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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
Examination
Much of the examination can be performed by simply observing the child; this
usually has the advantage of limiting tears. Approach younger children gently
while they are sitting on a parent’s knee and feeling secure. Examination is
much the same as for adult patients, but include the following:
2
If unwell ABC and resuscitate, E pp. 234–6. Always records obs— for
normal ranges by age, see Table 6.4 (Ep. 236).
Chaperone Ask a nurse to accompany you if a child of either sex is over
0yr, if there is a child protection issue, or whenever you feel it is necessary.
Hydration Fontanelle, capillary rell (≤2s), warm peripheries, mucous
membranes, tears if crying, skin turgor, sunken eyes, tachycardia, lethargy.
Respiratory Grunting, head bobbing, nasal aring, tracheal tug, cervical
lymphadenopathy, recession (sternal, subcostal, intercostal).
CardiovascularCyanosis (check mouth), clubbing, mottled skin, murmurs
may radiate to the back, femoral pulses (coarctation), radiofemoral
delay, dextrocardia, hepatomegaly (heart failure).
Abdominal Check the external genitalia if young, relevant, or boys with
abdominal pain (torsion); never do a PR (though seniors might).
Neurological AVPU (Alert, responds to Voice, responds to Pain,
Unresponsive), fontanelles, tone, reexes (including Moro and grasp reex
if young), head circumference (growth chart), development (Table3.6).
Table3.6 Key stages inchildhood development
Age Gross motor Fine motor Speech Social
6wk Holds head
in line
3mth Lifts head up Eyes follow 80° Coos Laughs
6mth Sits
unsupported
9mth Pulls to stand Finger– thumb grip ‘Mama, dada’ Waves goodbye
2mth Walks
unsupported
8mth Running Scribbles Asks for ‘wants’ Feeds alone
2yr Jumps Copies line 2– 3- word
3yr Uses tricycle Copies circle Name and age Dry by day
4yr Hops Copies cross Counts to 0 Dry by night
Eyes follow 90° Startles to
Transfers objects Babbles Objects to
Points First words Finger foods
sound
sentences
Smiles
mouth
Uses fork
163PAEDIATRIC
ENT Always check the ears and throat if there is a suspicion of infection;
describe the colour, appearance, and if an eusion or pus is present.
Weight, height These should be plotted on a sex- specic growthchart.
Head circumference This is especially important in infants and those
with neurological disease; the measurement should be plotted on a
sex- specicchart.
Chapter4
Prescribing
Prescribing— general considerations 66
How to prescribe— best practice 67
Drug interactions 69
Special considerations 70
Enzyme inducers and inhibitors 72
Reporting adverse drug reactions 72
Drug monitoring 73
Controlled drugs 73
Night sedation 74
Steroid therapy 75
Topical corticosteroids 76
Empirical antibiotic treatment 77
165
166 CHAPTER4 Prescribing
Prescribing— general considerations
Exposure to safe prescribing is increasing in medical schools, yet it is only
really when you are faced daily with drug charts and decisions that you
get the hang of it. Even the most experienced of doctors will only know
by heart the dose and frequency of a maximum of 30– 40 drugs, so do
not worry if you cannot remember everything. 2
should be available on every ward and are a fantastic source of knowledge, as well as assisting with checking prescriptions, advising on eg drug
interactions and formulary alternatives.
Medical errors Many medical errors in hospital involve drugs, so it is
important to consider a few things every time you want to prescribe a
drug, rather than just writing a prescription as a knee- jerk reaction.
IndicationIs there a valid indication for the drug? Is there an alternative
method to solve the problem in question (such as move the patient to a
quiet area of the ward rather than prescribe night- time sedation)?
Contraindications What contraindications are there to the drug?
Does the patient have asthma or Raynaud’s syndrome, in which case
β- blockers may create more problems than theysolve.
