Word: Pediatric Intensive Care Unit: Continuous Infusion...

Word: Pediatric Intensive Care Unit: Continuous Infusion Guidelines for Infants and Children

PEDIATRIC INTENSIVE CARE UNIT: CONTINUOUS INFUSION GUIDELINES FOR INFANTS AND CHILDREN

DOCUMENT TYPE: GUIDELINES

Site Applicability

This chart has been developed for use in The Pediatric Intensive Care Area of BC Children’s Hospital. The information contained here is intended as a guideline for use of standard concentrations of “high alert” medications administered by continuous infusion. For more detailed information on these drugs, the user should consult other comprehensive reference sources.

Definitions:

Patient Group: These guidelines normally apply to full term neonates, infants and children. This information is not intended to apply to premature newborns. Please refer to the Neonatal Drug Manual from Newborn Services for information about this specific age group

Drug: Listed by generic name. Trademark and alternate names are included in parenthesis. Other pharmaceutical information such as solution pH, osmolality (in mOsm/mL), specific gravity (SG) and additive content has been included to assist in decision making about the administration of these drugs.

Concentration: Represented as a weight/volume relationship, namely milligrams per milliliter or micrograms per milliliter. The concentrations suggested reflect those that are approved at this facility for administration to critically ill children. These standard concentrations will be supplied by Pharmacy. In some situations, nurses may mix the drugs at the bedside. Generally the listed concentrations are appropriate for all age groups; however, when applicable, specific recommendations are presented for different age groups. The concentration selected will be determined by the tolerance for fluid volume delivered with medications. Fluid restricted patients may require more concentrated solutions. In cases where the patient is not fluid restricted more dilute solutions should be chosen. Solution properties such as osmolality and pH may be considered when selecting concentrations suitable for peripheral line or central line administration. As a general rule, osmolality values greater than 600 mOsm/mL indicate that the medication be given by central venous catheter. Minimum and maximum recommended concentrations for infusion are included where applicable.

Infusion Rate and Dose Delivered: This relationship will be determined with the use of infusion drug charts or “smart pumps” which have been programmed to infuse at the proper rate when dose and weight are entered into the database.

Dose Range: The usual dose range for continuous infusions recommended by the literature under standard conditions. Loading doses, bolus doses, and maximum recommended doses are included where applicable.

Y-Site Compatibility: Medications should not be admixed in one container. To avoid directly admixing of two drugs medications are administered via Y-site connectors. This compatibility information contained in the chart applies to Y-site administration only. Legend: C; compatible at Y-site, I: incompatible at Y-site. Where co-infusion of TPN by Y-site is acceptable, it is noted in the comments section.

Comments:Other useful information pertaining to the use of each drug is presented, such as:

· central or peripheral line recommendations. (Most standard concentrations can be administered via peripheral line)

· adverse effects, including infusion reactions

· protect infusion container (syringe or bag) and/or tubing from light, only where noted

· solution expiry noted, change tubing at specified time

It is the responsibility of the nurse to verify that the dilution used will deliver the correct dose at a calculated infusion rate.

Two nurses must verify the infusion rate is correct.

Drug

Concentrations

Infusion Rate

Dose Range

Y-Site Compatibility

Comments

Alprostadil

[Prostaglandin E1, Prostin VP]

500 mcg/mL

pH = 4.8 – 5

Osmolality = 23,250

Revised February 2020

Standard Concentrations

Patients < 6 kg:

5 mcg/mL

Add 0.25 mL of

500 mcg/mL to

24.75 mL D5W to make 25 mL of

5 mcg/mL

Patients > 6 kg, Peripheral line:

10 mcg/mL

Add 0.5 mL of

500 mcg/mL to


10 mcg/mL

Patients > 6 kg,

Central line:

20 mcg/mL

Add 1 mL of

500 mcg/mL to

24 mL D5W to make 25 mL of

20 mcg/mL

Use Alaris Pump to determine infusion rate.

AND

Confirm with the following calculation:

Infusion rate (mL/h) = Dose (mcg/kg/min)

x Weight (kg)

x 60 (min/h)

divided by

Concentration (mcg/mL)

To maintain patency of ductus arteriosus

0.005 – 0.1 mcg/kg/min

C: dextrose and saline solutions, aminophylline, atropine, caffeine, calcium chloride, calcium gluconate, dexamethasone, dobutamine, dopamine, epinephrine, furosemide, heparin, hydrocortisone, isoproterenol, lidocaine, midazolam, morphine, nitroglycerin, nitroprusside, pancuronium, potassium chloride,

I: sodium bicarbonate

Compatible with TPN

· Central line administration only for concentrations >10 mcg/mL.

· If being administered via peripheral line or low-lying UVC, patient should have two lines in place during the infusion (one for alprostadil and an additional line)

• Adverse effects include apnea and bradycardia

• For fever or hypotension, reduce infusion rate

• For cutaneous flushing, reposition catheter

• Extravasation of concentrated solution may cause tissue sloughing and necrosis.

· Keep ampoules in refrigerator.

· Change solution at 24 hours.

· Ref: 1, 2, 3, 4

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Alteplase (rTPA)

[Activase]

50 mg vial containing lyophilized powder (plus 50 mL of diluent, SWI)

pH = 7.3,

Osmolality = 215

Revised Feb 2020

Standard Concentration

1 mg/mL

Add 50 mL enclosed diluent to 50 mg vial to make 1 mg/mL solution.


AND


Infusion rate (mL/h) = Dose (mg/kg/h)

x Weight (kg)

divided by

Concentration (mg/mL)

Systemic Thrombolysis

0.1 – 0.6 mg/kg/h

Start at 0.1 mg/kg/h; may increase dose by 0.1 mg/kg/h every 6 hours

Dose is titrated to target fibrinogen levels: >1 g/L

(>1.5 g/L in neonates)

C: D5W, NS, morphine, lidocaine, propranolol

I: dobutamine, dopamine, heparin, nitroglycerin, bacteriostatic water, bacteriostatic saline

· Reconstitute with enclosed diluent (SWI) only. Roll gently, do not shake. Let stand for several minutes prior to administration.

· Monitor for signs of bleeding.

· Extravasation can cause ecchymosis and inflammation

· Dilutions <0.5 mg/mL may result in precipitation.

· Do not directly admix with other medications or solutions.

· Change solution every 8 hours.

· Ref: 2

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Aminophylline

Revised Feb 2020


1 mg/mL:

Add 2 mL of

25 mg/mL to

48 mL of D5W to make 50 mL of 1 mg/mL

5 mg/mL:

Add 10 mL of

25 mg/mL to


10 mg/mL:

Add 20 mL of

25 mg/mL to



AND


Infusion rate (mL/h) = Dose (mg/kg/h) x Weight (kg)

divided by Concentration (mg/mL)

Bronchodilator

Loading Dose:

6 mg/kg IV over 20 minutes

Continuous infusion:

6 wk-6 mos: 0.5 mg/kg/h IV

6-12 mos: 0.7 mg/kg/h IV

1-9 years: 1-1.2 mg/kg/h IV

9-16 yrs: 0.7-0.8 mg/kg/h IV

C: D5W, D10W, D5NS, NS, D51/2NS, D5LR, calcium chloride, calcium gluconate, dopamine, esmolol, fentanyl, furosemide, heparin, regular insulin, labetalol, lidocaine, lorazepam, milrinone, morphine, nitroglycerin, phenobarbital, potassium chloride, procainamide, sodium bicarbonate

I: TPN, amiodarone, dobutamine, epinephrine, hydralazine, isoproterenol, magnesium sulfate (250mg/mL), midazolam, norepinephrine, ondansetron, phenytoin

· May cause hypotension and/or bradycardia with rapid infusions or loading doses.


