Jeffrey L. Segar, MD, John M. Dagle, MD, PhD, and Sarah B. Tierney PharmD
Peer Review Status: Internally Peer Reviewed
Jeffrey L. Segar, MD, Elizabeth W. Amelon, Pharm.D., BCPS, Sarah B. Tierney, Pharm.D. Systemic narcotics are the most commonly
used agents for management of pain in the post-operative patient. They are also the most frequently used agents given to ventilated children, particularly when paralyzed with neuromuscular blockers, or those with bronchopulmonary dysplasia.
Analgesics and Sedatives *Treatment of withdrawal [abstinence] from narcotics:Analgesics and Sedatives
Peer Review Status: Internally Peer Reviewed [6/19/2014]DrugDoseOnset/Duration of ActionComments Narcotic analgesic and sedative:
Morphine
IV infusion: 10 - 20 mcg/kg/hr IV [may need up to 50 mcg/kg/hr] IV: 0.05 - 0.1 mg/kg IV q 1 h PRNPO: 0.05 - 0.1 mg/kg PO q 4-6 h PRN
IV: Peak effect occurs in 20 minutes and lasts for 6-8 hours in preterm infants and 2-4 hours in full-term infants.PO: Peak effect occurs in 1 hour.
Increased entero-hepatic circulation prolongs half-life in preterm infants. Can cause histamine release. Higher doses may be needed as tolerance develops.
Narcotic analgesic and sedative:
Fentanyl
IV infusion: 1 - 5 mcg/kg/hr IV IV: 2 - 5 mcg/kg IV q 1 h PRNand up to 10 mcg/kg IV PRN for procedures
IV: Onset of action is almost immediate and lasts ~ 1 hour.
Minimal hemodynamic effects. No histamine release. Rapid onset of tolerance.
Benzodiazepine:
Lorazepam
IV/PO: 0.05 - 0.1 mg/kg IV q 1-2 h PRN
IV: Onset of action occurs within 5 minutes with peak effect occurring in 45 minutes. Duration of action is 3-24 hours.PO: Onset occurs within 60 minutes.
May repeat dose in 10-15 minutes for status epilepticus. Note: some products contain benzyl alcohol and propylene glycol. Do not exceed 25 mg/kg/day of benzyl alcohol.
Benzodiazepine:
Midazolam
IV: 0.05 - 0.15 mg/kg IV q 2-4 h PRN PO: 0.25 mg/kg PO 30-60 min prior to procedureIntranasal: 0.3 mg/kg prior to procedure
Rapid onset of action. Duration of action is 2-6 hours. Intranasal: Onset occurs in 5 minutes and lasts 30-60 minutes. Can repeat dose once in 5-15 minutes.
Contains benzyl alcohol. Do not exceed 25 mg/kg/day of benzyl alcohol.
Non-narcotic analgesic and sedative:
Dexmedetomidine
IV infusion: 0.25 - 1 mcg/kg/hr [start at 0.25 mcg/kg/hr and increase dose by 0.25 mcg/kg/hr q 2-4 h PRN]
Must wean off drip. To wean, decrease dose by 0.1 mcg/kg/hr q 12-48 h. Consider starting PO clonidine if patient has been on dexmedetomidine for > 3 days. Overlap clonidine with dexmedetomidine therapy for 2 days. Clonidine PO dose: 2 mcg/kg q 6 h, then 1 mcg/kg q 6 h, then 1 mcg/kg q 12 h, then 0.5 mcg/kg q 12 h.
Barbiturate sedative/ anticonvulsant:
Phenobarbital
PO/IV: 2.5 mg/kg/dose BID
PO: Onset occurs within 20-60 minutes. IV: Onset occurs within 5 minutes with peak effect in 30 minutes.Half life is 40-200 hours.
