Read Pediatric Intensive Care Unit (PICU) Nurse's Guide: Intravenous Drip List ­ Approved for RN Administration text version

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Aminophylline

Antiasthmatic, bronchodilator, respiratory stimulant, theophyline derivative

Continuous infusion: 6 wks-6 months: 0.5 mg/kg/hr 6mo-1 year: 0.6-0.7 mg/kg/hr 1-9 yrs: 1-1.2 mg/kg/hr 9-12 yrs: 0.9 mg/kg/hr > 12 yrs: 0.7 mg/kg/hr Dosage should be adjusted to serum level measurements during the first 12-24 hrs

25 mg/ml

0.36 mg/kg/min

Amiodarone/ Cordarone

Antiarrhythmic

Initial maintenance: 5 mcg/kg/min (7.2 mg/kg/day) Increase incrementally until desired effect or 15 mcg/kg/min

15 mcg/kg/min (21.6 mg/kg/day)

6 mg/mL in D5W 30 mg/min

Monitoring Parameters: Respiratory rate, heart rate, serum theophyline levels, Asthma levels: 10- arterial or capillary blood gases (if applicable); number and 20mcg/ml severity of apnea spells (apnea Neonatal apnea: 6- of prematurity) Adverse Effects: may cause 13 mcg/ml dysrhythmias; GI upset, GE reflux, diarrhea, n/v, abd pain, nervousness, agitation, dizziness, muscle cramp, tremor, tachycardia, PVC, seizure Administer via Monitoring Parameters: cardiac, liver, renal, pulmonary, central venous catheter, if possible and thyroid function. EKG due to phlebitis with should be monitored. peripheral infusions Ophthalmologic exams are > 3 mg/ml in D5W recommended. Adverse Effects: bradycardia, (but conc <= 2.5 mg/ml may be less corneal deposit, hypotension, irritating). Use of photosensitivity, tremor and involuntary disturbances. glass bottles for infusion > 2 hours; polyvinyl tubing is recommended. Infused via infusion pump.

Monitor theophylline levels

Page 1 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Alteplase (TPA, Cathflo)

Antithrombotic

0.6 Occluded catheters: mg/kg/hour <10 kg: 0.5 mg in NS in a volume required to fill lumen 10-29 kg: 1 mg/mL, dose equal to 110% of catheter lumen volume, max of 2 mL, instilled into occluded catheter, up to 2 doses may be used, separated by 120 min >30 kg: 2 mg/2 mL instilled into occluded catheter, up to 2 doses may be used, separated by 120 min catheter clearance: attempt to aspirate blood after 30 min of dwell time; if successful, aspirate 4-5 mL of blood and flush gently with NS; if unsuccessful, allow to dwell 90 more min and repeat. catheter clearance: if still unsuccessful after 120 minutes, a second dose may be instilled Systemic thromboses: 0.1-0.6 mg/kg/hour for 6 hours (some pts may require longer or shorter duration of therapy); initiate at 0.1 mg/kg/hour if no response after 6 hours, increase infusion by 0.1 mg/kg/hr to maximum of 0.5 mg/kg/hr; maintain fibrinogen > 100 mg/dl

1 mg/ml

Administer via infusion pump; extravasation may cause bruising or inflammation

Monitoring Parameters: systemic use: blood pressure, temp, CBC, reticulocyte, platelet count, fibrinogen, plasminogen, signs of bleeding Adverse Effects with systemic use: sepsis, GI bleed, venous thrombosis, hypotension, fever, intracranial or cerebral hemorrhage, bleeding, bruising

Page 2 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Alprostadil (Prostin VR, PGE1)

Prostaglandin

Temporary maintenance of patency of ductus arteriosus (PDA) neonates with ductaldependent cyanotic and acyanotic congenital heart disease until surgery can be performed: 0.01-0.1 mcg/kg/min

>0.1 mcg/kg/min have not improved efficacy in PDA

Not established, highest conc in package insert is 20 mcg/ml

0.1 mcg/kg/min (once therapeutic response is attained, gradually decrease infusion rate to lowest effective dose)

Apnea occurs in 1012% of neonates weighing <2kg, usually within the first hour of therapy. Infusion rate should be slowed if fever or hypotension develops.

