Neonatal Intensive Care Drug Manual
Canberra Hospital
Contents:
Introduction
Drug Name
Acetylcysteine (Inhalation Therapy)
Acetylcysteine (Mucomyst)
Aciclovir
Adenosine
Adrenaline (Resuscitation)
Adrenaline (Infusion, Inhalation)
Albumin
Amlodipine
Ampicillin
Amphotericin B
Amphotericin B (Lipid Complex)
Aspirin
Atenolol
Atropine
Azithromycin
Buccal Glucose Gel 40%
Budesonide
Caffeine Base
Calcium Gluconate
Calcium Carbonate Suspension
Calcitriol
Captopril
Cefotaxime
Ceftazidime penthydrate
Cephazolin
Chloral Hydrate
Chloramphenicol
Ciprofloxacin
Clinoleic Lipid Emulsion
Clonazepam
Clotrimazole
Co-trimoxazole
Cryoprecipitate
Curosurf: Poractant alfa
Cyclopentolate hydrochloride eye drops (0.25%)
Dexamethasone
Diazepam
Diazoxide
Digoxin
Dobutamine
Dopamine
Epoprostenol
Erythromycin
Erythropoietin
Fentanyl
Ferrous Sulfate (Ferro-Liquid)
Flecainide
Flucloxacillin
Fluconazole
Flumazenil
Fluticasone (Flixotide)
Folic Acid
Frusemide
Ganciclovir
Gaviscon (Alginic acid)
G-CSF (Granulocyte-colony stimulating factor
Gentamicin
Glucagon
Heparin
Heparin CVC Lock
Hepatitis B Immunoglobulin
Hepatitis B Vaccine
Hydralazine
Hydrochlorothiazide
Hydrocortisone
Ibuprofen
Indomethacin
Imipenem/Cilastatin
Immunoglobulin IV (Intragram®P): Draft
Indomethacin
Infanrix hexa
Infloran®
Insulin (Actrapid – for hyperglycaemia)
Insulin (for hyperkalaemia)
Ipratropium Bromide
Isoprenaline
Isovue
Labetalol
Lactulose
Levetiracetam (Keppra)
Lignocaine for seizures
Lignocaine for local anaesthetic, cardiac arrhythmia
Magnesium Sulphate
Magnesium Aspartate
Meropenem
Metoclopramide
Metoprolol
Metronidazole
Miconazole (Topical Gel)
Midazolam
Milrinone
Morphine IV
Morphine Oral
Mylanta
Naloxone
Neostigmine
Noradrenaline
Nystatin (Oral)
Nystatin (Topical)
Octreotide
Omegaven 10% Lipid Emulsion
Omeprazole
Pancreatic Enzymes/Creon
Pancuronium
Pantoprazole
Paracetamol (Draft)
Penicillin, Benzyl (Penicillin G)
Pentavite (Multivitamin Prep)
Phenobarbitone
Phenylephrine hydrochloride eye drops (2.5%)
Phenytoin
Phosphate Supplement
Potassium Chloride
Povidone-Iodine (Betadine)
Prednisolone
Prevenar 13
Propofol
Propanolol
Prostaglandin E1(Alprostadil)
Prostacyclin PGI2(Epoprostenol)
Pyridoxine
Ranitidine
Recombinant Factor VIIa
Resonium A
Rifampicin
Rotavirus Vaccine
Salbutamol - for I.V. Administration
Salbutamol (Nebulised)
Sandoglobulin (Normal Human Immunoglobulin)
Sildenafil
Sodium Bicarbonate
Sodium Chloride 20% (NaCl)
Sotalol
Spironolactone
Streptokinase
Sucrose
Survanta: Beractant
Suxamethonium Chloride (Scoline)
Teicoplanin
Theophylline
Thyroxine
Ticarcillin/clavulanic acid
Tobramycin
Ursodeoxycholic Acid (URSO)
Valproate
Vancomycin
Vecuronium
Vigabatrin
Vitamin A (Retinol)
Vitamin E (Alpha-Tocopherol)
Vitamin K
Zidovudine
Zoster Immunoglobulin
Introduction
Revision Date : 20 February 2015 / Approved : Department of NeonatologyThe following list is a compilation of drugs commonly and not so commonly used in Neonatal Care. The list has developed over a period of years and is based on experiences within this unit or on data collected from published reports in recent perinatal literature.
The current revision includes data concerning drug compatibilities which have been previously considered a problem but now which have been shown to be safe and effective.
