Page 268 CSF analysis (Table 6.2) a) Specimens: Send fluid for laboratory studies, including electrolytes, glucose, protein, cell count and differential, Gram's stain, and cultures Label the tubes as follows: ''#1 Culture," "#2 Chemistries," and "#3 Cell count." Send specimens to the laboratory immediately b) Appearance: Record the color and clarity of the fluid Note the presence of coagula, pellicles, or sediment Time required for the formation will vary with different diseases Table 6.2 Cerebrospinal Fluid Laboratory Values Condition CSF pressure Glucose level Cytology Predominant leukocyte Increased Normal Rare Mononuclear Normal Rare Mononuclear Disease related Tumor Meningeal carcinomatosis Decreased Infectious related Bacterial meningitis Increased Decreased None Neutrophil Cryptococcal meningitis Increased Increased Decreased Normal None Lymphocyte Epidural abscess Decreased Normal None Lymphocyte V Microbiology A Organism staining: To identify microorganisms under the microscope, staining is a critical element The three stains most commonly used are the Gram's stain, acid-fast stain, and India ink stain The techniques that provide the best results are thin smears, allowing smears to dry before they are fixed (heating wet smears distorts the organisms and cells), and fixing smears with heat by Page 269 quickly passing the slide through a flame The slide should not be stained until it cools Gram's stain a) Place gentian violet on the slide for one minute, and wash with running water b) Flood with iodine solution for one minute, and wash with running water c) Decolorize with acetone/alcohol for three to four seconds, and wash with water d) Stain with safranin for 30 seconds, and wash with water Acid-fast stain a) Place Kinyoun carbolfuchsin stain on slide for five minutes, and wash with water b) Decolorize with acid alcohol for two minutes, and wash with water c) Counterstain with 0.5% methylene blue for two minutes, and wash with water India ink capsule stain a) Mix one drop of test fluid with one drop of India ink b) Cover with a coverslip c) Ring with petrolatum d) Look for a round organism against a dark background B Culture techniques: If culturing is unavailable from the hospital laboratory, culturing should be done as follows: Bacterial cultures a) Blood: The sample volume should equal 10% of the volume of the culture medium When the patient is treated with penicillin, consider using penicillinasecontaining broth for culture b) Ear and nose: chocolate blood agar, followed by 5% sheep blood agar, followed by MacConkey agar Place the swab in the transport medium Page 270 c) Throat: 5% sheep bland agar, followed by MacConkey agar Place the swab in the transport medium d) Skin: 5% sheep blood agar, followed by MacConkey agar, followed by thioglycollate, broth Place the swab in the transport medium e) Cavity fluids: Place in anaerobic culture containers Fungal cultures a) Use a scalpel to scrape the edges of the lesion in which fungus is suspected onto a glass slide b) Cover scraping with 10% to 20% KOH or NaOH, and apply a coverslip c) Warm for a few minutes d) Examine for spore fragments Viral cultures a) Pharyngeal, nasopharyngeal, and rectal cultures: Send in viral culture media b) Blood, bone marrow, CSF, and urine: Send in sterile containers c) Specimens should be cultured and sent within one hour after collection VI Liver Functions and Gastroenterology A Stool examination Blood: occult blood guaiac method a) Purpose: to screen for the presence of blood in the stool b) Reagents: glacial acetic acid, guaiac, hydrogen peroxide c) Method: Place a small amount of stool on the filter paper Serially apply two drops of each reagent in the following order: acetic acid, guaiac, and hydrogen peroxide Page 271 d) Interpretation: A positive test result will be a purple or dark blue color on the filter paper A negative test result is a green color on the filter paper Parasites a) Direct smear: Add a small amount of fecal material to a drop of saline mix, remove feces with an applicator stick, and cover Examine the specimen under low power to locate the parasites and high power to identify the parasites b) Preservatives: Specimens should be delivered to the laboratory immediately, Place in formalin if a delay in specimen delivery is anticipated B Diarrhea Definition: watery, frequent loose stool caused by a shift in the intestinal water and electrolyte transport due to an increased osmolar load or active secretion of water into the intestinal lumen Etiology of acute diarrhea (self-limiting, < 14 days) a) Infectious b) Preparative regimen: total body irradiation (TBI), ifosfamide, and carboplatin c) Drugs: antacids, antimicrobial agents, chemotherapy conditioning regimen, cardiac medications, magnesium replacement secondary to cyclosporin A Etiology of chronic diarrhea (> 14 days) a) Infectious: fungal (e.g., Candida), parasitic (e.g., Giardia), viral (e.g., cytomegalovirus) b) Inflammatory (e.g., ulcerative enterocolitis) c) GVHD of the gut d) Pseudomembranous colitis: secondary to antibiotic therapy caused by Clostridium difficile e) Secretory diarrhea: caused by an abnormal secretion of water and electrolytes into the intestinal lumen It persists despite fasting Page 272 f) Osmotic diarrhea: caused by the accumulation of poorly absorbed solutes in the intestine It usually stops with fasting Stool evaluation a) Fecal leukocytes: The presence of white blood cells is indicative of bacterial infection b) Occult blood (Hemoccult): Blood present in the stool may indicate bacterial infection or inflammation of the bowel c) Sudan III: Screen for fecal fat malabsorption d) Stool electrolytes: Secretory diarrhea tends to have an elevated stool sodium and a lower osmotic gap (< 100 mOsm/L) In malabsorption or viral illness, the stool tends to have a decreased sodium and increased osmotic gap (> 100 mOsm/L) e) Endoscopy evaluation with biopsy: Platelet count should be in the 50,000/L range Coagulation parameters should be within the normal range before a biopsy is performed Biopsies should be taken from the normal mucosa and the edges of the ulcerated mucosa Endoscopy intubation should be done with caution to prevent laryngeal bleeding C Constipation Definition: a decrease in the frequency of the stool, usually associated with painful or difficult passage of hard stool Etiology a) Functional: idiopathic b) Electrolyte imbalance: hypokalemia, hypocalcemia c) Drugs: antacids, anticonvulsants, antihypertensives, diuretics, opiates, phenothiazines Diagnostic studies a) Abdominal plain films to determine bowel obstruction Page 273 b) Barium enema/large intestine study: The test provides both x-ray and fluoroscopic techniques to demonstrate the anatomy of the large intestine Indications include to rule out obstruction, masses, and inflammatory changes Normal outcome shows normal position, contour, filling, and patency of the large bowel The procedure is as follows: Contrast agent (barium) is given in the form of an enema via the rectum Under fluoroscopy, the colon is completely filled to the ileocecal junction Contrast is maintained in the colon for several minutes while the x-rays are taken A postevacuation film is taken to ensure that all the barium is expelled The importance of forcing fluids after the procedure is stressed D Hemorrhage Definition: Minor gastrointestinal bleeding presenting as small hematemesis or bleeding Resolution usually occurs with correction of thrombocytopenia and correction of abnormal clotting Etiology a) Acute GVHD b) Duodenal ulcer c) Small