Word: Pediatric Intensive Care Unit: Continuous Infusion ...
Site ApplicabilityThis chart has been developed for use in The Pediatric Intensive Care Area of BC Children’s Hospital. The information contained here is intended as a guideline for use of standard concentrations of “high alert” medications administered by continuous infusion. For more detailed information on these drugs, the user should consult other comprehensive reference sources.Definitions:Patient Group: These guidelines normally apply to full term neonates, infants and children. This information is not intended to apply to premature newborns. Please refer to the Neonatal Drug Manual from Newborn Services for information about this specific age groupDrug: Listed by generic name. Trademark and alternate names are included in parenthesis. Other pharmaceutical information such as solution pH, osmolality (in mOsm/mL), specific gravity (SG) and additive content has been included to assist in decision making about the administration of these drugs.Concentration: Represented as a weight/volume relationship, namely milligrams per milliliter or micrograms per milliliter. The concentrations suggested reflect those that are approved at this facility for administration to critically ill children. These standard concentrations will be supplied by Pharmacy. In some situations, nurses may mix the drugs at the bedside. Generally the listed concentrations are appropriate for all age groups; however, when applicable, specific recommendations are presented for different age groups. The concentration selected will be determined by the tolerance for fluid volume delivered with medications. Fluid restricted patients may require more concentrated solutions. In cases where the patient is not fluid restricted more dilute solutions should be chosen. Solution properties such as osmolality and pH may be considered when selecting concentrations suitable for peripheral line or central line administration. As a general rule, osmolality values greater than 600 mOsm/mL indicate that the medication be given by central venous catheter. Minimum and maximum recommended concentrations for infusion are included where applicable.Infusion Rate and Dose Delivered: This relationship will be determined with the use of infusion drug charts or “smart pumps” which have been programmed to infuse at the proper rate when dose and weight are entered into the database.Dose Range: The usual dose range for continuous infusions recommended by the literature under standard conditions. Loading doses, bolus doses, and maximum recommended doses are included where applicable.Y-Site Compatibility: Medications should not be admixed in one container. To avoid directly admixing of two drugs medications are administered via Y-site connectors. This compatibility information contained in the chart applies to Y-site administration only. Legend: C; compatible at Y-site, I: incompatible at Y-site. Where co-infusion of TPN by Y-site is acceptable, it is noted in the comments ments:Other useful information pertaining to the use of each drug is presented, such as:central or peripheral line recommendations. (Most standard concentrations can be administered via peripheral line)adverse effects, including infusion reactionsprotect infusion container (syringe or bag) and/or tubing from light, only where notedsolution expiry noted, change tubing at specified timeIt is the responsibility of the nurse to verify that the dilution used will deliver the correct dose at a calculated infusion rate. Two nurses must verify the infusion rate is correct.DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsAlprostadil[Prostaglandin E1, Prostin VP]500 mcg/mLpH = 4.8 – 5 Osmolality = 23,250Revised February 2020Standard ConcentrationsPatients < 6 kg:5 mcg/mL Add 0.25 mL of500 mcg/mL to 24.75 mL D5W to make 25 mL of 5 mcg/mLPatients > 6 kg, Peripheral line:10 mcg/mLAdd 0.5 mL of500 mcg/mL to 24.5 mL D5W to make 25 mL of 10 mcg/mLPatients > 6 kg, Central line:20 mcg/mLAdd 1 mL of500 mcg/mL to 24 mL D5W to make 25 mL of 20 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)To maintain patency of ductus arteriosus 0.005 – 0.1 mcg/kg/minC: dextrose and saline solutions, aminophylline, atropine, caffeine, calcium chloride, calcium gluconate, dexamethasone, dobutamine, dopamine, epinephrine, furosemide, heparin, hydrocortisone, isoproterenol, lidocaine, midazolam, morphine, nitroglycerin, nitroprusside, pancuronium, potassium chloride, I: sodium bicarbonateCompatible with TPNCentral line administration only for concentrations >10 mcg/mL.If being administered via peripheral line or low-lying UVC, patient should have two lines in place during the infusion (one for alprostadil and an additional line)? Adverse effects include apnea and bradycardia? For fever or hypotension, reduce infusion rate? For cutaneous flushing, reposition catheter? Extravasation of concentrated solution may cause tissue sloughing and necrosis.Keep ampoules in refrigerator.Change solution at 24 hours.Ref: 1, 2, 3, 4DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsAlteplase (rTPA)[Activase]50 mg vial containing lyophilized powder (plus 50 mL of diluent, SWI)pH = 7.3, Osmolality = 215Revised Feb 2020Standard Concentration1 mg/mLAdd 50 mL enclosed diluent to 50 mg vial to make 1 mg/mL solution.Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mg/kg/h) x Weight (kg) divided byConcentration (mg/mL)Systemic Thrombolysis0.1 – 0.6 mg/kg/hStart at 0.1 mg/kg/h; may increase dose by 0.1 mg/kg/h every 6 hoursDose is titrated to target fibrinogen levels: >1 g/L (>1.5 g/L in neonates)C: D5W, NS, morphine, lidocaine, propranololI: dobutamine, dopamine, heparin, nitroglycerin, bacteriostatic water, bacteriostatic saline Reconstitute with enclosed diluent (SWI) only. Roll gently, do not shake. Let stand for several minutes prior to administration.Monitor for signs of bleeding.Extravasation can cause ecchymosis and inflammationDilutions <0.5 mg/mL may result in precipitation.Do not directly admix with other medications or solutions.Change solution every 8 hours.Ref: 2DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsAminophyllineRevised Feb 2020Standard Concentrations1 mg/mL:Add 2 mL of 25 mg/mL to 48 mL of D5W to make 50 mL of 1 mg/mL5 mg/mL:Add 10 mL of 25 mg/mL to 40 mL of D5W to make 50 mL of 5 mg/mL10 mg/mL:Add 20 mL of 25 mg/mL to 30 mL of D5W to make 50 mL of 10 mg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mg/kg/h) x Weight (kg) divided by Concentration (mg/mL)BronchodilatorLoading Dose:6 mg/kg IV over 20 minutesContinuous infusion:6 wk-6 mos: 0.5 mg/kg/h IV6-12 mos: 0.7 mg/kg/h IV1-9 years: 1-1.2 mg/kg/h IV9-16 yrs: 0.7-0.8 mg/kg/h IVC: D5W, D10W, D5NS, NS, D51/2NS, D5LR, calcium chloride, calcium gluconate, dopamine, esmolol, fentanyl, furosemide, heparin, regular insulin, labetalol, lidocaine, lorazepam, milrinone, morphine, nitroglycerin, phenobarbital, potassium chloride, procainamide, sodium bicarbonate I: TPN, amiodarone, dobutamine, epinephrine, hydralazine, isoproterenol, magnesium sulfate (250mg/mL), midazolam, norepinephrine, ondansetron, phenytoin May cause hypotension and/or bradycardia with rapid infusions or loading doses.Change solution at 24 hours.Therapeutic Drug Monitoring:Aminophylline contains 80% theophyllineTherapeutic theophylline range is 55 to 111 micromoles/LDraw serum theophylline levels - 30 mins after loading dose, and at 24-hour intervals for the duration of an infusionFor loading doses, each 1.25mg/kg of aminophylline raises the serum theophylline approximately 11 micromoles/LRefer to BCCH Pediatric Drug Dosage Guidelines for guidelines to adjust dosage based on serum concentrationRef: 2, 3, 4, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsAmiodarone[Cordarone]150 mg/3 mLpH = 4.08Contains polysorbate 80, benzyl alcoholRevised Feb 2020Standard ConcentrationsPeripheral line:2000 mcg/mL (2 mg/mL)Add 2 mL of 50 mg/mL to 48 mL D5W to make 50 mL of 2000 mcg/mL(2000 mcg/mL = 2 mg/mL)Central line:6000 mcg/mL (6 mg/mL)Add 6 mL of 50 mg/mL to 44 mL of D5W to make 50 mL of 6000 mcg/mL (6000 mcg/mL = 6 mg/mL)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg) x 60 (min/h)divided by Concentration (mcg/mL)Arrhythmia2 mg/kg IV loading dose over 20 minutes, followed by5 mcg/kg/minIf inadequate response:1 mg/kg IV over 10 minutes, followed by 5-10 mcg/kg/minUsual continuous infusion dosage:5-15 mcg/kg/minOR25 mcg/kg/min IV for 4 hours, followed by 5 – 15 mcg/kg/minPALS algorithms: 5 mg/kg IV loading dose over 20-60 minutesC: D5W, NS, calcium chloride, calcium gluconate, dobutamine, dopamine, esmolol, fentanyl, insulin, isoproterenol, potassium chloride, labetalol, lidocaine, lorazepam, midazolam, milrinone, morphine, nitroglycerin, norepinephrineI: aminophylline, heparin, furosemide, procainamide, sodium bicarbonate, magnesium sulfate (500 mg/mL)Central line administration preferred.Peripheral line administration may be used for concentrations <2000 mcg/mL (2 mg/mL).Use Medex non-DEHP tubing # MX448HL60 with 30 mL tubing to infuse the solution.Use of 0.22 micron inline filter is recommended.May cause hypotension and/or bradycardia with rapid infusions or loading doses.Change solution at 24 hours.Ref: 2, 3, 4, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsCalcium Chloride[CaCl2]10% (100 mg/mL)Each mL contains: 100 mg CaCl2 27.2 mg Ca+2 0.68 mmol Ca+2 pH = 5.5 – 7.5Osmolality = 1760Revised Dec 2013Reviewed Jan 2020Standard ConcentrationsCentral line:100 mg/mL (undiluted)(0.68 mmol Ca+2/mL)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = [Dose (mmol/kg/d) x Weight (kg)]divided by[Concentration (mmol/mL)x 24 (h/d)]Hypocalcemia0.5 – 1.5 mmol Ca+2/kg/day(74 – 221 mg/kg/day of calcium chloride)C: dextrose and saline solutions, dopamine, esmolol, fentanyl, furosemide, heparin, insulin, isoproterenol, midazolam, milrinone, morphine, nitroprusside, norepinephrine, I: amphotericin, bicarbonate, ceftriaxone, dobutamine, lipids magnesium, phosphate, propofolIncompatible with TPN solutions containing phosphatesExtravasation may cause severe tissue burns and necrosis. Central line administration only. If peripheral line infusion use calcium gluconateDo not infuse via small veins (i.e., scalp).Monitor ionized calcium daily (target 1.1 – 1.3 mmol/L).Change solution at 96 hours.Ref: 3, 5DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsCalcium Gluconate10% (100 mg/mL)Each mL contains: 100 mg calcium gluconate 9.3 mg Ca+2 0.232 mmol Ca+2pH = 6 – 8.2Osmolality = 276Revised Nov 2013Reviewed Jan 2020Standard ConcentrationsPeripheral line:20 mg/mL (0.046 mmol Ca+2/mL)Add 10 mL of 10% solution to 40 mL D5W to make 50 mL of 20 mg/mLCentral line:100 mg/mL(undiluted)(0.232 mmol Ca+2/mL)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = [Dose (mg/kg/d) x Weight (kg)] divided by[Concentration (mg/mL)x 24 (h/d)]Hypocalcemia, Hyperkalemia, or Calcium Channel Blocker ToxicityNeonates200 – 400 mg/kg/day(0.46 – 0.93 mmol Ca+2/kg/day)Infants & Children200 – 500 mg/kg/day(0.46 – 1.2 mmol Ca+2/kg/day)Maximum Dose240 mg/kg/hC: aminophylline, dobutamine, dopamine, epinephrine, fentanyl, furosemide, heparin, insulin, isoproterenol, labetalol, lidocaine, magnesium, midazolam, milrinone, morphine, nitroprusside, norepinephrine, potassium chloride, propofolI: amphotericin, bicarbonate, phosphatesIncompatible with TPN solutions containing phosphates Extravasation may cause severe tissue burns and necrosis. Central line administration is preferred. Peripheral line infusions must be approved by the Attending Physician and use standard concentration of 20 mg/mL Central line administration only for concentrations >20 mg/mL.Do not infuse via small veins (i.e., scalp).Change solution at 96 hours.Ref: 3, 6, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsCisatracurium20 mg/10mL(2mg/mL)Revised Feb 2020Standard Concentration:100 mcg/mLAdd 2.5 mL of 2 mg/mL to 47.5 mL D5W or NS to make 50 mL of 0.1 mg/mL = 100 mcg/mL) 400 mcg/mLAdd 10 mL of 2mg/mL to 40 mL D5W or NS to make 50 mL of 0.4 mg/mL = 400 mcg/mL)Calculate the infusion rate with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)Continuous infusion:1 – 4 mcg/kg/min (0.06 – 0.24 mg/kg/hr)Intermittent: Initial 0.1 mg/kg followed by maintenance of 0.03 mg/kg PRN to maintain blockadeC: D5W, NS, D5NS, D5LR, bumetanide, dopamine, epinephrine, fentanyl, gentamicin, midazolam, morphine, norepinephrine, vancomycinVariable compatibility (depends on concentrations):cefazolin, cefotaximeChange solution at: 96 hoursRef: 1, 3DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsDexmedetomidine(Precedex)100 mcg/mL (2mL vial)pH = 4.5 – 7Revised Dec 2013Reviewed Feb 2020Standard Concentrations4 mcg/mL:Add 2mL of 100 mcg/mL solution to 48 mL NS to make 50 mL of 4 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = [Dose (mcg/kg/hour) x Weight (kg)] divided by4 (mcg/mL)Sedation for Mechanical VentilationLoading dose: 0.2 – 0.6 mcg/kg over 10 – 20 minutesInfusion: Initially 0.2 micrograms/kg/hourTitrate to range of 0.2-0.7 mcg/kg/hourUsual max 1 mcg/kg/hour (may go up to 1.4 mcg/kg/hour)Burn Patients.Loading dose: 0.2 – 0.6 mcg/kg over 10 – 20 minutesInfusion: Initially 0.2 mcg/kg/hour Titrate to range of 0.1–2 mcg/kg/hour**Note: higher dosage range in burn patientsC: NS, D5W, Ringer’s and Lactated Ringer’s, aminophylline, amiodarone, ampicillin, azithromycin, cefazolin, cefotaxime, digoxin, dopamine, epinephrine, esmolol, fluconazole, furosemide, gentamicin, heparin, hydromorphone, ketorolac, labetalol, lorazepam, magnesium sulphate, methylprednisolone, milrinone, norepinephrine, piperacillin-tazobactam, potassium chloride, ranitidine, sodium bicarbonate, sodium nitroprusside, vancomycinI: amphotericin B, diazepamUse caution when administering loading dose as rapid rate of infusion is associated with increased adverse cardiovascular effects (including hypotension, bradycardia andcardiac arrest)Hypotension and bradycardia may be treated by stopping or decreasing the infusion, administration of atropine or glycopyrrolate, increasing the rate of IV fluid administration, use of vasopressor agents and