Download NICU/3NEO Medication Dilution Guidelines

University of Kentucky Children’s Hospital
Common Pediatric IV Drugs
Quick Reference for Administration in NICU / 3NEO
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
Acyclovir
15-60 mg/kg/day divided Q8H
7 mg/ml final
concentration
Over at least 1 hr.
Pharmacy should dispense in a syringe diluted to
<= 7 mg/ml, so no further dilution required.
Rapid infusion can cause nephrotoxicity.
TPN: no
Lipids: no
Adenosine
Initial 50-100 mcg/kg/dose; if not
effective within 1-2 min, increase
dose by 50-100 mcg/kg
increments every 1-2 min until
max single dose of 300 mcg/kg or
until termination of PSVT
3 mg/ml
For rapid IV bolus
Administer over 1-2
seconds at peripheral IV site
closest to patient’s heart
Follow each bolus dose with a NSS flush
TPN: no
Lipids: no
Albumin
0.5 – 2 gram/kg/day
25% (250 mg/ml)
5% (50 mg/ml)
Over 2 – 24 hours
(generally a bolus over 4 hrs
or continuous infusion)
Compatible with TPN.
May or may not be filtered prior to administration
TPN: yes
Lipids: yes
Aminophylline
Loading dose = 4-6 mg/kg
Maintenance dose = 1.5-3
mg/kg/dose IV/po Q8-12H
*Adjust dose based on drug levels
25 mg/ml (max)
Intermittent infusion: infuse
over 15-30 minutes
Monitor HR, RR, and check blood glucose
Target level for apnea = 7 – 12 mcg/ml
Target level for bronchospasm = 10-20 mcg/ml
*Monitor by drawing THEOPHYLLINE trough 30
minutes prior to dose.
TPN: yes
Lipids: no
Amphotericin B
0.1-1mg/kg/day
PIV: 0.1 mg/ml
Central line: 0.5 mg/ml
Over 2-6 hours.
Usually over 4 hours.
Give in DEXTROSE ONLY. Protect from light.
TPN: no
Lipids: no
Amphotericin B
liposome
(Ambisome)
3-5 mg/kg/day
1 mg/ml
(max conc: 2 mg/ml)
Over 2 hours.
Range= 2-6 hours
Give in DEXTROSE ONLY. Stable for 48 hrs
when refrigerated or 6 hours at room
temperature. Flush line with D5W before infusion
or use separate line.
TPN: no
Lipids:no
(Zovirax)
Page 1 of 9
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
Ampicillin
Neonates: 100 mg/kg/dose IV
Q12H
Meningitis: 200-400mg/kg/day
30 mg/ml
IV push: 100 mg/ml
Intermittent infusion over
15-30 min.
IVP: doses < 500mg give
over 3-5 minutes
IVP: not to exceed 100
mg/min
Do not administer concurrently with Gentamicin.
Ampicillin 125mg vial; add 1.2ml NSS = 125
mg/ml
Ampicillin 250mg vial: add 1ml NSS = 250 mg/ml
Ampicillin 500mg vial: add 1.8ml NSS = 250
mg/ml
TPN: no
Lipids: no
Azithromycin
(Zithromax)
Day 1: 10 mg/kg/day
Days 2-5: 5 mg/kg/day
2 mg/ml
Over 1-3 hours
Usually over 60 min
Max 500 mg/day
TPN: no
Lipids: no
Bactrim
(TMP/SMZ)
6-20 mg TMP/kg/day divided
Q12h
Serious infections: 15-20mg
TMP/kg/day divided Q6-8H
Dilute each 1ml of
drug in 20-25ml of
D5W (diluted by
pharmacy prior to
administration)
Over 60-90 min.
Give in D5W only.
Maintain adequate fluid intake.
Do not refrigerate. Protect from light.
TPN: no
Lipids: no
Caffeine
(Calfcit)
Loading dose = 10-20 mg/kg
Maintenance dose =
5-10 mg/kg/day
20 mg/ml (max)
Over 15-30 min.