Therapeutic Drug Monitoring:

· Aminophylline contains 80% theophylline

· Therapeutic theophylline range is 55 to 111 micromoles/L

· Draw serum theophylline levels - 30 mins after loading dose, and at 24-hour intervals for the duration of an infusion

· For loading doses, each 1.25mg/kg of aminophylline raises the serum theophylline approximately 11 micromoles/L

· Refer to BCCH Pediatric Drug Dosage Guidelines for guidelines to adjust dosage based on serum concentration

· Ref: 2, 3, 4, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Amiodarone

[Cordarone]

150 mg/3 mL

pH = 4.08

Contains polysorbate 80, benzyl alcohol

Revised Feb 2020


Peripheral line:

2000 mcg/mL

(2 mg/mL)

Add 2 mL of

50 mg/mL to


2000 mcg/mL

(2000 mcg/mL = 2 mg/mL)

Central line:

6000 mcg/mL

(6 mg/mL)

Add 6 mL of

50 mg/mL to

44 mL of D5W to make 50 mL of 6000 mcg/mL (6000 mcg/mL = 6 mg/mL)


AND


Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)

x 60 (min/h)

divided by Concentration (mcg/mL)

Arrhythmia

2 mg/kg IV loading dose over 20 minutes, followed by

5 mcg/kg/min

If inadequate response:

1 mg/kg IV over 10 minutes, followed by 5-10 mcg/kg/min

Usual continuous infusion dosage:

5-15 mcg/kg/min

OR

25 mcg/kg/min IV for 4 hours, followed by

5 – 15 mcg/kg/min

PALS algorithms:

5 mg/kg IV loading dose over 20-60 minutes

C: D5W, NS, calcium chloride, calcium gluconate, dobutamine, dopamine, esmolol, fentanyl, insulin, isoproterenol, potassium chloride, labetalol, lidocaine, lorazepam, midazolam, milrinone, morphine, nitroglycerin, norepinephrine

I: aminophylline, heparin, furosemide, procainamide, sodium bicarbonate, magnesium sulfate (500 mg/mL)

· Central line administration preferred.

· Peripheral line administration may be used for concentrations <2000 mcg/mL (2 mg/mL).

· Use Medex non-DEHP tubing # MX448HL60 with 30 mL tubing to infuse the solution.

· Use of 0.22 micron inline filter is recommended.

· May cause hypotension and/or bradycardia with rapid infusions or loading doses.


· Ref: 2, 3, 4, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Calcium Chloride

[CaCl2]

10% (100 mg/mL)

Each mL contains:

100 mg CaCl2

27.2 mg Ca+2

0.68 mmol Ca+2

pH = 5.5 – 7.5

Osmolality = 1760

Revised Dec 2013

Reviewed Jan 2020


Central line:

100 mg/mL

(undiluted)

(0.68 mmol Ca+2/mL)


AND


Infusion rate (mL/h) = [Dose (mmol/kg/d)

x Weight (kg)]

divided by

[Concentration (mmol/mL)

x 24 (h/d)]

Hypocalcemia

0.5 – 1.5 mmol Ca+2/kg/day

(74 – 221 mg/kg/day of calcium chloride)

C: dextrose and saline solutions, dopamine, esmolol, fentanyl, furosemide, heparin, insulin, isoproterenol, midazolam, milrinone, morphine, nitroprusside, norepinephrine,

I: amphotericin, bicarbonate, ceftriaxone, dobutamine, lipids magnesium, phosphate, propofol

Incompatible with TPN solutions containing phosphates

· Extravasation may cause severe tissue burns and necrosis.

· Central line administration only.

· If peripheral line infusion use calcium gluconate

· Do not infuse via small veins (i.e., scalp).

· Monitor ionized calcium daily (target 1.1 – 1.3 mmol/L).


· Ref: 3, 5

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Calcium Gluconate

10% (100 mg/mL)

Each mL contains:

100 mg calcium

gluconate

9.3 mg Ca+2

0.232 mmol Ca+2

pH = 6 – 8.2

Osmolality = 276

Revised Nov 2013

Reviewed Jan 2020


Peripheral line:

20 mg/mL

(0.046 mmol Ca+2/mL)

Add 10 mL of 10% solution to 40 mL D5W to make

50 mL of

20 mg/mL

Central line:

100 mg/mL

(undiluted)

(0.232 mmol Ca+2/mL)


AND


Infusion rate (mL/h) = [Dose (mg/kg/d)

x Weight (kg)]

divided by

[Concentration (mg/mL)

x 24 (h/d)]

Hypocalcemia, Hyperkalemia, or Calcium Channel Blocker Toxicity

Neonates

200 – 400 mg/kg/day

(0.46 – 0.93 mmol Ca+2/kg/day)

Infants & Children

200 – 500 mg/kg/day

(0.46 – 1.2 mmol Ca+2/kg/day)

Maximum Dose

240 mg/kg/h

C: aminophylline, dobutamine, dopamine, epinephrine, fentanyl, furosemide, heparin, insulin, isoproterenol, labetalol, lidocaine, magnesium, midazolam, milrinone, morphine, nitroprusside, norepinephrine, potassium chloride, propofol

I: amphotericin, bicarbonate, phosphates

Incompatible with TPN solutions containing phosphates

· Extravasation may cause severe tissue burns and necrosis.

· Central line administration is preferred.

· Peripheral line infusions must be approved by the Attending Physician and use standard concentration of 20 mg/mL

· Central line administration only for concentrations >20 mg/mL.

· Do not infuse via small veins (i.e., scalp).


· Ref: 3, 6, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Cisatracurium

20 mg/10mL

(2mg/mL)

Revised Feb 2020

Standard Concentration:

100 mcg/mL

Add 2.5 mL of 2 mg/mL to 47.5 mL D5W or NS to make 50 mL of 0.1 mg/mL = 100 mcg/mL)

400 mcg/mL

Add 10 mL of 2mg/mL to 40 mL D5W or NS to make 50 mL of 0.4 mg/mL = 400 mcg/mL)

Calculate the infusion rate with the following calculation:


x Weight (kg)

x 60 (min/h)

divided by


Continuous infusion:

1 – 4 mcg/kg/min

(0.06 – 0.24 mg/kg/hr)

Intermittent:

Initial 0.1 mg/kg followed by maintenance of 0.03 mg/kg PRN to maintain blockade

C: D5W, NS, D5NS, D5LR, bumetanide, dopamine, epinephrine, fentanyl, gentamicin, midazolam, morphine, norepinephrine, vancomycin

Variable compatibility (depends on concentrations):

cefazolin, cefotaxime

· Change solution at: 96 hours

· Ref: 1, 3

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Dexmedetomidine

(Precedex)

100 mcg/mL (2mL vial)

pH = 4.5 – 7

Revised Dec 2013

Reviewed Feb 2020


4 mcg/mL:

Add 2mL of 100 mcg/mL solution to 48 mL NS to make 50 mL of 4 mcg/mL


AND


Infusion rate (mL/h) = [Dose (mcg/kg/hour)

x Weight (kg)]

divided by

4 (mcg/mL)

Sedation for Mechanical Ventilation

Loading dose: 0.2 – 0.6 mcg/kg over 10 – 20 minutes

Infusion: Initially 0.2 micrograms/kg/hour

Titrate to range of 0.2-0.7 mcg/kg/hour

Usual max 1 mcg/kg/hour (may go up to 1.4 mcg/kg/hour)

Burn Patients.

Loading dose: 0.2 – 0.6 mcg/kg over 10 – 20 minutes

Infusion: Initially 0.2 mcg/kg/hour

Titrate to range of 0.1–2 mcg/kg/hour

**Note: higher dosage range in burn patients

C: NS, D5W, Ringer’s and Lactated Ringer’s, aminophylline, amiodarone, ampicillin, azithromycin, cefazolin, cefotaxime, digoxin, dopamine, epinephrine, esmolol, fluconazole, furosemide, gentamicin, heparin, hydromorphone, ketorolac, labetalol, lorazepam, magnesium sulphate, methylprednisolone, milrinone, norepinephrine, piperacillin-tazobactam, potassium chloride, ranitidine, sodium bicarbonate, sodium nitroprusside, vancomycin

I: amphotericin B, diazepam

· Use caution when administering loading dose as rapid rate of infusion is associated with increased adverse cardiovascular effects (including hypotension, bradycardia and

cardiac arrest)

· Hypotension and bradycardia may be treated by stopping or decreasing the infusion, administration of atropine or glycopyrrolate, increasing the rate of IV fluid administration, use of vasopressor agents and elevation of lower extremities.


