What are the admitting orders for a pediatric patient with Kawasaki disease?

Admitting Orders for Pediatric Kawasaki Disease

Admit the child to an inpatient unit with continuous cardiac monitoring and initiate immediate treatment with IVIG 2 g/kg as a single infusion combined with high-dose aspirin 80-100 mg/kg/day divided into four doses. 1, 2

Admission Status and Monitoring

• Admit to inpatient pediatric unit with continuous cardiac monitoring capability 2
• Vital signs every 4 hours including temperature monitoring until afebrile for 48-72 hours 1, 2
• Strict intake and output monitoring 1
• Daily weight 1

Immediate Diagnostic Workup

Laboratory Studies (Stat)

• Complete blood count with differential - expect thrombocytosis (often >450,000/μL), leukocytosis, and anemia 1
• Erythrocyte sedimentation rate (ESR) - typically >40 mm/hr, often >100 mm/hr 1
• C-reactive protein (CRP) - typically ≥3 mg/dL (30 mg/L) 1
• Comprehensive metabolic panel including liver function tests (ALT, AST), albumin (often low), and electrolytes 1
• Urinalysis - may show sterile pyuria 1
• Blood culture - to exclude bacterial sepsis 1

Cardiac Evaluation

• Baseline echocardiogram within 24 hours of admission to assess for coronary artery abnormalities, ventricular function, valvular regurgitation, and pericardial effusion 1, 2
• Baseline electrocardiogram 2, 3

Immediate Treatment Orders

Primary Therapy (Initiate Immediately)

• Intravenous immunoglobulin (IVIG) 2 g/kg as a single infusion over 10-12 hours 1, 2

  • Administer within 10 days of fever onset if possible, though treatment is indicated even after 10 days if fever or inflammation persists 1, 2
  • Pre-medicate with acetaminophen to reduce infusion-related reactions 2

• High-dose aspirin 80-100 mg/kg/day divided into four doses (every 6 hours) 1, 2

  • Continue until patient is afebrile for 48-72 hours 1, 2, 3
  • Then transition to low-dose aspirin 3-5 mg/kg/day as single daily dose 1, 2

Supportive Care

• IV fluids: Maintenance rate with D5 0.45% NaCl unless patient is taking adequate oral fluids 1
• Acetaminophen 10-15 mg/kg every 4-6 hours PRN for fever or discomfort (in addition to aspirin) 2
• Avoid ibuprofen as it antagonizes the antiplatelet effect of aspirin 1, 3

Activity and Diet

• Activity: Bedrest during acute febrile phase, then activity as tolerated 2
• Diet: Regular diet as tolerated; encourage oral fluids 1

Nursing Orders

• Monitor for signs of IVIG infusion reactions including headache, chills, fever, nausea, vomiting, and rarely anaphylaxis 2
• Assess for signs of heart failure including tachycardia, gallop rhythm, respiratory distress 2
• Monitor for bleeding given high-dose aspirin therapy 1
• Document daily presence or resolution of clinical features: conjunctival injection, oral changes, rash, extremity changes, lymphadenopathy 1

Contingency Orders for IVIG Resistance

If fever persists or recurs ≥36 hours after completion of initial IVIG infusion:

• Administer second dose of IVIG 2 g/kg as single infusion 1, 2, 4, 3
• Continue high-dose aspirin until afebrile for 48-72 hours 4
• Repeat echocardiogram to assess for evolving coronary changes 2, 4

If fever persists after second IVIG dose, consider:

• Methylprednisolone 20-30 mg/kg IV daily for 3 days 2, 3
• Infliximab 5 mg/kg IV as alternative 2, 4, 3
• Consult pediatric cardiology and/or rheumatology 2, 4

Follow-up Imaging

• Repeat echocardiogram at 2 weeks and 6-8 weeks after diagnosis if initial echocardiogram is normal 2, 3
• More frequent echocardiography (weekly initially) if coronary abnormalities detected 2, 3

Anticoagulation for Coronary Abnormalities

If coronary aneurysms develop:

• Small aneurysms: Continue low-dose aspirin indefinitely 3
• Moderate aneurysms (4-6 mm): Add clopidogrel to aspirin 4, 3
• Giant aneurysms (≥8 mm): Add warfarin (target INR 2.0-3.0) or therapeutic LMWH to aspirin 1, 3

Critical Pitfalls to Avoid

• Do not delay IVIG administration waiting for echocardiogram results if clinical diagnosis is clear - treatment within 10 days significantly reduces coronary complications from 15-25% to approximately 5% 1, 2
• Do not skip second IVIG dose and jump directly to corticosteroids in IVIG-resistant cases - this violates established protocols 4
• Do not use corticosteroids as first-line therapy or before at least two IVIG doses have been administered 1, 4
• Incomplete Kawasaki disease in infants <1 year has paradoxically higher risk of coronary aneurysms - maintain high index of suspicion and treat aggressively 1, 3
• Note that CRP is more accurate than ESR after IVIG administration since IVIG artificially elevates ESR 1

Vaccination Considerations

• Defer measles, mumps, rubella, and varicella vaccines for 11 months after high-dose IVIG administration 2, 3
• Administer annual influenza vaccine given long-term aspirin therapy and Reye's syndrome risk 1, 2, 3

Discharge Planning

• Transition to low-dose aspirin 3-5 mg/kg/day once afebrile for 48-72 hours 1, 2, 3
• Continue low-dose aspirin for 6-8 weeks if no coronary abnormalities, or indefinitely if abnormalities present 1, 2
• Arrange outpatient cardiology follow-up within 1-2 weeks of discharge 2, 3
• Educate family about signs of cardiac complications and when to seek emergency care 2