This handout is for reye syndrome. Your care team identified this based on: intractable vomiting + altered ms in child / adolescent 3-7 days after viral illness (especially influenza b / varicella) (belay nejm 1999 pmid 10228187).
Other reasons your team may use this plan: progressive encephalopathy + behavior change + lethargy in child post-viral (belay nejm 1999); aspirin or salicylate-containing medication (pepto-bismol, oil of wintergreen) given during viral illness in child < 19 yr (belay nejm 1999); elevated ast/alt > 3× uln + ammonia > 1.5× uln + minimal jaundice in child — reye-syndrome differential (cdc surveillance criteria).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| PICU admission + early transfer to pediatric liver transplant center | Mandatory PICU + early transfer to facility with pediatric liver transplant capability; involve pediatric hepatology, metabolism, genetics, neurology, neurosurgery, transplant teams | — | — | Belay NEJM 1999 PMID 10228187 — 31% case-fatality even with treatment; early transplant-center transfer is mandatory |
| IEM workup in parallel with treatment | Plasma amino acids + acylcarnitine profile + urine organic acids + acylglycines + carnitine + VLCFA + biotinidase; consult metabolism / genetics | — | — | Belay NEJM 1999 — since 1980 aspirin warning, IEM mimics far more likely than true Reye; do not delay workup |
| mannitol | 0.25-1 g/kg IV q4-6h PRN for ICP crisis | IV | PRN q4-6h | ICS pediatric severe TBI consensus — hyperosmolar therapy for cerebral edema in PALF / Reye / metabolic encephalopathy (AAP Red Book 2024-2027, Lexicomp Peds) |
| hypertonic saline 3% NaCl | 3-5 mL/kg IV bolus over 10-15 min for ICP crisis; may follow with continuous infusion 0.1-1 mL/kg/h titrated to serum Na 145-155 mEq/L | IV | bolus + infusion | ICS pediatric severe TBI consensus — preferred over mannitol when hypovolemic / hypotensive (Lexicomp Peds; AAP Red Book 2024-2027) — listed as non_pharm because 3% NaCl is a compounded concentration not a single RxCUI |
| glucose | D10W or D25W 5 mL/kg IV bolus for hypoglycemia, then D10W continuous infusion GIR 6-8 mg/kg/min titrated to glucose 100-200 mg/dL | IV | bolus then continuous | Reverses hypoglycemia + suppresses lipolysis in suspected FAO defects (e.g., MCAD) — D10W at GIR 6-8 mg/kg/min is the standard metabolic-crisis backbone (AAP Red Book 2024-2027, Lexicomp Peds) |
| phytonadione (vitamin K1) | 0.3 mg/kg IV/IM/SC slow IV (max 10 mg single dose); for vitamin-K-dependent coagulopathy from hepatic synthetic dysfunction | IV/IM/SC | single dose; may repeat per INR | Reverses vitamin-K-dependent coagulopathy from hepatic synthetic dysfunction; slow IV due to anaphylactoid risk (AAP Red Book 2024-2027, Lexicomp Peds) |
| fresh frozen plasma + cryoprecipitate | FFP 10-15 mL/kg IV for INR > 1.5 with bleeding OR pre-procedure; cryoprecipitate 1 unit / 5-10 kg for fibrinogen < 100 | IV | per coagulopathy + bleeding | AAP transfusion guidance — blood-product reversal for active bleeding with hepatic synthetic dysfunction |
| lactulose | 1 mL/kg PO/PR q2-4h titrated to 2-3 soft stools/day | PO/PR | q2-4h titrated | Reduces serum ammonia via gut acidification + ammonia trapping; first-line for hepatic encephalopathy (AAP Red Book 2024-2027, Lexicomp Peds) |
| lorazepam | 0.1 mg/kg IV (max 4 mg per dose) | IV | q5 min x 2 | AES 2016 Glauser PMID 26900382 — first-line acute seizure abortive; routes to peds.status_epilepticus.v1 if recurrent |
| levetiracetam | 20-40 mg/kg IV load over 15 min, then 30-60 mg/kg/day divided BID | IV/PO | BID after load | AES 2016 Glauser PMID 26900382 — levetiracetam preferred (no hepatic toxicity); AVOID valproate (worsens mitochondrial dysfunction + hepatotoxicity); AVOID phenytoin (hepatic enzyme inducer) (AAP Red Book 2024-2027, Lexicomp Peds) |
Plan: Reye syndrome — supportive ICU bundle (NO specific antidote) (Belay NEJM 1999 PMID 10228187)
Call 911 or go to the nearest emergency room right away if you have:
Pediatric hepatology + neurology (cognitive impairment in significant fraction of survivors per Belay 1999) + genetics + metabolism (lifetime IEM monitoring even if initial workup negative) + family education (NEVER give aspirin to children < 19 yr unless specifically prescribed) + school re-entry plan (Belay NEJM 1999; CDC)
Guideline: Belay NEJM 1999 PMID 10228187 (CDC surveillance Reye syndrome 1981-1997) + CDC clinical case definition + AES 2016 Glauser PMID 26900382 (status epilepticus cross-reference) + ICS pediatric severe TBI consensus + PALS 2020