· Ref: 1, 2, 3

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Dobutamine

[Dobutrex]

250 mg/20 mL vial (12.5 mg/mL)

pH = 2.5 – 5

Osmolality = 276

Contains EDTA & metabisulfite

Revised

Feb 2020


patients < 6 kg:

2000 mcg/mL

(2 mg/mL)

Add 4 mL of

12.5 mg/mL to

21 mL D5W to make 25 mL of 2000 mcg/mL

patients > 6 kg:

5000 mcg/mL

(5 mg/mL)

Add 20 mL of

12.5 mg/mL to



AND



x Weight (kg)

x 60 (min/h)

divided by


Hypotension

2 – 20 mcg/kg/min

Maximum Dose

40 mcg/kg/min (toxicity may occur)

C: D5W, D10W, NS, D5LR, D5NS, alprostadil, amiodarone, calcium, dopamine, epinephrine, fentanyl, hydromorphone, insulin, isoproterenol, labetalol, lidocaine, magnesium sulfate, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, propofol

I: aminophylline, alteplase, furosemide, heparin, midazolam, potassium phosphate, sodium bicarbonate, alkaline solutions, diluents containing bisulfite, ethanol

Compatible with TPN


· Peripheral line administration may be used for rates < 5 mcg/kg/min.

· Extravasation may cause sloughing or necrosis.

· Tachycardia, arrhythmias, hypertension at higher doses.

· Protect from light.

· Pink discoloration of solution may occur – do not need to discard.


· Ref: 1, 3, 6, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Dopamine

[Intropin]

40 mg/mL (5 mL), 1.6 or 3.2 mg/mL (250 mL)

pH = 2.5 – 4.5

Osmolality =

619 (40 mg/mL)

295 (3.2 mg/mL)

Revised Nov 2013

Reviewed Feb 2020


commercially available:

1600 mcg/mL

3200 mcg/mL


AND



x Weight (kg)

x 60 (min/h)

divided by


Hypotension

2 – 20 mcg/kg/min

Dopaminergic (contractility):

< 5 mcg/kg/min

Beta-Adrenergic

(increased HR):

5 – 15 mcg/kg/min

Alpha-Adrenergic

(vasoconstriction):

>15 mcg/kg/min

Maximum Dose

50 mcg/kg/min

C: D5W, D10W, NS, D5LR, Ringer’s Lactate, amiodarone, aminophylline, calcium, dobutamine, epinephrine, fentanyl, heparin, isoproterenol, labetalol, lidocaine, lorazepam, magnesium, mannitol, midazolam, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, propofol, potassium chloride, potassium phosphate

I: alteplase, furosemide, insulin, phenytoin, sodium bicarbonate, thiopental, iron salts, oxidizing agents, alkaline solutions

Compatible with TPN


· Do not infuse via umbilical artery catheter.

· May be prepared as 250 or 500 mL PVC containers when required (if rate > 5mL/hour). Request from pharmacy.

· Extravasation may cause ischemia or tissue necrosis.

· In case of infiltration, notify physician immediately to initiate phentolamine protocol.

· Adverse effects include tachycardia, arrhythmia, hypotension, hypertension, peripheral gangrene.

· Discard solution if yellow-brown discoloration occurs.


· Ref: 1, 2, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Epinephrine

[Adrenalin]

1:1000 (1 mg/mL)

1:10,000

(0.1 mg/mL)

pH = 2.5 – 5

Osmolality =

348 (1:1000)

273 (1:10,000)

Revised Jun 2020


25 mcg/mL

Add 0.63 mL of 1 mg/mL (1:1000) to 24.37 mL D5W or NS to make 25 mL of 25 mcg/mL

50 mcg/mL

Add 2.5 mL of 1 mg/mL (1:1000) to 47.5 mL D5W or NS to make 50 mL of 50 mcg/mL

100 mcg/mL

Add 5 mL of 1 mg/mL (1:1000) to 45 mL D5W or NS to make 50mL of 100 mcg/mL


AND



x Weight (kg)

x 60 (min/h)

divided by


Circulatory Support After Volume Resuscitation

0.01 – 1 mcg/kg/min

Beta-adrenergic (inotropy & vasodilation):

<0.2 mcg/kg/min

Alpha-adrenergic (vasoconstriction):

>0.2 mcg/kg/min

C: D5W, D10W, NS, D5NS, D5LR, dobutamine, dopamine, fentanyl, furosemide, heparin, hydromorphone, labetalol, lidocaine, lorazepam, midazolam, milrinone, morphine, nitroglycerin, norepinephrine, potassium chloride, propofol

I: aminophylline, calcium, sodium bicarbonate, thiopental

Compatible with TPN


· Extravasation may cause ischemia or tissue necrosis

· In case of infiltration, notify physician immediately to initiate phentolamine protocol.


· Adverse effects include tachycardia, dysrhythmias, myocardial ischemia, hypertension.


· Discard solution if precipitation or pink or brown discoloration occurs.


· Ref: 3, 4, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Epoprostenol

[Prostacyclin, Flolan, PG-12]

500 mcg vial with

5 mL diluent

pH = 10.2

Revised April 2008

Reviewed Feb 2020


10 mcg/mL

Add 2.5 mL of

100 mcg/mL to


10 mcg/mL


AND


Infusion rate (mL/h) = Dose (ng/kg/min)

x Weight (kg)

x 60 (min/h)

divided by


divided by

1000 (ng/mcg)

Pulmonary Hypertension

Note: doses are in nanograms

(1 mcg = 1000 ng)

2 – 60 ng/kg/min

Start at 2 ng/kg/min and increase by

2 ng/kg/min every 15 min until desired response is achieved or adverse effects appear.

Maximum Dose

120 ng/kg/min

C: diluent supplied, sodium chloride (0.45% or 0.9%); limited data to support co-infusion with heparin 1 unit/mL in NaCl 0.45%

I: all medications & other solutions

Incompatible with TPN


· Reconstitution: inject diluent slowly down side of vial to avoid foaming. Do not shake the vial.

· Light-protected solution is stable for 48 hours if refrigerated, or for 8 hours at room temperature.

· Pharmacy will supply 3 syringes per day – store in refrigerator until use.

· Do not abruptly discontinue the infusion. Have an extra syringe available at all times in case of pump or syringe failure.

· Adverse effects include hypotension and tachycardia. Bleeding may occur at higher doses (>20 ng/kg/min) due to platelet inhibition.

· Protect syringe and tubing from light.

· Change solution every 8 hours.

· Ref: 1, 3, 10, 11

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Esmolol

[Brevibloc]

100 mg/10 mL

pH = 4.5 – 5.5

Revised Feb 2020


10 mg/mL

(undiluted)


AND



x Weight (kg)

x 60 (min/h)

divided by


divided by 1000 (mcg/mg)

Hypertension

50 – 300 mcg/kg/min

Maximum Dose

1000 mcg/kg/min

Supraventricular Tachycardia

500 – 600 mcg/kg IV loading dose over

1 – 2 min, followed by 200 mcg/kg/min infusion. Titrate by

50 – 100 mcg/kg/min every 5 – 10 min until a 10% reduction in heart rate and blood pressure occurs.

Postoperative Hypertension

Loading dose as for SVT, followed by 100 – 500 mcg/kg/min infusion. Titrate as for SVT.

C: D5W, NS, D5NS, D5LR, amiodarone, calcium, dopamine, fentanyl, heparin, insulin, lidocaine, midazolam, morphine, nitroglycerin, nitroprusside, potassium chloride, propofol

I: diazepam, furosemide, procainamide, sodium bicarbonate, thiopental, strong acids or bases

Compatible with TPN

· Monitor heart rate, blood pressure, ECG, respiratory rate continuously.

· A 10% decrease in heart rate or MAP signifies beta blockade.

