin 250 mg QID 80~ mg mg/kg/day aspirin 50 mg QD aspirin 3~5 mg 3~5 aspirin mg/kg/day aspirin aspirin 3 10~20 % 3 aspirin ESR CRP aspirin 3

Phenylephrine (Mitapp elixir ) 60 ml/bot 50 mg QD 1/4 pk QID 250 mg QID 3 ml QID 3 ml QID aspirin 80~100 Aspirin

5 20 mg aspirin 22 mg aspirin aspirin aspirin dipyridamole aspirin 3 IVIG IVIG 1980 Stevens-Johnson 85 % syndrome 2 3~5 % 3 2 mg/kg 10~20 IVIG 2 10 mg nako#1 500 ml Age Fever Eyes <5yr 12 days Kawasaki Disease Nonexudative conjunctivitis, limbal sparing, anterior uveitis >10yr <10days Toxic Shock Syndrome 2-8yr Variable Streptococcal Scarlet Fever All ages Prolonged Stevens-Johnson Syndrome Conjuncivtis Normal Exudative conjunctivitis keratitis Oral mucosa Erthema, strawberry tongue Erythema Pharyngitis, strawberry tongu circumoral pallor Extremities Rash Erythema of palms and soles, indurative edema, peiungual desguamation Polymorphous ; targetoid or purpuric in 20 % Erythema, ulcerations, pseudomembrane formation Systemic Juvenile Rheumatoid Arthritis 2-5yr Prolonged Normal Normal Peripheral edema Fine flaking desquamation Normal Arthritis Erythroderma Erythroderma, Pastia s liness Lymph nodes Single anterior lymph node Normal Painful, diffuse cervical nodes Other Arthritis Shock, coagulopathy, Positive throat culture mental status changes Target lesions Normal Arthralgia, associated herpes virus infection (30 ~ 50%) Modified with permission from Yanagihara R, Todd JK. Acute febrile mucocutaneous lymph node syndrome. Am J Dis Child 1980;134 ; 603. Transient,salmon pink Diffuse Pericarditis 4

Conjuncivtis Normal Exudative conjunctivitis keratitis Oral mucosa Erthema, strawberry tongue Erythema Pharyngitis, strawberry tongu circumoral pallor Extremities Rash Erythema of palms and soles,

6 Suspected Acute Kawasaki Disease Fuifills criteria Does not fulfill criteria Watchful waiting Before day 7 of illness After day 7 of illness IV grmma-globulin 2 g/kg over hours Aspirin mg/kg/day until afebrile, then 3-5 mg/kg/day Echocardiogram Diagnosis confirme Check complete blood count. erythrocyte sedimentation rate. platelet count Urinalysis, liver function tests Obtain appropriate cultures and serologies Slitlamp examination by ophthalmologist Echocardiogram Abnormal findings Normal findings Diagnosis remains uncertain Repeat echocardiogram 1 week and 3 weeks after hospital discharge Weigh risks versus benefits of empiric therapy with intravenous gamma globulin Abnormal findings Normal findings Continue antithrombotic and/or anticoagulant therapy on indivduaiized basis Discontinue aspirin when platelet count normal Follow-up every 1-2 years 2. Textbook of Pediatric Emergency Medicine. P1218~ Lewis Abarness. Pediatrics. Chaper 5 P115~130 Kawasaki disease. P157~171 5

platelet count Urinalysis, liver function tests Obtain appropriate cultures and serologies Slitlamp examination by ophthalmologist Echocardiogram Abnormal findings Normal findings Diagnosis remains