Calcium chloride

Antacid, antidote for hydrofluoric acid, electrolyte supplement

1-2 grams per (Dose expressed in mg of dose calcium chloride): Cardiac arrest in presence of hyperkalemia or hypocalcemia: 20 mg/kg; may repeat in 10 min if necessary Hypocalcemia: 10-20 mg/kg/dose repeated Q4-6H if needed Hypocalcemia secondary to citrated blood transfusion: give 0.45meq elemental calcium for each 100ml citrated blood transfused Tetany: 10mg/kg over 5-10 min; may repeat after 6-8 hours or follow with an infusion with a max dose of 200 mg/kg/day

10% solution (100 mg/ml); (1.4 meq/ml of elemental calcium for direct IV push); IV infusion: 10-20 mEq/L for peripheral infusion

Infusion through central line preferred- avoid infusion into small veins in dorsum of hand or foot and scalp veins because of risk of IV push: 50-100 mg/min of extravasation. calcium chloride Infusion should be stopped if patient complains of discomfort. IV infusion: 20 mg/mL; 45-90 mg/kg over 1 hour. 0.6-1.2 mEq/kg over 1 hour.

Monitoring Parameters: Arterial pressure, respiratory rate, heart rate, temperature, pO2, monitor for gastric obstruction in pts on drip > 120 hrs Adverse Effects: Hypotension, flushing, bradycardia, tachycardia, fever, cortical proliferation of long bones, respiratory depression, apnea Monitoring Parameters: Heart rate, ECG during IV administration, serum calcium, phosphate, magnesium. Adverse Effects: Metallic taste, cardiac arrest (with rapid IV injection), hyperkalemia, hypertension, hypomagnesemia, hypophosphatemia, milk-alkali syndrome, vasodilation, arrhythmias

Page 3 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Cisatracurium/ Nimbex

Neuromuscular blocker; skeletal muscle relaxant

Initial: 0.1 mg/kg over 5-10 seconds during halothane or opioid anesthesia. Maintenance: initial infusion of 3 mcg/kg/min, then decrease to 1-2 mcg/kg/min Loading dose: 1 mcg/kg Maintenance infusion of 0.2 to 0.7 mcg/kg/hour for a maximum of 24 hours Adjunct to anesthesia, 0.5 to 0.6 microgram/kilogram intravenously 10 to 15 minutes prior to anesthesia induction Post-op pain: 0.4 mcg/kg has been effective.

Bolus: 10 mg/ml Infusion: 0.4 mg/ml

Dexmedetomidine

(Precedex)

Alpha-2 adrenergic agonist, sedative

4 mcg/ml

Monitoring Parameters: muscle twitch response to peripheral nerve stimulation, heart rate, blood pressure Adverse Effects: bradycardia, hypotension, bronchospasm (all rare) Monitoring Parameters: HR, BP, Adverse Effects: Hypertension, hypotension, bradycardia, nausea, dizziness, fatigue

Diltiazem (Cardizem)

Antianginal, Antihypertensiv e Calcium channel blocker

Loading dose: 0.25mg/kg over 25 min; if response inadequate after 15 min, a second 0.35 mg/kg may be given Continuous infusion: 0.050.15mg/kg/hr Continuous infusions rates of 515mg/hr have been reported but are not adjusted for weight or age.

1 mg/ml

Monitoring Parameters: Heart rate, blood pressure Adverse Effects: Bradycardia, hypotension, tachycardia (rare), flushing, peripheral edema, CHF, headache, dizziness, insomnia

Page 4 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Dobutamine/ Dobutrex

Adrenergic agonist

Dose: 2-20 mcg/kg/min; titrate according to response. Cardiac testing initial: 0.5-5 mcg/kg/min

40 mcg/kg/min

8000 mcg/ml

Correct hypovolemia prior to initiation of therapy. Infiltration causes local inflammatory changes or extravasation may cause dermal necrosis

Monitoring Parameters: blood pressure, ECG, heart rate, electrolytes (potassium), pulmonary wedge pressure, cardiac output. Adverse Effects: chest pain, hypertension, HA, hypokalemia, injection site rxns, arrhythmias, eosinophilic myocarditis

Dopamine/ Adrenergic Dopastat, Intropin agonist

Initial: 0.5-10 mcg/kg/min Maintenance: 2-10 mcg/kg/min; increase by 510 mcg/kg/min q10-40 min to desired response

50 mcg/kg/min

6400 mcg/ml

Epinephrine/ Adrenalin

Adrenergic agonist

Cardiac arrest- initial 0.01 mg/kg (10 mcg/kg) or 0.1 ml/kg of 1:10,000 as 1st dose; 2nd dose 100 mcg/kg (0.1 ml/kg of 1:1000) IV; may be repeated every 3-5 min. Initial Endotracheal dose: 0.1 mg/kg, may repeat q3-5 min. Continuous infusion: 0.01-1 mcg/kg/min; titrate to effect.

