Neonatal Guidelines. Chapter 15: Pharmacy related Version: Date Revised: 24 th January 2017

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1 Neonatal Guidelines Chapter 15: Pharmacy related Version: Specialty: Neonatal Medicine Revised by: Katherine Wilson Edited by: Sujoy Banerjee Date Revised: 24 th January 2017 Approved by: ABMU Joint Perinatal Forum Date Ratified: 6 th February 2017 Date of implementation 1 st March 2017 Date for Review: 1 st March

2 Directorate of Child Health Checklist for Clinical Guidelines being submitted for Approval by ABMU Joint Perinatal Forum Title of Guideline: Name(s) of revision author: Chair of Group or Committee supporting submission: Katherine Willson; Edited :Sujoy Banerjee Neonatal Guideline Group Sujoy Banerjee Issue / Version No: Next Review / Guideline Expiry: Review date: 1 st March 2020 Details of persons included in consultation process: Neonatal Consultants, Neonatal junior doctors, Nursing Managers, Neonatal Pharmacist Brief outline giving reasons for document being submitted for ratification Routine Revision Name of Pharmacist (mandatory if drugs involved): Please list any policies/guidelines this document will supercede: Katherine Willson Chapter 15: Pharmacy related v th September 2015 Keywords linked to document: Pharmacy, drugs, formulary, neonate Date approved by ABMU Joint Perinatal Forum: 6 th February 2015 File Name: Used to locate where file is stores on hard drive 2

3 New guidance on Changes included in the latest revision v Clonidine 2. Peripheral dopamine 3. Hydrocortisone for Chronic Lung Disease Minor modification on 1. IV Midazolam 2. Dexamethasone 3. Dobutamine 4. Tazocin 3

4 Topics CONTENTS Page number Aciclovir 5 Adrenaline 6 Bicarbonate 7 Calcium gluconate 9 Clonazepam 10 Clonidine 11 Dexamethasone 12 (Dinoprostone)Prostaglandin E2 13 Dobutamine 14 Dopamine 16 Dopamine by peripheral route 17 Heparin 18 Hydrocortisone 19 Insulin 20 Liver medication for conjugated jaundice 21 Levetiracetam 22 Magnesium Sulphate 23 Midazolam 25 Morphine 26 Noradrenaline 28 Tazocin 29 THAM 30 Vecuronium 31 4

5 ACICLOVIR Treatment and prophylaxis of herpes simplex and varicella zoster infection 10-20mg/kg iv every 8 hours Infusion given over 1 hour PREPARATIONS: Aciclovir infusion 250mg in 10ml DILUTION: Dilute to a concentration of at least 5mg in 1ml before administration DILUENTS: Glucose 5% Sodium chloride 0.9% KNOWN COMPATIBILITY: KNOWN INCOMPATIBILITIES: Cefotaxime, Ceftazidime,Fluconazole, Gentamicin, Heparin, Imepenem, Metronidazole, Potassium, Ranitidine, Vancomycin Dobutamine, Dopamine, Meropenem,Morphine, Tazocin 5

6 ADRENALINE Inotrope VIA A CENTRAL LINE Initially nanograms /kg/minute up to a maximum of 1.5micrograms/kg/minute PREPARATIONS: Adrenaline 1mg in 1ml (1:1000) Adrenaline 100micrograms in 1ml (1:10,000) DILUTION: Weight in Kg x1.5= mg of adrenaline made up to 25ml with 10% dextrose 0.1ml /hour = 100nanogram/kg/minute DILUENTS: Dextrose 5%,Dextrose 10%, Sodium Chloride 0.9% KNOWN COMPATIBILITY: Calcium Salts, Dopamine,Dobutamine,Doxapram,Fentanyl,Frusemide, Heparin,Insulin,Midazolam,Milrinone,Morphine,Noradrenaline, Pancuronium,Potassium Chloride,Ranitidine,TPN, Vecuronium KNOWN INCOMPATIBILITIES: Lipid, Lignocaine, Sodium bicarbonate 6

