** Medication exercises ** NICU Phase II A) Baby A has had a bowel resection six hours ago. She weighs 3 kg. Post-op, she is quite agitated and she is on a fentanyl drip at 2 micrograms/kg/hr (#1). She becomes more agitated and desaturates frequently. The doctor orders you to increase the fentanyl drip to 4 micrograms/kg/hr (#2). The concentration of fentanyl ordered by the doctor is 50 mcg/ml. i. Calculate your infusion rates for #1 and #2 ii. Do you believe that 50 mcg/ml is an acceptable concentration for this patient? iii. How would you prepare your drip? i. Using a concentration of 50 mcg/ml (pure fentanyl), your rates are: #1 rate=dose x Wt x 1hr = 2mcg/kg/hr x 3.0kg x 1hr = 0.12 ml/hr [ ] 50mcg/ml #2 4mcg/kg/hr x 3.0kg x 1hr = 0.24ml/hr 50mcg/ml ii. Looking at the standard concentration table, 50 mcg/ml is the recommended concentration for babies 2.5 kg. And the rates calculated for the doses ordered are appropriate not too high so as to compromise nutrition, and not too low that the pump cannot run them accurately. iii. This drip at this concentration is prepared using the pure solution you should draw up 10 ml of pure fentanyl. (No need to make a bigger syringe as a 10 ml syringe will last you > 24 hrs even if the dose is increased). B) What problem would occur if your baby weighed only 780g? What should be done about this problem? #1 rate=dose x Wt x 1hr = 2mcg/kg/hr x 0.780kg x 1hr = 0.03 ml/hr [ ] 50mcg/ml For smaller BBs it is better to dilute the fentanyl to avoid this. Usually for BBs less than or equal to 2.49kg, we prefer [ 12.5mcg/ml ]. The dilution is normally done in D5W. #2 In this case we would choose the concentration of [ 12.5mcg/ml ]. rate=dose x Wt x 1hr = 2mcg/kg/hr x 0.780kg x 1hr = 0.12ml/hr [ ] 12.5mcg/ml 1
C) How do you prepare your drip dilution in question i) if you want to prepare a 20 ml syringe? Pure Fentanyl solution (50mcg/ml) needs to be diluted 4 times to get a concentration of 12.5mcg/ml. To prepare a 20 ml syringe, you need to dilute 5 ml of pure Fentanyl with 15 ml of D5W. Another way of looking at it is to ask how many micrograms of fentanyl you would need in 20 ml: 20 ml x 12.5 mcg/ml = 250 mcg needed. If your vial contains fentanyl at 50 mcg/ml, how many mls do you need to draw up for 250 mcg? 250 mcg/50 mcg/ml = 5 ml So you would draw up 5 ml of pure fentanyl and mix with (20-5 =) 15 ml of D5W) for your total volume of 20 ml. D) Baby D is 2.850kg. The doctor orders a dopamine drip to improve her urinary output. The dosage ordered is 5 micrograms/kg/min. The concentration of the dopamine in the bag is 3200mcg/ml. 1) Choose a concentration and determine the rate. 2) Which concentration seems most appropriate? #1 Using pure dopamine from the bag: 5mcg/kg/min x 2.85kg x 60min = 0.267 (rounded up to 0.27 ml/hr)l 3200mcg/ml 5mcg/kg/min x 2.85kg x 60min = 0.53 ml/hr 1600 mcg/ml 5 mcg/kg/min x 2.85kg x 60min = 1.07mL/hr 800 mcg/ml #2 The pure concentration can be used, given the options for rates. If the doctor decides to wean the Dopamine, the rate will stay acceptable at a lower dose. If a concentration of 800 mcg/ml were used, as recommended by the standard concentrations table, your rate would be 1.1 ml/hr, which is a high rate for a small baby and may compromise the amount of TPN we can give. E) You need to start a dopamine drip on baby E in order to maintain a good blood 2
pressure. The medical order reads: Start dopamine at 5 micrograms/kg/min based on a weight of 1.2 kg. The concentration of the dopamine in the bag is 3200mcg/ml. 1) Which concentration will you choose to make? 2) Which solution will you take to dilute it with? 3) How would you dilute the dilution to prepare a 30 ml syringe? 