Route ofadministrationIf a patient is nil by mouth (NBM), then it is
pointless prescribing oral medications; use the BNF or ask the pharmacist
to help you use alternative routes of administration. Remember IM and
SC injections can be painful, so avoid these if possible.
Drug interactions Some drugs are incompatible when physically mixed
together (eg IV furosemide and IV metoclopramide), and other combinations cause physiological problems (eg ACEi with K+- sparing diuretics). Look
through the patient’s drug chart to spot potential drug interactions (Ep. 69).
Adverse eects All drugs have side eects. Ensure the benets of
treatment outweigh the risk of side eects and remember some patients
are more prone to some side eects than others (eg Reye’s syndrome
in children with aspirin, or oculogyric crises in young females with
metoclopramide). Some side eects should prompt urgent action (such as
stopping statin drugs in patients who complain of muscle pains, or patients
who get wheezy with β- blockers), but others can be advantageous if they
do not expose the patient to unnecessary risks (such as slight sedation
with some antihistamines).
Administering drugs Always double check the drug prescription and
the drug with another member of sta (qualied nurse or doctor). This
is not a sign of uncertainty, this is a sign that you are meticulous and will
greatly limit the chance of a drug error occurring, which would make you
look careless. Equally, if you are asked to check a drug calculation then
take it seriously and pay attention (often this means performing the drug
calculation again yourself).
Hospital pharmacists
2If indoubt Never prescribe or administer a drug you are unsure about,
even if it is a dire emergency— seek senior help or consult the BNF or
a pharmacist.
How toprescribe— best practice
At rst, it can be dicult to remember all the aspects to consider before
prescribing. Take your time, it is better to be slow and safe. The routine will
become second nature over time. You should concentrate on the task to
avoid making an error. If you are being interrupted, don’t be afraid to politely
ask the person to come back in 5min.
Electronic prescribingMost hospitals now use electronic systems for
prescribing. There is no universal system. Many electronic systems have
pop-up safety alerts for certain conditions or drugs, such as a steroid dependency alert for patients with adrenal insuciency. Some systems provide
a drop-down selection of drug doses and frequencies which can save you
time when prescribing, but always check the BNF if you are unsure.
Paper drug charts Some hospitals still use paper drug charts. There are
usually at least four drug sections in the chart; once- only/ STAT doses, regular
medications, PRN (‘as required’) medications, and infusions/ uids (E p p.
402–5). Other sections include O
(often a separate card), medications prior to admission, and nurse prescriptions. If amending a prescription, cross out the original clearly and write a new
prescription (Fig. 4.). Initial and date and record the reason.
Labelling thepaper drug chart As with the patient’s notes, the drug
chart should have at least three identifying features:name, DoB, and NHS
number (the NPSA advice is that the NHS number should be used whenever possible). There are usually spaces to document the ward, consultant,
date of admission, and number of drug charts in use ( of 2, 2 of 2,etc).
When a drug chart is no longer used, cross through the pages to prevent
any new prescriptions being written. When rewriting drug cards, ensure the
correct drugs, doses, and original start dates are carried over.
Check you have the correct patient This sounds basic, but it is
an easy error to make when busy and working under pressure. You may
have the wrong patient’s drug chart handed to you, the wrong patient’s
drug chart may have been inserted into the nursing notes, or you may
not have exited the last patient’s electronic record before prescribing.
Always check allergies If unsure, ask the patient. Document any aller-
gies in this box and the reaction precipitated; eg penicillin l rash. If there are
no known drug allergies then record this too. Nurses are unable to give any
drugs unless the allergy box is complete.
Check for any special considerations Before prescribing, you
should ensure there are no contraindications to a particular drug in the
patient’s medical history and take into account any conditions which affect the dose or route of drug you are about to prescribe (E p. 70).
