What is the appropriate management for a patient with a history of vomiting, onset of dry cough, febrile episodes, and dehydration signs, who is currently tachycardic but afebrile, after being switched from paracetamol (acetaminophen) to ibuprofen?

Hospital Day 1 Progress Note

Subjective

Patient experienced 4 episodes of vomiting overnight, developed new-onset dry cough, and had persistent febrile episodes despite paracetamol administration. 1 Decreased appetite, dry lips, and thirst were noted, indicating mild dehydration. 1 No sunken eyeballs observed, suggesting dehydration has not progressed to severe stage.

Objective

• Vital Signs: Currently afebrile, tachycardic (heart rate elevated), respiratory rate normal
• Hydration Status: Dry lips and thirst present, but no sunken eyeballs
• Respiratory: Dry cough noted
• Medication Change: Paracetamol switched to ibuprofen
• Response: No recurrence of vomiting since medication change

Assessment

Fever Management

The switch from paracetamol to ibuprofen was appropriate given the persistent febrile episodes. 2, 1 Ibuprofen has demonstrated superior antipyretic efficacy compared to paracetamol in multiple studies, particularly for bacterial infections. 3, 4 In pediatric populations, ibuprofen achieves fever clearance faster and maintains longer periods without fever. 5, 4

Dehydration Status

Patient shows early signs of dehydration (dry lips, thirst) but has not progressed to moderate-severe dehydration (absence of sunken eyeballs). 1 Adequate hydration should be maintained, with fluid intake not exceeding 2 liters per day to avoid overhydration. 1

Vomiting Resolution

The cessation of vomiting following medication change may indicate either natural disease progression or improved tolerance to ibuprofen versus paracetamol. 6 Gastrointestinal side effects occur in approximately 3-9% of patients on ibuprofen, though this is significantly lower than aspirin. 6

Tachycardia

The persistent tachycardia despite fever resolution warrants attention. 6 Ibuprofen can cause sinus tachycardia as a cardiovascular side effect, though this is uncommon. 6 Alternative causes include:

• Residual dehydration requiring fluid replacement
• Underlying infection driving inflammatory response
• Pain or discomfort from the primary illness

New Respiratory Symptoms

The dry cough represents a new symptom requiring monitoring for potential progression to lower respiratory tract involvement or pneumonia. 2

Plan

Antipyretic Management

• Continue ibuprofen at appropriate weight-based dosing (10 mg/kg per dose, maximum 3 doses per 24 hours). 2, 5 Do not exceed maximum recommended daily dose to avoid renal and gastrointestinal complications. 6
• Monitor temperature every 4-6 hours and document all medication administration times to prevent inadvertent overdosing. 5

Hydration

• Encourage oral intake of electrolyte-rich fluids (sports drinks) or nutrient drinks. 2 Target maintenance hydration without exceeding 2 liters daily. 1
• Monitor for improvement in dry lips and thirst as markers of adequate rehydration
• Reassess for development of sunken eyeballs or other signs of worsening dehydration

Cardiovascular Monitoring

• Continue monitoring heart rate closely. 6 If tachycardia persists despite adequate hydration and fever control, consider:
  • Cardiac monitoring if tachycardia worsens or becomes symptomatic 2
  • Evaluation for underlying infection requiring antibiotics 2
  • Assessment for ibuprofen-related cardiovascular effects 6

Respiratory Assessment

• Monitor cough progression and respiratory rate
• If fever recurs with worsening respiratory symptoms, consider empiric broad-spectrum antibiotics (e.g., ceftriaxone 100 mg/kg/day) for possible secondary bacterial infection. 2
• Assess for signs of pneumonia or bronchiolitis requiring escalation of care

Gastrointestinal Monitoring

• Document any recurrence of vomiting, as this may indicate ibuprofen intolerance or disease progression. 6 If vomiting recurs:
  • Consider antiemetic therapy (ondansetron sublingual) 2
  • Reassess for alternative diagnoses
  • Monitor for gastrointestinal bleeding (rare but serious ibuprofen complication) 6

Source Identification

Actively investigate and treat the underlying source of fever. 2, 1 The combination of fever, vomiting, and new cough suggests possible viral illness or early bacterial infection requiring definitive diagnosis and treatment.

Safety Considerations

• Avoid exceeding ibuprofen maximum dosing: Risk of renal failure, metabolic acidosis, and respiratory failure in overdose. 7
• Monitor for rare but serious ibuprofen adverse effects including Stevens-Johnson syndrome, toxic epidermal necrolysis, and anaphylaxis. 6
• If patient has chronic alcohol use or liver disease history, exercise extreme caution with any antipyretic use. 7