elevation of lower extremities.Change solution at 48 hours.Ref: 1, 2, 3DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsDobutamine[Dobutrex]250 mg/20 mL vial (12.5 mg/mL)pH = 2.5 – 5 Osmolality = 276Contains EDTA & metabisulfiteRevised Feb 2020Standard Concentrationspatients < 6 kg:2000 mcg/mL (2 mg/mL)Add 4 mL of 12.5 mg/mL to 21 mL D5W to make 25 mL of 2000 mcg/mLpatients > 6 kg:5000 mcg/mL(5 mg/mL) Add 20 mL of 12.5 mg/mL to 30 mL D5W to make 50 mL of 5000 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h)divided byConcentration (mcg/mL)Hypotension2 – 20 mcg/kg/minMaximum Dose40 mcg/kg/min (toxicity may occur)C: D5W, D10W, NS, D5LR, D5NS, alprostadil, amiodarone, calcium, dopamine, epinephrine, fentanyl, hydromorphone, insulin, isoproterenol, labetalol, lidocaine, magnesium sulfate, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, propofolI: aminophylline, alteplase, furosemide, heparin, midazolam, potassium phosphate, sodium bicarbonate, alkaline solutions, diluents containing bisulfite, ethanolCompatible with TPNCentral line administration preferred.Peripheral line administration may be used for rates < 5 mcg/kg/min.Extravasation may cause sloughing or necrosis.Tachycardia, arrhythmias, hypertension at higher doses.Protect from light.Pink discoloration of solution may occur – do not need to discard.Change solution at 96 hours.Ref: 1, 3, 6, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsDopamine[Intropin]40 mg/mL (5 mL), 1.6 or 3.2 mg/mL (250 mL)pH = 2.5 – 4.5Osmolality = 619 (40 mg/mL) 295 (3.2 mg/mL)Revised Nov 2013Reviewed Feb 2020Standard Concentrationscommercially available:1600 mcg/mL 3200 mcg/mL Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg) x 60 (min/h)divided byConcentration (mcg/mL)Hypotension2 – 20 mcg/kg/minDopaminergic (contractility):< 5 mcg/kg/minBeta-Adrenergic(increased HR):5 – 15 mcg/kg/minAlpha-Adrenergic(vasoconstriction):>15 mcg/kg/minMaximum Dose50 mcg/kg/minC: D5W, D10W, NS, D5LR, Ringer’s Lactate, amiodarone, aminophylline, calcium, dobutamine, epinephrine, fentanyl, heparin, isoproterenol, labetalol, lidocaine, lorazepam, magnesium, mannitol, midazolam, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, propofol, potassium chloride, potassium phosphateI: alteplase, furosemide, insulin, phenytoin, sodium bicarbonate, thiopental, iron salts, oxidizing agents, alkaline solutionsCompatible with TPNCentral line administration preferred.Do not infuse via umbilical artery catheter.May be prepared as 250 or 500 mL PVC containers when required (if rate > 5mL/hour). Request from pharmacy.Extravasation may cause ischemia or tissue necrosis.In case of infiltration, notify physician immediately to initiate phentolamine protocol.Adverse effects include tachycardia, arrhythmia, hypotension, hypertension, peripheral gangrene.Discard solution if yellow-brown discoloration occurs.Change solution at 96 hours.Ref: 1, 2, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsEpinephrine[Adrenalin]1:1000 (1 mg/mL)1:10,000 (0.1 mg/mL)pH = 2.5 – 5Osmolality = 348 (1:1000) 273 (1:10,000)Revised Jun 2020Standard Concentrations25 mcg/mL Add 0.63 mL of 1 mg/mL (1:1000) to 24.37 mL D5W or NS to make 25 mL of 25 mcg/mL50 mcg/mL Add 2.5 mL of 1 mg/mL (1:1000) to 47.5 mL D5W or NS to make 50 mL of 50 mcg/mL100 mcg/mL Add 5 mL of 1 mg/mL (1:1000) to 45 mL D5W or NS to make 50mL of 100 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)Circulatory Support After Volume Resuscitation0.01 – 1 mcg/kg/minBeta-adrenergic (inotropy & vasodilation):<0.2 mcg/kg/minAlpha-adrenergic (vasoconstriction):>0.2 mcg/kg/minC: D5W, D10W, NS, D5NS, D5LR, dobutamine, dopamine, fentanyl, furosemide, heparin, hydromorphone, labetalol, lidocaine, lorazepam, midazolam, milrinone, morphine, nitroglycerin, norepinephrine, potassium chloride, propofolI: aminophylline, calcium, sodium bicarbonate, thiopentalCompatible with TPNCentral line administration preferred.Extravasation may cause ischemia or tissue necrosisIn case of infiltration, notify physician immediately to initiate phentolamine protocol.May be prepared as 250 or 500 mL PVC containers when required (if rate > 5mL/hour). Request from pharmacy.Adverse effects include tachycardia, dysrhythmias, myocardial ischemia, hypertension.Protect from light.Discard solution if precipitation or pink or brown discoloration occurs.Change solution at 96 hours.Ref: 3, 4, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsEpoprostenol[Prostacyclin, Flolan, PG-12]500 mcg vial with 5 mL diluentpH = 10.2Revised April 2008Reviewed Feb 2020Standard Concentration10 mcg/mLAdd 2.5 mL of 100 mcg/mL to 22.5 mL D5W to make 25 mL of 10 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (ng/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)divided by1000 (ng/mcg)Pulmonary HypertensionNote: doses are in nanograms (1 mcg = 1000 ng)2 – 60 ng/kg/minStart at 2 ng/kg/min and increase by 2 ng/kg/min every 15 min until desired response is achieved or adverse effects appear.Maximum Dose120 ng/kg/minC: diluent supplied, sodium chloride (0.45% or 0.9%); limited data to support co-infusion with heparin 1 unit/mL in NaCl 0.45%I: all medications & other solutionsIncompatible with TPNCentral line administration preferred.Reconstitution: inject diluent slowly down side of vial to avoid foaming. Do not shake the vial.Light-protected solution is stable for 48 hours if refrigerated, or for 8 hours at room temperature.Pharmacy will supply 3 syringes per day – store in refrigerator until use.Do not abruptly discontinue the infusion. Have an extra syringe available at all times in case of pump or syringe failure.Adverse effects include hypotension and tachycardia. Bleeding may occur at higher doses (>20 ng/kg/min) due to platelet inhibition.Protect syringe and tubing from light.Change solution every 8 hours.Ref: 1, 3, 10, 11DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsEsmolol[Brevibloc]100 mg/10 mLpH = 4.5 – 5.5 Revised Feb 2020Standard Concentration10 mg/mL(undiluted)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mg/mL)divided by 1000 (mcg/mg)Hypertension50 – 300 mcg/kg/minMaximum Dose 1000 mcg/kg/minSupraventricular Tachycardia500 – 600 mcg/kg IV loading dose over 1 – 2 min, followed by 200 mcg/kg/min infusion. Titrate by 50 – 100 mcg/kg/min every 5 – 10 min until a 10% reduction in heart rate and blood pressure occurs.Postoperative HypertensionLoading dose as for SVT, followed by 100 – 500 mcg/kg/min infusion. Titrate as for SVT.C: D5W, NS, D5NS, D5LR, amiodarone, calcium, dopamine, fentanyl, heparin, insulin, lidocaine, midazolam, morphine, nitroglycerin, nitroprusside, potassium chloride, propofolI: diazepam, furosemide, procainamide, sodium bicarbonate, thiopental, strong acids or basesCompatible with TPNMonitor heart rate, blood pressure, ECG, respiratory rate continuously.A 10% decrease in heart rate or MAP signifies beta blockade.Effects will last 2 – 16 minutes after infusion stopped.Avoid abrupt discontinuation as acute tachycardia, hypertension and/or ischemia may occurChange solution at 96 hoursRef: 1, 2, 