Phenobarbital is not necessarily recommended for sedation in neonates. Tolerance to sedation develops rapidly. Also used for Neonatal Abstinence Syndrome [see protocol].*
Non-narcotic analgesic:
Ibuprofen
PO: 5 - 10 mg/kg PO q 6-8 h PRN [max: 40 mg/kg/24 h]
PO: Onset occurs within ~ 1 hour with peak effect in 2-4 hours. Duration of action is 6-8 hours.
Recommended for pain in children who are > 6 months of age.
Non-narcotic analgesic:
Acetaminophen
PO: 10 - 15 mg/kg PO q 4-6 h PRN
PR: 15 - 30 mg/kg PR q 6 h PRN
IV: PO: Peak effect occurs within 1 hour. Duration of action is 4-6 hours. PR: Absorption is erratic and onset of action can be prolonged.IV: Onset of action is within 5-10 minutes with peak effect in 1 hour. Duration of action is 4-6 hours.
Note: Higher rectal doses may be used [up to 40 mg/kg/dose PR].
Hypnotic:
Chloral hydrate
PO: 25 - 50 mg/kg/doseq 6-12 h
Note: Chloral hydrate is no longer available because it was discontinued by the manufacturer. Can cause cardiac toxicity at high levels. Repeated high doses in TPN dependent patients increases the risk of cholestasis.
Jeffrey L. Segar, MD and Sarah B. Tierney, PharmD
Peer Review Status: Internally Peer Reviewed 12/19/12
Agents should always be used in concert with adequate sedatives and analgesics
Vecuronium | IV: 0.1 [0.1 mg/kg/h for continuous infusion] | 1-3 | Duration [dose-dependent]: 30-40 minutes Dosing interval: 60-120 minutes Protein binding: 60-80% |
|
Pancuronium | IV: 0.15 | 1-5 | Duration [dose-dependent]: 24 minutes Dosing interval: 60-120 minutes Protein binding: 87% |
|
Rocuronium | IV: 0.4 – 0.6 Do not give IM | 0.5-1.0 | Duration: 20-120 minutes Dosing interval: 10-30 minutes Protein binding: 30% |
|
*Depolarizing agents are not routinely recommended because they persist for a longer duration due to their resistance to acetylcholinesterase.
*Reversal of neuromuscular blockade: Neostigmine 0.04 – 0.08 mg/kg IV and atropine 0.02 mg/kg.
References:
- Feltman DM, Weiss MG, Nicoski P, and Sinacore J. Rocuronium for nonemergent intubation of term and preterm infants. Journal of Perinatology 2011; 31: 38-43.
- Lexi-Comp, Inc. Pediatric Drug Information. Accessed online. Updated annually.
- Johnson PN, Miller J, Gormley AK. Continuous-infusion neuromuscular blocking agents in critically ill neonates and children. Pharmacotherapy 2011; 31 [6]: 609-620.
- Thomas Reuters. Neofax. 24th Edition. 2011.
Anticonvulsants
Jeffrey L. Segar, MD and Sarah B. Tierney, PharmD
Peer Review Status: Internally Peer Reviewed 3/13/12
Phenobarbitial | 1Loading 15-20 mg/kg IV over 15 - 20 min. 2Maintenance: 3-5 mg/kg IV, IM , POq 12 - 24 hr. [first dose given 12 to 24 hours after loading] | 15-40 mg/L | IV: Within 5 minutes PO: Within 20-60 minutes Max IV effect within 30 minutes Duration: 5-10 hours | Sedation, respiratory arrest, hypotension, T1/2 96 h / increase 1st two wk of life; induces drug metabolism[interactions], sensitivity reactions IV push < 1 mg/kg/min. |
3Phenytoin | Loading: 15 - 20 mg/kg IV *Maintenance: 5 - 8 mg/kg/d q 8 - 12 hr IV [first maintenance dose 24 hours after loading] | 10-20 mg/L4 | Large patient variability in onset and duration | Extravasation risk due to high pH. *If >1 week old, may need to increase dosage to ³ 8 mg/kg IV q12 h or q 8h to maintain therapeutic effect / levels IV push < 0.5 mg/kg/min. Ø IM |
Fosphenytoin [prodrug of phenytoin] | Dosing the same as for phenytoin; however, doses are expressed in phenytoin sodium equivalents [PEs]. 1 PE = 1 mg phenytoin | Same as for phenytoin | Conversion of fosphenytoin to phenytoin is 7-15 minutes then phenytoin kinetics take over | Rapidly absorbed via IV and IM route. Can give intraosseously. Fosphenytoin is preferred product for pediatrics. |