0.03 mg/kg/dose for neonates, 0.1 mg/kg/dose for infants and children by IV push.

Maximum concentration for continuous infusion is 64 mcg/ml (due to phlebitis)

Do not infuse Monitoring Parameters: through an umbilical EKG, heart rate, CVP, MAP, urine output, if pulmonary artery catheter. artery catheter is in place Extravasation causes monitor CI, PECP, SVR, RAP, PVR tissue necrosis. Adverse Effects: anxiety, HA, injection site rxns, ectopic heartbeats, widened QRS complex, ventricular arrhythmias Do not administer if Monitoring Parameters: solution is brown or blood pressure, heart rate otherwise discolored Adverse Effects: anxiety, or if a precipitate is dizziness, sweating, arrhythmias, pulmonary edema present.

Page 5 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Epoprostenol / Flolan

Peripheral vasodilator, platelet aggregation inhibitor, prostaglandin

Dose: 2 ng/kg/min up to 20 ng/kg/min; may increase by 1-2 ng/kg/min increments every 15 minutes

20 ng/kg/min

15000 ng/ml

Abrupt withdrawal, interruptions in delivery, or large reductions in dosage may cause symptoms associated with rebound pulmonary hypertension (ie, dyspnea, dizziness, and asthenia. Short expiration (8 hrs) without cool pack

Monitoring Parameters: Pulmonary artery pressure, total pulmonary vascular resistance, systemic arterial pressure, cardiac output, and heart rate should be monitored during acute infusion in patients with primary pulmonary hypertension Adverse Effects: Flushing, sweating, nausea, hypotension, bradycardia, tachycardia, hyperglycemia,

Esmolol/ Brevibloc

Antiarrhythmic, Bolus dose: 100-500 mcg/kg beta-adrenergic infuse over 1 minute blocker Continuous infusion: 50-250 mcg/kg/min

1000 mcg/kg/min

10 mg/ml

Infusion rate should be controlled carefully, preferably with volumetric infusion pump

Fentanyl citrate/ Sublimaze

Analgesic, narcotic, general anesthetic, opioid

Dose: 1-5 mcg/kg followed by continuous infusion of 1-20 mcg/kg/hr until desired effect

75-100 50 mcg/ml mcg/kg/dose for anesthesia

Monitoring Parameters: blood pressure, EKG, heart rate, respiratory rate, IV site Adverse Effects: bradycardia, chest pain, HA, pain at injection site, bronchospasm (rare), seizures (rare) Chest wall rigidity Monitoring Parameters: related to high doses Respiratory rate, blood and rapid escalation pressure, heart rate, O2 to moderate doses- saturations, bowel sounds, may be reversed abdominal distention. with naloxone Adverse Effects: asthenia, confusion, urinary retention, arrhythmias, chest pain, apnea, circulatory depression

Page 6 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Furosemide/ Lasix

Antihypertensiv Edema initial, 1 mg/kg/dose; up e, diuretic to 2 mg/kg/dose every 6 hours

For edema: max 10 mg/kg/day

10 mg/ml

For doses less than 120mg: 0.5 mg/kg/min For doses greater than 120mg: 4 mg/min

Continuous infusion: initial 0.05 Or mg/kg/hour; titrate dosage to clinical effect up to 0.4 mg/kg/hr 6mg/kg/dose (600mg/day in adult-size patients)

Heparin

Anticoagulant

Neonates and children < 1 yr: loading dose = 75 units/kg over 10 minutes with initial drip at 28 units/kg/hr; adjust to APTT Children > 1 yr: loading dose = 75 units/kg with initial drip at 20 units/kg/hr; adjust APTT

Insulin, Regular

Antidiabetic agent

Diabetic ketoacidosis: loading dose = 0.1 unit/kg then maintenance infusion of 0.1 unit/kg/hour (range: 0.05-0.2 unit/kg/hour depending upon rate of decrease in serum glucose)