7 Sodium Bicarbonate Half correction for Metabolic acidosis: Base deficit (mmol/l) x body weight (Kg) x 0.3 = mmol of bicarbonate required 4.2% sodium bicarbonate contains 0.5 mmol bicarbonate / ml. Always try to correct the underlying condition leading to metabolic acidosis. The correction if necessary, should ideally be undertaken over several hours as a slow infusion. This correction will always undercorrect the acidaemia but is usually sufficient. THAM is an alternative base. It has the advantage of being sodium free and shouldn t raise the PaCO 2. Therefore this may be preferred if the baby has very high sodium or PaCO 2. However it stops premature babies breathing so should only be used in babies who are being ventilated. 1 ml of 7.2% THAM is approx equivalent to 1 mmol bicarbonate. Bicarbonate infusion through arterial line in extremely premature babies (<26 weeks gestation): Extremely preterm neonates (<26/40 weeks) can be anticipated to develop a metabolic acidosis. This can be due to renal tubular loss of bicarbonate accompanied by chloride retention leading to a hyperchloremic metabolic acidosis. In the short term, metabolic acidosis is associated with the following abnormalities: Inhibition of surfactant production Increases in pulmonary vascular resistance Reduction in cardiac output Abnormal EEGs (consequences unclear) In the longer term, a ph <7.2 is associated with an abnormal neurodevelopmental outcome in preterm neonates <1000g. Metabolic acidosis is predominantly corrected by identifying its cause. Whether correction of metabolic acidosis improves outcome has not been studied in a randomised trial. 7

8 However, if bicarbonate treatment is given, it is best administered slowly. Twenty-four hour intravenous infusions are associated with decreased mortality, whereas rapid infusions are associated with an increased incidence of IVH. 5 Hence, prophylactic arterial infusion of low dose bicarbonate in this high risk population is established clinical management in many UK neonatal units. Route: Dose: Preparation: Bicarbonate should be infused through a UA or peripheral arterial line. 0.54mmols of NaHCO 3 administered per 24-hours (or about 1mmol/kg/day for a 500g neonate). 3mls of 4.2% NaHCO 3 (=1.5mmol) 16mls of sterile water for injection 1ml of hepsaline equivalent to 10 iu of heparin Total volume 20 mls with heparin conc. of 0.5 i.u/ml Infusion rate: Run solution at 0.3ml/hr Use a three way tap in between the baby and the transducer to infuse continuous bicarbonate solution as above through the side arm (Transducer set in a normal way with 0.45% hepsaline attached but not infusing from the syringe). During sampling stop bicarbonate infusion, sample in the usual way and flush with hepsaline from the syringe. Once flushed restart bicarbonate solution. 8

9 CALCIUM GLUCONATE Hypocalcaemia Urgent IV Correction 200mg/kg calcium gluconate 2ml/kg calcium gluconate 10% Maintenance 0.5mmol/kg/24hours calcium 2.5ml/kg/24hours calcium gluconate10% PREPARATIONS: Calcium Gluconate 10% 100mg calcium gluconate in 1ml 0.22mmol calcium in 1ml DILUTION: Urgent Correction Slow IV injection over 5-10minutes Continuous infusion Dilute dose required 10 fold Maximum administration rate 22micromol/kg/hour DILUENTS: Dextrose 5% Dextrose 10% Sodium Chloride 0.9% KNOWN COMPATIBILITY: Adrenaline, Heparin, Midazolam, Noradrenaline, Potassium Chloride 9

10 CLONAZEPAM Anticonvulsant IV Bolus 100microgram/kg/day over 30mins IV Infusion Initially 50microgram/kg THEN 10microgram/kg/hour adjustedaccording to response (Max 60microgram/kg/hour) PREPARATIONS: DILUTION: Clonazepam 1mg in 1ml supplied with a further 1ml ampoule water for injection. Mix immediately before use IV BOLUS Dilute dose to 100microgram in 1ml IV INFUSION (Weight in grams x0.5)=micrograms of clonazepam made up to 50ml with 5% dextrose 1ml/hr=10micrograms/kg/hour Administer in NON PVC containers Expiry 12 hours DILUENTS: Dextrose 5% Dextrose 10% Sodium chloride 0.9% KNOWN COMPATIBILITY: KNOWN INCOMPATIBILITIES: None Sodium bicarbonate 10