Levetiracetam [Keppra] | Loading dose5 10 mg/kg IV over 15 minutes. Up to 50 mg/kg loading dose has been used. PO can also be used. Maintenance dose 10 – 30 mg/kg/dose q 24 hours in neonatal period and q12 hours in infancy. | 10-40 mcg/mL However, not routinely monitored. | IV/PO: Rapid Max effects within 60 minutes. Duration: not specified t1/2 = 9 hours | Must dilute to a concentration of 5 mg/ml in D5W or NS prior to IV administration. No drug-drug interactions. PO rapidly and completely absorbed. IV:PO conversion is 1:1. Well-tolerated even at a loading dose of 50 mg/kg. Adverse effects reported are some sedation and irritability at 24 hours after initial dose. |
Lorazepam | 0.05 - 0.1 mg/kg/dose slow IV push over 2 - 3 min. | IV: Within 5 minutes Duration: 3-24 hours. | May increase phenobarbital level. May cause respiratory depression. | |
Diazepam | 50.2 to 0.75 mg/kg slow IV push. Give in maximum increments of 0.2 mg/kg q 2 min. If seizures stop before completion of dosing, discontinue infusion. Rectal dose: 0.5-1.0 mg/kg. | 0.15-0.3mcg/ml | IV: Within 1-3 minutes Rectal: Within 2-10 minutes | CNS depression, respiratory depression including apnea, phlebitis. Doses may be repeated q 15 - 30 min. x 2 to 3 doses total |
Footnotes:
- If seizures are noted to continue after the initial phenobarbital loading dose, an additional 5 mg/kg bolus dose can be given every 15 - 30 minutes [total load dose should not exceed 35 mg/kg]. Sedation occurs at serum concentrations above 40 mg/L. Respiratory depression may develop with larger loading doses [serum concentrations above 60 mg/L] or if given in conjunction with diazepam.
- Maintenance phenobarbital doses of 5 mg/kg/day may occasionally result in accumulation of serum levels to >30 mg/L in the neonate less than 1 week of age. Unless undue sedation occurs [monitoring of serum phenobarbital levels will be of assistance in identifying and managing such patients] little adverse consequences should be anticipated from the higher serum levels. Therapeutic levels may be > 45 mg/L and require very careful respiratory monitoring.
- Phenytoin is contraindicated in patients with heart block or sinus bradycardia. FDA Alert [11/24/08]: Potential increased risk of serious skin reactions including Stevens Johnson syndrome and toxic epidermal necrolysis in Asian patients positive for HLA allele, HLA-B*1502. This allele occurs almost exclusively in patients with ancestry across broad areas of Asia, including Han Chinese, Filipinos, Malaysians, South Asian Indians, and Thais.
- Maintenance doses of phenytoin are impossible to accurately establish because of marked individual variation. Frequent plasma phenytoin concentration measurements are essential, particularly in the rapidly changing period of the first 3 weeks of age. Drug is highly protein bound; free fraction of drug may be increased in patients with hypoalbuminemia and/or hyperbilirubinemia. If the therapeutic range is based on the premise that in the neonate there is a greater concentration of unbound phenytoin in plasma at any given total plasma concentration, then a total plasma phenytoin concentration of 6-14 mcg/ml will provide the same concentration of unbound phenytoin as a 10-20 mcg/ml total concentration in an adult [Loughnan et al, 1977]. However, the actual relationship between serum levels and anticonvulsant activity of phenytoin [alone] has not been demonstrated in the neonate. The plasma level 8 hr. after dosing should be the most representative of the average phenytoin concentration.