100 units/ml

Monitoring Parameters: serum potassium, serum sodium, blood pressure, blood glucose, hepatic and renal function. Adverse Effects: anorexia, constipation, cramping, diarrhea, blurred vision, dizziness, parathesias, vertigo, muscle spasms, purpura, photosensitivity, pruritus, urticaria, rash Continuous IV Monitoring Parameters: infusion preferred APTT, platelet count, signs of over intermittent bleeding, hemoglobin, injections hematocrit Adverse Effects: Hemorrhage, thrombocytopenia, fever, headache, chills, n/v, elevated liver enzymes Optimal rate of Monitoring Parameters: Urine sugar and acetone, blood decrease is 80-100 sugar, serum electrolytes, mg/dl/hour hemoglobin A1C (decreasing serum glucose too rapidly Adverse Effects: may lead to cerebral Palpitations, tachycardia, fatigue, hypoglycemia, edema) hypokalemia

Transient and permanent ototoxicity has been associated with administration rates > 4 mg/min or 0.5 mg/kg/min

Page 7 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Isoproterenol/ Isuprel

Dose: 0.05-2 mcg/kg/min; titrate 2 mcg/kg/min 64 mcg/ml to response by increments of 0.1 sympathomimetic mcg/kg/min every 10-15 minutes

Adrenergic, bronchodilator,

Do not use if solution is colored or ppt is present. Incompatible with epinephrine

Monitoring Parameters: cardiac rhythms, BP, HR, RR, EKG Adverse Effects: confusion, syncope, tremor, myocardial ischemia (rare) Monitoring Parameters: monitor cardiac function in patients with cardiac decompensation or hypertension, monitor for signs of emergency symptoms Adverse Effects: vivid dreams, increased blood pressure, tachycardia, muscle hyperactivity Monitoring Parameters: continuous EKG monitoring, serum concentration, IV site (thrombophlebitis may occur with prolonged infusion). Adverse Effects: hypotension, paresthesias, tremor, arrhythmias, cardiac arrest, seizures

Ketamine/ Ketalar

Anesthetic adjunct

Dose: 0.5-1 mg/kg occur 2-3 Not minutes followed by 5-20 established, mcg/kg/min continuous infusion, but large with or without supplemental O2 doses prolong recovery and Anesthesia maintenance: 0.01increase risk 0.03 mg/kg/min of adverse effects

50 mg/ml for IV push; do not exceed 2 mg/ml for continuous infusion

2 mg/min or 0.5 mg/kg/min

Laryngospasm or apnea requiring intubation may occur

Lidocaine/ Xylocaine

Antiarrhythmic, Ventricular arrhythmia: 0.5-1 local anesthetic mg/kg q5-10 min Loading dose: 1 mg/kg Maintenance: 10-50 mcg/kg/min by infusion

3 mg/kg intermittent infusion (although this

route is not recommended) 88 mcg/kg/min

8 mg/ml for continuous infusion 20 mg/ml for IV push

Not to exceed 0.7 mg/kg/min or 50 mg/min whichever is less

Serum concentration monitoring suggested, cardiac monitoring essential

by continuous IV has been proposed

Page 8 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Lorazepam/ Ativan

Antianxiety, Adjunct antiemetic: 0.05 mg/kg benzodiazepine, up to 2mg/dose effective in anticonvulsant, controlling chemo-induced N/V. antiemetic Status Epilepticus: 0.03-0.1 mg/kg and may repeat 0.05 mg/kg in 10-15 min if no response Agitation in the ICU pt (unlabeled use): 0.01-0.1 mg/kg/hour Hypomagnesium: Neonates: 25-50 mg/kg/dose (0.2-0.4 meq/kg/dose) Q8-12H Children: 25-50 mg/kg/dose (0.2-0.4 meq/kg/dose) Q4-6H Management of seizures and hypertension: 20100 mg/kg/dose Q4-6H Treatment of Torsades de Pointes VT: 25-50 mg/kg/dose (not to exceed 2gm/dose) Bronchodilation (asthma): 25 mg/kg/dose (max 2gm) as a single dose; 30-70 mg/kg over 20 minutes has been given

4 mg/dose or 0.25-0.4 mg/kg/dose

4 mg/ml

2 mg/min

Protect from light and refrigerate.