4) What will the rate be? #1 5mcg/kg/min x 1.2kg x 60 mins = 0.11 ml/hr 3200 mcg/ml 5mcg/kg/min x 1.2kg x 60 mins = 0.23 ml/hr 1600 mcg/ml 5 mcg/kg/min x 1.2kg x 60 mins = 0.45 ml/hr 800 mcg/ml The Dopamine needs to be diluted the concentration of 1600 mcg/ml seems most reasonable At the pure concentration, the weaning of Dopamine will give too low a rate, and the at the lowest concentration, if the dose of dopamine is increased, you will be giving too much fluid. #2 D5W solution (unless the doctor prescribes something else as NS 0.9% solution for example, to correct hyponatremia). #3 Dopamine solution will be diluted 1:1 with D5W. So, if you want to prepare a syringe of 30 ml total, 15 ml of Dopamine will be mixed with 15 ml of D5W. 30 ml x 1600 mcg dopamine = 48000 mcg, divided by 3200 mcg/ml = 15 ml. #4 5mcg/kg/min x 1.2kg x 60min = 0.225 (rounded up to 0.23 ml/hr) 1600mcg/ml F) You are taking care of baby F who just arrived from the O.R. for a PDA ligation. He is intubated. His HR is 196 beats/min and he is very stiff, the physician prescribed a fentanyl drip at 2mcg/kg/hr and the baby s weight is 1.37 kg. Prepare the drip and start it. From the table, you choose a concentration of 12.5 mcg/ml rate=dose x Wt x 1hr = 2mcg/kg/hr x 1.37kg x 1hr = 0.22ml/hr [ ] 12.5mcg/ml To prepare it in a total volume of 20 ml, you need 20mL x 12.5 mcg/ml = 250 mcg. Divided by 50 mcg/ml in vial = 5 ml. You will mix 5 ml of fentanyl with 15 ml of D5W. 15 minutes after you start your fentanyl drip, you notice that your baby is very agitated and his HR is still 190-195 beats/min. The physician orders a fentanyl bolus of 2mcg/kg and subsequently increase your drip to 3mcg/kg/hr. 1)How will 3
you give your bolus? 2)What volume will you give and how fast should you give it? 3)How you will set your pump? #1 With the pump if you don t have inotropes running. #2 2mcg x 1.37kg = 2.74mcg 2.74mcg 12.5mcg/ml =0.22ml over 10 minutes #3 Use your bolus function, do not set it manually but adjust your new rate first for the dose of 3 mcg/kg/hr (0.33ml/hr). When it finishes, it will automatically go back to your infusion rate previously set. 48 hours after the O.R., your baby s condition improves. The physician decides to wean the fentanyl. He asks you to decrease your fentanyl to 1 mcg/kg/hr. What would your infusion rate be? rate=dose x Wt x 1hr = 1mcg/kg/hr x 1.37kg x 1hr = 0.11ml/hr [ ] 12.5mcg/ml G) Baby G needs a drip of midazolam to be started at 1mcg/kg/min. He weighs 2.230kg. The concentration of midazolam in the vial is 5 mg/ml. 1)Calculate your rate and 2)prepare the drip dilution to have 20 ml in your syringe. #1 Because the bb s weight is less than 4.99 kg, you choose to prepare a Midazolam concentration of [1mg/ml] or [1000mcg/ml]. 1mcg/kg/min x 2.23kg x 60min = 0.13 ml/hr 1mg/ml (1000mcg/ml) Is this a reasonable rate? It seem fast enough to ensure accuracy, and not too fast so as to compromise nutrition. #2 Pure midazolam solution (5mg/ml) needs to be diluted 5 times to get a concentration of 1mg/ml. To prepare a 20 ml syringe, you need to dilute 4 ml of pure midazolam with 16 ml of D5W. H) Epinephrine is the most important drug used in resuscitation. What is the dosage and the route of administration preferred? Answer: IV 0.1ml/kg is preferred but a single dose via ETT 1ml/kg (max 3 ml) can be given while attempting to establish a venous access What does 1:10 000 on the epinephrine vial mean? Answer: 1g/10 000ml = 1000mg/10 000ml 1000mg/10 000ml=1mg/10ml 1mg/10ml=1000mcg/10ml 1000mcg/10ml=100mcg/ml 4
This is what is written on your epinephrine boxes You need to start an epinephrine drip at 0.1 micrograms/kg/min. Baby H weighs 1.21kg. 1)Which concentration will you choose? 2)What will the rate be? 3)How would you prepare the dilution to have a 30 ml syringe total? #1 [10mcg/ml] based on calculated rates #2 rate=dose x Wt x 60min. = 0.1mcg/kg/min x 1.21kg x 60min. = 0.73 ml/hr [ ] 10mcg/ml #3 Pure epinephrine solution (100mcg/ml) needs to be diluted 10 times to get a concentration of 10mcg/ml. To prepare a 30 ml syringe, you need to dilute 3 ml of pure epinephrine with 27 ml of D5W. I) Baby I, 1 month old, is in room air and has an abdominal wound infection. He is in pain and the physician orders a bolus of morphine. Baby weighs 4.250 kg. 1)What is the minimal dose the physician is suppose to start with? The concentration of the morphine