Some methods of administration may be considered new or novel but should not be avoided for this reason. In general, recommendations are made on the best available evidence. Should there be any discrepancies these should be brought to our attention. Suggestions for change are welcome.
Entries in this manual should not be annotated or marked without the approval of the Consultant in Charge as this will only serve to confuse and may lead to mistakes or errors in administration.
Note that the following abreviations are used throughout this document:
WFI = Water for injection.
D5W= 5% Dextrose Water
D10W= 10% Dextrose Water
NS= 0.9% Normal Saline
This manual is constantly updated by the Dept of Neonatology and Pharmacy. Thank you for your continued efforts in keeping this document up to date with the latest evidence.
Professor Alison Kentand Dr Tejasvi Chaudhari,
Department of Neonatology
Drug Name
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / A brief description of the uses for the chosen drug
Dose : / Single Dose amount
Interval : / Dosage interval or number of doses per day
Route : / Oral, intravenous, intra-arterial or other routes available
Total Daily Dose : / Maximum recommended daily dosage
Comments : / Description of action, precautions, side effects etc.
Supplied as : / Company or trade name is not usually recorded and should not be used in prescriptions. Amount usually found in supplied units.
Dilution : / Instructions for appropriate dilution. May differ from that recommended by suppliers because has been adjusted for use in small babies.
Stability : / Refers to how long drug can be used after being reconstituted or diluted.
Storage : / Usual method and place of storage - cupboard, fridge, freezer etc.
Incompatibility : / Drug and diluent incompatibilities, comments on whether can be given mixed with other drugs or solutions.
Serum Levels : / Therapeutic range - if known
Acetylcysteine (Inhalation Therapy)
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / A mucolytic agent used as adjuvant therapy in patients with thick or viscid bronchial secretions and mucous obstruction.
Dose : / 1-2 ml of 100mg/mL or 200mg/mL solution
Interval : / 1- 4 hourly as necessary
Route : / Intratracheal via Endotracheal tube
Total Daily Dose : / Use with care in small babies where fluids are restricted.
Comments : / May be mixed with bronchodilators without loss off of effect. Generally it is used on its own, and bronchodilators are given pre mucomyst, so that the mucomyst can penetrate further into the bronchioles.
Not for Injection
Supplied as : / Acetylcysteine, 200mg/mL solution, 10 mL vial.
Trade name Mucomyst®
Dilution : / Not required or can be diluted with an equal volume of Water For Injection to make a 100mg/mL solution
Stability : / Open vials may be stored in a refrigerator for up to 96 hrs. Use diluted solution within an hour and discard any unused diluted solution
Storage : / Store at room temperature until vial is accessed, then in refrigerator. Label vial as to the time of the first access.
Incompatibility : / Not applicable
Serum Levels : / Nil
Acetylcysteine (Mucomyst)
Revision Date : 18 June 2012 / Approved : AK, JDIndication : / Cystic fibrosis, meconium plug syndrome related to IUGR
Dose : / Order dose in terms of mLs of 50mg/mL solution
Rectal enema: 2-10 mL (max of 10mL/kg) of 50mg/mL solution
Retention time of 30-45 minutes, but max effect if retained for 6 hours.
Interval : / Daily, up to 6/24
Route : / PR or via fistula/stoma
Total Daily Dose :
Comments : / Give enema in a slow steady manner to avoid over distension and observe abdomen for signs of distension.
Thought to act by disrupting disulphide linkages of mucoproteins i.e. it breaks up the protein matrix and lowers the viscosity of meconium.
Not for Injection
Supplied as : / 200 mg/mL vial. Trade name Mucomyst®
Dilution : / Dilute with water to make 50 mg/mL - take 1mL of solution (200mg) from the vial and add 3 mL of Water For Injection to make 200mg/4mL.
Stability : / Prepare fresh solution for each dose and discard any unused diluted portion. The vial can be reused for up to 96 hours.
Storage : / Vials: protect from light. Store below 25°C
Compatibility : / Not applicable
Incompatibility :
Serum Levels : / Not required
Taken from RCH Paediatric Pharmacopoeia, SHPA Injectable Drugs Handbook
Aciclovir
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / An antiviral agent active against Herpes Simplex (types 1 and 2), varicella zoster. Disease should be treated quickly even if clinical signs are minimal or superficial.