bowel ulcer d) Gastric erosion Diagnostic study: upper endoscopy evaluation with biopsy a) Platelet count should be in the 50,000/L range b) Coagulation parameters should be within the normal range before a biopsy is performed c) Biopsies should be taken from the normal mucosa and the edges of the ulcerated mucosa d) Endoscopy intubation should be done with caution to prevent laryngeal bleeding Page 274 E Abdominal pain Etiology a) Duodenal ulcer b) Gallbladder disease c) GVHD d) Hemorrhagic cystitis e) Liver disease, veno-occlusive disease, viral hepatitis f) Pancreatitis Diagnostic studies a) Abdominal x-rays to determine bowel obstruction Films should be performed erect and supine b) Upper and/or lower endoscopy with biopsy: Platelet count should be in the 50,000/L range Coagulation parameters should be within the normal range before a biopsy is performed Biopsies should be taken from the normal mucosa and edges of the ulcerated mucosa Endoscopy intubation should be done with caution in the transplant patient to prevent laryngeal or rectal bleeding Symptoms of bowel perforation are abdominal distention, bleeding, fever, and pain c) Abdominal ultrasound: noninvasive procedure that produces sound waves from a handheld transducer Food restriction usually applies six to 12 hours prior to the examination Water is normally permitted The patient will be required to change position during the scanning procedure Breathing may need to be controlled during the imaging Examination time is usually 30 to 60 minutes VII Cytogenetics A Definition: Cytogenetics is the study of the origin, structure, and function of chromosomes It has the ability to identify certain genes that are associated with chromosomal abnormalities There are normally Page 275 23 pairs of chromosomes A chromosome is divided into three parts: a short arm called p, a long arm called q, and a centromere B Karyotype analysis: When chromosomes are stained, regions and bands are named from the centromere toward the telomere (the region at the end of each chromosomal arm) Chromosomal abnormalities are then identified according to the banding pattern Commonly identified chromosomal alterations are referred to as translocations, duplications, deletions, or inversions There are genes that are located close to the chromosomal rearrangement that cause the aberrant expression of the genes that control cell growth If there are changes in the leukocyte, they will result in unregulated leukocyte proliferation, and subsequently leukemia will develop C Application Abnormalities of the patient's karyotype classify disease and predict prognosis Cytogenetic markers not always predict remission; however, they are often indicative of remission duration Cytogenetic abnormalities can be classified as primary and secondary Primary abnormalities influence the patient's treatment and prognosis Secondary abnormalities, when identified, are indicative of a poor prognosis The presence of additions or deletions on chromosomes has a more favorable prognosis D Cytogenetic specimen sampling Cytogenetic specimens are usually obtained from bone marrow aspirate specimens Page 276 In the event that bone marrow aspirate is unavailable, cytogenetics can be obtained from peripheral blood VIII Endocrinology A Gonadal dysfunction Definition: damage that occurs to the germ cells resulting in substantial alteration of gonadotropin-releasing hormone levels Etiology a) TBI b) Chemotherapy conditioning regimen Diagnostic studies a) Measure pituitary luteinizing hormone (LH) and follicle-stimulating hormone (FSH) b) Males: elevation of FSH Testosterone ad LH are normal c) Females: elevation of FSH and LH Estrogen is usually low, d) Prepubescent girls: Delayed puberty will occur in 50% of the cases The delay is related to