· Effects will last 2 – 16 minutes after infusion stopped.

· Avoid abrupt discontinuation as acute tachycardia, hypertension and/or ischemia may occur

· Change solution at 96 hours

· Ref: 1, 2, 3, 4, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Fentanyl

[Sublimaze]

10 mcg/mL in 250 mL bag

50 mcg/mL in 2, 5 or 20 mL vials

pH = 4.7 – 5

Osmolality = 0

Revised Nov 2013

Reviewed Feb 2020


patient 2 - 6 kg:

10 mcg/mL

(undiluted)

patient 6- 30 kg:

25 mcg/mL

Add 25 mL of

50 mcg/mL to 25 mL NS to make 50 mL of

25 mcg/mL

patient 30-120 kg:

50 mcg/mL

(undiluted)


AND


Infusion rate (mL/h) = Dose (mcg/kg/h)

x Weight (kg)

divided by


Sedation & Analgesia

Infants & Children

1 – 2 mcg/kg slow IV bolus over 3 – 5 min, followed by

1 – 5 mcg/kg/h

Extracorporeal Membrane Oxygenation

5 – 10 mcg/kg slow IV bolus over 10 min, followed by 5 – 20 mcg/kg/h

C: D5W, NS, lactated Ringers, aminophylline, calcium chloride, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, furosemide, heparin, insulin, isoproterenol, hydromorphone, labetalol, lidocaine, lorazepam, magnesium, midazolam, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, propofol, potassium chloride, sodium bicarbonate, vasopressin

I: amphotericin, phenytoin

Compatible with TPN

· Peripheral or central line administration.

· Higher doses may be required in ECMO as the drug is sequestered by the circuit. Morphine is the preferred opiate for continuous analgesia and sedation in ECMO.

· Chest rigidity may occur with large loading doses (>5 mcg/kg) and is reversible with naloxone.

· Monitor for respiratory depression in non-ventilated patients.

· Antidote is naloxone 0.01 – 0.1 mg/kg IV prn


· Ref: 2, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Furosemide

[Lasix]

10 mg/mL

pH = 8.5 – 9.3

Osmolality = 290

Revised Feb 2020


1 mg/mL

Add 5 mL of 10 mg/mL to 45 mL of NS to make 50 mL

of 1 mg/mL

2 mg/mL

Add 10 mL of

10 mg/mL to

40 mL NS to make 50 mL

of 2 mg/mL

10 mg/mL

(undiluted)

central line only


AND



x Weight (kg)

divided by


Diuresis

0.1 – 1 mg/kg/h

Maximum Dose

4 mg/min OR

0.5 mg/kg/min

C: D5W, D10W, NS, Ringer’s Lactate, D5LR, aminophylline, calcium gluconate, epinephrine, fentanyl, heparin, hydromorphone, hydrocortisone, lidocaine, lorazepam, nitroglycerin, norepinephrine, sodium bicarbonate, propofol, potassium chloride

I: acidic solutions, amiodarone, amphotericin, dobutamine, esmolol, isoproterenol, labetalol midazolam, milrinone, morphine, thiopental


· Central line administration for concentrations > 5 mg/mL

· Increased risk of electrolyte abnormalities with continuous infusions.

· Rapid administration may cuase transient or permanent ototoxicity . Concurrent aminoglycosides potentiate this risk.

· Contraindicated in anuria.

· Discard discolored solutions.


· Change solution at 24 hours (light exposed) or 96 hours (light protected).

· Ref: 1, 3, 7, 9

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Heparin

[Heparin Sodium]

25,000 units/500 mL

bag (50 IU/mL)

10,000 units/10 mL

vial (1000 IU/mL)

pH = 5 – 7.5

Osmolality = 280 –

380 (100 IU/mL)

May contain sulfites and benzyl alcohol

Revised Feb 2020


50 units/mL

(draw up from commercially available bag 25,000 units/

500 mL D5W)

Fluid-Restricted:

100 units/mL

(draw up from commercially available bag 50,000 units/

500 mL D5W)


AND


Infusion rate (mL/h) = Dose (units/kg/h)

x Weight (kg)

divided by

Concentration (units/mL)

Consult Heparin Protocol in BCCH Pediatric Drug Dosage Guidelines

Therapeutic Heparinization

75 units/kg IV loading dose (max 5000 units) over 10 minutes, followed by:

<1 year:

28 units/kg/h

>1 year:

20 units/kg/h

Adjust rate based on PTT results

C: D5W, NS, D5LR, alprostadil, aminophylline, calcium chloride, calcium gluconate, dopamine, epinephrine, esmolol, fentanyl, furosemide, hydromorphone, insulin, isoproterenol, labetalol, lidocaine, lorazepam, magnesium midazolam, milrinone, morphine, nitroglycerin, norepinephrine, potassium chloride, propofol, sodium bicarbonate, thiopental

I: alteplase, amiodarone, diazepam, dobutamine

Compatible with TPN


· See Heparin Protocol in BCCH Pediatric Drug Dosage Guidelines, 2018 (Esau, ed)

· Change solution and tubing at 72 hours.

· Ref: 1, 2, 3, 5, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Hydromorphone

[Dilaudid]

2 mg/mL

pH = 4 – 5.5

Revised May 2015

Reviewed Feb 2020


40 mcg/mL

Add 0.5 mL of

2 mg/mL to

24.5 mL D5W or NS to make 25 mL of

40 mcg/mL

80 mcg/mL

Add 2 mL of

2 mg/mL to

48 mL D5W or NS to make 50 mL of 80 mcg/mL

200 mcg/mL

Add 5 mL of

2 mg/mL to



AND



x Weight (kg)

divided by


Postoperative Analgesia & Sedation

1 – 8 mcg/kg/h

Severe pain may require much higher doses.

C: D5W, NS, D5NS, D5LR, dobutamine, dopamine, epinephrine, fentanyl, furosemide, heparin, ketamine, labetolol, lorazepam, magnesium, midazolam, milrinone, morphine, nitroglycerin, norepinephrine, propofol

I: phenobarbital, phenytoin, sodium bicarbonate, thiopental


· CAUTION: Hydromorphone is 5X more potent than morphine.

· Semi-synthetic opiate analgesic indicated in patients with an allergy or intolerance to morphine.

· Prolonged use of a high-dose infusion may result in tolerance.

· Abrupt discontinuation after prolonged use (>2 weeks) may result in withdrawal.


· Antidote is naloxone 0.01 mg/kg IV

· Not recommended in neonates.


· Ref: 3, 6, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Insulin, Regular

[Humulin]

1000 units/10 mL

vial (100 U/mL)

pH = 7 – 7.8

Revised January 2020


For DKA patients:

0.1 unit/mL

Add 0.5 mL of

100 U/mL to

500 mL NS to make 500 mL of

0.1 unit/mL

For fluid restricted patients:

0.5 units/mL

Add 0.25 mL of 100 U/mL to

49.75 mL NS to make 50 mL of 0.5 units/mL


AND


Infusion rate (mL/h) = Dose (units/kg/h)

x Weight (kg)

divided by

Concentration (units/mL)

Diabetic Ketoacidosis (DKA)

0.05 – 0.2 unit/kg/h

Glucose Intolerance

0.03 – 0.05 unit/kg/h

Adjust rate to desired blood glucose concentration.

Hyperkalemia

0.05 – 0.1 unit/kg/h

Infused with glucose 400 mg/kg (or 4 g for every 1 unit insulin)

C: D5W, NS, amiodarone, calcium gluconate, dobutamine, esmolol, heparin, magnesium midazolam, milrinone, morphine, nitroglycerin, nitroprusside, potassium chloride, propofol, sodium bicarbonate

I: aminophylline, dopamine, norepinephrine

Compatible with TPN


· Titrate infusion rate to desired blood glucose concentration.

· Monitor closely for hypoglycemia.

· Only Human Regular insulin is to be given intravenously.

· Pre-flush tubing with twice the volume of tubing dead space.

· Higher concentrations to be used only for fluid-restricted patients.