Dose : / 20 mg/kg
< 30 weeks daily
30-32 weeks 18/24 1st week of life
32 - 37 weeks 12/24
> 37 weeks 8/24
2-12 weeks of life 8/24
Interval : / 8 hourly
Route : / Intravenous infuse over 1 hour
Total Daily Dose : / 30-60 mg/kg
Comments : / Aciclovir triphosphate acts as an inhibitor of and substrate for herpes DNA polymerase preventing further DNA synthesis. Must be infused over 1 hour. If infused too rapidly may cause renal failure by precipitation of crystals in the kidney and transient renal dysfunction. Give adequate hydration to prevent precipitation of crystals in the renal tubules. Monitor urine output and creatinine carefully. Monitor IV site for phlebitis (has a pH of 10). If phlebitis occurs, then make the solution more dilute. Treatment should continue for at least 10 days. 21 days may be needed for CNS disease.
Supplied as : / Zovirax (and other brand names) 250 mg and 500mg vials of powder for reconstitution. 250mg/10 ml vials of solution.
Dilution : / 250mg and 500mg vials of powder are reconstituted with 10 ml and 20ml of WFI to give a solution of 25mg/ml. 1 ml of this solution or of the ready prepared solution can be further diluted with NS to a total of 5 ml to make a solution of 5mg/ml. Discard remainder of vial.
Stability : / Solution stable for 24 hours at room temperature. Do not put solution in refrigerator as crystals will develop and not re-dissolve at room temperature.
Storage : / Store at room temperature. 3 yr. shelf life. DO NOT refrigerate.
Compatibility / Compatible with Cefotaxime, 5% Dextrose, gentamicin, lorazepam, potassium chloride, NS, metronidazole, fluconazole, ampicillin, vancomycin.
Incompatibility : / Do not give with TPN solutions, Dopamine, Dobutamine.
Serum Levels : / Reduce dose in renal failure and hepatic failure.
Adenosine
Revision Date: 09/01/2014 14:40:00 / Approved : AK, JDIndication : / Rapid conversion of paroxysmal tachycardias to normal sinus rhythm, and as an aid to the diagnosis of supraventricular tachycardias.
Dose : / Initial dose 0.1mg/kg, increasing by 0.05mg/kg to a maximum of 0.35 mg/kg/dose
Interval : / Every 1-2 minutes until termination of arrythmia
Route : / Rapid bolus IV, over 1-2 seconds directly into a vein or at the most proximal port available. Follow rapidly with a saline flush.
Total Daily Dose : / Not Applicable.
Comments : / The half-life of adenosine is less than 10 seconds, thus adverse effects are generally self-limiting. May produce heart block and bronchospasm and may induce pulmonary hypertension. Methylxanthines are competitive antagonists of adenosine. Larger doses of adenosine may be required when these drugs are used concurrently. Dipyridamole enhances and prolongs the effect. Contraindicated in adenosine deaminase deficiency. Side effects include flushing, headache and nausea. Rarely may produce apnoea.
Supplied as : / Vials (Adenocor) containing 6mg adenosine in 2 ml Normal saline
Dilution : / Use 1 ml with 9 ml of Normal Saline to make up a solution with a final concentration of 0.3 mg/ml.
Stability : / Single use only. Discard immediately after use.
Storage : / Do not refrigerate. Keep at room temperature below 25’C
Incompatibility : / No data
Serum Levels : / Not required
Green AP, Giattina KH. Adenosine administration in neonatal SVT. Neonatal Network1993;12:15-18.
Paret et al. Adenosine for the treatment of Paroxysmal SVT in full term and preterm infants. Am J Perinatol 1996 13:343-346
Adrenaline (Resuscitation)
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / Cardiac resuscitation
Dose : / IV = 0.01-0.03 mg/kg = 0.1-0.3 mls/kg of 1:10,000 solution
ETT = 0.05 – 0.10 mg/kg = 0.5-1.0 mls/kg of 1:10,000 solution
Interval : / Stat. repeat if necessary
Route : / IV, ETT
Dose used for resuscitation : / 0.1-0.3 ml of 1:10,000 solution/kg body weight for IV administration. May be repeated every 1-3 minutes. 0.5-1.0ml/kg of 1:10,000 solution/kg body weight for ETT administration.
Comments : / Of value in cardiac arrest because of alpha-adrenergic properties. Beta-mimetic use uncertain in resuscitation conditions. May cause cardiac arrythmias, hypertension, tachycardia.
Supplied as : / Adrenaline 1 in 10,000 (1 mg in 10 ml)
Dilution : / Undiluted in resuscitation
Stability : / Use immediately. Discard after opening.
Storage : / Room temperature. Shield from light. Do not use if solution is brown or turbid.
Compatibility: / May be co-infused with TPN, amikacin, calcium gluconate, cimetidine, dopamine, hydrocortisone, morphine, vecuronium, dobutamine, heparin.