- Levetiracetam can be used as monotherapy or adjunctive therapy for neonatal seizures. In a retrospective case review of 22 neonates ≥ 37 weeks [Khan et al 2011]; 20 patients received a loading dose of 50 mg/kg, 1 patient a loading dose of 20 mg/kg, and 1 patient a loading dose of 10 mg/kg. The patients’ were then maintained on 25 mg/kg q 12 hours, 20 mg/kg q 12 hours, and 10 mg/kg q 12 hours, respectively. Of the 22 patients, 19 [86%] demonstrated immediate seizure cessation at 1 hour. Furthermore, 7/22 [32%] achieved complete seizure cessation after administration of the loading dose, 14 [64%] achieved seizure cessation by 24 hours, 19 [86%] by 48 hours, and all 22 [100%] by 72 hours. Outcomes were confirmed by electroencephalographic correlation. Follow-up at 6 months after initiation of therapy demonstrated no new adverse effects. When used as 2nd or 3rd line therapy phenobarbital and phenobarbital and phenytoin/fosphenytoin where the first-line agents, respectively.
- The total acute IV dose of diazepam necessary to control neonatal seizures has ranged from less than 0.1 mg/kg to 2.7 mg/kg. Based on the proposed therapeutic serum level of diazepam, a dose of 0.5 mg/kg should produce levels in excess of that ordinarily necessary. Only in very unusual circumstances should alternate routes of administration be considered. Evidence does exist to support the efficacy of rectal administration. The parenteral injection form is used in conjunction with a syringe and catheter inserted 5 cm into the rectum. It is important to note that there is no evident advantage in using diazepam instead of phenobarbital, but to maintain anticonvulsant effect, a longer acting anticonvulsant such as phenobarbital is generally used following diazepam or lorazepam [as this combination often produces respiratory depression, close monitoring of the patient is essential].
References:
- Abend NS, Gutierrez-Colina AM, Monk, HM, et al. Levetiracetam for Treatment of Neonatal Seizures. J Child Neurol 2011; 26[4]: 465-470.
- Khan O, Chang E, Cipriani C, et al. Use of Intravenous Levetiracetam for Management of Acute Seizures in Neonates. Pediatr Neurol 2011; 44: 265-269.
- Lexi-Comp, Inc. Pediatric Drug Information. Accessed online. Updated annually.
- Merhar SL, Schibler KR, Sherwin CM, et al. Pharmacokinetics of Levetiracetam in Neonates with Seizures. J Pediatr 2011; 159: 152-4.
- Thomas Reuters. Neofax. 23rd Edition. 2010.
- Warner A, Privitera M, Bates D. Standards of laboratory practice: antiepileptic drug monitoring. Clinical Chemistry 1998; 44: 1085-1095.
Antimicrobials
Sarah Tierney, Pharm.D. and Jonathan Klein, MD
Peer
Review Status: Internally Peer Reviewed 12/20/12
Gentamicin peak and trough guidelines1
Initial trough | 0.3-1.0 | Just prior to 2nd dose |
Late troughs | 0.3-1.0 | Obtain on day 7 if continuing therapy >7 days and then weekly thereafter. Draw earlier and/or more frequent if there is decreased urine output or other changes in renal function. |
Peaks | 5-12 | IV: 30 minutes after the end of the infusion |
Gentamicin is a concentration-dependent, bactericidal antibiotic used for the treatment of gram-negative organisms including Pseudomonas, Escherichia coli, Proteus, and Serratia. It is also used in combination with ampicillin for treatment of gram-positive group B Streptococcus species and Listeria monocytogenes. The rationale for using the extended-interval dosing protocol for gentamicin is based on the concentration-dependent bactericidal activity of aminoglycosides, the extended post-antibiotic effect, and the possibility of reduced nephrotoxicity and ototoxicity.1,2
Bactericidal effects