in the vial is 10mg/ml. 2)How will you prepare your dilution to have a bolus? #1 For infants 3 months requiring opioids that have never received any, the starting dose, should be 0.02mg/kg/dose IV. If older than 3 months, dose can be started at 0.05mg/kg/dose. So dose is 0.085mg 10mg/ml =0.0085ml #2 Further dilution is needed to draw dose: 0,1ml of 10mg/ml of morphine in 0,9ml of NS to make [1mg/ml].SO now 0.085mg 1mg/ml = 0,085ml = 0,09ml of morphine. The baby is now really in pain, so the physician orders a morphine drip of 10mcg/kg/hr. What would your infusion rate be if the concentration of the drip is ordered as 100 mcg/ml? Rate = 10mcg/kg/hr x 4.25kg x 1hr = 0.425 or 0.43 ml/hr [100mcg/ml] The 2 nurses preparing the above drip made a huge error and ran the drip at 4.3ml/hr. The baby becomes apneic. What would you do in this situation? What emergency medication would you expect to be prescribed? Answer: Stimulate the patient - Administer FiO2 to achieve appropriate targeted sats, if remains apneic after stimulation start PPV. Give Naloxone(Narcan) IV (SC if IV route is not available): 0.01 mg/kg. Give slowly over 30 sec to titrate against patient response; Stop with appropriate patient response (normal respiratory rate, targeted SpO2 maintained). Try not to reverse analgesic effect. May repeat the dose q2-5 minutes PRN; Considering 5
the short half-life of naloxone; you can also start a continuous IV infusion of naloxone: 1-2 mcg/kg/hr Fill out an incident report and write clear notes in the chart about the event. J) You need to start an insulin drip for baby J at 0.1 unit/kg/hr and the ordered concentration is 0.04 units/ml. Baby weighs 750g. 1)What would be the rate of infusion? 2) The vial concentration is 100 unit/ml. Are there any precautions you need to take when you prepare your drip of insulin? Prepare your dilution to make a 50 ml syringe. #1 Answer: rate=dose x Wt x 1hr = 0.1unit/kg/hr x 0.750kg x 1hr = 1.88ml/hr [ ] 0.04unit/ml #2 0.04unit/ml x 50ml = 2 unit 2 unit 100unit/ml = 0.02 ml Mix 2 unit (0.02ml) of insulin in 50 ml of NS= [0.04unit/ml]. Flush the tubing and let it sit for 30mins. After 30 min. flush out 10 ml extra and start your infusion OR if infusion must be started stat mix same solution and flush out 20 ml and start your infusion. K) A cardiac echo just revealed a ductus dependant systemic blood flow lesion on baby K. You need to start a PgE drip now. The doctor orders PgE at 0.01 micrograms/kg/min. You have on hand an ampoule of Prostin in the fridge with a concentration of 500 micrograms/ml. BB weighs 4 kg. #1 - Which infusion concentration do you and the team choose? #2 - What would your infusion rate be? #3 - How do you prepare your drip dilution if you want to prepare a 20 ml syringe? #1 10mcg/ml. Usually with cardiac babies, fluid are restricted. So, you prefer to take a higher concentration to reduce at the maximum the infusion rate. #2 0.01mcg/kg/min x 4kg x 60min = 0.24ml/hr [10mcg/ml] l #3 10mcg/ml x 20ml = 0.4ml of PgE to dilute in 19.6ml of D5W for a total volume [500mcg/ml] of 20ml Could you infuse your PgE with your maintenance solution? Answer: It is acceptable as per pharmacy to infuse in Y the PgE with most solutions (Amino acids, lipids, fentanyl, dopamine, dobutamine, epinephrine, midazolam ) BUT if you have a double lumen central line ( ex. UVL, double CVL fem. or axil., or even a double PICC line ) It is always preferable to infuse alone since there is no clear data on the PgE s compatibility with these drugs. 6
Another consideration is to always have another PIV extra when it is infusing peripherally. The baby's saturation is in the low 50's. The doctor asks you to increase the dose of PgE to 0.015 micrograms/kg/min. At what rate would you run the PgE at? rate=dose x Wt x 60min = 0.015mcg/kg/min x 4.0kg x 60min. = 0.36 ml/hr [ ] 10mcg/ml What are the most significant side effects of PgE? Apnea High temperature Flushing of the skin Prepared by Martine Chagnon, July 2012 Revised by Karine Huppé / Elissa Remmer, Oct. 2015 7