the age at the time treatment occurs e) Postpubertal females: anovulation with low estrogen levels and elevated FSH and LH levels f) Prepubescent boys: Delayed puberty occurs in 70% to 90% of the cases g) Spermatogenesis may be impaired B Growth hormone (GH) Definition: Impaired growth velocity and GH secretion may occur after high-dose chemotherapy and TBI This is caused by the decreased production of GH and growth factors like IGF-I, an insulin-like growth factor Etiology a) Chemotherapy b) TBI c) GVHD P Drug Supplied as Dose and route Special considerations of qd therapy); treat for 12 mo Class: antitubercular Adults: mg/kg/24 h qd PO (usual dose 300 mg) for 12 mo Supplemental pyridoxine 1–2 mg/kg/24 h) is recommended May cause false positive urine g test results; increases serum concentrations of carbamazepine, diazepam, phenytoin, & prednis SE: peripheral neuropathy, optic neuritis, seizur encephalopathy, psychosis Treatment: Infants & children: 10–20 mg/kg/24 h qd PO OR 20–40 mg/kg/dose times per wkfor months with rifampin Adults: mg/kg/24 h qd PO OR 15 mg/kg/24 h times per wk for months with rifampin Max dose: 300 mg Max single times per wk dose: 900 mg Kanamycin Caps: 500 mg Infants & children: 15–30 Therapeutic levels: mg/kg/24 h divided q8–12 h IV/IM (Kantrex) Injection: 37.5, 250, 333 mg/mL Max dose: 1.5 g/24 h Peak: 15–30 µg/mL Adults: 15 mg/kg/24 h divided q8–12 h IV/IM Trough: no > 5–10 µg/mL Max dose: 1.5 g/24 h Use with caution in patients with renal dysfunct Also has ototoxicity; PO poorly absorbed, and u treat bacterial overgrowth Class: aminoglycoside Keflex (see cephalexin, p 299) Kefzol (see cefazolin sodium, p 295 P Drug Supplied as Dose and route Special considerations Injection: 1, 4, g Infants > mo & children: Has allergic cross-reactivity with penicillin SE: hematuria, nephritis, reversible bone marrow depression, phlebitis at infusion site, eosinophil Mefoxin (see cefoxitin sodium, p 297 Methicillin sodium (Staphcillin) 100–400 mg/kg/24 h divided q4–6 h IV Class: penicillinase-resistant Adults: 4–12 g/24 h divided q4–6 h IV Max dose: 12 g/24 h Metronidazole Tab: 250, 500 mg Anaerobic infection: (Flagyl) Susp: 100 mg/mL or 50 mg/mL Infants, children & adults: Class: anti-infective, antiprotozoal Injection: 500 mg or mg/mL Loading dose: 15 mg/kg ready to use IV Maintenance: 7.5 mg/kg/dose divided q6 h IV Max dose: g/24 h Giardiasis: Children: 15 mg/kg/24 h divided tid PO for 10 d Adults: 500–750 mg/24 h divided tid PO for 10 d Clostridium difficile: 0.75–2 g/24 h divided tidqid PO Instruct to refrain from alcohol use; potentiates anticoagulants SE: N/V, urticaria, dry mouth, leukopenia, vertigo P Drug Supplied as Dose and route Mezlocillin Injection: 1, 2, 3, g Infants & children: 50–75 Contains 1.85 mEq of Na per g SE: Hypersensi mg/kg per dose divided N/V, eosinophilia, leukopenia, neutropenia, ane q4–6 h IV elevated levels of BUN, creatinine & liver enzy (Mezlin) Adults: 1–4 g per dose divided q4–6 IV Class: penicillinase-resistant Special considerations Max dose: 24 g/24 h Ointment: 2% (15 g) Apply small amount to affected area tid May cause local irritation, burning Nafcillin sodium Tab: 500 mg Infants & children: Allergic cross-reactivity with penicillin; poor absorption PO; high incidence of phlebitis with route; contains 2.9 mEq of Na per g (Unipen, Nafcil, Naftopen) Caps: 250 mg PO: 50–100 mg/kg/24 h divided q6 h Class: penicillin Oral solution: 250 mg/5 mL IV: 100–200 mg/kg 24 h divided q6 h Mupirocin (Bactroban) Class: topical antibacterial Adults: PO: 250–1000 mg q4–6 h IV: 500–2000 mg q4–6 h Max: 12 g/24 h Neomycin sulfate Tab: 500 mg Infants & children: 50–100 mg/kg/24 h divided q4–6 h PO Potent aminoglycoside; IV administration shoul avoided (Mycifradin) Susp: 125 mg/5 mL Adults: 500–2000 