Writing a prescription Use black pen and write clearly, ideally in cap-
itals. Use the generic drug name (eg diclofenac, not Voltarol
dicate the dose, route, frequency of administration, date started, and circle
the times the drug should be given (Figs 4.2, 4.3). Note that some drugs do
require generic names in addition to brand names— often the case with medications used in Parkinson’s disease. Record any specic instructions (such as
‘with food’) and sign the entry, writing your name and bleep number clearly
on the rst prescription. See Box 4. for verbal prescriptions and Box 4.2 for
self- prescribing.
, anticoagulants, insulin, blood products
2
®
) and clearly in-
167HOW TOPRESCRIBE—BEST PRACTICE
168 CHAPTER4 Prescribing
Fig.4. Example of cancelled drug prescription for a regular medication.
Fig.4.2 Example of drug prescription for a PRN medication.
Fig.4.3 Example of a once- only (STAT) medication.
Box 4. Verbal prescriptions
Verbal prescriptions are only generally acceptable for emergency situations, and the drug(s) should be written up at the rst opportunity. If a
verbal prescription is to be used, say the prescription to two nurses to
minimize the risk of the wrong drug or dose being given. Check your
local prescribing policyrst.
Box 4.2 Self- prescribing
Fs can only prescribe on in- patient drug charts and TTOs. The GMC’s
‘Good Medical Practice’ guidance states you should ‘avoid providing
medical care to yourself or anyone with whom you have a close personal relationship’. Do not get tempted or pressured to ignorethis.
Drug interactions
Individual drug interactions can be found in the BNF.
2Drugs which commonly have interactions are worth keeping an eye out for.
These include digoxin, warfarin, antiepileptics, antibiotics, antidepressants, antipsychotics, theophylline, and amiodarone.
Pharmacokinetic interactions Occur when one drug alters the
absorption, distribution, metabolism, or excretion of another drug which alters the fraction of active drug, causing an aberrant response to a standardized dose. See the following examples:
Absorption Metal ions (Ca
which decreases their absorption and bioavailability.
Distribution Warfarin is highly bound to albumin, so drugs such as
sulfonamides which compete for binding sites on albumin cause displacement of warfarin, increasing its free fraction and anticoagulant eect.
There are many drugs which inuence the binding of warfarin likethis.
Metabolism Rifampicin is a potent enzyme inducer (E p. 72) and in-
creases metabolism of the OCP, reducing its clinical eectiveness; other
forms of contraception should be used in such circumstances.
Excretion Quinidine reduces the renal clearance of digoxin, resulting in
higher than anticipated levels of serum digoxin and increasing the risk of
digoxin side eects and/ or toxicity.
Pharmacodynamic interactions Describe the eect that drugs
have on the body and their mechanism of action. Interactions occur when
two or more agents have anity for the same site of drug action,eg:
• Salbutamol and propranolol (a non- specic β- blocker) have opposing
eects at the β- adrenergic receptor; clinical eect is determined by the
relative concentrations of the two agents and their receptor anity.
The relative importance of interactions The BNF grades each
drug interaction based on the severity of the reaction.
include life-threatening events or have a permanent detrimental eect.
Moderate interactions can cause considerable distress but are unlikely to
be life-threatening or result in long-term eects.
likely to cause concern or incapacitate the majority of patients.
Drug interactions on the wards It is impossible to list all poten-
tial drug interactions here. Electronic prescribing systems will automatically check a new drug against the patient’s pre-existing medications and
create an alert if an interaction is present, although these can feel overzealous at times. When prescribing a new drug on a paper drug chart,
you should check the BNF for potential interactions. In some cases, the
benets of the treatment may outweigh the risks of a mild drug interaction, but if unsure you should discuss with your senior or a pharmacist.
2+
, Fe3+) form complexes with tetracyclines
Severe reactions
Mild interactions are un-
169DRUG INTERACTIONS
For more information see Mbnf.nice.org.uk/interaction/introduction.html
170 CHAPTER4 Prescribing
Special considerations
Every prescription should be carefully considered with specic reection of the patient in question. If in doubt, consult the BNF or speak to
the pharmacist or a senior. Special considerations are listed under each drug
monograph in theBNF.