Monitoring Parameters: Respiratory rate, BP, HR, CBC w/ diff, and liver function tests Expires in 60 days at w/ long term usage Adverse Effects: CNS and room temp. respiratory depression, drowsiness, GI symptoms, propylene glycol toxicity, nystagmus, hypertension or hypotension

Magnesium sulfate

Electrolyte supplement

200 mg/kg/dose

200 mg/ml or 1.6 meq/ml (20%)

83.3 meq (41.1 mmol) of magnesium = 1 gm magnesium

Monitoring Parameters: Serum magnesium, deep tendon reflexes, respiratory rate Adverse Effects: Hypotension, diarrhea, hypermagnesia, abdominal cramps, gas formation, muscle weakness Adverse effects are related to serum concentration: >3 mg/dl: depressed CNS, blocked peripheral neuromuscular transmission leading to anticonvulsant effects >5 mg/dl: depressed deep tendon reflexes, flushing, somnolence >12 mg/dl: respiratory paralysis, complete heart block

Page 9 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Midazolam/ Versed

Anticonvulsant, benzodiazepine, hypnotic, sedative

Anesthesia: 0.15 mg/kg initially followed by up to three doses of 0.05 mg/kg at 2 minute intervals Continuous IV: neonates <=32 weeks gestational age: 1 mcg/kg/min, then decrease to 0.5 mcg/kg/min ASAP Neonates >32 weeks: 1 mcg/kg/min Infants/children: 0.05- 0.2 mg/kg as loading dose over 2-3 min. followed by 1-2 mcg/kg/min; titrate by 1 mcg/kg/min increments q 30 min until desired effect.

Max 5 mg/ml for IV use, 1 mg/ml for IM use

Respiratory depression and arrest requiring mechanical ventilation may occur following excessive dosing, rapid administration, or use with fentanyl

Monitoring Parameters: level of sedation, respiratory rate, heart rate, blood pressure, oxygen saturation Adverse effects: cardiac arrest, hypotension, bradycardia, drowsiness, sedation, amnesia, muscle tremor

Milrinone/ Primacor

Phosphodiesteras e enzyme inhibitor

Dose: 50-75 mcg/kg as a loading dose over 15 minutes followed by a maintenance dose ranging from 0.2 -1.2 mcg/kg/min

Max dose in adults is 1.13 mg/kg/day (not established in children)

1 mg/ml for loading dose and 400 mcg/ml as continuous infusion

Furosemide is incompatible with milrinone

Monitoring Parameters: Blood pressure, heart rate, cardiac output, CI, SVR, PVR, CVP, EKG, platelet count, serum potassium, renal function, clinical signs and symptoms of CHF Adverse effects: ventricular arrhythmias, chest pain, HA

Page 10 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Morphine/ Astramorph PF, Duramorph, Infumorph

Analgesic Dose: 0.05-0.2 mg/kg/dose q2narcotic, opioid 4h prn continuous infusion of 10-150 mcg/kg/hour

Suggested: 5 mg/ml for IV 0.1-0.2 mg/kg push not to exceed 15 mg/dose 4 mg/ml for continuous infusion

Naloxone / Narcan

Antidote for narcotic agonists

Nesiritide / Natrecor

Cardiovascular agent, natriuretic peptide

Opiate intoxification: 0.1 mg/kg, repeat every 2-3 min if needed If continuous infusion is required, calculate the initial dosage/hour based on the effective intermittent dose used and duration of adequate response seen; titrate dose; a range of 2.5160mcg/kg/hr has been reported. Narcotic induced pruritis: initial 2 mcg/kg/hour; may increase by 0.5 mcg/kg/hour every few hours if pruritis continues Bolus: 2 mcg/kg 0.03 Continuous infusion: 0.005 mcg/kg/min mcg/kg/min; may increase by 0.005 mcg/kg/min every 3 hours until max of 0.03 mcg/kg/min

4 mcg/ml

Monitoring Parameters: respiratory and cardio status, O2 saturation, pain relief, level of sedation Adverse Effects: Use with Respiratory caution and at lower doses in depression is infants and neonates less than 3 reversible with months because they are more naloxone susceptible to respiratory depression. Abrupt dc may cause withdrawal. Naloxone has been Monitoring Parameters: used to increase Respiratory rate, heart rate, blood pressure in pts blood pressure with septic shock Adverse Effects: Hypertension, hypotension, tachycardia, ventricular arrhythmias, nausea, vomiting, increased diaphoresis