The current gentamicin dosing protocol [Neofax] achieves an early and high peak gentamicin plasma concentration for optimal bactericidal effect about 94% of the time.3,4 In vitro, aminoglycosides eradicate bacteria at a rate proportional to the peak concentration attained. Therefore, a high peak level results in a more rapid and efficient bactericidal effect against susceptible organisms. In addition, aminoglycosides have an extended post-antibiotic effect [PAE] which is defined as the time period that surviving bacteria, following exposure to an antibiotic, cannot metabolize or multiply even though extracellular antibiotic is no longer present. The duration of PAE is approximately 8-12 hours in the immunocompromised patient.1
Potential toxicity
The uptake of aminoglycosides occurs in the renal tubular cells and is a saturable process; therefore, larger doses would not be expected to be any more nephrotoxic than smaller doses. Both animal and human studies have shown that the concentration in the renal cortex is significantly lower when administered as a single daily dose than when divided and administered more frequently. Animal data supports an accumulation threshold in the organ of Corti as well, so there is the potential for less ototoxicity.1,5 Although neonates are believed to experience a lower risk for ototoxicity and nephrotoxicity than adults;5 sustained elevated peak [>12 mg/L] or trough [>2 mg/L] concentrations may cause these toxicities in neonates.3
References
- Behm-Dillon, DM. Appropriate Use of Antibiotics: The Antibiotic Advisory Subcommittee and You. UIHC P&T News; Jan/Feb 2000. Accessed 10/28/2009.
- Gentamicin. Pediatric Dosage Handbook. 15 Edition. 2008: 819-823.
- Hoff DS, et al. Pharmacokinetic Outcomes of a Simplified, Weight-Based, Extended-Interval Gentamicin Dosing Protocol in Critically Ill Neonates. Pharmacotherapy 2009; 29 [11]: 1297-1305.
- Gentamicin. Neofax. 2008: 42-43.
- Haughey DB, et al. Two-compartment gentamicin pharmacokinetics in premature neonates: a comparison to adults with decreased glomerular filtration rates. J Pediatr 1980; 96:325-30.
Edward F. Bell, MD and Jeffrey L. Segar, MD
Peer Review Status: Internally Peer Reviewed
This nomogram is for use only in term neonates [40 mcg/mL [SI: >172 micromoles/L] Lexi-Comp, Inc. Pediatric Drug Information. Accessed online. Updated annually. Jeffrey L. Segar, MD Purpose: To Determine Patient Drug Kinetic Parameters Enabling Optimal Dosage Selection Drug half-life studies are most valuable in cases of: B. unpredictable variations in individual pharmacokinetics [i.e., aminoglycosides in neonates]. C. suspected alteration of drug metabolism and/or elimination [renal disease, liver disease, shock, etc.] In most situations, half-life studies should be done rather than single "peak" or "trough" studies - particularly in situations I.A - I.C above. B. The time interval between sampling should be sufficient to allow the drug concentration to decrease by one-half [i.e., T 1/2]. This will avoid errors in "extrapolation". If the patient is known or suspected
of having a prolonged T 1/2, the draw times should be greater in interval than the prolonged T 1/2, but not greater than the dosing interval [see recommendation in Table 2]. C. Two or preferably three blood samples should be drawn to assure greatest accuracy. All information regarding patient's weight, drug dose, dosing interval, time of administration, route of administration, and time blood samples were drawn should be provided. This information will
then appear in the chart record and will allow accurate pharmacokinetic calculations to be made.
A. Determination of T1/2: [First Order]Phenytoin/fosphenytoin
References:
Warner A, Privitera M, Bates D. Standards of laboratory practice: antiepileptic
drug monitoring. Clinical Chemistry 44:5 [1998] 1085-1095.
Peer Review Status: Internally Peer ReviewedWhen to use:
A. drug with narrow therapeutic index [little
difference between therapeutic and toxic blood levels].