3, 4, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsFentanyl[Sublimaze]10 mcg/mL in 250 mL bag50 mcg/mL in 2, 5 or 20 mL vialspH = 4.7 – 5 Osmolality = 0Revised Nov 2013Reviewed Feb 2020Standard Concentrationspatient 2 - 6 kg: 10 mcg/mL (undiluted)patient 6- 30 kg:25 mcg/mL Add 25 mL of50 mcg/mL to 25 mL NS to make 50 mL of 25 mcg/mLpatient 30-120 kg:50 mcg/mL(undiluted)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/h) x Weight (kg) divided byConcentration (mcg/mL)Sedation & AnalgesiaInfants & Children1 – 2 mcg/kg slow IV bolus over 3 – 5 min, followed by 1 – 5 mcg/kg/hExtracorporeal Membrane Oxygenation5 – 10 mcg/kg slow IV bolus over 10 min, followed by 5 – 20 mcg/kg/hC: D5W, NS, lactated Ringers, aminophylline, calcium chloride, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, furosemide, heparin, insulin, isoproterenol, hydromorphone, labetalol, lidocaine, lorazepam, magnesium, midazolam, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, propofol, potassium chloride, sodium bicarbonate, vasopressinI: amphotericin, phenytoinCompatible with TPNPeripheral or central line administration.Higher doses may be required in ECMO as the drug is sequestered by the circuit. Morphine is the preferred opiate for continuous analgesia and sedation in ECMO.Chest rigidity may occur with large loading doses (>5 mcg/kg) and is reversible with naloxone.Monitor for respiratory depression in non-ventilated patients.Antidote is naloxone 0.01 – 0.1 mg/kg IV prnChange solution at 96 hours.Ref: 2, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsFurosemide[Lasix]10 mg/mLpH = 8.5 – 9.3 Osmolality = 290Revised Feb 2020Standard Concentrations1 mg/mLAdd 5 mL of 10 mg/mL to 45 mL of NS to make 50 mLof 1 mg/mL2 mg/mLAdd 10 mL of10 mg/mL to 40 mL NS to make 50 mLof 2 mg/mL10 mg/mL(undiluted)central line onlyUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mg/kg/h) x Weight (kg)divided byConcentration (mg/mL)Diuresis0.1 – 1 mg/kg/hMaximum Dose4 mg/min OR0.5 mg/kg/minC: D5W, D10W, NS, Ringer’s Lactate, D5LR, aminophylline, calcium gluconate, epinephrine, fentanyl, heparin, hydromorphone, hydrocortisone, lidocaine, lorazepam, nitroglycerin, norepinephrine, sodium bicarbonate, propofol, potassium chlorideI: acidic solutions, amiodarone, amphotericin, dobutamine, esmolol, isoproterenol, labetalol midazolam, milrinone, morphine, thiopentalIncompatible with TPNCentral line administration for concentrations > 5 mg/mLIncreased risk of electrolyte abnormalities with continuous infusions.Rapid administration may cuase transient or permanent ototoxicity . Concurrent aminoglycosides potentiate this risk.Contraindicated in anuria.Discard discolored solutions.Protect from light. Change solution at 24 hours (light exposed) or 96 hours (light protected). Ref: 1, 3, 7, 9DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsHeparin[Heparin Sodium]25,000 units/500 mL bag (50 IU/mL)10,000 units/10 mL vial (1000 IU/mL)pH = 5 – 7.5 Osmolality = 280 – 380 (100 IU/mL)May contain sulfites and benzyl alcoholRevised Feb 2020Standard Concentrations50 units/mL (draw up from commercially available bag 25,000 units/500 mL D5W)Fluid-Restricted:100 units/mL (draw up from commercially available bag 50,000 units/500 mL D5W)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (units/kg/h) x Weight (kg) divided byConcentration (units/mL)Consult Heparin Protocol in BCCH Pediatric Drug Dosage GuidelinesTherapeutic Heparinization75 units/kg IV loading dose (max 5000 units) over 10 minutes, followed by:<1 year:28 units/kg/h>1 year:20 units/kg/hAdjust rate based on PTT resultsC: D5W, NS, D5LR, alprostadil, aminophylline, calcium chloride, calcium gluconate, dopamine, epinephrine, esmolol, fentanyl, furosemide, hydromorphone, insulin, isoproterenol, labetalol, lidocaine, lorazepam, magnesium midazolam, milrinone, morphine, nitroglycerin, norepinephrine, potassium chloride, propofol, sodium bicarbonate, thiopentalI: alteplase, amiodarone, diazepam, dobutamineCompatible with TPNPeripheral or central line administration.See Heparin Protocol in BCCH Pediatric Drug Dosage Guidelines, 2018 (Esau, ed)Change solution and tubing at 72 hours.Ref: 1, 2, 3, 5, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsHydromorphone[Dilaudid]2 mg/mLpH = 4 – 5.5 Revised May 2015Reviewed Feb 2020Standard Concentrations40 mcg/mL Add 0.5 mL of 2 mg/mL to 24.5 mL D5W or NS to make 25 mL of 40 mcg/mL80 mcg/mL Add 2 mL of 2 mg/mL to 48 mL D5W or NS to make 50 mL of 80 mcg/mL200 mcg/mLAdd 5 mL of 2 mg/mL to 45 mL D5W or NS to make 50 mL of 200 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/h) x Weight (kg)divided byConcentration (mcg/mL)Postoperative Analgesia & Sedation1 – 8 mcg/kg/hSevere pain may require much higher doses.C: D5W, NS, D5NS, D5LR, dobutamine, dopamine, epinephrine, fentanyl, furosemide, heparin, ketamine, labetolol, lorazepam, magnesium, midazolam, milrinone, morphine, nitroglycerin, norepinephrine, propofolI: phenobarbital, phenytoin, sodium bicarbonate, thiopentalPeripheral or central line administration.CAUTION: Hydromorphone is 5X more potent than morphine.Semi-synthetic opiate analgesic indicated in patients with an allergy or intolerance to morphine.Prolonged use of a high-dose infusion may result in tolerance.Abrupt discontinuation after prolonged use (>2 weeks) may result in withdrawal.Monitor for respiratory depression in non-ventilated patients.Antidote is naloxone 0.01 mg/kg IVNot recommended in neonates.Change solution at 96 hours.Ref: 3, 6, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsInsulin, Regular[Humulin]1000 units/10 mL vial (100 U/mL)pH = 7 – 7.8Revised January 2020Standard ConcentrationsFor DKA patients:0.1 unit/mLAdd 0.5 mL of 100 U/mL to 500 mL NS to make 500 mL of 0.1 unit/mL For fluid restricted patients:0.5 units/mLAdd 0.25 mL of 100 U/mL to 49.75 mL NS to make 50 mL of 0.5 units/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (units/kg/h) x Weight (kg)divided byConcentration (units/mL)Diabetic Ketoacidosis (DKA)0.05 – 0.2 unit/kg/hGlucose Intolerance 0.03 – 0.05 unit/kg/hAdjust rate to desired blood glucose concentration.Hyperkalemia0.05 – 0.1 unit/kg/hInfused with glucose 400 mg/kg (or 4 g for every 1 unit insulin)C: D5W, NS, amiodarone, calcium gluconate, dobutamine, esmolol, heparin, magnesium midazolam, milrinone, morphine, nitroglycerin, nitroprusside, potassium chloride, propofol, sodium bicarbonateI: aminophylline, dopamine, norepinephrineCompatible with TPNPeripheral or central line administration.Titrate infusion rate to desired blood glucose concentration.Monitor closely for hypoglycemia.Only Human Regular insulin is to be given intravenously.Pre-flush tubing with twice the volume of tubing dead space.Higher concentrations to be used only for fluid-restricted patients.Change solution and tubing at 24 hours.Ref: 1, 2, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsIsoproterenol[Isuprel]1:5000 (0.2 mg/mL) 1 mL ampulepH = 3.5 – 4.5Osmolality = 277Contains sodium chloride, sodium lactate, lactic acid, metabisulfiteRevised Feb 2020Standard