Hypotension and chest wall rigidity may occur with rapid administration

Hypotension is the dose-limiting effect. If hypotension occurs, the nesiritide dose should be reduced or the drug discontinued

Monitoring Parameters: Plasma brain natriuretic peptide concentrations, Plasma aldosterone, heart rate, blood pressure Adverse Effects: Hypotension, nausea, cough, apnea, headache, confusion

Page 11 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Nicardipine / Cardene

Antianginal, Initial dose: 0.5-5 mc/kg/min antihypertensiv Usual dose: 1-4 mcg/kg/min e, calcium channel blocker, dihydropyridine

5 mcg/kg/min 0.5 mg/ml

Administration via central line eliminates risks for phlebitis which is occasionally seen when using the max 0.5 mg/ml conc through PIV

Monitoring Parameters: Blood pressure, heart rate Adverse Effects: Flushing, palpitations, tachycardia, headache, dizziness, nausea

Nitroglycerin/ Nitro-Bid IV, Nitrostat IV, Tridil

Antianginal, antihypertensiv e, nitrate, vasodilator

Nitroprusside/ Nitropress

Dose: 0.5-20 mcg/kg/min Neonates, infants, & children: begin infusion at 0.1-1 mcg/kg/min and increase by 0.51 mcg/kg/min q3-5 min until desired response or toxicity occurs Adolescents: begin infusion at 5 mcg/min until desired clinical response Antihypertensiv Hypertension initial rate: 0.3-0.5 e and mcg/kg/min with dose titration. vasodilator After load reduction: initial rate at 0.5-3 mcg/kg/min with dose titration.

20 mcg/kg/min

400 mcg/ml

Do not mix with other IV drugs. nonPVC tubing is recommended; must dispense in glass bottles (adsorbs to plastic)

Monitoring Parameters: blood pressure, heart rate Adverse Effects: dizziness, vision disorders, rash, xerostomia, prolonged bleeding time, syncope

10 mcg/kg/min (6 mcg/kg/min neonates)

800 mcg/ml in adults and 200 mcg/ml in pediatrics

(Sodium thiosulfate is a cyanide antidote. May add 1gm sodium thiosulfate for each 100mg of Nitroprusside in the drip)

10 mcg/kg/min (if adequate reduction in BP is not obtained after 10 min at 10 mcg/kg/min, the infusion should be stopped)

Continuous blood pressure monitoring, administer via infusion pump; thiocyanate levels if requiring prolonged infusion > 3 days or dose >= 4 mcg/kg/min or if pt has renal dysfunction.

Monitoring Parameters: blood pressure, acid-base balance, heart rate, hepatic and renal function, methemoglobin, thiocyanate levels Adverse Effects: dizziness, drowsiness, infusion site irritation, muscle twitching, rash, palpitations, arrhythmias, ileus, excessive bleeding, cyanide toxicity (Sodium thiosulfate is a cyanide antidote. May add 1gm sodium thiosulfate for each 100mg of Nitroprusside in the drip)

Page 12 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Norepinephrine/ Levophed

Alphaadrenergic agonist

Initial: 0.05-0.1 mcg/kg/min Maintenance: titrate according to clinical response, using frequent BP monitoring and continuous EKG. Avoid abrupt withdrawal

1-2 64 mcg/ml mcg/kg/min in infants and children 12 mcg/min in adults

Contains sodium metabisulfate which may cause allergic type reaction. Protect from light.

Do not infuse if solution is pinkish or darker than slightly yellow or contains precipitates

Monitoring Parameters: blood pressure, heart rate, urine output, peripheral perfusion. Adverse Effects: anxiety, urinary retention, extravasation leading to necrosis, cardiac arrhythmias

Octreotide / Sandostatin

Antisecretory agent, Somatostatin analog, antidiarrheal

Diarrhea: 1 mcg/kg bolus then continuous infusion of 1 mcg/kg/hour GI bleed: 1 mcg/kg bolus then continuous infusion of 1 mcg/kg/hour Chylothorax: 1-4 mcg/kg/hour Titrate to response

