What are the admitting orders for a 10kg pediatric patient with Kawasaki disease?

Admitting Orders for Kawasaki Disease in a 10kg Pediatric Patient

Admit this 10kg child with Kawasaki disease to the hospital for immediate administration of IVIG 20 grams (2 g/kg) as a single infusion over 10 hours, combined with high-dose aspirin 800-1000 mg/day (80-100 mg/kg/day) divided into four doses every 6 hours. 1, 2

Immediate Treatment Orders

Primary Therapy

• IVIG 20 grams (2 g/kg) IV as a single infusion over 10 hours - this is the cornerstone of treatment and should be initiated as soon as possible, ideally within the first 10 days of fever onset 1
• Aspirin 250 mg PO every 6 hours (total 1000 mg/day = 100 mg/kg/day) - continue high-dose aspirin until patient is afebrile for 48-72 hours 1, 2
• After fever resolves for 48-72 hours, reduce aspirin to 30-50 mg PO once daily (3-5 mg/kg/day) for antiplatelet effect 1

Monitoring Orders

• Baseline echocardiogram - must be obtained at diagnosis to assess for coronary artery abnormalities 1, 2, 3
• Continuous cardiac monitoring during IVIG infusion to detect potential adverse effects 1
• Vital signs every 4 hours including temperature monitoring 1
• Daily weights to assess fluid status 1

Laboratory Orders

• Baseline labs before IVIG: CBC with differential, ESR, CRP, comprehensive metabolic panel (including albumin and transaminases), urinalysis 1
• Repeat CRP and inflammatory markers 48 hours after IVIG completion to assess treatment response (note: ESR is less reliable after IVIG) 1
• Follow-up echocardiogram at 1-2 weeks and 4-6 weeks after diagnosis 2, 4

Supportive Care Orders

Fluid Management

• Maintenance IV fluids: D5 0.45% NaCl at 40 mL/hour (using 4-2-1 rule: 40 mL/hr for first 10kg) - run concurrently with IVIG infusion 1
• Monitor for fluid overload during IVIG administration, particularly watching for signs of congestive heart failure 5

Activity and Diet

• Bedrest during acute febrile phase 1
• Regular diet as tolerated - encourage oral hydration 1
• NPO 4 hours before IVIG if patient has nausea or vomiting risk 1

Precautions

• Standard precautions - Kawasaki disease is not contagious 1
• Fall precautions due to potential irritability and weakness 1

Anticipatory Management

IVIG Resistance Protocol

• If fever persists or recurs ≥36 hours after completing IVIG infusion, prepare for second dose of IVIG 20 grams (2 g/kg) as single infusion 6, 2, 7
• Do not advance to corticosteroids unless fever persists after two doses of IVIG 6, 2
• Continue high-dose aspirin throughout any retreatment 1

Adverse Effect Monitoring

• Watch for IVIG-related adverse effects: headache, fever, chills, myalgias (occur in approximately 2.7% of patients) 5
• Monitor for new or worsening heart failure during infusion - this is the most serious potential complication 5
• Acetaminophen 150 mg PO/IV every 6 hours PRN for fever or discomfort during IVIG infusion 1
• Avoid ibuprofen - it antagonizes aspirin's antiplatelet effects 1, 2

Long-Term Considerations

Immunization Hold

• Document that measles and varicella vaccines must be deferred for 11 months after high-dose IVIG administration 1, 2
• Order annual influenza vaccine for this patient who will be on long-term aspirin therapy 1, 2, 7

Aspirin Duration

• If no coronary abnormalities on follow-up echocardiograms: continue low-dose aspirin until 6-8 weeks after disease onset 1, 2, 7
• If coronary abnormalities develop: continue low-dose aspirin indefinitely 1, 2
• If moderate aneurysms (4-6 mm) develop: add clopidogrel to aspirin 1
• If giant aneurysms (≥8 mm) develop: add warfarin (target INR 2.0-3.0) or LMWH to aspirin 1

Critical Pitfalls to Avoid

• Do not delay IVIG waiting for all diagnostic criteria to be met if clinical suspicion is high - incomplete Kawasaki disease still requires treatment 1, 2
• Do not skip the second IVIG dose and jump to corticosteroids for IVIG resistance - this violates established protocols 6
• Do not assume aspirin alone is adequate - aspirin does not prevent coronary abnormalities and is only adjunctive therapy 6
• Do not use ibuprofen for fever control in patients on aspirin therapy 1, 2
• Infants under 1 year are at highest risk for coronary aneurysms despite having incomplete presentations - maintain high index of suspicion 1, 8

Discharge Planning

• Cardiology follow-up within 1-2 weeks for repeat echocardiogram 2, 4
• Primary care follow-up within 1 week of discharge 2
• Parent education regarding aspirin administration, Reye's syndrome risk with influenza/varicella exposure, and signs of cardiac complications 1
• Activity restrictions until cleared by cardiology based on coronary artery status 1, 3