11 Drug: Clonidine Use: Sedation/Opiate withdrawal Dosage: Orally 3 microgram/kg/dose three times daily, can be increased upto 5 microgram/kg/dose TDS Weaning: Can be stopped immediately if used for < 2 weeks. If used for > 2 weeks, reduce daily over 5 days by 1 microgram/kg/dose (i.e. 5,4,3,2,1) tds then stop Preparation : Clonidine Hydrochloride ( 10 microgram in 1 ml) oral Solution Note : Close cardiovascular monitoring especially baby s blood pressure ( hourly for first 6 hours, 2 hourly over next 6 hours, then 4 hourly over next 12 hours.) 11

12 PREPARATIONS: DEXAMETHASONE Treatment of chronic lung disease 60mcg/kg bd day1-3 40mcg/kg bd day4-6 20mcg/kg bd day7-8 8mcg/kg bd day 9-10 Doses given are as dexamethasone base DEXAMETHASONE 3.3mg in 1ml (Hameln) This is 3.3mg/ml dexamethasone base DILUTION: Take 0.3ml and dilute to 10ml with 5% dextrose to give a solution containing 100microgram/ml dexamethasone base. Give as infusion over minimum of 5-10mins DILUENTS: Dextrose 5% Sodium Chloride 0.9% KNOWN COMPATIBILITY: Aciclovir, Heparin, Morphine, Potassium, Ranitidine, KNOWN INCOMPATIBILITIES: Ciprofloxacin, Midazolam, Vancomycin 12

13 DINOPROSTONE (Prostagandin E2) Maintain patency of ductus arteriosus Initially 5nanograms/kg/minute up to a maximum of 40nanogram/kg/minute PREPARATIONS: 0.75ml ampoule containing 1mg in 1ml DILUTION: For 5nanogram/kg/minute Add 0.5ml(500microgram) to 500ml of 10% glucose to give a solution of 1microgram in 1ml. Infuse at 0.3ml/kg/hour DILUENTS: Dextrose 5% Dextrose 10% KNOWN COMPATIBILITY: None KNOWN INCOMPATIBILITIES: VERY UNSTABLE do not use with any other drugs 13

14 PREPARATIONS: DILUTION: DOBUTAMINE Inotrope 5-20micrograms/kg/minute by continuous infusion Concentrations above 5mg in 1ml must be given centrally Dobutamine 250mg in 20ml (12.5mg in 1ml) SINGLE STRENGTH (Weight in Kgx30)=mg dobutamine made up to 50ml with 5% or 10% dextrose 0.2-2ml/hour=2-20microgram/kg/minute DOUBLE STRENGTH (Weight in Kg x30)=mg dobutamine made up to 25ml with 5% or 10% dextrose 0.1-1ml/hour =2-20microgram/kg/minute QUADRUPLE STRENGTH (Weight in Kg x30)=mg dobutamine made up to 12.5ml with 5% or 10% dextrose ml/hour=4-20microgram/kg/minute DILUENTS: KNOWN COMPATIBILITY: Dextrose5%, Dextose10% Sodium chloride 0.9% Adrenaline, amiodarone, dopamine, fentanyl, lignocaine, morphine, noradrenaline, pancuronium, potassium, ranitidine 14

15 KNOWN INCOMPATIBILITIES: Aciclovir, calcium gluconate, digoxin, frusemide, heparin, indomethacin, magnesium sulphate, phenytoin, sodium bicarbonate, Tazocin 15