Start maintenance dose 24 hours after loading
dose. Consider holding dose if HR > 180 bpm
TPN: no
Lipids: no
Cefazolin
(Ancef, Kefzol)
50-100 mg/kg/day divided Q8H
100 mg/ml
Over 10-60 min.
Do NOT administer concurrently with
aminoglycosides
TPN: yes
Lipids: yes
Cefepime
(Maxipime)
50mg/kg/dose given Q12H
50mg/kg/dose given Q8H for
neutropenic fever (max dose)
100 mg/ml
Over 30-60 min.
Do NOT administer concurrently with
aminoglycosides.
TPN: yes
Lipids: no
Cefotaxime
(Claforan)
100-200 mg/kg/day divided
Q6-8H; 300 mg/kg/day meningitis
100 mg/ml
Over 30 min.
Do NOT administer concurrently with
aminoglycosides.
TPN: yes
Lipids: no
Ceftazidime
(Fortaz)
150 mg/kg/day divided Q8h
CF: 320 mg/kg/day
100 mg/ml
Over 30 min.
Do NOT administer concurrently with
aminoglycosides.
TPN: yes
Lipids: yes
Cefuroxime
(Zinacef)
75-150 mg/kg/day divided Q8H
(300 mg/kg/day MAX)
100 mg/ml
Over-30 min.
Do OT administer concurrently with
aminoglycosides.
TPN: yes
Lipids: yes
Page 2 of 9
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
Clindamycin
(Cleocin)
25-40 mg/kg/day divided Q 6-8h
18 mg/ml
Over 10-60 min.
Not to exceed 30mg/min.
Hypotension/cardiac arrest possible after rapid IV
administration.
TPN: yes
Lipids: yes
Cosyntropin
High dose test: 0.25 mg
Low dose test: 1 mg/m2
0.25 mg/ml (max)
Dilution of 1 mcg/ml
for low dose test
IV push over 2 min
Draw labs as specified (usually plasma cortisol
conc immediately BEFORE and exactly 30
minutes LATER)
TPN: no
Lipids: no
Dexamethasone
(Decadron)
Anti-inflammatory: 0.08-0.3
mg/kg/day divided Q 6-12h
Airway edema: 0.5-2 mg/kg/day
divided Q6h
4 mg/ml (MAX)
Over 15-30 min.
IV Push: over 1-4 min. if dose<10mg.
TPN: yes
Lipids: yes
Digoxin
(Lanoxin)
Loading dose: 15-50 mcg/kg
Maintenance dose: 4-6
mcg/kg/day
Over 5-30 min
Monitor electrolytes (K+, Mag, Ca++)
TPN: yes
Lipids: yes
Diphenhydramine
(Benadryl)
1.25 mg/kg/dose Q 6 hours
25 mg/ml or 1 mg/ml
dilution (if dose
immeasurable)
Over 15 min.
Max infusion rate: 25 mg/min.
TPN: yes
Lipids: yes
Erythromycin
5-40 mg/kg/day
(lower dose when given as a
prokinetic agent)
5 mg/ml
Over 20-120 min
May be given as a prokinetic agent (if not
responsive to metoclopramide)
TPN: yes
Lipids: yes
Erythropoietin
(Epotein alfa)
(Epogen)
200-400 units/kg/dose 3 times per
week
Dilute with an equal
volume of NSS
Over 3 minutes to 4 hours
Treatment of anemia
TPN: yes
Lipids: no
Famotidine
(Pepcid)
0.5-1 mg/kg/day divided Q12-24h
2 mg/ml
Over 15-30 min.
May be added into TPN
TPN: yes
Lipids: yes
Fentanyl
(Sublimaze,
Duragesic)
1-4 mcg/kg/dose
Max 50 mcg/ml
Over 3-5 min
Apnea or chest wall rigidity may occur with rapid
bolus injection. Peak respiratory depression
occurs 5-15 min after dosing. Respiratory
depression reversible with naloxone.