· Change solution and tubing at 24 hours.

· Ref: 1, 2, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Isoproterenol

[Isuprel]

1:5000 (0.2 mg/mL)

1 mL ampule

pH = 3.5 – 4.5

Osmolality = 277

Contains sodium chloride, sodium lactate, lactic acid, metabisulfite

Revised Feb 2020


25 mcg/mL

Add 6.25 mL of 0.2 mg/mL (1:5000) to


25 mcg/mL

50 mcg/mL

Add 12.5 mL of 0.2 mg/mL (1:5000) to


50 mcg/mL

100 mcg/mL

Add 25 mL of 0.2 mg/mL (1:5000) to 25 mL D5W to make

50 mL of

100 mcg/mL


AND



x Weight (kg)

x 60 (min/h)

divided by


Hypotension

Neonates & Children


C: D5W, NS, D5NS, D5LR, amiodarone, calcium chloride, dobutamine, dopamine, epinephrine, fentanyl, heparin, lidocaine, magnesium, midazolam, milrinone, morphine, nitroprusside, potassium chloride, propofol

I: aminophylline, furosemide, sodium bicarbonate

Compatible with TPN


· Very potent chronotrope, inotrope, and peripheral vasodilator.

· Not considered drug of choice for bradycardia.

· Do not use for digitalis toxicity.

· Significant degradation occurs above pH 6.


· Discard discolored or precipitated solutions.


· Ref: 1, 2, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Ketamine

[Ketalar]

10 mg/mL vial

50 mg/mL vial

pH = 3.5 – 5.5

Osmolality = 300

(10 mg/mL)

Revised Feb 2020


patient < 70 kg:

10 mg/mL

(undiluted)

(= 10000 mcg/mL)

patient > 70 kg:

50 mg/mL

(undiluted)

**request from pharmacy

(= 50 000 mcg/mL)


AND

Confirm with the calculation at bottom of page

Continuous Sedation

5 – 20 mcg/kg/min

Bronchospasm

3 – 40 mcg/kg/min

C: D5W, NS, calcium gluconate, dobutamine, dopamine, epinephrine, lidocaine, magnesium, morphine, propofol

I: Acyclovir, aminophylline, ampicillin, diazepam, furosemide, heparin, insulin, pentobarbital, salbutamol, sodium bicarbonate


• Rapid administration may cause increased apnea, respiratory depression and enhanced pressor response.

• Emergence reactions (e.g. dream-like states, hallucinations, delirium) may occur. Minimizing verbal, tactile

and visual stimulation after dosing decreases the likelihood of these reactions.

· May see increased secretions. Glycopyrrolate may be effective in reversing some of the sialogogue effect.

· Monitor closely for transient laryngospasm, apnea, respiratory arrest.


· Ref: 1, 2, 7

Infusion rate mL/hour = Dose (mcg/kg/min) X Weight (kg) X 60 min/hour)

Concentration (mg/mL) X 1000 mcg/mg

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Labetalol

[Trandate]

5 mg/mL

pH = 3 – 4

Osmolality = 287

May contain parabens

Revised Jan 2020


1 mg/mL

Add 10 mL of

5 mg/mL to 40 mL

D5W to make

50 mL of 1 mg/mL

5 mg/mL

(undiluted)


AND



x Weight (kg)

divided by


Hypertension

Continuous Infusion

0.25 – 3 mg/kg/h

*Increase in increments of 0.05 mg/kg/h as needed to control BP to a max of 3 mg/kg/h

May give bolus just prior to starting infusion

Hypertensive Emergencies

Intermittent Boluses 0.2 – 1 mg/kg IV over at least 2 minutes

May repeat at 10 min intervals until desired BP has been achieved

C: D5W, NS, D5NS, lactated Ringer’s, D5LR, aminophylline, amiodarone, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, fentanyl, hydromorphone, isoproterenol, lorazepam, lidocaine, magnesium sulfate, midazolam, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, potassium phosphate, propofol

I: furosemide, insulin, sodium bicarbonate, thiopental


· Use cautiously in pediatrics: limited information on use in children.

· Alpha and beta adrenergic blocker. Contraindicated in patients with asthma, COPD, cardiac failure, heart block, bradycardia, cardiogenic shock.

· Orthostatic hypotension may occur with intravenous administration.

· Caution in hepatic dysfunction.

· Change solution at 72 hours for 1 mg/mL in D5W and at 24 hours for 1 mg/mL in NS and 96 hours for 5 mg/mL concentration.

·

· Ref: 1, 2, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Lidocaine

[Xylocaine]

20 mg/mL vial

1000 mg/250 mL

bag (4 mg/mL)

pH =

5 – 7 (20 mg/mL)

3.5 – 6 (4 mg/mL)

Osmolality =

352 (20 mg/mL)

May contain sulfites and parabens

Revised Nov 2013

Reviewed May 2020


4 mg/mL: commercially available in 250 mL bag

-or-:

Add 10 mL of

20 mg/mL to


4 mg/mL

8 mg/mL

Add 20 mL of

20 mg/mL to

30 mL D5W to

make 50 mL of

8 mg/mL


AND



x Weight (kg)

x 60 (min/h)

divided by


divided by 1000 (mcg/mg)

Ventricular Arrhythmia

1 mg/kg IV loading dose over 2 – 3 min, may repeat q10min (max 5 mg/kg total), followed by


C: D5W, NS, D5NS, D5LR, Ringer’s Lactate, alteplase, aminophylline, amiodarone, calcium, dobutamine, dopamine, epinephrine, esmolol, fentanyl, furosemide, heparin, isoproterenol, labetalol, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, procainamide, propofol

I: sodium bicarbonate, thiopental


· Contraindicated in infants with congenital heart disease and severe heart block.

· Decrease dose in patients with shock, CHF, liver failure or reduced hepatic blood flow.

· Therapeutic Drug Monitoring

Therapeutic range = 4.5 – 21 mcmol/L (1.5 – 5 mcg/mL)

Potentially toxic range = >26 mcmol/L (>6 mcg/mL)

Toxic range => 38 mcmol/L (>9 mcg/mL)

· Signs of toxicity include myocardial and CNS depression.


· Ref: 1, 2, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Lorazepam

[Ativan]

4 mg/mL vials

pKa = 1.3 & 11.5

(ampholyte)

Isoelectric @ 6.4

Contains propylene glycol and benzyl alcohol

Revised April 2008

Reviewed May 2020


0.2 mg/mL

Add 2.5 mL of

4 mg/mL to

47.5 mL D5W to make 50 mL of 0.2 mg/mL


AND



x Weight (kg)

divided by


Sedation with Mechanical Ventilation

0.01 – 0.1 mg/kg/h

Larger doses may be required in ECMO due to extraction of ~ 50% by the circuit

Maximum Dose

2 mg/h

C: D5W, amiodarone, dobutamine, dopamine, epinephrine, fentanyl, furosemide, heparin, hydromorphone, labetalol, milrinone, midazolam, morphine, norepinephrine, potassium chloride, propofol

I: sufentanil, thiopental


· Requirements for sedation are highly variable and dose titration is necessary.

· May cause metabolic complications (lactic acidosis, hyperosmolality, increased osmolar gap) with doses >8 mg/h or nephrotoxicity due to propylene glycol content.

· Use with caution in patients with renal or hepatic impairment.

· Use D5W only for dilutions and observe frequently for precipitate.

· Store vials in refrigerator.