mg divided q6–8 h PO Follow for renal toxicity and ototoxicity Do no ulcerative colitis or bowel obstruction Class: aminoglycoside Injection: 500 mg Bowel prep: 90 mg/kg/24 Oral absorption is limited but may accumulate h P Drug Supplied as Dose and route Special considerations Nitrofurantoin Tab: 50, 100 mg Children: 5–7 mg/kg/24 h Contraindicated in patients with G6PD deficien divided q6 h PO children < mo, renal disease SE: N/V, anorex H/A, dizziness, interstitial pneumonitis/fibrosis, hepatotoxicity, rash, exfoliative dermatitis, hem anemia (Furadantin, Macrodantin) Caps: 25, 50, 100 mg Prophylaxis: 1–2 mg/kg qhs Class: nitrofurans Susp: 25 mg/5 mL Adults: 50–100 mg per dose divided q6 h PO Prophylaxis: 50–100 mg qhs Max dose: 400 mg/day Omnipen (see ampicillin, p 293) Oxacillin sodium Caps: 250, 500 mg Children: 50–100 mg/kg/24 h divided q6 h PO (Bactocil, Prostaphin) Oral solution: 250 mg/5 mL Adults: 500–1000 mg/dose Class: penicillinase-resistant Injections: 0.25, 0.5, 1, g Penicillin G preparations/potassium & sodium Potassium: Children: SE: anaphylaxis, hemolytic anemia, interstitial 100,000–300,000 nephritis, confusion, myoclonus, positive Coom U/kg/24 h divided q4–6 h result mg = appropriately 1600 U IM/IV 40,000–80,000 U/kg/24 h divided q6 h PO Class: penicillin Tab: 250,000, 400,000, 500,000, 800,000 Adults: 100,000–250,000 Contains 1.7 mEq of Na K per million U U/kg/24 h divided q4–6 h IV/IM 300,000–1.2 million U/24 h G-related Solution: 200,000, 400,000, U/5 mL (100, 200 mL) Injection: 0.2, 0.5, 1, 5, 10, 20 million U SE: hypersensitivity reaction, N/V, leukopenia, elevated serum glutamic-oxaloacetic transamina (SGOT) level P Drug Supplied as Dose and route Sodium: Special considerations divided q6 h Injection: million U Penicillin V potassium (Pen•Vee K, V-Cillin K) Tab: 250, 500 mg Children: 25–50 mg/kg/d SE: hypersensitivity reaction, N/V, diarrhea, fev divided q6–8 h rash, anaphylaxis, acute interstitial nephritis, convulsions, positive Coombs' test results, hem anemia Class: penicillin G-related Susp: 50 mg/mL (100 mL) Max dose: g/24 h Adults: 1–2 g/24 h divided q6–8 h Pneumococcal prophylaxis: < y: 125 mg PO bid >5 y: 250 mg PO bid Pentamidine Isethionate Injection: 300 mg (Pentam) IV (or IM): (Pentam 300, Nebupent) Inhalation: 300 mg (Nebupent) Trypanosoma gambiense: mg/kg/24 h qd for 10 d Class: antiprotozoal P carinii: mg/kg/24 h qd for 10 d PCP prophylaxis: mg/kg per dose IV q2 wk OR > y 300 mg in mL H2O via Respirgard jet nebulizer q2–4 wk Pen•Vee K (see penicillin V potassium, this page) Infuse IV slowly over h to reduce risk of hypotension Inhaled difficult to administer to v young children SE: hypoglycemia, transient hypotension, tachycardia, N/V, mild liver toxici megaloblastic anemia, granulocytopenia, hypocalcemia, renal toxicity, pancreatitis, fever P Drug Supplied as Dose and route Special considerations Piperacillin sodium Injection: 2, 3, g Children > 12 y: 200–300 Similar to penicillin; should not be used in patie mg/kg/24 h divided q4–6 with known hypersensitivity SE: fever, rash, h IV eosinophilia, exfoliative dermatitis, serum sickn reaction, positive direct Coombs' test results, he anemia, thrombocytopenia, prolonged bleeding diarrhea, interstitial nephritis, hypokalemia, elev LFT levels, seizures, thrombophlebitis (Pipracil) Class: extended-spectrum penicillin Adults: 3–4 g per dose q4–6 h IV Max dose: 24 g/24 h Polycillin (see ampicillin, p 293) Primaxin (see imipenem-cilastatin p 304) Pyrimethamine Tab: 25 mg Children: (Daraprim) Initial dose: mg/kg/d qd for d Class: antiprotozoal antitoxoplasmosis Maintenance: consult Infectious Disease Service Adults: 25 mg qd with sulfadiazine for 3–4 wk (depending on response) SE: Megaloblastic anemia, hypersensitivity, leukopenia, thrombocytopenia, folic