Concentrations25 mcg/mL Add 6.25 mL of 0.2 mg/mL (1:5000) to 43.75 mL D5W to make 50 mL of 25 mcg/mL 50 mcg/mL Add 12.5 mL of 0.2 mg/mL (1:5000) to 37.5 mL D5W to make 50 mL of 50 mcg/mL100 mcg/mL Add 25 mL of 0.2 mg/mL (1:5000) to 25 mL D5W to make 50 mL of 100 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)HypotensionNeonates & Children0.025 – 2 mcg/kg/minC: D5W, NS, D5NS, D5LR, amiodarone, calcium chloride, dobutamine, dopamine, epinephrine, fentanyl, heparin, lidocaine, magnesium, midazolam, milrinone, morphine, nitroprusside, potassium chloride, propofolI: aminophylline, furosemide, sodium bicarbonateCompatible with TPNCentral line administration preferred.Very potent chronotrope, inotrope, and peripheral vasodilator.Not considered drug of choice for bradycardia.Do not use for digitalis toxicity.Significant degradation occurs above pH 6.Protect from light.Discard discolored or precipitated solutions.Change solution at 96 hours.Ref: 1, 2, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsKetamine[Ketalar]10 mg/mL vial 50 mg/mL vialpH = 3.5 – 5.5 Osmolality = 300 (10 mg/mL)Revised Feb 2020Standard Concentrationspatient < 70 kg:10 mg/mL (undiluted)(= 10000 mcg/mL)patient > 70 kg:50 mg/mL(undiluted)**request from pharmacy(= 50 000 mcg/mL)Use Alaris Pump to determine infusion rate.ANDConfirm with the calculation at bottom of pageContinuous Sedation5 – 20 mcg/kg/minBronchospasm3 – 40 mcg/kg/minC: D5W, NS, calcium gluconate, dobutamine, dopamine, epinephrine, lidocaine, magnesium, morphine, propofolI: Acyclovir, aminophylline, ampicillin, diazepam, furosemide, heparin, insulin, pentobarbital, salbutamol, sodium bicarbonate Peripheral or central line administration.? Rapid administration may cause increased apnea, respiratory depression and enhanced pressor response.? Emergence reactions (e.g. dream-like states, hallucinations, delirium) may occur. Minimizing verbal, tactileand visual stimulation after dosing decreases the likelihood of these reactions.May see increased secretions. Glycopyrrolate may be effective in reversing some of the sialogogue effect.Monitor closely for transient laryngospasm, apnea, respiratory arrest.Change solution at 96 hours.Ref: 1, 2, 7left27940Infusion rate mL/hour = Dose (mcg/kg/min) X Weight (kg) X 60 min/hour) Concentration (mg/mL) X 1000 mcg/mg00Infusion rate mL/hour = Dose (mcg/kg/min) X Weight (kg) X 60 min/hour) Concentration (mg/mL) X 1000 mcg/mgDrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsLabetalol[Trandate]5 mg/mLpH = 3 – 4 Osmolality = 287May contain parabensRevised Jan 2020Standard Concentrations1 mg/mL Add 10 mL of 5 mg/mL to 40 mLD5W to make 50 mL of 1 mg/mL5 mg/mL(undiluted)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mg/kg/h) x Weight (kg) divided byConcentration (mg/mL)HypertensionContinuous Infusion0.25 – 3 mg/kg/h*Increase in increments of 0.05 mg/kg/h as needed to control BP to a max of 3 mg/kg/hMay give bolus just prior to starting infusionHypertensive EmergenciesIntermittent Boluses 0.2 – 1 mg/kg IV over at least 2 minutes May repeat at 10 min intervals until desired BP has been achievedC: D5W, NS, D5NS, lactated Ringer’s, D5LR, aminophylline, amiodarone, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, fentanyl, hydromorphone, isoproterenol, lorazepam, lidocaine, magnesium sulfate, midazolam, milrinone, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, potassium phosphate, propofolI: furosemide, insulin, sodium bicarbonate, thiopentalPeripheral or central line administration.Use cautiously in pediatrics: limited information on use in children.Alpha and beta adrenergic blocker. Contraindicated in patients with asthma, COPD, cardiac failure, heart block, bradycardia, cardiogenic shock.Orthostatic hypotension may occur with intravenous administration.Caution in hepatic dysfunction.Change solution at 72 hours for 1 mg/mL in D5W and at 24 hours for 1 mg/mL in NS and 96 hours for 5 mg/mL concentration.Ref: 1, 2, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsLidocaine[Xylocaine]20 mg/mL vial1000 mg/250 mL bag (4 mg/mL)pH = 5 – 7 (20 mg/mL) 3.5 – 6 (4 mg/mL)Osmolality = 352 (20 mg/mL)May contain sulfites and parabensRevised Nov 2013Reviewed May 2020Standard Concentrations4 mg/mL: commercially available in 250 mL bag -or-: Add 10 mL of20 mg/mL to 40 mL D5W to make 50 mL of4 mg/mL 8 mg/mL Add 20 mL of 20 mg/mL to 30 mL D5W to make 50 mL of 8 mg/mL Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mg/mL)divided by 1000 (mcg/mg)Ventricular Arrhythmia1 mg/kg IV loading dose over 2 – 3 min, may repeat q10min (max 5 mg/kg total), followed by10 – 50 mcg/kg/minC: D5W, NS, D5NS, D5LR, Ringer’s Lactate, alteplase, aminophylline, amiodarone, calcium, dobutamine, dopamine, epinephrine, esmolol, fentanyl, furosemide, heparin, isoproterenol, labetalol, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, procainamide, propofolI: sodium bicarbonate, thiopentalPeripheral or central line administration.Contraindicated in infants with congenital heart disease and severe heart block.Decrease dose in patients with shock, CHF, liver failure or reduced hepatic blood flow.Therapeutic Drug MonitoringTherapeutic range = 4.5 – 21 mcmol/L (1.5 – 5 mcg/mL)Potentially toxic range = >26 mcmol/L (>6 mcg/mL)Toxic range => 38 mcmol/L (>9 mcg/mL)Signs of toxicity include myocardial and CNS depression.Change solution at 96 hours.Ref: 1, 2, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsLorazepam[Ativan]4 mg/mL vials pKa = 1.3 & 11.5 (ampholyte) Isoelectric @ 6.4 Contains propylene glycol and benzyl alcoholRevised April 2008Reviewed May 2020Standard Concentration0.2 mg/mLAdd 2.5 mL of 4 mg/mL to 47.5 mL D5W to make 50 mL of 0.2 mg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mg/kg/h) x Weight (kg)divided byConcentration (mg/mL)Sedation with Mechanical Ventilation0.01 – 0.1 mg/kg/hLarger doses may be required in ECMO due to extraction of ~ 50% by the circuitMaximum Dose2 mg/hC: D5W, amiodarone, dobutamine, dopamine, epinephrine, fentanyl, furosemide, heparin, hydromorphone, labetalol, milrinone, midazolam, morphine, norepinephrine, potassium chloride, propofolI: sufentanil, thiopentalPeripheral or central line administration.Requirements for sedation are highly variable and dose titration is necessary.May cause metabolic complications (lactic acidosis, hyperosmolality, increased osmolar gap) with doses >8 mg/h or nephrotoxicity due to propylene glycol content.Use with caution in patients with renal or hepatic impairment.Use D5W only for dilutions and observe frequently for precipitate.Store vials in refrigerator.Change solution at 24 hours.Ref: 1, 3DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsMagnesium Sulfate[MgSO4]50% ( 500 mg/mL)Each mL contains: 500 mg MgSO4 2 mmol Mg+2 4 mEq Mg+2 Osmolality = 2620 – 2875 Revised Dec 2013Reviewed May 2020Standard ConcentrationsNeonates:10 mg/mL (0.04 mmol/mL)Add 0.5 mL of 50% to 24.5 mL D5W to make 25 mL of 10 mg/mLNon neonates:100 mg/mL (0.4 mmol/mL)Add 10 mL of 50% to 40 mL D5W to make 50 mL of100 mg/mLNon neonates,Fluid Restricted:200 