16 PREPARATIONS: DOPAMINE Inotrope 2-20micrograms/kg/minute by continuous iv infusion Dopamine Hydrochloride 200mg in 5ml DILUTION: SINGLE STRENGTH (Weight in Kg x30) = mg dopamine made up to 50ml with 5% or 10% dextrose 0.2-2ml/hour = 2-20 microgram/kg/minute DOUBLE STRENGTH (Weight in Kg x30) = mg dopamine made up to 25ml with 5% or 10% dextrose 0.1-1ml/hour= 2-20 microgram/kg/minute QUADRUPLE STRENGTH (Weight in kg x30) = mg dopamine made up to 12.5ml with 5% or 10% dextrose ml/hour= 4-20 microgram/kg/minute DILUENTS: Dextrose 5% Dextrose 10% Sodium chloride 0.9% KNOWN COMPATIBILITY: Adrenaline, amiodarone, dobutamine, fentanyl Gentamicin, heparin, midazolam, morphine, noradrenaline, pancuronium, potassium chloride, ranitidine, vecuronium 16

17 KNOWN INCOMPATIBILITIES: Alkaline solutions, aciclovir, amphotericin, ampicillin, benzylpenicillin, indomethacin, insulin, metronidazole, sodium bicarbonate, tolazoline, TPN SINGLETON HOSPITAL - NEONATAL UNIT DOPAMINE INFUSION VIA PERIPHERAL IV LINE Preparation: Infusion: Diluent: Please note: 40mg of Dopamine to be diluted to 25 ml of preferred diluent 5 microgram/kg/minute at a rate of 0.19 ml/kg/hr 10 microgram/kg/minute at a rate of 0.38 ml/kg/hr 15 microgram/kg/minute at a rate of 0.57 ml/kg/hr 20 microgram/kg/minute at a rate of 0.76 ml/kg/hr Dextrose 5%, Dextrose 10%, 0.9% normal saline 1. Dopamine should only be given peripherally in exceptional circumstances. 2. Maximum infusion concentration should not exceed 1.6 mg/ml via peripheral line. 3. For babies less than 1.3 kg, our current single and double strength dilutions are using dopamine less than 1.6 mg/ml limit. 17

18 HEPARIN solution For arterial lines PREPARATIONS: DILUTION: 0.5units/hour =0.5ml/hour (made up as below) Pre-filled syringes 50units heparin in 50ml of 0.45% sodium chloride To make on the unit - if pre-filled syringe not available Add 5ml (50units) of Hepsal to 45ml Sodium chloride 0.45% to give 50units in 50ml (1unit /ml) NB 0.45% sodium administers 0.9mmol of Na / 24 hours. This with 0.18mmol from heparin means baby gets 1mmol of Na /24 hrs by this route DILUENTS: Sodium chloride 0.45% Dextrose 5% Dextrose 10% KNOWN COMPATIBILITY: KNOWN INCOMPATIBILITIES: Aciclovir, adrenaline, benzylpenicillin, calcium gluconate, dopamine, fentanyl, frusemide, insulin, lipid, magnesium sulphate, metronidazole, morphine, noradrenaline, pancuronium, ranitidine, sodium bicarbonate, TPN, vecuronium Erythromycin, gentamicin, vancomycin 18

19 Hydrocortisone Hypotension in pre-term neonates. To reduce CLD and facilitate extubation Hypotension 1-2mg/kg bd for 3 days Facilitate extubation 1.25mg/kg qds for 7 days 0.9mg/kg qds for 5 days 0.6mg/kg qds for 5 days 0.3mg/kg qds for 5days Give as iv bolus over 3-5mins PREPARATIONS: DILUTION: Hydrocortisone sodium succinate 100mg Hydrocortisone in 2ml Reconstitute 100mg with diluents (water for injection) provided to give 100mg in 2ml.Further dilute 1ml to 10mlto give 5mg in 1ml DILUENTS: Sodium Chloride 0.9% Glucose 5% KNOWN COMPATIBILITIES: KNOWN INCOMPATIBILITIES: Dopamine, Frusemide, Morphine Midazolam, Phenytoin 19