Pancuronium/ Pavulon

Neuromuscular blocker, skeletal muscle relaxant, paralytic

Neonates and infants: 0.02-0.04 mg/kg/hr or 0.4-0.6 mcg/kg/min Children: 0.03-0.1 mg/kg/hr or 0.5-1.7 mcg/kg/min Adolescents and adults: 0.02-0.04 mg/kg/hr or 0.4-0.6 mcg/kg/min

1 mg/ml for continuous infusion 2 mg/ml for IV push

Monitoring Parameters: Blood sugar, thyroid function test, fluid and electrolyte balance Adverse Effects: Hyperglycemia, nausea, hypoglycemia, diarrhea, hypothyroidism, Abdominal discomfort, Constipation, Flatulence, Pancreatitis, dizziness, headache Monitoring Parameters: heart Cardiac rate, blood pressure, assisted dysrhythmias, ventilation status, peripheral tachycardia, and nerve stimulator measuring hypertension have twitch response been reported. Do not alter patients Adverse effects: most frequent adverse reactions are related to state of prolongation of pharmacologic consciousness; addition of sedation actions: hypertension, rash, excessive salivation, burning and analgesia are sensation along vein, muscle recommended weakness, wheezes, bronchospasm

Page 13 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Papavarine

Vasodilator

Arterial catheter infusions: Add 60mg per 500ml in NSS or 1/2NSS with heparin 1 unit/ml

One study showed lower risk of arterial catheter failure and longer duration of arterial catheter function

Monitoring Parameters: Liver function tests Adverse Effects: Flushing, tachycardia, diaphoresis

Pentobarbital

Anticonvulsant, barbiturate, general anesthetic, sedative

Pentobarbital coma: loading dose = 10-15 mg/kg over 1-2 hours with continuous infusion of 1-3 mg/kg/hour to maintain burst suppression on EEG

50 mg/ml

Phenylephrine/ Neosynephrine

Adrenergic agonist, vasoconstrictor

IV bolus: 5-20 mcg/kg Continuous infusion: 0.1-0.5 mcg/kg/min, titrate to effect

400 mcg/ml

Monitoring Parameters: Vital signs, respiratory status, cardiovascular status, CNS status, ICP, CCP Adverse Effects: Arrhythmias, bradycardia, hypotension, lethargy, CNS excitation or depression, laryngospasm, respiratory depression, apnea Infuse in large vein Monitoring Parameters: Heart rate, blood pressure, to prevent extravasation which central venous pressure, arterial may cause severe blood gases (hypotension/shock necrosis tx) Adverse Effects: hypertension, myocardial infarction, pulmonary edema, tachycardia, ventricular arrhythmias

Do not inject > 50 mg/min; rapid injection may cause resp depression, apnea, laryngospasm, and hypotension

Page 14 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Propofol

General anesthetic

Sedation: 100-150 mcg/kg/min for 3-5 min and titrate to desired sedation while monitoring resp function. During first 10-15 min following induction, infusion rates of 25-75 mcg/kg/min are generally required. After first 30 min, adjust infusion rate to clinical response.

10 mg/ml

Cardiorespiratory

depression may result from bolus dosing or rapid increase in infusion rate. Therefore, wait 3-4 min between dosage adjustments to assess pt response.

Monitoring Parameters: Respiratory rate, blood pressure, heart rate, oxygen saturation, ABG, depth of sedation, serum lipids or triglycerides with use >24hr Adverse Effects: Hypotension (dose related), bradycardia, myocardial depression, flushing, fever, headache, dizziness, hyperlipidemia, respiratory depression, apnea, myalgia

Terbutaline/ Brethine

BetaAdrenergic agonist, antiasthmatic B2 agonist, bronchodilator, tocolytic

Loading: 2-10 mcg/kg over 5-30 minutes. Maintenance: 0.08-0.4 mcg/kg/min with an increase of 0.1-0.2 mcg/kg/min every 30 minutes until response

10 mcg/kg/min

1 mg/ml

May administer undiluted, direct IV over 5-10 minutes

Monitoring Parameters: heart rate, blood pressure, respiratory rate, serum potassium, arterial or blood gases Adverse Effects: hyperglycemia, tremor, tachycardia , headache, flushing, hypokalemia, nausea, vomiting, nervousness

Page 15 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Tromethamine (THAM)