acid defici atrophic glossitis, rash, ataxia, tremors, seizures fatigue, shock P Drug Supplied as Dose and route Special considerations Rifampin (Rifadin) Caps: 150, 300 mg Anti-TB: Cause red discoloration of body fluids SE: N/V diarrhea, rash, pruritus, stomatitis, eosinophilia, drowsiness, fatige, ataxia, confusion, fever, hep blood dyscrasias, flulike syndrome Class: antitubercular Liquid: 10 mg/mL (1%) 10–20 mg/kg per dose up to max dose of 600 mg per dose PO qd or times per wk Susp: 15 mg/mL H influenzae & legionella: 0–1 mo: 10 mg/kg/24 PO qd for d > mo: 20 mg/kg/24 h PO qd for d Meningococcal prophylaxis: Children: 20 mg/kg/d q12 h for d Adults: 600 mg q12 h for 2d Rocephin (see ceftriaxone sodium p 298) Septra (see co-trimoxazole p.301) Silver sulfadiazine (Silvadene) Class: Topical antibacterial/antifungal Topical cream: 10 mg/g (20 g 40 g) Apply 1–2 times per d with sterile gloves Use with caution in BMT patient with large bod surface area (BSA) involvement because of granulocytopenia; may accumulate in patients w impaired renal or hepatic function SE: pain, ras itching, hemolytic anemia, intertitial nephritis, a reaction P Drug Supplied as Dose and route Special considerations Sulfacetamide sodium Ointment: 10% (3.5 g) Ointment: Apply to lower Inactivated by purulent exudates SE: local irrita conjunctival sac 1–4 stinging, burning, local irritation, Stevens-John times per d syndrome (Bleph-10, Sodium Sulamyd) Solution: 10% (5 mL, 10 mL) Solution: Instill 1–2 gtt q2–3 h Class: topical opthalmicantibacterial Sulfadiazine Tab: 500 mg Toxoplasmosis: (Microsulfon) Children: 25 mg/kg q6 h for 3–4 wk with pyrimethamine Class: sulfonamide; antioxoplasmosis Contraindicated in patients with known sulfa al Adults: g q6 h for 3–4 wk with pyrimenthamine Sulfisoxazole Susp: 100 mg/mL (480 mL) Children: > mo Contraindicated in patients with known sulfa al 120–150 mg/kg/d divided SE: thrombocytopenia, leukopenia, hemolytic a q6 h hypersensitivity reaction, jaundice, kernicterus, nephrotoxicity (Gantrisin) Tab: 500 mg Max dose: g/d Class: sulfonamide-related Suprax (see cefixime, p 296) Tazidime (see ceftazidime, p 297) Adults: 4–8 g/24 h divided q6 h P Drug Supplied as Dose and route Special considerations Tetracycline hydrochloride Caps: 100, 250, 500, mg Children: > y 25–50 mg/kg/d divided qid PO SE: N/V, diarrhea, stomatitis, glossitis, candida superinfection, pseudomembranous colitis, rash hypersensitivity reactions, photosensitivity, live toxicity, Fanconi's-like syndrome, thrombophle injury to growing bones and teeth, pseudotumor cerebri, renal damage Injection: 250, 500 mg (IV) (Sumycin, Tetracyn) Max dose: g/d IV: 20–30 mg/kg/24 h divided q8–12 h Class: tetracyline; antiprotozoal Adults: 250–500 mg divided qid PO IV: 250–500 mg per dose divided q6–12 h Ticarcillin disodium Injection: 1, 3, 6, 20, 30 g Children: 200–300 Contraindicated in patients with known penicill mg/kg/24 h divided q4–6 allergy; contains 5.2–6.5 mEg of Na+ SE: may h IV inhibition of platelet aggregation, bleeding, diat hypernatremia, hypocalcemia, allergy, rash, inc SGOT level (Ticar) Max dose: 24–30 g/d Class: penicillin derivative Adults: 200–300 mg/kg/24 h divided q4–6 h IV Max dose: 24–30 g/d (Timentin) Class: penicillin derivative Injection: 3.1 g Dosing same as ticarcillin Similar to ticarcillin except ß-lactamase inhibito broadens spectrum to include S aureus and H influenzae (3.0 g ticarcillin and g clavulanate) Ticarcillin and clavulanate Max dose: 18 g/24 h P Drug Supplied as Dose and route Tobramycin sulfate Injection: 10, 40 mg/mL Children: 6–7.5 mg/kg/24 Therapeutic levels: h divided q8 h IV (Nebcin) Opthalmic ointment: 0.3% (3.5 g) Peak: 6–10 mg/mL Adults: 3–5 mg/kg/24 h divided q8 h IV Class: aminoglycoside Special considerations Opthalmic