20 -- INSULIN Plastic tubing used for infusion should be flushed with at least 20mls of insulin solution and primed by for at least 20 minutes before use because insulin binds to the tubing resulting in decreased availability to the baby. It is extremely important that any replacement set is also fully primed. Do not use the line to give any other medications e.g. antibiotics as this will result in a bolus of insulin with potentially significant hypoglycaemia. If there is only one peripheral cannula other infusions should be administered at the hub of the cannula. Insulin infusion Add 25 units/kg of insulin to 50 ml of i.v. solution, then infuse at 0.2 ml/hr (which equates to 0.1 units/kg/hr). Infuse at units/kg/hr. The following sliding scale is a recommendation, but may need adjusting to suit individual requirements. Blood Glucose Rate of infusion of solution >20 mmol/l 0.2ml/hr (0.1 units/kg/hr) 8 20 mmol/l 0.1 ml/hr (0.05 unit/kg/hr) < 8 mmol/l Stop insulin infusion If fluids are restricted a double strength infusion can be prepared by diluting 50 units/kg to 50 ml i.v. solution where 0.1 ml/hour = 0.1 unit/kg/hour. No more than 0.5 units/kg/hr is usually needed. Some growth retarded and very pre-term babies can be very sensitive to the effects of insulin so monitor blood glucose very frequently at the start of the infusion. Diluents: Sodium chloride (0.45% and 0.9%) and Dextrose 5% and 10%. The infusion should be freshly prepared every 24 hours. Vials of insulin should be stored in a refrigerator at 2 8 o C. Do not use if the solution appears hazy or coloured. Known compatibilities: Can be added (terminally) to a line containing: Dobutamine, Heparin, Midazolam, Milrinone, Morphine, Potassium, TPN (Aqueous), Vancomycin Known incompatibilities: Aminophylline, Phenytoin, Phenobarbitone, Dopamine, sodium bicarbonate 20

21 Liver medication for babies with conjugated jaundice Babies with neonatal cholestasis where the conjugated bilirubin fraction is greater than 50 umol/l will need additional supplements of fat soluble vitamins. This recommendation is adapted from the King s college, London guidelines 2009 for neonatal cholestatsis. Option 1: Dalavit 0.3 mls BD OR Abidec 0.3mls BD orally Vitamin E 10mg/Kg OD orally Vitamin K 1mg OD orally / intravenously Ursodeoxycholic acid 5-10mg/Kg TDS orally Option 2 (If medications in option 1 are not available): Ketovite liquid 5mls OD orally Ketovite tablet 3tab crushed along with Ketovite liquid Vitamin K 1mg OD orally / intravenously Ursodeoxycholic acid 5-10mg/Kg TDS orally In addition, for both options, you may consider Alfacalcidol 5-10nanogram/kg/day if you have confirmed evidence of Vitamin D deficiency. You will need close monitoring of serum calcium and phosphate levels. 21

22 PREPARATIONS: DILUTION: LEVETIRACETAM Treatment of seizures GIVE ONLY BY IV INFUSION OVER 15 MINS. *Loading dose of 30mg/kg iv followed after 12 hours by a maintenance dose of 10mg/kg iv/po bd. Levetiracetam 500mg in 5ml infusion Dilute 1ml to 10ml to give a concentration of 10mg in 1ml before administering. DILUENTS: Glucose 5% Sodium chloride 0.9% 22

23 SINGLETON HOSPITAL-NEONATAL UNIT MAGNESIUM SULPHATE Hypocalcaemia Hypomagnesaemia Persistent Pulmonary Hypertension Hypocalcaemia/Hypomagnesaemia Persistent Pulmonary Hypertension 100mg/kg by iv infusion This dose can be repeated every 12 hours as necessary for 2-3 doses Maximum infusion rate 10mg/kg/min Loading dose 200mg/kg over 20-30mins,if response occurs then by continuous infusion of 20-75mg/kg/hour to maintain plasma magnesium concentration between mmol/litre for 2-5days PREPARATIONS: Magnesium Sulphate 50% 10ml ampoule (contains 5g in 10ml) DILUTION: * Dilute to 100mg in 1ml before administration as follows* Draw up 2ml Magnesium Sulphate 50% and make up to 10ml with diluent to give a solution containing 100mg in 1ml Give required dose as infusion over 20-30minutes. For continuous infusion 20mg/kg/hour=0.2ml/kg/hour 23