TPN: yes
Lipids: yes
100 mcg/ml (MAX)
Page 3 of 9
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
Filgrastim
(Neupogen)
5-10 mcg/kg/day
5-15 mcg/ml; diluted
by pharmacy in a
syringe
Over 15-60 min
Albumin added to IV infusions. Albumin acts as
a carrier molecule to prevent drug adsorption to
the IV tubing
TPN: no
Lipids: no
Fluconazole
(Diflucan)
3-12 mg/kg/day once daily
2 mg/ml
Over 1-2 hours.
Not to exceed 200 mg/hr.
Do not mix with any other drugs.
TPN: yes
Lipids: yes
Flumazenil
(Romazicon)
Initial dose = 0.01 mg/kg; may
repeat until max of 0.05 mg/kg
Max 1 mg
0.1 mg/ml
Over 15 SECONDS
Benzodiazepine antagonist – reverses sedative
effects of benzodiazepines
TPN: no
Lipids: no
Fosphenytoin
(Cerebyx)
5-10 mg/kg/day divided Q 8-12h
(Dose varies with drug levels.)
25 mg/ml (MAX)
1-3 mg/kg/MIN
Dose adjustments based on drug levels. Obtain
post load level 2 hours after end of the infusion or
troughs PRIOR to a dose.
Compatible with NSS and D5W
TPN: no
Lipids: no
Furosemide
(Lasix)
1-2 mg/kg/dose Q 6-12h
10 mg/ml (MAX)
Over 10-15 min.
IV Push: max rate 0.5mg/kg/min
Monitor serum electrolytes
TPN: yes
Lipids: yes
Gentamicin
NICU: 4 mg/kg/day IV Q24H
Infants: 2.5 mg/kg/dose Q8H
(Dose varies with drug levels.)
10 mg/ml
30 min.
Serum levels with 3 -4 dose. Obtain trough 30
minutes prior to dose and obtain peak 30 minutes
after the 30 minute infusion. Improper
administration increases the risk of side effects
(renal failure, hearing loss, vertigo).
TPN: yes
Lipids: yes
Glycopyrrolate
(Robinul)
0.004-0.01mg/kg Q4-8H or 4-10
mcg/kg/dose Q3-4H
IV push conc = 0.2
mg/ml
0.2mg over 1-2 minutes
May give IM or IV
TPN: no
Lipids: no
Heparin
Art lines = 0.5 - 2 units/ml
PIV = 0.5 - 1 unit/ml
UAC = 0.5 - 2 units/ml
Promotion of lipid clearance=1
unit/ml in TPN
Generally continuous
infusion
Generally continuous
infusion
HIT (heparin induced thrombocytopenia) is NOT
dose related.
TPN: yes
Lipids: no
Hydralazine
0.1-0.6 mg/kg/dose Q3-6H
20 mg/ml (max) or
1 mg/ml DILUTION
Over 1-2 min
Monitor BP and HR for 30-60 min after infusion
TPN: no
Lipids: no
Hydrocortisone
(Solu-cortef)
1-2 mg/kg/dose IV Q6-24H
50 mg/ml (max)
Over 10-30 min
Uses: treatment of coritsol deficiency, blood
pressure support, or adjunctive for persistent
hypoglycemia.
TPN: yes
Lipids: yes
rd
th
Page 4 of 9
TPN/IL
compatible
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
Ibuprofen lysine
IV for PDA closure:
Initial dose = 10 mg/kg
nd
2 dose = 5 mg/kg
rd
3 dose = 5 mg/kg
4 mg/ml
Over 15 min
May hold 2 or 3 doses if UOP < 0.6 ml/kg/hr
May give second course if first course ineffective.