· Ref: 1, 3

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Magnesium Sulfate

[MgSO4]

50% ( 500 mg/mL)

Each mL contains:

500 mg MgSO4

2 mmol Mg+2

4 mEq Mg+2

Osmolality =

2620 – 2875

Revised Dec 2013

Reviewed May 2020


Neonates:

10 mg/mL

(0.04 mmol/mL)

Add 0.5 mL of 50% to 24.5 mL D5W to make

25 mL of

10 mg/mL

Non neonates:

100 mg/mL

(0.4 mmol/mL)

Add 10 mL of 50% to 40 mL D5W to make 50 mL of

100 mg/mL

Non neonates,

Fluid Restricted:

200 mg/mL

(0.8 mmol/mL)

Add 20 mL of 50% to 30 mL D5W to make 50 mL of

200 mg/mL


AND


Infusion rate (mL/h) = Dose (mg/kg/day)

x Weight (kg)

divided by


divided by

24 (h/day)

OR

Infusion rate (mL/h) = Dose (mmol/kg/d)

x Weight (kg)

divided by

Concentration (mmol/mL)

divided by

24 (h/day)

Maximum Rate

150 mg/min

Postoperative Cardiac Patients

0.2 – 0.8 mmol/kg/day

Hypomagnesemia

25 – 50 mg/kg/dose (0.1 – 0.2 mmol/kg) IV q6h x 3 – 4 doses

C: D5W, NS, aminophylline, dobutamine, dopamine, epinephrine, fentanyl, heparin, hydromorphone, insulin, isoproterenol, labetalol, milrinone, morphine, nitroprusside, norepinephrine, potassium chloride, propofol

I: amiodarone, calcium chloride, calcium gluconate, lipid emulsion, sodium bicarbonate

Compatible with TPN


· Monitor serum magnesium levels daily while on infusion (Normal Range = 0.78 – 1.03 mmol/L)

· Usual duration of infusion is 1 – 2 days.

· Signs of toxicity include respiratory depression or heart block. Toxicity is reversed using calcium gluconate.

· Renal impairment will increase risk of toxicity.


· Ref: 1, 3, 6

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Midazolam

[Versed]

5 mg/mL in 2 or

10 mL vial

1 mg/1 mL vial

pH = 3 – 3.6

Osmolality = 385

Contains benzyl alcohol

Revised Dec 2013

Reviewed May 2020


1 mg/mL

Add 10 mL of

5 mg/mL to 40 mL D5W or NS to make

50 mL of

1 mg/mL

Fluid Restriction:

5 mg/mL

(undiluted from 5 mg/mL strength vials)


AND

Confirm with the calculation below.

Sedation in Mechanical Ventilation

20 – 360 mcg/kg/h

(0.33 – 6 mcg/kg/min)*

Loading Dose

0.05 – 0.2 mg/kg IV over at least

3 minutes

* Note:

20 mcg/kg/h = 0.33 mcg/kg/min


60 mcg/kg/h = 1 mcg/kg/min








C: D5W, NS, D5NS, amiodarone, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, fentanyl, heparin, hydromorphone, insulin, labetalol, magnesium, milrinone, morphine, nitroglycerin, norepinephrine, potassium chloride, propofol

I: amphotericin, furosemide, hydrocortisone, omeprazole, sodium bicarbonate, thiopental

Compatible with TPN


· Use lowest effective dose, as may accumulate in tissues with prolonged use.

· May cause hypotension. Use cautiously and avoid loading doses in postoperative open-heart patients, septic shock, or meningococcemia.

· Rapid infusion may cause respiratory depression or apnea.


· Ref: 1, 2, 3, 7

Infusion rate (mL/hour) = _____dose (mcg/kg/hour) X weight (kg)_______

Concentration (mg/mL) X 1000mcg/mg

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Milrinone

[Primacor]

1 mg/mL

pH = 3.2 – 4

Contains lactic acid (0.93 – 1.29 mg/mL)

Revised Jan 2020


patient 2 - 6 kg:

100 mcg/mL

Add 2.5 mL of

1 mg/mL to


100 mcg/mL

patient 6- 30 kg:

200 mcg/mL

Add 10 mL of

1 mg/mL to


200 mcg/mL

patient 30-120 kg:

400 mcg/mL

Add 20 mL of

1 mg/mL to



AND



x Weight (kg)

x 60 (min/h)

divided by



50 mcg/kg IV loading dose over 10 min, followed by

0.25 – 0.75 mcg/kg/min

Maximum Dose

1 mcg/kg/min

C: D5W, NS, amiodarone, calcium chloride, dobutamine, dopamine, epinephrine, fentanyl, heparin, hydromorphone, insulin, labetalol, lorazepam, magnesium sulfate, midazolam, morphine, nitroglycerin, norepinephrine, potassium chloride, propofol, sodium bicarbonate, thiopental

I: furosemide, procainamide,


· Loading doses require the approval of a pediatric intensivist due to risk of significant hypotension.


· Half-life is prolonged in renal failure.

· Adverse effects include hypotension, arrhythmias, bronchospasm.


· Ref: 1, 2, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Morphine

[MOS]

10 mg/mL

pH = 2.5 – 6

Osmolality = 54

Revised Feb 2020


200 mcg/mL

Add 0.5 mL of

10 mg/mL to

24.5 mL D5W or NS to make 25 mL of 200 mcg/mL

400 mcg/mL

Add 2 mL of

10 mg/mL to

48 mL NS or D5W to make 50 mL of

400 mcg/mL

1 mg/mL

(=1000 mcg/mL)

Add 5 mL of

10 mg/mL to

45 mL NS or D5W to make 50 mL of

1 mg/mL


AND



x Weight (kg)

divided by


Postoperative Analgesia & Sedation

5 – 20 mcg/kg/h

C: D5W, NS,D5NS, D51/2NS, D5LR, , aminophylline, amiodarone, calcium chloride, calcium gluconate, dopamine, dobutamine, epinephrine, esmolol, fentanyl, heparin, hydromorphone, insulin, ketamine, labetalol, lidocaine, magnesium sulfate, midazolam, milrinone, nitroglycerin, nitroprusside, norepinephrine, potassium chloride

I: amphotericin, furosemide

Compatible with TPN



· Antidote is naloxone 0.01 – 0.1 mg/kg IV prn

· Prolonged use of high-dose infusion may result in tolerance.

· Abrupt discontinuation of infusion after prolonged use (>2 weeks) may result in withdrawal symptoms.


· Ref: 1, 2, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Nitroglycerin

[Nitrostat, NTG]

5 mg/mL

pH = 3 – 6.5

Osmolality = 281

(1 mg/mL)

Contains propylene glycol and ethanol

Revised Dec 2013

Reviewed May 2020


100 mcg/mL

Add 0.5 mL of

5 mg/mL to


100 mcg/mL

200 mcg/mL

Add 2 mL of

5 mg/mL to 48 mL D5W to make

50 mL of

200 mcg/mL

500 mcg/mL

Add 5 mL of

5 mg/mL to


500 mcg/mL


AND



x Weight (kg)

x 60 (min/h)

divided by



Pediatric


Start at

0.1 – 1 mcg/kg/min and increase by

0.5 – 1 mcg/kg/min every 3 – 5 min until desired clinical effect

Adults

5 – 100 mcg/min

Start at 5 mcg/min and increase by

5 – 10 mcg/min until desired clinical effect

C: D5W, NS, D5LR, aminophylline, amiodarone, dobutamine, dopamine, epinephrine, esmolol, fentanyl, furosemide, heparin, hydromorphone, insulin, labetalol, lidocaine, lorazepam, midazolam, milrinone, morphine, nitroprusside, norepinephrine, propofol

I: lipid emulsion

Compatible with TPN


· Administer via syringe pump with non-PVC tubing. Do not use a filter.

· Precipitation may occur at concentrations > 500 mcg/mL

· Adverse effects include severe hypotension and shock. Methemoglobinemia is observed in adults who receive > 7 mcg/kg/min.