mg/mL(0.8 mmol/mL)Add 20 mL of 50% to 30 mL D5W to make 50 mL of200 mg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mg/kg/day) x Weight (kg)divided byConcentration (mg/mL)divided by24 (h/day)OR Infusion rate (mL/h) = Dose (mmol/kg/d) x Weight (kg)divided byConcentration (mmol/mL)divided by24 (h/day)Maximum Rate150 mg/minPostoperative Cardiac Patients0.2 – 0.8 mmol/kg/dayHypomagnesemia25 – 50 mg/kg/dose (0.1 – 0.2 mmol/kg) IV q6h x 3 – 4 dosesC: D5W, NS, aminophylline, dobutamine, dopamine, epinephrine, fentanyl, heparin, hydromorphone, insulin, isoproterenol, labetalol, milrinone, morphine, nitroprusside, norepinephrine, potassium chloride, propofolI: amiodarone, calcium chloride, calcium gluconate, lipid emulsion, sodium bicarbonateCompatible with TPNPeripheral or central line administration.Monitor serum magnesium levels daily while on infusion (Normal Range = 0.78 – 1.03 mmol/L)Usual duration of infusion is 1 – 2 days.Signs of toxicity include respiratory depression or heart block. Toxicity is reversed using calcium gluconate.Renal impairment will increase risk of toxicity.Change solution at 24 hours.Ref: 1, 3, 6DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsMidazolam[Versed]5 mg/mL in 2 or 10 mL vial1 mg/1 mL vialpH = 3 – 3.6Osmolality = 385Contains benzyl alcoholRevised Dec 2013Reviewed May 2020Standard Concentrations1 mg/mLAdd 10 mL of 5 mg/mL to 40 mL D5W or NS to make 50 mL of 1 mg/mLFluid Restriction:5 mg/mL(undiluted from 5 mg/mL strength vials) Use Alaris Pump to determine infusion rate.ANDConfirm with the calculation below.Sedation in Mechanical Ventilation20 – 360 mcg/kg/h(0.33 – 6 mcg/kg/min)*Loading Dose0.05 – 0.2 mg/kg IV over at least 3 minutes* Note:20 mcg/kg/h = 0.33 mcg/kg/min30 mcg/kg/h = 0.5 mcg/kg/min60 mcg/kg/h = 1 mcg/kg/min100 mcg/kg/h = 1.7 mcg/kg/min120 mcg/kg/h = 2 mcg/kg/min150 mcg/kg/h = 2.5 mcg/kg/min180 mcg/kg/h = 3 mcg/kg/min210 mcg/kg/h = 3.5 mcg/kg/min240 mcg/kg/h = 4 mcg/kg/min360 mcg/kg/h = 6 mcg/kg/minC: D5W, NS, D5NS, amiodarone, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, fentanyl, heparin, hydromorphone, insulin, labetalol, magnesium, milrinone, morphine, nitroglycerin, norepinephrine, potassium chloride, propofolI: amphotericin, furosemide, hydrocortisone, omeprazole, sodium bicarbonate, thiopentalCompatible with TPNPeripheral or central line administration.Use lowest effective dose, as may accumulate in tissues with prolonged use.May cause hypotension. Use cautiously and avoid loading doses in postoperative open-heart patients, septic shock, or meningococcemia.Rapid infusion may cause respiratory depression or apnea.Change solution at 96 hours.Ref: 1, 2, 3, 70115570Infusion rate (mL/hour) = _____dose (mcg/kg/hour) X weight (kg)_______ Concentration (mg/mL) X 1000mcg/mg00Infusion rate (mL/hour) = _____dose (mcg/kg/hour) X weight (kg)_______ Concentration (mg/mL) X 1000mcg/mgDrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsMilrinone[Primacor]1 mg/mLpH = 3.2 – 4 Contains lactic acid (0.93 – 1.29 mg/mL)Revised Jan 2020Standard Concentrationspatient 2 - 6 kg:100 mcg/mL Add 2.5 mL of 1 mg/mL to 22.5 mL D5W to make 25 mL of100 mcg/mL patient 6- 30 kg:200 mcg/mL Add 10 mL of 1 mg/mL to 40 mL D5W to make 50 mL of 200 mcg/mLpatient 30-120 kg:400 mcg/mL Add 20 mL of1 mg/mL to 30 mL D5W to make 50 mL of 400 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)Postoperative Cardiac Patients50 mcg/kg IV loading dose over 10 min, followed by0.25 – 0.75 mcg/kg/minMaximum Dose1 mcg/kg/minC: D5W, NS, amiodarone, calcium chloride, dobutamine, dopamine, epinephrine, fentanyl, heparin, hydromorphone, insulin, labetalol, lorazepam, magnesium sulfate, midazolam, morphine, nitroglycerin, norepinephrine, potassium chloride, propofol, sodium bicarbonate, thiopentalI: furosemide, procainamide, Peripheral or central line administration.Loading doses require the approval of a pediatric intensivist due to risk of significant hypotension.May be prepared as 250 or 500 mL PVC containers when required (if rate > 5mL/hour). Request from pharmacy.Half-life is prolonged in renal failure.Adverse effects include hypotension, arrhythmias, bronchospasm.Change solution at 96 hours.Ref: 1, 2, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsMorphine[MOS]10 mg/mLpH = 2.5 – 6 Osmolality = 54Revised Feb 2020Standard Concentrations200 mcg/mL Add 0.5 mL of 10 mg/mL to 24.5 mL D5W or NS to make 25 mL of 200 mcg/mL400 mcg/mLAdd 2 mL of10 mg/mL to 48 mL NS or D5W to make 50 mL of400 mcg/mL1 mg/mL (=1000 mcg/mL)Add 5 mL of10 mg/mL to 45 mL NS or D5W to make 50 mL of1 mg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/h) x Weight (kg)divided byConcentration (mcg/mL)Postoperative Analgesia & Sedation5 – 20 mcg/kg/hC: D5W, NS,D5NS, D51/2NS, D5LR, , aminophylline, amiodarone, calcium chloride, calcium gluconate, dopamine, dobutamine, epinephrine, esmolol, fentanyl, heparin, hydromorphone, insulin, ketamine, labetalol, lidocaine, magnesium sulfate, midazolam, milrinone, nitroglycerin, nitroprusside, norepinephrine, potassium chlorideI: amphotericin, furosemideCompatible with TPNPeripheral or central line administration.Monitor for respiratory depression in non-ventilated patients.Antidote is naloxone 0.01 – 0.1 mg/kg IV prnProlonged use of high-dose infusion may result in tolerance.Abrupt discontinuation of infusion after prolonged use (>2 weeks) may result in withdrawal symptoms.Change solution at 96 hours.Ref: 1, 2, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsNitroglycerin[Nitrostat, NTG]5 mg/mLpH = 3 – 6.5Osmolality = 281 (1 mg/mL)Contains propylene glycol and ethanolRevised Dec 2013Reviewed May 2020Standard Concentrations100 mcg/mL Add 0.5 mL of 5 mg/mL to 24.5 mL D5W to make 25 mL of 100 mcg/mL200 mcg/mLAdd 2 mL of 5 mg/mL to 48 mL D5W to make 50 mL of 200 mcg/mL500 mcg/mLAdd 5 mL of 5 mg/mL to 45 mL D5W to make 50 mL of 500 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)Postoperative Cardiac PatientsPediatric0.5 – 10 mcg/kg/minStart at 0.1 – 1 mcg/kg/min and increase by 0.5 – 1 mcg/kg/min every 3 – 5 min until desired clinical effectAdults5 – 100 mcg/minStart at 5 mcg/min and increase by 5 – 10 mcg/min until desired clinical effectC: D5W, NS, D5LR, aminophylline, amiodarone, dobutamine, dopamine, epinephrine, esmolol, fentanyl, furosemide, heparin, hydromorphone, insulin, labetalol, lidocaine, lorazepam, midazolam, milrinone, morphine, nitroprusside, norepinephrine, propofolI: lipid emulsionCompatible with TPNPeripheral or central line administration.Administer via syringe pump with non-PVC tubing. Do not use a filter.Precipitation may occur at concentrations > 500 mcg/mLAdverse effects include severe hypotension and shock. Methemoglobinemia is observed in adults who receive > 7 mcg/kg/min.Change solution at 24 hours.Ref: 1, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsNitroprusside[Nipride, Nitropress, Sodium Nitroprusside, SNP]50 mg/2 mL vial(25 mg/mL)pH = 3.5 – 6 Osmolality = 214Reconstituted solutions are colored straw/pink to reddish-brownRevised June 2020Standard Concentrations200 mcg/mL Add 