7 (DIC) DIC fibrin ( Disseminated intravascular coagulation DIC ) DIC microangiopathic hemolytic anemia plasminogen DIC DIC tissue factor thromboplastic substances fibrinolysis (acute Fibrin degradation products FDPs promyelocytic leukemia) FDPs antithrombin DIC (monocyte) interleukin-1 TNF- DIC TNF- DIC DIC DIC DIC DIC - DIC DIC 6

substances fibrinolysis (acute Fibrin degradation products FDPs promyelocytic

8 DIC DIC Prothrombin time PT Thrombin time TT fibrinogen V -aminocaproic acid EACA FDPs 500 unit EACA 1 g/hour DIC DIC DIC DIC 1. Fresh frozen plasma FFP mesilate serine protease inhibitor DIC Tamaki Okamura antithrombin gabexate mesilate PT aptt 1-2 mg/kg/hr 50 % DIC FFP 15 ml/kg heparin : DIC 5. gabexate DIC gabexate mesilate cryoprecipitate thrombin a hypofibrinogenemia <100 mg/dl gabexate mesilate 0.3 unit/kg DIC unit/kg gabexate mesilate 3. 20,000/ L thrombocytopenia 7

Fresh frozen plasma FFP mesilate serine protease inhibitor DIC Tamaki Okamura antithrombin gabexate mesilate PT aptt 1-2

9 DIC DIC Obstetric Complications abruptio placentae retained dead fetus septic abortion toxemia amniotic fluid embolish Infections aspergillosis malaria meningococcemia histoplasmosis Gram-negative sepsis Rocky mountain spotted fever Neoplasms carcinomas of pancreas prostate lung and stomach acute promyelocytic leukemia Massive Tissue Injury traumatic burns extensive surgery Miscellaneous acute intravascular hemolysis giant hemangioma aortic aneurysm vasculitis liver disease shock heat stroke snakebite Massive tissue destruction Sepsis Endothelial injury Release of tissue factor Activation of plasmin Microangiopathic hemolytic anemia Widespread microvasular thrombosis Vascular occlussion Platelet aggregation Consumption of clotting factors and platelets Fibrinolysis Fibrin split products Proteolysis of clotting factors Ischemic tissue d Inhibition of thrombin, platelet aggregation, and fibrin polymerization Bleeding 8

intravascular hemolysis giant hemangioma aortic aneurysm vasculitis liver disease shock heat stroke snakebite Massive tissue destruction Sepsis Endothelial injury Release of tissue factor Activation

10 1. Robbins pathologic basis of disease: Red cells and bleeding disorders. 6 th ed The merck manual: Hemostasis and coagulation disorders. 17 th ed The washington manual of medical therapeutics. Disorders of hemostasis. 29 th ed Micromedex: Gabexate. Vol 110,

17 th ed. 1999 3. The washington manual of medical therapeutics.

11 Meropenem Carbapenems Imipenem/Cilastatin imipenem/cilastatin G(+) cocci G(-) bacilli Pseudomonas aeruginosa trans conformation β-lactams Anaerobes Bacteroides fragilis cis conformation carbapenems imipenem -lactamase β-lactam β-lactam 2 Imipenem/cilastatin 3 penicillin Acinetobacter baumanii neutropenic fever meropenem imipenem/cilastatin carbapenem PBPs multidrug-resistant infection Penicillin-binding proteins Extended-spectrum β-lactamase ESBL Klebsiella pneumoniae Escherichia coli Proteus mirabilis ESBL carbapenems ceftazidime β-lactam ceftriaxone cefotaxime aztreonam Oxacillin-resistant AmpC β-lactamase Staphylococcus aureus ORSA Pseudomonas aeruginosa Oxacillin-resistant Staphylococcus epidermidis ORSE Ampicillin-resistant enterococci Enterobacter spp. Citrobacter spp. Serratia marcescens Morganella morganii Penicillin-resistant pneumococci Meropenem Stenotrophomonas maltophilia imipenem/cilastatin S.maltophilia B.cepacia GABA gama-aminobutyric acid imipenem class B β-lactamase seizure imipenem imipenem/cilastatin 10

infection Penicillin-binding proteins Extended-spectrum β-lactamase ESBL Klebsiella pneumoniae Escherichia coli Proteus mirabilis ESBL carbapenems ceftazidime β-lactam ceftriaxone cefotaxime