TPN: no
Lipids: no
Immune globulin
(IVIG)
0.4-2 gm/kg/dose
Usual 10% solution
(100 mg/ml)
May use dilution of
1-4 mg/ml
Over 2-12 hours
Initial infusion rate is 0.5 ml/kg/hr x 15-30 min,
then 1 ml/kg/hr x 15-30 min, then 2 ml/kg/hr x 1530 min, and a max rate of 4 ml/kg/hr
TPN: no
Lipids: no
Indomethacin
(Indocin)
Initial dose = 0.2 mg/kg
st
PNA at time of 1 dose < 48 hrs =
0.1 mg/kg Q12-24H
st
PNA at time of 1 dose 2-7 days =
0.2 mg/kg Q12-24H
st
PNA at time of 1 dose > 7 days=
0.25 mg/kg IV Q12-24H
0.5 mg/ml
30 min – 6 hours
Rapid administration causes a significant
decrease in mesenteric artery and cerebral blood
flow, which may contribute to the development of
NEC or cerebral ischemia. Generally use Q12H
TPN: no
Lipids: no
Insulin
(Regular insulin)
DKA: 0.1 unit/kg, followed by
0.05-0.1 unit/kg/hour
Per MD/Pharmacy
Continuous infusion
Only regular insulin can be given IV. Prime IV
tubing with insulin drip to prevent adsorption of
the insulin to the tubing.
TPN: yes
Lipids: yes
Levofloxacin
(Levaquin)
10 mg/kg/dose IV Q12H
5 mg/ml
Over at least 60 minutes
Too rapid of infusion may cause hypotension.
Flush IV tubing before and after infusion. May
alter blood glucose levels.
TPN: no
Lipids: no
Levothyroxine
(Synthroid)
5-15 mcg/kg/day
100 mcg/ml
Over 2-3 min
AAP recommends an initial oral dose of 10-15
mcg/kg/day. IV doses should be 50-75% of oral
doses.
TPN: no
Lipids: no
Linezolid
(Zyvox)
10 mg/kg/dose IV Q8-12H
2 mg/ml
Infuse over 30-120 min
(Usually over 1-2 hrs)
Sent by pharmacy as 2 mg/ml concentration.
Further dilution not required. Administer through
dedicated IV line (do not mix with other drugs).
Protect from light.
TPN: no
Lipids: no
Lipids
0.5-4 g/kg/day
20% solution
Continuous infusion over 24
hours
Must turn off lipid infusion off for at least 2 hours
prior to drawing a serum triglyceride level.
nd
rd
Page 5 of 9
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
Lorazepam
(Ativan)
0.01-0.1 mg/kg/dose Q4-8h
1 mg/ml
Max = 2 mg/ml
(undiluted drug)
IV Push: 2-5 min. not
exceeding 2 mg/min.
Inadvertent intra-arterial injection can cause
vasospasm; could result in gangrene. Use
repeated aspiration with slow IV push, to make
sure the injection is not intra-arterial and
extravasation has not occurred. Flumazenil is
antidote.
TPN: yes
Lipids: no
Meropenem
(Merrem)
20-40 mg/kg Q8-12H
120 mg/kg/day for meningitis
20 mg/ml
Over 30 minutes
Restricted – must have ID service approval.
TPN: yes
Lipids: yes
Methadone
(Dolophine)
0.05-0.2 mg/kg/dose IV Q12-24H
1 mg/ml
10 mg/ml (max)
Over 30 minutes
Usually taper dose by 10-20% every 3-7 days
TPN: no
Lipids: no
Methylprednisolone
(Solu-Medrol)
Anti-inflammatory dose: 0.5-1.7
mg/kg/day divided Q6-12h
Asthma: 2mg/kg x 1 dose, then
0.5-1mg/kg/dose Q6H
20 mg/ml
IV Push:
≤1.8 mg/kg: 3-15 min.
≥2mg/kg: 15-20 min.
>15mg/kg: 30-60 min.
Intermittent: 15-60 min.
IV push of high dose→ cardiac arrhythmias,
hypotension, sudden death.