0.4 mL of 25 mg/mL to 49.6 mL D5W or NS to make 50 mL of 200 mcg/mL800 mcg/mLAdd 1.6 mL of 25 mg/mL to 48.4 mL D5W or NS to make 50 mL of 800 mcg/mL2000 mcg/mL Add 4 mL of 25 mg/mL to 46 mL D5W or NS to make 50 mL of 2000 mcg/mL5000 mcg/mLAdd 10 mL of 25 mg/mL to 40 mL D5W or NS to make 50 mL of 5000 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)Hypertensive Crisis or Postoperative Cardiac PatientsNeonatesStart at 0.025 – 0.5 mcg/kg/min to max 6 mcg/kg/min PediatricStart at 0.25 mcg/kg/min and titrate by 0.25 mcg/kg/min to max 8 mcg/kg/minC: D5W, NS, amiodarone, dobutamine, dopamine, esmolol, heparin, insulin, labetalol, lidocaine, milrinone, morphine, nitroglycerin, potassium chloride, procainamide, propofolI: norepinephrine, lipid emulsionCompatible with TPNPeripheral or central line administration.Protect solution from light with aluminum foil. Not necessary to cover tubing.Hypotension may occur. Monitor blood pressure continuously.Methemoglobinuria can occur at doses > 10 mcg/kg/min. Methylene blue is used as an antidote.Check thiocyanate levels with high doses, prolonged use (>48h) or renal failure.Avoid rapid dose escalation.Use cautiously in patients with increased intracranial pressure.Discard solution if blue discoloration occurs.Change solution at 24 hours.Ref: 1, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsNorepinephrine[Noradrenalin]4 mg (base)/4 mL ampoulepH = 3 – 4.5 Osmolality = 319Contains metabisulfite All calculations are based on norepinephrine base ( 1 mg base = 2 mg bitartrate)Revised January 2020Standard Concentrations25 mcg/mL Add 0.63 mL of 1 mg/mL to 24.37 mL D5W or NS to make 25 mL of25 mcg/mL50 mcg/mL Add 2.5 mL of 1 mg/mL to 47.5 mL D5W or NS to make 50mL of 50 mcg/mL200 mcg/mL Add 10 mL of 1 mg/mL to 40 mL D5W or NS to make 50 mL of200 mcg/mLFluid Restricted and >30 kg:500 mcg/mL Add 25 mL of 1 mg/mL to 25 mL D5W or NS to make 50 mL of500 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)Blood Pressure SupportInfants & Children0.02 – 0.4 mcg/kg/min titrated to maximum 1 mcg/kg/minC: D5W, NS, D5NS, amiodarone, calcium chloride, calcium gluconate, dobutamine, dopamine, epinephrine, esmolol, fentanyl, furosemide, heparin, hydromorphone, labetalol, magnesium , lorazepam, midazolam, milrinone, morphine, nitroglycerin, potassium chloride, propofol, vecuroniumI: aminophylline, insulin, sodium bicarbonate, thiopentalCompatible with TPNCentral line administration preferred.Dextrose-containing solutions protect from oxidation and are the preferred diluent over sodium chloride-containing solutions (NS).Correct intravascular volume before initiating norepinephrine.Extravasation may cause local ischemia and tissue necrosis.Notify physician in case of infiltration to initiate phentolamine protocol.Protect from light.Discard solution if brown discoloration occurs.Change solution at 96 hours.Ref: 1, 3, 7DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsPapaverine HCl32.5 mg/mL (2mL)Revised Nov 2013Reviewed May 2020Standard Concentration:0.12 mg/mL: Add 1.8 mL (60 mg of 32.5 mg/mL) to 500 mL heparin 2U/mL in NS or 1/2NS to make 500 mL of 0.12 mg/mLTo prolong life of arterial catheters in neonates and infants:< 20 kg:Infuse in arterial line at 1 mL/hourProlongation life of arterial catheters in neonates and infants:0.12 mg/hour CIVINot applicable. Other medications should not be infused into arterial line.Note: at higher concentrations papaverine & heparin are incompatible. Therefore when withdrawing from the papaverine-heparin bag, use a new syringe. If residual higher concentration of the papaverine remains in the syringe, the solution will precipitate and result in a cloudy mixture.Note: At higher concentrations, administration by rapid IV push may cause arrhythmias, apnea, or death. If need to give IV push, administer over 1-2 minutes.Discard solution if solution remains cloudy after mixing.Change solution at 96 hours.Ref: 1, 3, 12DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsPhenylephrine10 mg/mL (1 mL, 5 mL, 10 mL vials)Contains sulphites and sodium benzoateCreated July 2015Reviewed May 2020Standard Concentrations: 40 mcg/mL:Add 0.1 mL of 10 mg/mL to 24.9 mL D5W or NS to make 25 mL of 40 mcg/mL100 mcg/mL: Add 0.25 mL of 10 mg/mL to 24.75 mL D5W or NS to make 25 mL of 100 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg) X 60 (min/h)divided byConcentration (mcg/mL)Hypotension/shock:IV bolus: 5-20 mcg/kg IV q10-15 min PRNIV infusion: 0.5 mcg/kg/min titrated to effectC: D5W, NS, D5NS, D51/2NS, D5LR, aminophylline, amiodarone, calcium chloride, calcium gluconate, cisatracurium, midazolam, morphineI: acyclovir, phenytoin Incompatible with TPNCentral line administration. Do not use if solution turns brown. Selective alpha agonist Extravasation may cause local ischemia and tissue necrosis.Notify physician in case of infiltration to initiate phentolamine protocol.Change solution at 96 hours.Ref: 3 DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsProcainamide[Pronestyl, PCA]100 mg/mLpH = 4 – 6 Osmolality = 2000May contain sulfites and benzyl alcoholRevised Dec 2013Reviewed May 2020Standard Concentrationspatient < 30 kg:10 mg/mL Add 5 mL of 100 mg/mL to 45 mL NS to make 50 mL of 10 mg/mLpatient > 30 kg:30 mg/mLAdd 15 mL of 100 mg/mL to 35 mL NS to make 50 mL of 30 mg/mL**Note: mix in NSUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/mL)Cardiac Arrhythmias20 – 80 mcg/kg/minLoading dose:2 – 5 mg/kg (max 100 mg) over 5 min, may repeat q5min to a max of 15 mg/kg in 30 minutesC: D5W, NS, calcium gluconate, dobutamine, esmolol (in D5W), heparin, lidocaine, potassium chloride, sodium nitroprusside (in D5W)I: amiodarone, milrinonePeripheral or central line administration.Adjust dose in renal impairment.Monitor EKG. Discontinue infusion if QRS widens >50% or hypotension develops.Active metabolite (NPCA) contributes to toxicity.Therapeutic Drug MonitoringTarget range:Procainamide: 15 – 37 mcmol/LPCA + NPCA: < 110 mcmol/LToxic range:NPCA: >37 mcmol/LDiscard solution if dark amber discoloration occurs.Change solution at 24 hours.Ref: 1, 2, 3DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsPropofol[Diprivan]200 mg/20 mL in 10% soybean emulsionpH = 6.5 – 8.5Osmolality = isotonicMay contain metabisulfite or benzyl alcoholRevised Feb 2020Standard Concentrations10 mg/mL* (undiluted)(10 000 mcg/mL)To convert to mcg/mL:1 mg/mL = 1000 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/min) x Weight (kg)x 60 (min/h) divided byConcentration (mcg/ml) Sedation in Mechanical Ventilation20 – 60 mcg/kg/minStart with the lowest effective dose usually5-10 mcg/kg/mintitrate by5 – 10 mcg/kg/min q5minMaintenance of Anesthesia100 – 250 mcg/kg/minC:D5W, D5W1/2NS, D5LR, lactated Ringer’s, aminophylline, calcium gluconate, dobutamine, dopamine, esmolol, epinephrine, fentanyl, furosemide, heparin, hydrocortisone, hydromorphone, insulin, isoproterenol, ketamine, labetalol, lidocaine, lorazepam, midazolam, morphine, nitroglycerin, nitroprusside, norepinephrine, potassium chloride, sodium bicarbonateI: calcium