· Ref: 1, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Nitroprusside

[Nipride, Nitropress, Sodium Nitroprusside, SNP]

50 mg/2 mL vial

(25 mg/mL)

pH = 3.5 – 6

Osmolality = 214

Reconstituted solutions are colored straw/pink to reddish-brown

Revised June 2020


200 mcg/mL

Add 0.4 mL of

25 mg/mL to

49.6 mL D5W or NS to make 50 mL of 200 mcg/mL

800 mcg/mL

Add 1.6 mL of 25 mg/mL to 48.4 mL D5W or NS to make 50 mL of 800 mcg/mL

2000 mcg/mL

Add 4 mL of

25 mg/mL to


5000 mcg/mL

Add 10 mL of

25 mg/mL to



AND



x Weight (kg)

x 60 (min/h)

divided by


Hypertensive Crisis or Postoperative Cardiac Patients

Neonates

Start at 0.025 – 0.5 mcg/kg/min to max

6 mcg/kg/min

Pediatric

Start at

0.25 mcg/kg/min and titrate by

0.25 mcg/kg/min to max 8 mcg/kg/min

C: D5W, NS, amiodarone, dobutamine, dopamine, esmolol, heparin, insulin, labetalol, lidocaine, milrinone, morphine, nitroglycerin, potassium chloride, procainamide, propofol

I: norepinephrine, lipid emulsion

Compatible with TPN


· Protect solution from light with aluminum foil. Not necessary to cover tubing.

· Hypotension may occur. Monitor blood pressure continuously.

· Methemoglobinuria can occur at doses > 10 mcg/kg/min. Methylene blue is used as an antidote.

· Check thiocyanate levels with high doses, prolonged use (>48h) or renal failure.

· Avoid rapid dose escalation.

· Use cautiously in patients with increased intracranial pressure.

· Discard solution if blue discoloration occurs.


· Ref: 1, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Norepinephrine

[Noradrenalin]

4 mg (base)/4 mL

ampoule

pH = 3 – 4.5

Osmolality = 319

Contains metabisulfite

All calculations are based on norepinephrine base ( 1 mg base = 2 mg bitartrate)

Revised January 2020


25 mcg/mL

Add 0.63 mL of

1 mg/mL to

24.37 mL D5W or NS to make 25 mL of

25 mcg/mL

50 mcg/mL

Add 2.5 mL of

1 mg/mL to

47.5 mL D5W or NS to make 50mL of 50 mcg/mL

200 mcg/mL

Add 10 mL of

1 mg/mL to

40 mL D5W or NS to make 50 mL of

200 mcg/mL

Fluid Restricted and >30 kg:

500 mcg/mL

Add 25 mL of

1 mg/mL to

25 mL D5W or NS to make 50 mL of

500 mcg/mL


AND



x Weight (kg)

x 60 (min/h)

divided by


Blood Pressure Support

Infants & Children

0.02 – 0.4 mcg/kg/min

titrated to maximum

1 mcg/kg/min

C: D5W, NS, D5NS, amiodarone, calcium chloride, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, fentanyl, furosemide, heparin, hydromorphone, labetalol, magnesium , lorazepam, midazolam, milrinone, morphine, nitroglycerin, potassium chloride, propofol, vecuronium

I: aminophylline, insulin, sodium bicarbonate, thiopental

Compatible with TPN


· Dextrose-containing solutions protect from oxidation and are the preferred diluent over sodium chloride-containing solutions (NS).

· Correct intravascular volume before initiating norepinephrine.

· Extravasation may cause local ischemia and tissue necrosis.

· Notify physician in case of infiltration to initiate phentolamine protocol.


· Discard solution if brown discoloration occurs.


· Ref: 1, 3, 7

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Papaverine HCl

32.5 mg/mL (2mL)

Revised Nov 2013

Reviewed May 2020

Standard Concentration:

0.12 mg/mL:

Add 1.8 mL (60 mg of 32.5 mg/mL) to 500 mL heparin 2U/mL in NS or 1/2NS to make 500 mL of

0.12 mg/mL

To prolong life of arterial catheters in neonates and infants:

< 20 kg:

Infuse in arterial line at 1 mL/hour

Prolongation life of arterial catheters in neonates and infants:

0.12 mg/hour CIVI

Not applicable. Other medications should not be infused into arterial line.

Note: at higher concentrations papaverine & heparin are incompatible. Therefore when withdrawing from the papaverine-heparin bag, use a new syringe. If residual higher concentration of the papaverine remains in the syringe, the solution will precipitate and result in a cloudy mixture.

· Note: At higher concentrations, administration by rapid IV push may cause arrhythmias, apnea, or death. If need to give IV push, administer over 1-2 minutes.

· Discard solution if solution remains cloudy after mixing.


· Ref: 1, 3, 12

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Phenylephrine

10 mg/mL (1 mL, 5 mL, 10 mL vials)

Contains sulphites and sodium benzoate

Created July 2015

Reviewed May 2020

Standard Concentrations:

40 mcg/mL:


100 mcg/mL:



AND



x Weight (kg) X 60 (min/h)

divided by


Hypotension/shock:

IV bolus: 5-20 mcg/kg IV q10-15 min PRN

IV infusion:

0.1- 0.5 mcg/kg/min titrated to effect

C: D5W, NS, D5NS, D51/2NS, D5LR, aminophylline, amiodarone, calcium chloride, calcium gluconate, cisatracurium, midazolam, morphine

I: acyclovir, phenytoin


· Central line administration.

· Do not use if solution turns brown.

· Selective alpha agonist

· Extravasation may cause local ischemia and tissue necrosis.

· Notify physician in case of infiltration to initiate phentolamine protocol.


· Ref: 3

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Procainamide

[Pronestyl, PCA]

100 mg/mL

pH = 4 – 6

Osmolality = 2000

May contain sulfites and benzyl alcohol

Revised Dec 2013

Reviewed May 2020


patient < 30 kg:

10 mg/mL

Add 5 mL of

100 mg/mL to

45 mL NS to make 50 mL of 10 mg/mL

patient > 30 kg:

30 mg/mL

Add 15 mL of

100 mg/mL to

35 mL NS to make 50 mL of 30 mg/mL

**Note: mix in NS


AND



x Weight (kg)

x 60 (min/h)

divided by


Cardiac Arrhythmias


Loading dose:

2 – 5 mg/kg (max 100 mg) over 5 min, may repeat q5min to a max of 15 mg/kg in 30 minutes

C: D5W, NS, calcium gluconate, dobutamine, esmolol (in D5W), heparin, lidocaine, potassium chloride, sodium nitroprusside (in D5W)

I: amiodarone, milrinone


· Adjust dose in renal impairment.

· Monitor EKG. Discontinue infusion if QRS widens >50% or hypotension develops.

· Active metabolite (NPCA) contributes to toxicity.

· Therapeutic Drug MonitoringTarget range:Procainamide: 15 – 37 mcmol/LPCA + NPCA: < 110 mcmol/L

Toxic range:NPCA: >37 mcmol/L

· Discard solution if dark amber discoloration occurs.


· Ref: 1, 2, 3

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Propofol

[Diprivan]

200 mg/20 mL in 10% soybean emulsion

pH = 6.5 – 8.5

Osmolality = isotonic

May contain metabisulfite or benzyl alcohol

Revised Feb 2020


10 mg/mL* (undiluted)

(10 000 mcg/mL)

To convert to mcg/mL:

· 1 mg/mL = 1000 mcg/mL


AND



x Weight (kg)

x 60 (min/h)

divided by

Concentration (mcg/ml)

Sedation in Mechanical Ventilation


Start with the lowest effective dose usually

5-10 mcg/kg/min

titrate by

5 – 10 mcg/kg/min q5min

Maintenance of Anesthesia


C:D5W, D5W1/2NS, D5LR, lactated Ringer’s, aminophylline, calcium gluconate, dobutamine, dopamine, esmolol, epinephrine, fentanyl, furosemide, heparin, hydrocortisone, hydromorphone, insulin, isoproterenol, ketamine, labetalol, lidocaine, lorazepam, midazolam, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, sodium bicarbonate

I: calcium chloride, diazepam



· The emulsion vehicle is similar to lipid emulsions such as Intralipid and similar precautions should be observed.

· Do not directly admix with any drug, solution, or blood product.

· For short-term or intermittent use only.

· Propofol-Related Infusion Syndrome (PRIS): metabolic acidosis, lipemia, hypotension, multi-system organ failure, rhabdomyolysis, cardiovascular collapse.

· Change solution and IV administration set at 6 hours.