Incompatibility : / Do not give with aminophylline, sodium bicarbonate, phenobarbitone.
Serum Levels : / Nil
Adrenaline (Infusion, Inhalation)
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / Inotropic support where alpha-adrenergic properties are desirable.
Croup or post-extubation stridor
Dose : / IV infusion - 0.1-1 microg/kg/min by continuous infusion
Inhalation - 4 mls of 1:1000
Interval : / Infusions
Inhalation – repeat if required
Route : / IV, Inhaled
Comments : / May cause cardiac arrythmias, hypertension, tachycardia.
Use in croup and post extubation stridor is for emergency, transient (1-2 hrs) relief of partial obstruction. ECG monitoring & continuous medical supervision is indicated. Not a substitute for intubation, if intubation is indicated.
Supplied as : / Adrenaline 1 in 1,000 (1 mg in 1 ml)
Dilution : / Infusion - Add 1.5 mg per Kg of Adrenaline 1:1,000 to a syringe and make up to 25 ml with D5W, D10W or NS.
Using this resulting concentration:
0.1 ml/ hr = 0.1 microg/kg/ min
Inhalation - use 1:1,000 ampoules undiluted.
Stability : / Use immediately. Discard after opening. Continuous infusion must be shielded from light.
Storage : / Room temperature. Shield from light. Do not use if solution is brown or turbid.
Compatibility: / May be co-infused with TPN, amikacin, calcium gluconate, cimetidine, dopamine, hydrocortisone, morphine, vecuronium, dobutamine, heparin.
Incompatibility : / Do not give with aminophylline, sodium bicarbonate, phenobarbitone.
Serum Levels : / Nil
Albumin
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / Intravenous albumin infusion is used in preterm and term infants as a fluid bolus or to treat hypoalbuminaemia
Dose : / 1] Fluid bolus - 4% albumin – 10 ml/kg
2] Hypoalbuminaemia - 20% albumin – 5-10 ml/kg (1-2g/kg)
Interval : / 1] May be repeated depending upon response
2] Daily depending upon response
Route : / 1] Intravenous – infuse over 30 minutes
2] Intravenous – infuse over 4 hours, generally followed by frusemide
Total Daily Dose :
Comments : / Adverse effects may include circulatory overload, hypotension, rigors and sodium overload.
Supplied as : / 1] Human albumin 4% 4 g/dL
2] Human albumin 20% 2g/dL
Dilution : / Nil required
Stability : / Discard after use
Storage : / Refrigerate – if not used must be returned to transfusion.
Protect from light
Compatibility : / 5% Dextrose, 10% Dextrose, 0.9% Sodium chloride
Incompatibility : / Cefotaxime, Ceftriaxone, Clindamycin, Dobutamine, Adrenaline, Insulin, Penicillin, Phenytoin, Midazolam, Vancomycin
Serum Levels : / Nil
Amlodipine
Revision Date : 24 June 2013 / Approved : AK, JDIndication : / Antihypertensive agent.
Dose : / 0.1-0.4 mg/kg
Interval : / Daily
Route : / Oral
Total Daily Dose : / Maximum dose 0.4 mg/kg/day
Comments : / Amlodipine is a long acting dihydropyridine calcium channel antagonist with resultant antihypertensive activity related to smooth muscle relaxation. Adverse effects may include hypotension, feed intolerance and alteration of liver function tests, flushing, peripheral oedema and palpitations. Caution when used in combination with other antihypertensives. Caution when used with other medications metabolised via CYP3A4 (eg erythromycin, antifungals).
Supplied as : / 5 mg tablet
1mg/mL Suspension (made in pharmacy)
Dilution : / Pharmacy will prepare a 1mg/mL suspension during normal hours. For doses after hours, crush and disperse a 5mg tablet in 5mL of sterile water to make a 1mg/mL mixture. Shake for even drug distribution immediately prior to drawing up dose and discard remainder. Use immediately as amlodipine is very sensitive to light.
Stability :
Storage : / Store below 25 degrees Celsius (tablets and mixture).
Protect from light.
Incompatibility :
Serum Levels :
Ampicillin
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / Neonatal sepsis, meningitis and other infections.
Dose : / 25 mg/kg for septicaemia
50 mg/kg for meningitis, GBS Sepsis.
Interval : / 12 hourly <7 days after birth
8 hourly >7 days after birth
6 hourly > 4 weeks of age
Route : / IV or IM.