12 meropenem 1 2 gm q8h carbapenem 3 20 imipenem/cilastatin 1996 seizures mg/kg/dose q8h meropenem imipenem/cilastatin imipenem meropenem 0.5 % imipenem/cilastatin 1.5 % P. aeruginosa meropenem 2 meropenem GABA FDA 3 3 carbapenems cephalosporin ceftriaxone cefotaxime community-acquired meropenem 2 imipenem CH 3 DHP-1 meropenem Dihydropepidase-1 carbapenem imipenem/cilastatin imipenem DHP-1 imipenem meropenem seizure cilastatin imipenem meropenem meropenem DHP-1 imipenem/cilastatin imipenem DHP-1 meropenem imipenem-resistant P. mg/kg/dose q8h 40 cilastatin imipenem aeruginosa meropenem imipenem meropenem 2 % 1~1.5 3 meropenem piperacillin/tazobactam 1 cefepime fluoroquinolones gm q8h 11

Dihydropepidase-1 carbapenem imipenem/cilastatin imipenem DHP-1 imipenem meropenem seizure cilastatin imipenem meropenem meropenem DHP-1 imipenem/cilastatin imipenem DHP-1

13 Meropenem Clcr (ml/min) Dose Dosing interval >50 1 gm Q8h gm Q8h mg Q12h < mg Q24h Handbook 8 th edition. 2000~2001; , Helio S. Sader and Ana C. Gales. New 2. David N Gilbert.etc. Guide to Antimicrobial Therapy 30 th edition Carbapenem and Trinem Antibacteril Agents. Drugs 2001; 61(5): Charles F Lacy.etc. Drug Information 12

Gales. New 2. David N Gilbert.etc. Guide to Antimicrobial Therapy 30 th edition. 2000.

14 Q&A QD TID

15 Aspirin (Docodon ) 100 mg/cap QD Amlodipine (Norvasc ) 5 mg/tab QD Bisoprolol (Concor ) 5 mg/tab QD Fosinopril (Monopril ) 5 mg/tab QD Indapamide (Natrilix ) 5 mg/tab QD Simvastatin (Zocor ) 20 mg/tab QD Furosemide (Lasix ) 40 mg/tab QOD Glibenclamide (Gliben ) 5 mg/tab TIDAC Tricyclic Antidepressants TCAs TCAs Aspirin Amlodipine Bisoprolol Fosinopril Simvastatin Indapamide Furosemide Glibenclamide Qunidine 14

Furosemide (Lasix ) 40 mg/tab QOD Glibenclamide (Gliben ) 5 mg/tab TIDAC Tricyclic Antidepressants TCAs

16 , 3.

19 - adverse drug reaction (2) FDA/ ADR 1. 8~15 20% 2. ( ) 28% vs 3 ADR (3) ASHP American Society of ADR Health-System Pharmacists WHO FDA 3. ASHP (1)WHO 18

1 1 2001 vs 3 ADR (3) ASHP American Society of

20 6. 7. prospective reviews 8. retrospective 9. reviews concurrent monitoring ADR definition algorithms questionnaires Naranjio Algorithm Jones Algorithm Type Kramer Questionnaire A Reaction Type B Reaction Type A temporal relationship Reaction anticipated 80% dechallenge rechallenge Type B Reaction bizarre 20% Naranjio Algorithm 10 Type C Reaction indicator drugs 1. idiosyncrasy tracer antihistamine epinephrine corticosteroids 2. hypersensitivity Clostridium difficile 3. intolerance aminoglycosides amphotericin B antineoplastics corticosteroids digoxin heparin lidocaine phenytoin lithium theophylline warfarin thrombolytic 4. drug interaction agents cisapride terbinafine 19

temporal relationship Reaction anticipated 80% dechallenge rechallenge Type B Reaction bizarre 20% Naranjio Algorithm 10 Type C Reaction indicator drugs 1.