chloride, diazepamIncompatible with TPNPeripheral or central line administration.The emulsion vehicle is similar to lipid emulsions such as Intralipid and similar precautions should be observed.Do not directly admix with any drug, solution, or blood product.For short-term or intermittent use only.Propofol-Related Infusion Syndrome (PRIS): metabolic acidosis, lipemia, hypotension, multi-system organ failure, rhabdomyolysis, cardiovascular collapse.Change solution and IV administration set at 6 hours.Ref: 1, 2, 3, 11-38100106680Propofol infusion rate (mL/hour) = Dose (mcg/kg/min) x Weight (kg) X (60 min/hour) Concentration (10 mg/mL) X 1000 mcg/mg00Propofol infusion rate (mL/hour) = Dose (mcg/kg/min) x Weight (kg) X (60 min/hour) Concentration (10 mg/mL) X 1000 mcg/mgDrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsSalbutamol[Ventolin]1 mg/mLpH: 3.5 Osmolality = isotonicCreated Jun 2020 Standard Concentrations 20 mcg/mLAdd 1 mL of 1 mg/mL to 49 mL NS or D5NS to make 50 mL of 20 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mmol/kg/h) x Weight (kg)divided byConcentration (mmol/mL)Severe asthma exacerbation1-5 mcg/kg/minStart at 1 mcg/kg/minC: D5W, NS, D5NS, aminophylline, dexamethasone, hydrocortisoneIncompatible with TPN, ketamineVery little Y site compatibility information.Contact pharmacy regarding compatibilities.Monitor for tachycardia, arrhythmias and hypertensionChange solution at 24 hours.Ref: 1, 3, 6DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsSodium Bicarbonate[NaHCO3]0.5 mmol/mL (4.2%)1 mmol/mL (8.4%)Each mL contains: 8.4% HCO3- 1 mmol HCO3- 1 mEq HCO3- 6% Na+ 1 mmol Na+ 1 mEq Na+pH = 7.4 – 8.5Osmolality = 815 (4.2%) 1815 (8.4%)Revised Dec 2013Reviewed May 2020Standard ConcentrationsPeripheral line:0.5 mmol/mL (4.2%, undiluted)Central line:1 mmol/mL (8.4%, undiluted)Use Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mmol/kg/h) x Weight (kg)divided byConcentration (mmol/mL)Metabolic Acidosis, Continuous Infusion0.5 – 2 mmol/kg/hMetabolic Acidosis, Intermittent InfusionHCO3 (mmol) = 0.3 x weight (kg)x base deficit (mmol/L)Administer ? the calculated dose over 30 – 60 minC: D5W, D10W, D5NS, NS, I: alprostadil, amiodarone, amrinone, calcium chloride, calcium gluconate, dopamine, dobutamine, epinephrine, isoproterenol, magnesium, midazolam, norepinephrine, thiopental, vancomycin Incompatible with TPNContact pharmacy regarding compatibilities.Central line administration only for 8.4% concentration.Rapid infusions in neonates and children may cause hypernatremia, decreased CSF pressure, and intracranial hemorrhage.Extravasation may cause local tissue necrosis.Change solution at 96 hours.Ref: 1, 3DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsSufentanil[Sufenta]50 mcg/mL in 1 mL and 5 mL vialspH = 3.5 – 6Revised April 2008Reviewed May 2020Standard ConcentrationsPatients < 6 kg:5 mcg/mL Add 2.5 mL of 50 mcg/mL to 22.5 mL of D5W to make 25 mL of 5 mcg/mLPatients 6- 30 kg:10 mcg/mL Add 10 mL of 50 mcg/mL to 40 mL of D5W to make 50 mL of 10 mcg/mLPatients > 30 kg:20 mcg/mL Add 20 mL of 50 mcg/mL to 30 mL of D5W to make 50 mL of 20 mcg/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (mcg/kg/h) x Weight (kg)divided byConcentration (mcg/mL)Analgesia0.2 – 1 mcg/kg/hIntermittent Bolus0.2 – 0.4 mcg/kgAnesthesiaNeonates1 – 2 mcg/kg/hInfants1 – 1.5 mcg/kg/hChildren & Adolescents<1 mcg/kg/hC: D5W, NS, midazolam, propofolI: lorazepam, phenobarbital, phenytoin, thiopentalPeripheral or central line administration.Infuse via non PVC tubing (PVC tubing can reduce infusion concentration by 15% in 24 hours)Most potent opioid analgesic.Bolus administration may cause significant apnea, bradycardia, muscle rigidity, chest wall rigidity. Pretreatment with atropine and a non-depolarizing muscular blocking agent may minimize these effects.Antidote: Naloxone 0.01 mg/kg IVChange solution at 24 hours.Ref: 1, 3, 9DrugConcentrationsInfusion RateDose RangeY-Site CompatibilityCommentsVasopressin[Pressyn]20 units/mL in 0.5 or 5 mL ampoule1 unit = 1000 milliunits**Note: for Alaris pump programming use milliunitspH = 2.5 – 4.5 Revised Dec 2013Reviewed May 2020Standard Concentrations0.005 units/mL (5 milliunits/mL)Add 0.25 mL of 20 units/mL to 1L bag of D5W, NS, or D5NS to make 1000 mL (1L) of 0.005 units/mL (*note concentration will not be exact and should only be used for DI management)0.4 units/mL Add 1 mL of20 units/mL to 49 mL D5W or NS to make 50 mL of 0.4 units/mL1 unit/mL Add 2.5 mL of20 units/mL to 47.5 mL D5W or NS to make 50 mL of 1 units/mLUse Alaris Pump to determine infusion rate.ANDConfirm with the following calculation:Infusion rate (mL/h) = Dose (milliunits/kg/min) x Weight (kg)x 60 (min/h)divided by(Concentration (units/mL) X1000 miliunits/unit)Central Diabetes Insipidus (DI)0.02 – 0.05 milliunits/kg/min = 0.00002 – 0.00005 units/kg/min(titrate to desired urine output)Maximum Dose0.2 milliunits/kg/min = 0.0002 units/kg/minVasodilatory Shock 0.3 – 2 milliunits/kg/min = 0.0003 – 0.002 units/kg/minC (in D5W): amiodarone, dobutamine, dopamine, heparin, lidocaine, milrinone, nitroglycerin, norepinephrine, phenylephrine, procainamideC (in NS): amiodarone, epinephrine, norepinephrineCentral line administration preferred.Only the aqueous form may be infused continuously.Extravasation may cause tissue necrosis.May cause water overload and hyponatremia.Change solution at 24 hours.Ref: 1, 9REFERENCESPhelps S, Hagemann TM, Lee KR, Thompson AJ. (Eds) Pediatric Injectable Drugs, 11th Edition . Bethesda. American Society of Health System Pharmacists; 2017.Taketomo CK, Hodding JH, Kraus DM, (Eds). Pediatric Dosage Handbook 25th Edition. Hudson Lexicomp; 2018.Trissel’s ? 2 Clinical Pharmaceutics Database , Micromedex 2.0 June 2020. TE, Mangum B. (Ed). Neofax: IBM Micromedex? June 2020Esau R (Ed).Pediatrics Drug Dosage Guidelines, 7th Edition . Vancouver. BC Children’s Hospital; 2018.BC Children’s Hospital Parenteral Manual. Vancouver. BC Children’s Hospital. June 2020“Our Standard Concentrations Updated 11/05/04”. University of Maryland School of Medicine. 2004. Kent D, WIlis G, (Editors). Poison Management Manual. Vancouver. British Columbia Drug and Poison Information Centre. 2017.Shann F. Drug Doses 17th Edition. Parkville. Intensive Care Unit, Royal Children’s Hospital.2017 Product Monograph 2019 C(ed). Compendium of Pharmaceutical and Specialties 2018 23rd Edition. Ottawa. Canadian Pharmacists Association. 2018Heulitt MJ et al. Double-blind, randomized, controlled trial of papaverine-containing infusions to prevent failure of arterial catheters in pediatric patients. Crit Care Med 1993;21:825-9.Version HistoryDATEDOCUMENT NUMBER and TITLEACTION TAKEN14-July-2020C-05-07-60741 Pediatric Intensive Care Unit: Continuous Infusion Guidelines for Infants and ChildrenApproved at: Pharmacy, Therapeutics & Nutrition CommitteeDISCLAIMERThis document is intended for use?within?BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.?This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.? ................
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