TPN: yes
Lipids: yes
Metoclopramide
0.1-0.2 mg/kg/dose IV
Q6-8H
0.2 mg/ml and 1
mg/ml and 5 mg/ml
(max) for fluid
restricted patients
Over 15 min
Same dose IV or po
TPN: yes
Lipids: yes
Metronidazole
(Flagyl)
0-4 weeks: <1200 gm = 7.5 mg/kg IV
Q48H
PNA <= 7 days: 1200-2000 gm =
7.5 mg/kg IV Q24H
PNA <= 7 days: >2000 gm =
7.5 mg/kg/dose IV Q12H
PNA > 7days: 1200-2000 gm =
7.5 mg/kg/dose IV Q12H
PNA > 7 days: > 2000gm =
15 mg/kg/dose IV Q12H
Infants & children: 15-30 mg/kg/day
divided Q6-8H
5 mg/ml
(concentration
dispensed by
pharmacy)
Over 60 min
Sent by pharmacy as a ready-to-administer
concentration of 5 mg/ml. No further dilution
required for administration.
TPN: yes
Lipids: yes
Midazolam
0.05-0.2 mg/kg/dose
1 mg/ml
IV push over 20-30 sec
Generally given over 5
minutes in neonates
Flumazenil is indicated for complete or partial
reversal of benzodiazepine toxicity
TPN: no
Lipids: no
Page 6 of 9
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
IVP: 0.5-5 mg/ml
Continuous IV
infusion: 0.1-1 mg/ml
IV Push: ≥5 min.
Intermittent: 15-30 min
Naloxone is reversal agent.
Do not administer rapidly IV.
TPN: yes
Lipids: yes
50-200mg/kg/day divided Q612H
40 mg/ml
(100 mg/ml for fluid
restricted patients)
Over 30-60 min
Extravasation may cause tissue sloughing and
necrosis.
TPN: yes
Lipids: yes
Naloxone
(Narcan)
0.01 – 0.1 mg/kg/dose
4 mcg/ml
Over 30 sec for IV push
May be given SQ, IM, ET, and IV
TPN: no
Lipids: no
Octreotide
(Sandostatin)
1-10 mcg/kg/day
1.5 – 250 mcg/ml
Dilute in D5W or
NSS
15-30 minutes
Usually given SQ (preferred route)
TPN: yes
Lipids: yes
Pantoprazole
(Protonix)
Dose = 0.5-1 mg/kg/dose; usually
Q24h but may be increased to
Q12H
4 mg/ml
Over 15-30 min
Do not exceed 3 mg/min infusion.
TPN: no
Lipids: no
Penicillin G
25,000-400,000 units/kg/day divided
Q4-12H (based on PNA & wt)
50,000 units/ml
Over 30-60 min
Give in NS or D5W.
TPN: yes
Lipids: yes
Pentobarbital
(Nembutal)
2-6 mg/kg/dose
Max 50 mg/ml
Over 10-30 min
Rapid administration may cause respiratory
depression, apnea, and laryngospasm.
Extravasation may cause tissue necrosis.
TPN: yes
Lipids: no
Phenobarbital
Hyperbilirubinemia: 3-8 mg/kg/day
Sedation: 1-3 mg/kg/dose
Seizures: (1-2 doses/day)
Neonates: 4-5 mg/kg/day
Infants: 5-6 mg/kg/day
*Loading dose = 10-20 mg/kg*
10 mg/ml
No faster than 1 mg/kg/min.
Monitored by levels (saliva or blood).
May cause respiratory depression if administered
too rapidly or when combined with other
sedatives.
Extravasation may cause tissue necrosis.
Usual loading dose = 10-20 mg/kg
IV to po conversion = 1:1
TPN: yes
Lipids: no
Phenytoin
(Dilantin)
5-10 mg/kg/day divided Q 8-12h
(Dose varies with drug levels.)
50 mg/ml
Max rate of 50mg/min.
Flush with NS after giving.