21 ADR 5. pharmacologic 2 1. ADR ADR 3 4 ADR 5 ICD 9 E.code / / / 3. ADR 1 4. [ ] 5. 20

22 Narnajio Algorithm ~8 1~4 0 21

23 indicator drugs tracer Antidiarrhea agents MgSO4 Atropine ( ) Topical steroids Calamine lotion Vitamin K Dextrose 50% (IV push) Diphenhydramine ( ) Epinephrine (IV push) Naloxone Flumazenil Protamine Glucagon Neostigmine Potassium supplement ( Diuretic Digoxin ) Sodium polystyrene sulfonate ( Potassiun sparing ACEI ) UD DUE ADR ICD9 E.code 22

24 1 2 Ketorolac 30 mg/amp - anaphylatic shock Tramadol 50 mg/cap Carbamazepine 200 mg/tab drowsiness fatigue Enalapril 20 mg/tab Bambuterol 10 mg/tab Ramipril 1.25 mg/cap dizziness weakness clammy perspiration Levodopa and Benserazide Selegiline 5 mg/tab hallucinations 250 mg/tab Etodolac 200 mg/cap - stomache Metoclopramide 5 mg/tab Formoterol MDI tremor Prednisolone 5 mg/tab Diclofenac 75 mg/tab edema Cushing s syndrome Prochlorperazine 5 mg/tab - EPS Nicorandil 5 mg/tab - dizziness headache malaise lassitude Antica syrup 120 ml/bot - tachycardia Acebutolol 400 mg/tab - itch on trunk and limb Bisoprolol 5 mg/tab - cold hand & cold feet hypotension bradycardia Lithium 300 mg/cap Propranolol 10 mg/tab diarrhea Quinidine 200 mg/tab Piperacillin and Tazobactam 250 mg/vial Amlodipine 5 mg/tab Aminophylline 225 mg/s.r. tab Gentamicin 80 mg/vial stomachache neutropenia thrombocytopenia Aminophylline 225 mg/s.r. tab - tremor Amitriptyline 25 mg/tab - drowsiness myasthenia Losartan and Hydrochlorothiazide Bisoprolol 5 mg/tab hypotension 62.5 mg/tab Methylprednisolone 4 mg/tab - ecchymosis Errors, Drug information. 2 nd edtion. 1. p.481~518 vol.20, NO.6 3. ASHP guidelines on adverse drug 2. Malone, Mosdell, Kier, Stanovich. Chaper reaction monitoring and reporting. Am sixteen, Medication Misadventures: J health-syst Pharm. 1995: 52; Adverse Drug Reactions and Medication 417~419 23

25 Antihemophilic Factor VIII 26.1/IU (Recombinant) 250 IU/vial Hexoprenaline (Ipradol) mcg/2 ml/amp Lopinavir & Ritonavir (Kaletra) mg & 33.3 mg/cap Otozambon Ear Drops Peginterferon alpha-2b (Peg-Intron) 80 mcg/vial Biperiden (Bipiden) mg/ml/amp Cefoxitin (Lofatin) injection g/vial Clozapine (Clopine) mg/tab Intrafat 10 % (Lipofundin MCT/LCT) 500 ml/bot Neomycin 250 mg/cap 2.85 OTM (Tetracyclin Hydrochloride Ophthalmic Ointment) 10 mg/5 g/tube Xylocaine 2% for IV bolus ml/amp Combantrin OME (Pedialyte) 500 ml/bt Salomol inhaler 24

26 H P Biperiden lactate 34.8 (Bipiden) 5 mg/ml/amp Extracomb cream 12 g/tube 87 Clarithromycin (Klaricid) mg/tab Human Albumin 20 % 1212 Behring low salt Nifedipine (Alonix S) mg/cap Clozapine (Clopine) 25 mg/tab Diltiazem HCl (Diltanexal) 60 mg/tab Urogel 6 ml/tube Clarithromycin 250 mg/tab

Claforan

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