Alkalinizing agent

Dose depends on severity and progession of acidosis: Neonates: manufacturer's recommendation: 1 ml/kg for each Ph unit < 7.4 Empiric dose based upon base deficit: Tromethamine dose = wt (in kg) x base deficit (mEq/L) (max 500 mg/kg/dose) = 13.9 ml/kg using 0.3 M solution Metabolic acidosis with cardiac arrest: tromethamine = 3.5-6 ml/kg/dose; maximum 500 mg/kg/dose = 13.9 ml/kg using 0.3 M soln Status epilepticus: loading dose = 20-40 mg/kg continuous infusion= 1-2 mg/kg/hour; up to 6 mg/kg/hour

0.3 Molar solution

Infuse slowly over at least one hour or 316 ml/kg/hour up to 33-40 ml/kg/day; Administer through a central line 1 mM = 120mg = 3.3ml = 1 mEq THAM Extravasation may cause tissue necrosis, severe inflammation, and sloughing.

Monitoring Parameters: Serum electrolyes, arterial blood gases, serum pH, blood sugar, EKG monitoring, renal function tests Adverse Effects: Overdose or excessively rapid administration may cause prolonged hypoglycemia, respiratory depression, apnea, hemmorhagic liver necrosis, venospasm, hyperosmolality of serum, hyperkalemia

Valproic Acid

Antiepileptic

150 mg/kg/day

25-50 mg/ml

Maintenance doses should be determined based on clinical response and total serum valproate concentrations (50150 mg/L)

Monitoring Parameters: Monitor for seizure activity Adverse Effects: Drowsiness, irritability, confusion, restlessness, headache, ataxia, hyperammonemia, nausea, vomiting, diarrhea, tremor

Page 16 of 17

Pediatric Intensive Care Unit (PICU) Nurse's Guide Intravenous Drip List ­ Approved for RN Administration

University of Kentucky Chandler Medical Center

GENERIC/ BRAND NAME THERAPEUTIC CATEGORY TYPICAL CHILD DOSE MAXIMUM CHILD DOSE MAXIMUM CONCENTRATION MAXIMUM RATE OF ADMINISTRATION ADMINISTRATION CONSIDERATIONS Updated: 10/2005 ADVERSE EFFECTS/COMMENTS MONITORING PARAMETERS

Vasopressin

Antidiuretic hormone analog, hormone

Diabetes insipidus: initial: 0.5 milliunits/kg/hour (0.0005 unit/kg/hr); double dosage as needed every 30 min to max of 10 milliunit/kg/hour (0.01 unit/kg/hr) GI hemorrhage: 0.002-0.005 units/kg/min; titrate dose as needed; max dose of 0.01 units/kg/min Vasodilatory shock: doses ranged from 0.0003 to 0.002 units/kg/min

0.01 units/kg/min

1 unit/ml

Extravasation may cause tissue necrosis.

Monitoring Parameters: Fluid intake and output, urine specific gravity, urine and serum osmolality, serum and urine sodium, hemoglobin and After hemorrhage has been controlled hematocrit (GI bleeding) for 12 hours, Adverse Effects: Circumoral pallor (with high gradually taper dosage over next 24- doses), hypertension, bradycardia, arrhythmias, 36 hours. venous thrombosis, vasoconstriction, distal limb ischemia, tremor, wheezing, bronchoconstriction, diaphoresis Monitoring Parameters: monitor muscle twitch response to peripheral nerve stimulation, HR, BP, ventilation status Adverse Effects: anaphylactic reaction (rare), apnea (rare), bronchospasm (rare), prolonged paralysis and/or muscle weakness, rash, tachycardia, hypotension or hypertension

Vecuronium/ Norcuron

Neuromuscular blocker (nondepolarizing), skeletal muscle relaxant, paralytic

IV bolus: 0.06-0.15 mg/kg Continuous infusion: 0.060.15 mg/kg/hr titrate up to 0.17 mg/kg/hour

0.27 mg/kg/hr 1 mg/ml for 21 hr is the largest reported continuous infusion

If the medication is not approved for administration and alternative routes of administration are not available, approval for this individual situation must be obtained through collaboration with pharmacy and the patient care manager

Updated: October 2005 Developed by: Amie Hatch Approved by: Karen Garlitz, PharmD and Julia Ho, PharmD Contact person for revisions: Kimberley Hite ([email protected])

Page 17 of 17

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