· Ref: 1, 2, 3, 11

Propofol infusion rate (mL/hour) = Dose (mcg/kg/min) x Weight (kg) X (60 min/hour)

Concentration (10 mg/mL) X 1000 mcg/mg

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Salbutamol

[Ventolin]

1 mg/mL

pH: 3.5

Osmolality = isotonic

Created Jun 2020


20 mcg/mL

Add 1 mL of

1 mg/mL to

49 mL NS or D5NS to make 50 mL of

20 mcg/mL


AND


Infusion rate (mL/h) = Dose (mmol/kg/h)

x Weight (kg)

divided by


Severe asthma exacerbation

1-5 mcg/kg/min

Start at 1 mcg/kg/min

C: D5W, NS, D5NS, aminophylline, dexamethasone, hydrocortisone

Incompatible with TPN, ketamine

Very little Y site compatibility information.

Contact pharmacy regarding compatibilities.

· Monitor for tachycardia, arrhythmias and hypertension


· Ref: 1, 3, 6

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Sodium Bicarbonate

[NaHCO3]

0.5 mmol/mL (4.2%)

1 mmol/mL (8.4%)

Each mL contains:

8.4% HCO3-

1 mmol HCO3-

1 mEq HCO3-

6% Na+

1 mmol Na+

1 mEq Na+

pH = 7.4 – 8.5

Osmolality =

815 (4.2%)

1815 (8.4%)

Revised Dec 2013

Reviewed May 2020


Peripheral line:

0.5 mmol/mL (4.2%, undiluted)

Central line:

1 mmol/mL (8.4%, undiluted)


AND


Infusion rate (mL/h) = Dose (mmol/kg/h)

x Weight (kg)

divided by


Metabolic Acidosis, Continuous Infusion

0.5 – 2 mmol/kg/h

Metabolic Acidosis, Intermittent Infusion

HCO3 (mmol) =

0.3 x weight (kg)

x base deficit (mmol/L)

Administer ½ the calculated dose over 30 – 60 min

C: D5W, D10W, D5NS, NS,

I: alprostadil, amiodarone, amrinone, calcium chloride, calcium gluconate, dopamine, dobutamine, epinephrine, isoproterenol, magnesium, midazolam, norepinephrine, thiopental, vancomycin


Contact pharmacy regarding compatibilities.

· Central line administration only for 8.4% concentration.

· Rapid infusions in neonates and children may cause hypernatremia, decreased CSF pressure, and intracranial hemorrhage.

· Extravasation may cause local tissue necrosis.


· Ref: 1, 3

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Sufentanil

[Sufenta]

50 mcg/mL in 1 mL and 5 mL vials

pH = 3.5 – 6

Revised April 2008

Reviewed May 2020


Patients < 6 kg:

5 mcg/mL

Add 2.5 mL of

50 mcg/mL to

22.5 mL of D5W to make 25 mL of

5 mcg/mL

Patients 6- 30 kg:

10 mcg/mL

Add 10 mL of

50 mcg/mL to

40 mL of D5W to make 50 mL of

10 mcg/mL

Patients > 30 kg:

20 mcg/mL

Add 20 mL of

50 mcg/mL to

30 mL of D5W to make 50 mL of

20 mcg/mL


AND



x Weight (kg)

divided by


Analgesia

0.2 – 1 mcg/kg/h

Intermittent Bolus

0.2 – 0.4 mcg/kg

Anesthesia

Neonates

1 – 2 mcg/kg/h

Infants

1 – 1.5 mcg/kg/h

Children & Adolescents

<1 mcg/kg/h

C: D5W, NS, midazolam, propofol

I: lorazepam, phenobarbital, phenytoin, thiopental


· Infuse via non PVC tubing (PVC tubing can reduce infusion concentration by 15% in 24 hours)

· Most potent opioid analgesic.

· Bolus administration may cause significant apnea, bradycardia, muscle rigidity, chest wall rigidity. Pretreatment with atropine and a non-depolarizing muscular blocking agent may minimize these effects.

· Antidote: Naloxone 0.01 mg/kg IV


· Ref: 1, 3, 9

Drug

Concentrations

Infusion Rate

Dose Range


Comments

Vasopressin

[Pressyn]

20 units/mL in 0.5 or

5 mL ampoule

1 unit =

1000 milliunits*

*Note: for Alaris pump programming use milliunits

pH = 2.5 – 4.5

Revised Dec 2013

Reviewed May 2020


0.005 units/mL

(5 milliunits/mL)

Add 0.25 mL of 20 units/mL to 1L bag of D5W, NS, or D5NS to make 1000 mL (1L) of 0.005 units/mL

(*note concentration will not be exact and should only be used for DI management)

0.4 units/mL

Add 1 mL of

20 units/mL to

49 mL D5W or NS to make 50 mL of 0.4 units/mL

1 unit/mL

Add 2.5 mL of

20 units/mL to

47.5 mL D5W or NS to make 50 mL of 1 units/mL


AND


Infusion rate (mL/h) = Dose (milliunits/kg/min)

x Weight (kg)

x 60 (min/h)

divided by

(Concentration (units/mL) X1000 miliunits/unit)

Central Diabetes Insipidus (DI)

0.02 – 0.05 milliunits/kg/min = 0.00002 – 0.00005 units/kg/min

(titrate to desired urine output)

Maximum Dose

0.2 milliunits/kg/min = 0.0002 units/kg/min

Vasodilatory Shock

0.3 – 2 milliunits/kg/min = 0.0003 – 0.002 units/kg/min

C (in D5W): amiodarone, dobutamine, dopamine, heparin, lidocaine, milrinone, nitroglycerin, norepinephrine, phenylephrine, procainamide

C (in NS): amiodarone, epinephrine, norepinephrine


· Only the aqueous form may be infused continuously.

· Extravasation may cause tissue necrosis.

· May cause water overload and hyponatremia.


· Ref: 1, 9

REFERENCES

1. Phelps S, Hagemann TM, Lee KR, Thompson AJ. (Eds) Pediatric Injectable Drugs, 11th Edition . Bethesda. American Society of Health System Pharmacists; 2017.

2. Taketomo CK, Hodding JH, Kraus DM, (Eds). Pediatric Dosage Handbook 25th Edition. Hudson Lexicomp; 2018.

3. Trissel’s ™ 2 Clinical Pharmaceutics Database , Micromedex 2.0 June 2020. https://www.micromedexsolutions.com/micromedex2/4.29.4.1/WebHelp/Tools/IV_Compatibility/IV_Compatibility.htm

4. Yong TE, Mangum B. (Ed). Neofax: IBM Micromedex® June 2020

5. Esau R (Ed).Pediatrics Drug Dosage Guidelines, 7th Edition . Vancouver. BC Children’s Hospital; 2018.

6. BC Children’s Hospital Parenteral Manual. Vancouver. BC Children’s Hospital. June 2020

7. “Our Standard Concentrations Updated 11/05/04”. University of Maryland School of Medicine. 2004. ICUDrips.org

8. Kent D, WIlis G, (Editors). Poison Management Manual. Vancouver. British Columbia Drug and Poison Information Centre. 2017.

9. Shann F. Drug Doses 17th Edition. Parkville. Intensive Care Unit, Royal Children’s Hospital.2017 http://www.drugdoses.com/

10. Flolan Product Monograph 2019 https://ca.gsk.com/media/1220385/flolan.pdf

11. Repchinsky C(ed). Compendium of Pharmaceutical and Specialties 2018 23rd Edition. Ottawa. Canadian Pharmacists Association. 2018

12. Heulitt MJ et al. Double-blind, randomized, controlled trial of papaverine-containing infusions to prevent failure of arterial catheters in pediatric patients. Crit Care Med 1993;21:825-9.

Version History

DATE

DOCUMENT NUMBER and TITLE

ACTION TAKEN

14-July-2020

C-05-07-60741 Pediatric Intensive Care Unit: Continuous Infusion Guidelines for Infants and Children

Approved at: Pharmacy, Therapeutics & Nutrition Committee

DISCLAIMER

This document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

C-05-07-60741 Published Date: 28-Jul-2020

Page 2 of 40 Review Date: 14-Jul-2023

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

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