Patients with liver disease The liver has tremendous capacity
and reserve so liver disease is often severe by the time the handling
of most drugs is altered. The liver clears some drugs directly into bile
(such as rifampicin) so these should be used cautiously if at all. The
liver also manufactures plasma proteins and hypoproteinaemia can result in increased free fractions of some agents (phenytoin, warfarin,
prednisolone) and result in exaggerated pharmacodynamic responses.
Hepatic encephalopathy can be made worse by sedative or anticholinergic drugs, and uid overload by NSAIDs and corticosteroids is well
documented in liver failure. Hepatotoxic drugs (such as methotrexate
and isotretinoin) should only be used by experts as they may precipitate fulminant hepatic failure and death. Patients with established liver
failure have an increased bleeding tendency so avoid IM injections and
employ caution if using any anticoagulant drugs. Paracetamol can be
used in liver disease, but consider a reduced dose; consult the BNF/
pharmacist.
Patients with renal disease Patients with impaired renal function
should only be given nephrotoxic drugs with extreme caution as these
may precipitate fulminant renal failure; these include NSAIDs, gentamicin,
lithium, ACEi, and IV contrast. Any patient with renal disease (impairment
or end- stage renal failure) will have altered drug handling (metabolism,
clearance, volume of distribution, etc) and more careful thought must
be given when prescribing for the patient with GFR <60mL/ min, and
senior input sought when GFR <30mL/ min (BNF, pharmacist, or senior);
the amount, dosing frequency, and choice of drug need careful thought.
Remember that a creatinine in the ‘normal’ range does not mean normal
renal function, E p. 395.
Pregnant patients Many drugs can cross the placenta and have eects
upon the foetus. In the st trimester (weeks – 2), this usually results in
congenital malformations, and in the 2nd (weeks 3– 26) and 3rd trimesters
(weeks 27– 42) usually results in growth retardation or has direct toxic eects
upon foetal tissues. There are no totally ‘safe’ drugs to use in pregnancy, but
there are drugs known to be particularly troublesome. The minimum dose
and the shortest duration possible should be used when prescribing in pregnancy and all drugs avoided if possible in the st trimester.
Drugs considered acceptablePenicillins, cephalosporins, heparin, ranitidine,
paracetamol, codeine.
2
Drugs to avoid Tetracyclines, streptomycin, quinolones, warfarin, thi-
azides, ACEi, lithium, NSAIDs, alcohol, retinoids, barbiturates, opioids,
cytotoxic drugs, and phenytoin.
Breastfeeding patients As with pregnant patients, drugs given to the
mother can get into breast milk and be passed on to the feeding baby.
Some drugs become more concentrated in breast milk than maternal
plasma (such as iodides) and can be toxic to the child. Other drugs can
stunt the child’s suckling reex (eg barbiturates), or act to stop breast milk
production altogether (eg bromocriptine). Speak to a pharmacist before
prescribing any drug to a mother who is feeding a child breast milk. Special
considerations for breastfeeding patients are listed under each drug monograph in theBNF. The Breastfeeding Network also has some helpful drug
factsheets Mwww.breastfeedingnetwork.org.uk/drugs-factsheets
ChildrenSee the BNF for Children. Neonates are more unpredictable in
terms of pharmacokinetics and pharmacodynamics than older children;
prescriptions for this age group should be undertaken by experienced
neonatal sta and drugs double- checked prior to administration. After
the rst month or two, the gut, renal system, and metabolic pathways become more predictable. Almost all drug doses still need to be calculated
by weight (eg mg/ kg) or by body surface area (BSA). There are a few drugs
which should never be prescribed in children by a non- specialist, including
tetracycline (causes irreversible staining of bones and teeth) and aspirin
(predisposes to Reye’s syndrome); others should be used with caution such
as prochlorperazine and isotretinoin. 2 Always consult the BNF for Children
when prescribing for paediatric patients.