How to accomplish accurate T1/2 determination:
A. Blood sampling times should be selected to assure maximum accuracy. This means that one should avoid sampling "too close to the time of administration" [drug still being infused] yet not sample at a time when the concentration of drug may be too low to chemically detect.
kel =
ln Co - ln Ct
t
[ Co: initial concentration; Ct: concentration after time = t]
t 1/2 =
0.693
kel
B. Optimal Dosing Schedule [T]:
T= log [Cmax/Cmin] x 3.3 x t 1/2 |
[Cmax: maximum concentration after dose] |
Cmin: trough concentration] |
When to do T1/2 studies vs. single time blood level studies
Single blood level determinations have only limited utility since they can be used for dosage adjustment only on a very limited scale. They are useful as a screening procedure to assure that adequate dosing is being accomplished. Drugs with relatively longer half-lives [very little difference in peak and trough levels] can ordinarily be followed by single blood levels determinations.
When a single blood level is used for monitoring the progress of the patient, be sure to select a time which avoids problems of IV delivery time. Generally, a -2-3 hour single time point- following IV administration is best.
TABLE 1: RECOMMENDED SINGLE BLOOD LEVEL SAMPLING TIMES
Digoxin | [1] | 6-8 hrs. post dose |
Phenobarbital | [2] | Time consistent with previous levels [if any] |
Phenytoin | [2] | Depends on formulation |
Theophylline | [3] | 2 hrs. post dose [rapidly dissolving tablet or liquid] |
In general, T 1/2 studies are not absolutely needed until several doses of the drug have been given [1 to 2 days]. The exception is the patient with severe organ dysfunction who will require repeated blood level determinations to adjust dosage. In these compromised patients, T 1/2 studies should be done after the first dose and before subsequent dosing. T 1/2 studies only need to be repeated if a marked change occurs in the patient's organ function status.
TABLE 2: RECOMMENDED T 1/2 SAMPLING TIMES
6 | 2 | 3 | 4 |
8 | 2 | 3 | 4-6 |
12 | 2 | 4 | 6 |
*Sampling within 1 hr. of drug administration is likely to be confusing because some drug may still be in the process of being infused or absorbed.
TABLE 3: USUAL THERAPEUTIC RANGE
Gentamicin | 5-8 | 1-2 |
Tobramycin | 5-8 | 1-2 |
Kanamycin | 20-25 | 5-10 |
Amikacin | 20-25 | 5-10 |
Chloramphenicol | 20 | 5-15 |
Vancomycin | 25-40 | 5-1 |
Other Resources
Jeffrey L. Segar, MD
Peer Review Status: Internally Peer Reviewed
The cause of apnea should be thoroughly investigated [see Pulmonary section]. Only if no treatable cause can be found, the diagnosis of apnea of prematurity can be considered [diagnosis of exclusion]. If necessary, central apnea of prematurity may be treated using one of the following drugs.
Caffeine citrate | 20 mg/kg IV/PO followed by 5 mg/kg/day may need up to 7.5 mg/kg/d | 5-20 | > 50 mcg/ml [see Theophylline] |
*Theophylline | 5 mg/kg IV followed by 2 mg/kg q 8 - 12 h | 5 - 15 | > 20 mcg/ml Irritability, tachycardia, arrhythmia, seizures |
Doxapram1 | 1 - 2 mg/kg/h IV 12 - 24 mg/kg q 6 h PO | 1-2 | > 5 mcg/ml Hypertension, feeding intolerance, seizures. Contains benzyl alcohol |
1 Further studies needed on bioavailability, toxicity, and long term efficacy. Potential toxicity with vehicle which contains benzyl alcohol. The drug of choice caffeine. If apnea persists despite appropriate doses, doxapram may replace caffeine. If response is still inadequate, both drugs may be combined.