Give in NS only
TPN: no
Lipids: no
Phytonadione
(Vitamin K)
Prophylaxis = 0.5-1 mg at birth
0.5 mg/ml
Over 15-30 min
Route = IV, IM, SQ
Max rate = 1 mg/min
TPN: yes
Lipids: no
Drug
Dose Range
Morphine
0.05-0.1 mg/kg/dose
Nafcillin
Q2-4H
Page 7 of 9
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
Rifampin
10-20 mg/kg/day divided Q1224H
6 mg/ml
30 min - 3 hours
Urine, tears, & sweat may turn orange-red.
Protect from light, use separate IV tubing. Give
in D5W (preferred) can use NS.
TPN: no
Lipids: no
Sodium
Bicarbonate
1-2 meq/kg/dose
0.5 meq/ml (infant
bicarb syringe
concentration)
IV push over 2 minutes
Over 2 hours (max rate 1
meq/kg/hour)
IV push reserved for cardiac arrest
TPN: yes
Lipids: yes
TPN
Infusion rate dependent on total
fluids for patient
Continuous infusion over 24
hours
New orders must be written daily for neonatal
TPN.
Tobramycin
Usual dose = 4 mg/kg/day or
2-2.5 mg/kg/dose Q8H
(depending on PNA and age)
10 mg/ml
Over 30 min.
Serum levels with 3 -4 dose. Obtain trough 30
minutes prior to dose and obtain peak 30 minutes
after the 30 minute infusion. Improper
administration increases the risk of side effects
(renal failure, hearing loss, vertigo).
TPN: yes
Lipids: yes
Tromethamine
(Tham)
Metabolic acidosis: 1 ml for each
pH unit < 7.4
Base deficit: dose in mls = base
deficit (meq/L) x body wt (kg) x
1.1
0.3 molar soln (max
conc)
Minimum 1 hour (3-16
ml/kg/hour)
Extravasation may result in tissue necrosis,
severe inflammation, and sloughing.
THAM is renally eliminated and may accumulate
in renal insufficiency.
TPN: no
Lipids: no
TPA
(alteplase)
<10kg: 0.5mg in NSS
Fill to volume size of
occluded catheter
Instill ordered dose in each
port. Leave in port for 1
hour, then aspirate.
No established guidelines for use in children.
Medication dose ordered will be diluted in varying
volumes based on the port size.
TPN: no
Lipids: no
Unasyn
(Ampicillin/
sulbactam)
100-200 mg/kg/day divided Q6H
(Ampicillin component)
meningitis: 400 mg/kg/day
30 mg/ml
(RN to further dilute
due to short
expiration)
15-30 minutes.
Mix 1.5 gram vial with 3.2 mL of NS.
Mix 3 gm vial with 6.4ml of NS.
Final conc = 250 mg/ml Ampicillin component.
TPN: yes
Lipids: yes
Vancomycin
10-20 mg/kg/dose Q8-24h
*dose based on age and renal
function
5 mg/ml
(10 mg/ml for fluid
restricted patients)
Over at least 1 hour.
Rapid infusion associated with red man
syndrome, and may also cause hypotension and
cardiac arrest. Obtain trough 30 minutes prior to
dose and peak one hour after the 1 hour infusion.
0.1 mg/kg/dose
1 mg/ml
IV push over seconds
Vecuronium
rd
th
Does not alter patient’s state of consiousness;
addition of sedation and analgesia is
recommended
TPN: yes
Lipids: yes
TPN: yes
Lipids: no
Page 8 of 9
Drug
Dose Range
Ready-toadminister
concentration
IV Administration
Notes
TPN/IL
compatible
Zosyn
(piperacillin/
tazobactam)
240 mg/kg/day divided Q6-8H
CF: 350-450 mg/kg/day
(piperacillin component)
200 mg/ml
Over 30 minutes
Do NOT administer concurrently with
aminoglycosides (piperacillin can inactivate
aminoglycosides).
TPN: yes
Lipids: yes
Updated: 3/6/12
Approved by: Karen Garlitz, PharmD
Contact person for revisions: Karen Garlitz, PharmD ([email protected])
Page 9 of 9