Parkinson’s disease Medications for Parkinson’s disease are time crit-
ical and must not be omitted on admission to hospital. Failure to give the
correct medication on time can result in a serious adverse reaction. Check
what time a patient usually takes their medications, they
must receive their
medications at that time regardless of whether it ts in with drug round timings. Consider NG tube if patients are unable to swallow their usual medication. If patients are NBM or their usual medication is unavailable, discuss
with a pharmacist for conversion to an alternative form, eg rotigotine patch.
Dopamine receptor antagonists (eg metoclopramide, haloperidol, prochlorperazine) must not be prescribed for these patients.
Infectious endocarditis (IE) See Box 4.3.
171SPECIAL CONSIDERATIONS
Box 4.3 Patients at risk of infectious endocarditis
Certain cardiac conditions increase the risk of IE. This includes valvular
disease, valve replacement, structural congenital heart disease, hypertrophic cardiomyopathy, and previous IE. Historically, these patients
received antibiotic prophylaxis for certain procedures. Current NICE
guidelines
2
do not recommend prescribing antibiotic prophylaxis against
IE routinely for high-risk patients undergoing dental, GI, genitourinary,
or ENT procedures. However, any episodes of infection in these patients should be investigated and treated promptly to reduce the risk
of endocarditis developing. If a high-risk patient is undergoing a GI or
genitourinary procedure at a site where there is a suspected infection, the
antimicrobial therapy they receive should cover organisms that cause IE.
2
NICE clinical guidelines available at Mwww.nice.org.uk/guidance/CG64
172 CHAPTER4 Prescribing
Enzyme inducers and inhibitors
$ The ‘enzymes’ referred to on this page are the cytochrome P450
enzymes. These hepatic enzymes catalyse oxidation, reduction, and
hydrolysis reactions involved in phase metabolism of drugs. Agents
which induce cytochrome P450 activity result in increased metabolism of
the aected drugs and subsequently reduce the systemic drug response;
inhibitors of cytochrome P450 have the reverse eect and result in exaggerated drug responses as more of the aected drug remains available
to exert its eect.
Common enzyme inducers and inhibitors are listed in Table 4..
Table4. Enzyme inducers and inhibitors
Enzyme inducers Enzyme inhibitors
Phenobarbital/ barbiturates Allopurinol
Rifampicin Antidepressants: uoxetine, sertraline
Antiepileptics: phenytoin,
carbamazepine
Ethanol (chronic use) Acute alcohol intake
†
Smoking
Griseofulvin Sodium valproate
†
Aects CYPA2, smokers require increased theophylline doses.
Imidazoles: ketoconazole, uconazole
Amiodarone
Antibiotics: erythromycin, ciprooxacin,
chloramphenicol, isoniazid, metronidazole
Cimetidine, omeprazole
Ritonavir
Reporting adverse drug reactions
The Yellow Card Scheme This has been running since 964 and
is coordinated by the Medicines and Healthcare products Regulatory
Agency (MHRA). It applies to all medicines, vaccines, medical devices,
and now e-cigarettes. During drug development, side eects with a frequency of :000 or greater (more common) are likely to be identied,
so the Yellow Card Scheme is important in detecting rarer side eects
once a drug is in general use. For established medicines, all serious adverse reactions should be reported (eg anaphylaxis, haemorrhage, severe skin reactions). All doctors have a duty to contribute to this. Yellow
tear- out slips in the back of the BNF can be sent o or go online to
Mhttps:// yellowcard.mhra.gov.uk . The forms can be completed by any
healthcare worker and even by patients.
New drugsThese are marked with an inverted triangle (▼) in the BNF
and are subject to additional monitoring. Any suspected reaction caused
by a new drug must be reported.