Jeffrey L. Segar, MD and Sarah B. Tierney,
PharmD
Peer Review Status: Internally Peer Reviewed 12/19/12
β-agonists | Albuterol [One MDI actuation delivers 100 mcg [0.1mg]] | Acute: 0.1 mg/kg via nebulization/MDI every 1-4 hours as needed. Can increase to 0.5 mg/kg. Chronic: 0.1 mg/kg every 12 hours | Increased heart rate, agitation | |
Albuterol-Ipatropium [One MDI actuation delivers | 1-2 puffs BID | Added anticholinergic effect. The combination of ipratropium with a beta-agonist produces more bronchodilation than either drug individually. | ||
Levalbuterol [0.63 mg] | 1-2 puffs BID | [R]-enantiomer of racemic albuterol and associated with less tachycardia | ||
Methylxanthines | 1Theophylline | LD: 5-6 mg/kg IV/PO followed by MD: 2 mg/kg IV/PO every 8 hours | Increased heart rate, irritability, arrhythmia, seizures. | Metabolism varies with age. Therapeutic levels [peak]: 10-20 mg/L. Consider changing to a Q6h schedule if unable to achieve adequate levels after 4 weeks on therapy. |
Footnotes:
- Monitoring serum levels is required. See “Use of Drug Monitoring Levels in the NICU” for more information.
References:
- Lexi-Comp, Inc. Pediatric Drug Information. Accessed online. Updated annually.
- Thomas Reuters. Neofax. 24th Edition. 2011.
Jeffrey L. Segar, MD and Sarah B.
Tierney, PharmD
Peer Review Status: Internally Peer Reviewed
Emergency Drug Doses
Adenosine [3 mg/ml] Acute treatment of supraventricular tachycardia |
| Rapid IV push over 1-2 seconds Flush line immediately with 5-20 ml NS Infuse as close to IV site as possible IO administration also successful |
Atropine [0.1 mg/ml] Bradycardia | 0.02 mg/kg/dose IV | May repeat x 1 dose in 3 minutes |
Calcium gluconate [100 mg/ml]= 9.4 mg elemental calcium /ml Cardia arrest Hypocalcemia | 100 mg/kg/dose IV Not for IM or SQ use | May repeat x 1 dose, then dose per ionized calcium results Administer by slow IV push for cardiac arrest, infuse over 30-60 minutes for other indications. Stop infusion if HR is greater than 100 bpm. Do not give intra-arterially. |
Dextrose 10% [0.1 Gm/ml] Hypoglycemia Hyperkalemia in combination with insulin | 0.2 Gm/kg/dose IV as D10W Then continuous infusion of D10W at a GIR of 4-8 mg/kg/min. Titrate to attain normoglycemia. | 2 ml/kg of Dextrose 10% Hyperkalemia: Continuous infusion of 0.5 g/kg/hr dextrose and 0.1-0.2 units/kg/hr regular insulin. Dextrose and insulin dosages are adjusted based on serum glucose and potassium concentrations. Abrupt discontinuation of dextrose infusion is not recommended due to the risk of rebound hypoglycemia. Glucose concentrations less than D15 should be administered via a central vein to minimize risk of phlebitis and thrombosis. |
Dopamine To give 10 mcg/kg/min. @ 1 ml/hr : weight x 30 = mg of dopamine [in kg] in 50 ml D5W/NS Hypotension | Begin at 5 mcg/kg/min. May increase in increments of 2.5 - 5 mcg/kg/min. as needed up to 20 mcg/kg/min. | Consider if poor peripheral perfusion, evidence of shock, or thready pulses after epinephrine and volume expansion [and bicarbonate] Administer into a central vein when possible. Phentolamine used for treatment of IV infiltrates. |