24 DILUENTS: Dextrose 5%, sodium Chloride 0.9% KNOWN COMPATIBILITY: Insulin, morphine, TPN, Vancomycin KNOWN INCOMPATIBILITIES: Ambisome,dobutamine, metronidazole, salbutamol and sodium bicarbonate 24

25 Midazolam Anticonvulsant Initially microgram/kg over 5minutes followed by a continuous infusion of microgram/kg/hour PREPARATIONS: Many different concentrations and ampoule sizes. CHECK CAREFULLY DILUTION: DILUENTS: Dilute 15mg/kg body-weight to 50ml Infuse at 0.1ml/hour to give 30microgram/kg/hour Dextrose 5% Dextrose10% Sodium Chloride 0.9% KNOWN COMPATIBILITY: KNOWN INCOMPATIBILITY: Adrenaline,Calcium Gluconate,Dopamine,Fentanyl, Heparin,Morphine,Noradrenaline,Pancuronium. Potassium chloride,tpn Furosemide, Sodium bicarbonate,ranitidine 25

26 MORPHINE SULPHATE Sedation during ventilation IV Infusion 5-20micrograms/kg/hour Pre-intubation dose=50microgram/kg PREPARATIONS: Morphine suphate 500microgram in 10 ml Dextrose 5% DILUTION: See attached nomogram DILUENTS: Dextrose 5% Dextrose 10% Sodium chloride 0.9% KNOWN COMPATIBILITY: Adrenaline, Amiodarone, Dobutamine, Dopamine, Magnesium sulphate, Midazolam, Noradrenaline,Pancuronium, Potassium chloride, Ranitidine KNOWN INCOMPATIBILITIES: Alkaline solutions, Aciclovir, Frusemide,Heparin, Sodium bicarbonate 26

27 MORPHINE SYRINGES 50 MICROGRAMS PER 1ML DEXTROSE 5% Baby s Weight 5 mcg/kg/hr 10 mcg/kg/hr 20 mcg/kg/hr 0.5 kg - 0.1ml/hr 0.2ml/hr 0.75 kg 0.1 ml/hr 0.15ml/hr 0.3ml/hr 1.0 kg 0.1ml/hr 0.2ml/hr 0.4ml/hr 1.25 kg 0.12 ml/hr 0.25ml/hr 0.5ml/hr 1.5 kg 0.15 ml/hr 0.3ml/hr 0.6ml/hr 1.75 kg 0.17ml/hr 0.35ml/hr 0.7ml/hr 2.0 kg 0.2ml/hr 0.4ml/hr 0.8ml/hr 2.25 kg 0.22ml/hr 0.45ml/hr 0.9ml/hr 2.5 kg 0.25ml/hr 0.5ml/hr 1.0ml/hr 2.75 kg 0.27ml/hr 0.55ml/hr 1.1ml/hr 3.0 kg 0.3ml/hr 0.6ml/hr 1.2ml/hr 3.25 kg 0.32ml/hr 0.65ml/hr 1.3ml/hr 3.5 kg 0.35ml/hr 0.7ml/hr 1.4ml/hr 3.75 kg 0.37ml/hr 0.75ml/hr 1.5ml/hr 4.0 kg 0.4ml/hr 0.8ml/hr 1.6ml/hr **For intermediate weights - round up or down to the nearest specified weight in the table. PRE-INTUBATION (ONLY FOR ELECTIVE INTUBATION) 50 micrograms/kg BOLUS (1 ml/kg) NOTE : Syringes are unable to infuse at rates < 0.1 ml/hr 27