Total Daily Dose : / According to maturity
Comments : / Slow intravenous infusion over not more than 100 mg/ minute
Supplied as : / Ampicyn 500 mg
Dilution : / Add 4.7 ml sterile water to vial (= 5 ml at 100 mg/ml). For use dilute to 10 ml with Normal Saline (50 mg/ml) and draw up required dose. Infuse slowly over 15 minutes.
Stability : / Discard after reconstitution. Ampicillin is unstable in concentrated solutions and should be used as soon as practical.
Compatibility: / May be co-infused with Calcium in saline, cimetidine, chloramphenicol, heparin, morphine, sodium bicarbonate, tolazoline, vancomycin.
Storage : / At room temperature
Incompatibility : / Do not give with Calcium and dextrose solutions, dopamine, adrenaline, fluconazole, gentamicin or hydralazine. Not compatible with TPN.
Serum Levels : / Not required.
Amphotericin B
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / Fungal sepsis
This is a RED ANTIMICROBIAL and requires approval from the Infectious Disease Team as per AMS SOP.
Dose : / Candida species: 0.5-0.7 mg/kg
Aspergillus species: 1-1.5 mg/kg
Zygomyces species: 1.5 mg/kg
Prolonged febrile neutropenia: 1 mg/kg
Interval : / 24 hourly
Route : / IV only infuse over 4-6 hours
Total Daily Dose : / 0.5-1.5 mg/kg
Comments : / Amphotericin is derived from streptomyces nodosus. In its crystalline form it is insoluble in water and is suspended in a colloidal dispersion for IV administration. The drug is toxic and causes renal impairment - notably hypokalaemia(by increasing renal potassium loss), renal tubular acidosis. Leucopenia and thrombocytopenia are less common and maybe due to the primary infection. Monitor serum creatinine, electrolytes, FBC. Test doses unnecessary in children and may delay therapy. If in-line filters are used, the mean pore diameter should not be less than 1 micron.
Supplied as : / Fungizone Intravenous 50 mg powder for reconstitution.
Dilution : / Single dose preparation from pharmacy. Reconstitute with 10 ml sterile water and shake until solution is clear. Dilute with 5% dextrose by adding 0.2 ml to 9.8 ml giving a solution with 0.1 mg/ml. Administer infusion over 4-6 hours. Protect entire line from light.
Stability : / Vial for single use only. Discard remainder.
Storage : / Refrigerate. Protect from light.
Compatibility: / 5%, 10%, 20% Dextrose, Heparin, Hydrocortisone, Sodium bicarbonate and Zidovudine.
Incompatibility : / Do not mix with 0.9% NaCl, CaCl2, KCl, dopamine, penicillin. Not compatible with TPN, give through separate line. Calcium gluconate, gentamicin, ranitidine.
Serum Levels : / Nil
Amphotericin B (Lipid Complex)
Revision Date : 09/01/2014 14:40:00 / Approved : AK, JDIndication : / Fungal sepsis. Restricted to patients with or at risk of developing renal failure, or in patients with infections resistant to conventional amphotericin B.
This is a RED ANTIMICROBIAL and requires approvalfrom the Infectious Disease Team as per AMS SOP.
Dose : / 2.5-5 mg/kg. Test dose unnecessary in children and may delay treatment.
Interval : / 24 hourly
Route : / IV only infuse over 1-2 hours. Infuse each 2.5 mg/kg over 1 hour.
Total Daily Dose : / Up to 5 mg/kg
Comments : / Amphotericin B is complexed to phospholipids. Decreases overall toxicity and side effects of Amphotericin. A greater concentration of Amphotericin is transported to the site of infection. Higher doses are tolerated without side effects. Monitor serum creatinine, electrolytes and FBC. Treat for at least 14 days.
Supplied as : / Abelcet 5 mg/ml vial.
Dilution : / Normally made by pharmacy. Shake vial gently to ensure no yellow sediment at bottom of vial. Using 5 ml syringe and 17 or 19 G needle withdraw 5 ml from vial. Replace needle with 5 micron high flow filter needle provided with each vial. Adjust volume to 1.25 ml (25 mg) and transfer it into a 25 ml syringe. Draw the 25 mg up to 25 ml with 5%D. Final concentration = 1mg/ml. If the syringe is not used immediately hold in refrigerator and shake vigorously prior to use.
Stability : / Single use vial. Discard any remaining solution.
Storage : / In refrigerator. Protect from light.
Incompatibility : / Not compatible with NS or TPN. Infuse through a separate line. Flush with 5% D before and after dose.
Serum Levels : / Nil
Compatibility: / 5%D ONLY
*Available only as SAS drug from TGA. Can be used in Level 3 units only.