Epinephrine 1 : 10,000 [0.1 mg/ml] Resuscitation Severe bradycardia Short term use for systemic hypotension | 0.1 - 0.3 ml/kg/dose IV, IO [0.01 – 0.03 mg/kg], - For continuous infusion - start at 0.05 mcg/kg/min to a maximum of 1 mcg/kg/min. | Rapid IV push followed by 0.5-1 ml NS flush May repeat every 3-5 minutes ALWAYS use the diluted 1:10,000 [0.1 mg/ml] concentration for individual doses. Only use the 1:1,000 [1 mg/ml] for continuous infusion solutions NEVER inject into an artery Do not mix with bicarbonate Effectiveness of drug increases if acidosis is corrected May mix dose volume with 3-5 ml NS Follow ET administration with several positive pressure ventilations. Do NOT administer these higher doses intravenously. |
Fentanyl [50 mcg/ml] Analgesia Sedation Anesthesia | 1 mcg/kg | Consider 10 mcg/ml for doses less than 5 mcg |
Hydralazine [20 mg/ ml] Hypertension by vasodilation | 0.1-0.5 mg/kg | Doses greater than 2 mg; consider 0.4 mg/ml |
Lorazepam [2 mg/ml] Sedation Seizures | 0.05-01 mg/kg | Slow IV push Seizures, may repeat q 10-15 minutes |
Morphine [1 mg/ml] Pain Sedation | 0.05-0.1 mg/kg | Slow IV push over 5-10 minutes, IM, SQ |
Naloxone [1 mg/ml] Narcotic antagonist | 0.1 ml/kg rapid IV push, IM | May repeat in 3 - 5 minutes if no response during resuscitation. Duration of reversal is brief; may need repeated doses. |
Phenobarbital [65 mg/ml] Anticonvulsant | 15 - 20 mg/kg -For refractory seizures- Additional 5 mg/kg doses, up to a total of 40 mg/kg can be given. | IV push over 10-15 minutes, no faster than 1 mg/min. Drug can be administered by slow IV push, IM, PR, or PO. Diluted IV product can be used orally. |
Sodium Bicarbonate 4.2% [0.5 mEq/ml] Metabolic acidosis | 1 - 2 mEq/kg | Slow IV push over 30 minutes. Use only 0.5 mEq/ml solution for infants Infuse 1 mEq/kg over ≥ 1 minute CAUSTIC; don’t infuse faster than 2 ml/kg/minute. NOT routinely given for resuscitation. Can also be given by continuous infusion, IO, or PO |
Vecuronium [ 1mg/ml] Paralysis Rapid Sequence Intubation* | 0.1 mg/kg | IV push over less than 1 minute |
Volume Expanders RBCs, NS Hypotension Hypovolemia With evidence of acute blood loss or a decrease in effective volume | RBCs: 15 ml/kg IV NS: 10 ml/kg IV | RBCs: Infuse over 4 hours NS: Infuse over at least 10 minutes, but preferably over 30-60 minutes. Consider if poor response to resuscitative efforts or weak pulses with a good heart rate |
Jeffrey L. Segar, MD
Peer Review Status: Internally Peer Reviewed
Definition [not fully clear]:
- Term infants: > 90/65 mm Hg
- Preterm infants: > 80/45 mm Hg [Liberman]
Management should be directed towards correcting the underlying etiology. It is uncertain whether moderate hypertension associated with bronchopulmonary dysplasia requires therapy, since it is mostly transient. Renovascular hypertension can be managed pharmacologically.
Pharmacologic Therapy for Neonatal Systemic Hypertension
Hydralazine | 0.1-0.5 mg/kg/dose q 4-6 h IV | hypotension |
Propranolol | 0.25 - 1.0 mg/kg/day q 6-12 h PO | hypoglycemia, hypotension |
Captopril | 0.05 -0.1 mg/kg/dose q 6-8 h PO | neutropenia, proteinuria, renal failure |
Methyldopa | 10 mg/kg/day q 6-12 h, followed by increments of 5-10 mg/kg/day every 2-4 days up to 65 mg/kg/day | hepatitis, leukopenia |
- Iowa Neonatology Handbook Home
- Cardiology: NICU Handbook
- Feeding: NICU Handbook
- Fluid management: NICU Handbook
- Gastrointestinal: NICU Handbook
- General: NICU Handbook
- Hematology: NICU Handbook
- Infection: NICU Handbook
- Jaundice: NICU Handbook
- Metabolic: NICU Handbook
- Neurology: NICU Handbook
- Pharmacology: NICU Handbook
- Procedures: NICU Handbook
- Pulmonary: NICU Handbook
- Temperature: NICU Handbook