solution: 0.3% (5 mL) Trough: < mg/mL SE: ototoxicity, nephrotoxicity, myelotoxicity, a ototoxic effects synergistics with furosemide (L higher doses may be needed in the neutropenic Opthalmic: Apply thin ribbon of ointment to affected eye bid-tid; or 1–2 gtt q4 h Trimethoprim and sulfamethoxazole (see co-trimoxazole, p 301) Vancomycin Injection: 500, 100 mg (Vancocin) Caps: 125, 250 mg Solution: 1, 10 g (reconstitute to 500 mg/6 mL) Class: anti-infective, other Children: 10 mg/kg/24 h divided q8–12 h Therapeutic levels: Peak: 25–40 m/mL Adults: g/24 h divided 12 h Trough: < 10 mg/mL Gut decontamination: 125 SE: ototoxicity, nephrotoxicity, allergy; ''red ma mg caps, 1–4 times per d syndrome" may occur with rapid infusion (incre PO infusion time to 2–3 h) Diphenhydramine is use premed to treat red man syndrome C difficile colitis: Children: 40–50 mg/kg/24 h divided q6 h PO Max dose: g/24 h Adults: 0.5–2 g/24 h divided q6 h PO P B Antidiarrheal agents Drug Supplied as Diphenoxylate hydrochloride Solution: diphenoxylate with atropine sulfate hydrochloride 2.5 mg and atropine sulfate 0.025 mg per mL (60 mL) (Lomotil) Dose and route Special considerations Children: 0.3–0.4 mg/kg/24 h in 2–4 divided doses Use with caution in patients with intestinal infec difficile < y: Not recommended SE: N/V, abdominal discomfort, paralytic ileus, pancreatitis, sedation, dizziness, pruritus, urticar tachycardia, blurred vision, dry mouth, euphoria respiratory depression, hyperthermia, urinary ret 2–5 y: 2.5 mg times per d Tab: diphenoxylate hydrochloride 5–8 y: 2.5 mg times per d 2.5 mg and atropine sulfate 0.025 mg 8–12 y: 2.5 mg times per d Adults: 15–20 mg/d in 3–4 divided doses Ioperamide hydrochloride (Imodium) Caps: mg 2–5 y: mg times per d Use with caution in patients with intestinal infec difficile 6–8 y: mg times per d 8–12 y: mg times per SE: N/V, abdominal discomfort, constipation, tir d drowsiness, dizziness, dry mouth Class: antidiarrheal Max dose: should exceed recommended daily dose Adults: Initials dose of mg then mg after each unformed stool Max dose: 16 mg/24 h P Drug Supplied as Dose and route Octreotide acetate Injection: 50, 100, 500, 1000 mg/mL 200–300 mg 3–4 times per SE: N/V, diarrhea, abdominal pain, H/A, dizzin d fatigue, flushing, edema, hypoglycemia (Sandostatin) Special considerations (IV/SQ) OR 450–1000 mg/24 h by continuous IV Class: antidiarrheal No data available in children C Antiemetic agents Drug Supplied as Dose and route Special considerations Chlorpromazine hydrochloride Tab: 10, 25, 50, 100, 200 mg Children: (> mo) SE: drowsiness, lowered seizure threshold, extrapyramidal symptons, jaundice, hypotension arrhythmias, agranulocytosis May potentiate effe narcotics Monitor vital signs closely Syrup: 10 mg/5 mL (120 mL) As antiemetic: Suppository: 25, 100 mg 0.5–1 mg/kg per dose divided q4–6 h PO (Thorazine) Oral concentration: 30 mg/mL (120 mL), 100 mg/mL (60 and 240 mL) Class: phenothiazine, antiemetic 0.5–1 mg/kg per dose q6–8 IV Max dose: < y: 40 mg/d Injection: 25 mg/mL 5–12 y: 75 mg/d Adults: As antiemetic: 10–25 mg per dose divided q4–6 h PO 25–50 mg per dose divided q4–6 h IV ... 1990 ;76 :235–244 Aucouturier P, Barra A, Intrator L, et al Long lasting IgG subclass and antibacterial polysaccharide antibody deficiency after allogeneic bone marrow transplantation Blood 19 87; 70 :77 9? ?78 5 Barnes... Immunological reconstruction after allogeneic marrow, autologous marrow or autologous peripheral blood stem cell transplantation In: Atkinson K, ed Clinical Bone Marrow Transplantation Cambridge, England:... children after bone marrow transplant for hematological malignancies Bone Marrow Transplant 1991;8(suppl 1)2–4 Savdie E Renal complications In: Atkinson K, ed Clinical Bone Marrow Transplantation Cambridge,