28 PREPARATIONS: DILUTION: NORADRENLINE Vasoconstrictor to treat hypotension VIA A CENTRAL LINE nanograms/kg/min noradrenaline base adjusted according to response. Max 1.5microgram/kg/minute Noradrenaline acid tartrate 2mg in 1ml equivalent to Noradrenaline BASE 1mg in 1ml Weight in kg x 1.5 = mg noradrenaline base made up to 25ml with dextrose 10% DILUENTS: Dextrose 5% Dextrose 10% 0.1ml/hour=100nanogram/kg/minute Protect infusion from light Discard solution if brown colour develops KNOWN COMPATIBILITY: KNOWN INCOMPATIBILITIES: Adrenaline, calcium gluconate, dobutamine dopamine, fentanyl, heparin, magnesium sulphate, midazolam, morphine,potassium chloride, TPN Insulin, lignocaine, sodium bicarbonate 28

29 PREPARATIONS: TAZOCIN (Piperacillin with tazobactam) Broad spectrum antibiotic See Neonatal Formulary AS IV Bolus over 3-5mins or infusion over 30mins Injection 2.25g vial NB 1g contains 2mmol Na (Tazocin) Manufacturers; Sandoz,Pfizer Wockhardt Actavis,Noridem Fresenius Kabi DILUTION: Displacement value 2.25g=1.58ml Add 8.4ml Water for Injection or Sodium chloride 0.9% to 2.25g vial to give a concentration of 225mg in 1ml For infusion further dilute above solution to at least 90mg in 1ml and give over 30mins Piperacillin/Tazobactam (Bowmed,Stragen) Displacement value 2.25g=1.7ml Add 8.3ml Water for Injection or Sodium chloride 0.9% to 2.25g vial to give a concentration of 225mg in 1ml For infusion further dilute above solution To at least 90mg in 1ml and give over 30mins 29

30 THAM (tris-hydroxymethyl aminomethane/ trometamol, tromethamine) Metabolic acidosis when sodium bicarbonate inappropriate Calculate total no. of mmol of bicarbonate required for half correction 0.3 base deficit (mmol/litre) weight (Kg) 1mmol of bicarbonate = 1ml of 7.2% THAM = 1 ml of 8.4% sodium bicarbonate Give over 30 minutes or longer PREPARATIONS: 5mL ampoule containing THAM 7.2% DILUTION: Dilute THAM 7.2% to 3.6% Concentration using an equal volume of dextrose 5% or water for injection If necessary, fluid restricted patients may be given THAM 7.2% undiluted via a long line or central line DILUENTS: Dextrose 5% Water for injection KNOWN INCOMPATIBILITIES: Benzylpenicillin 30

31 PREPARATIONS: VECURONIUM Non depolarising muscle relaxant used in ventilation IV BOLUS Initially microgram/kg then 30-50microgram/kg adjusted according to response, usually every 2-4hours IV INFUSION 50-80microgram/kg/hour 10mg vecuronium powder with 5ml water for injection to give a solution of 2mg in 1ml DILUTION: SINGLE STRENGTH (Weight in Kg x5) =mg of vecuronium made up to 50ml with 5% dextrose 0.5-1ml/hr=50-100microgram/kg/hr DOUBLE STRENGTH (Weight in Kg x10)=mg of vecuronium made up to 50ml with 5% dextrose ml/hr=50-100microgram/kg/hr QUADRUPLE STRENGTH (Weight in Kg x20)=mg of vecuronium made up to 50 ml with 5% dextrose ml/hr=50-100microgram/kg/hour DILUENTS: 5% dextrose 10% dextrose 0.9% sodium chloride 0.45% sodium chloride 31

32 KNOWN COMPATIBILITY: Adrenaline,Aminophylline, Dopamine,, Dobutamine, Fentanyl, Heparin, Hydrocortisone, Midazolam, Morphine,Noradrenaline, Ranitidine, Vancomycin KNOWN INCOMPATIBILITIES: Diazepam, Frusemide, Sodium bicarbonate Checked by Katherine Willson: Neonatal Pharmacist, January