Drug Dose.pdf

Aciclovir
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
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Effective Date: 25 August 2015
Review Date: August 2018
Page 1 of 2
Neonatal Protocol
Description and indication for use
Aciclovir is an anti-viral agent which is used in the treatment of herpes simplex encephalitis and
neonatal herpes simplex and varicella zoster infections with CNS and pulmonary involvement.
Preparations
Injection 250mg/10mL
Tablet 200mg dispersible tablet
Dose
Use only following discussion with consultant neonatologist and/or in consultation with
clinical microbiologist.
IV: 20mg/kg/dose
Interval
CA < 30 weeks 12 hourly
CA ≥ 30 weeks 8 hourly
Consult ID for duration of IV therapy.
Oral suppression after IV treatment: 300mg/m2
BSA/dose 8 hourly for 6 months
BSA calculator available in http://nicutools.org/MediCalcs/BSA.php3
Consider reducing dose interval if baby has renal impairment.
Reconstitution/Dilution
Ampoule = 250mg/10mL (25mg/mL)
IV: Withdraw 5mL of 25mg/mL solution from ampoule and add to 20mL of Water For Injection
or Sodium Chloride 0.9% in a 50mL syringe = 125mg in 25mL = 5mg/mL.
Mix thoroughly and withdraw required dose.
Route and Method of Administration
Do not give IV preparation orally.
Do not give by IM injection or IV injection as product is highly alkaline.
IV infusion: Give slowly over 1 hour through a syringe infusion pump (Guardrails) – see ‘How to
set up the Pump’.
Oral: Disperse 200mg tablet in 10mL of Water for Injection to give a concentration of 20mg/mL.
Give required dose by oral syringe. Prepare a fresh solution for each dose.

Aciclovir
Effective Date: 25 August 2015
Review Date: August 2018
Page 2 of 2
Neonatal Protocol
Side Effects
x Phlebitis at IV site. Extravasation may cause skin ulceration
x Rash, urticarial, pruritis
x Acute renal failure, anaemia, thrombocytopenia
x Transient renal dysfunction and crystalluria (minimised by slow infusion and adequate
hydration)
x Neutropenia (may require dose reduction)
Contraindications
x Caution in significant renal impairment. May require extending dose interval.
Drug Interactions
Aminoglycosides (gentamicin,
amikacin, tobramycin) and
vancomycin
May potentiate nephrotoxicity of aciclovir.
Nursing Responsibilities
x Monitor IV site
x Monitor urine output – ensure adequate hydration
Compatibility Information
IMPORTANT: Contact the pharmacist for medicines not appearing in the table below.
Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9%
Y-Site Amikacin, fluconazole, heparin,
metronidazole, vancomycin, zidovudine
Dopamine, dobutamine, gentamicin, IVN
starter, IVN maintenance, lipid 17%,
midazolam, morphine, phenytoin,
vecuronium
References
1. Young T and Mangum B, Neofax 21
st
Ed, Thomson Reuters, 2010
2. Australian Injectable Drugs Handbook, 6
th
Ed., The Society of Hospital Pharmacists of Australia, 2014
3. Neonatal Formulary 7
th
Ed, The Northern Neonatal Network, BMJ publishing, 2015
4. Paediatric Pharmacopoeia 13
th
Ed, Pharmacy Department, The Royal Children’s Hospital, Parkville 3052
5. Aciclovir: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility). Greenwood
Village, Colorado: Thomson Reuters (Healthcare). Accessed: 12/07/15.
6. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
7. Guidelines for Administration of Intravenous Medications to paediatric Patients 5
th
Ed. 1996 ASHSP
8. Paediatric Injectable Guidelines, 4
th
Ed , 2011, Pharmacy Department, RCH
9. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 13/08/2015.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Adenosine.doc
ADENOSINE
DESCRIPTION AND INDICATION FOR USE
Adenosine is a purine nucleoside endogenous to all cells of the body. It activates specific
receptors on the cell membrane to slow impulse generation in the sinoatrial node (negative
chronotropic effect), impair conduction through the atrio-ventricular node (negative dromotropic
effect) and dilate the coronary arteries. Adenosine has no negative inotropic effects and does not
cause significant systemic hypotension. It can therefore be used safely in infants with impaired
cardiac function.
Adenosine has a rapid onset (response should occur within 2 minutes of the dose) and a short
duration of action, with a serum half-life of approximately 10 seconds.
Adenosine is the drug of choice in the acute treatment of sustained paroxysmal supra-ventricular
tachycardia.
DOSE
IV: 0.05mg/kg/dose.
Dose may be increased by 0.05mg/kg/dose every 2 minutes until tachycardia is
terminated, to a maximum of 0.25mg/kg/dose.
5
RECONSTITUTION/DILUTION
Ampoule = 6mg in 2mL (3mg/mL)
IV Bolus: To be diluted to a 1mg/mL solution to enable measurement of dose.
Withdraw 1.0mL of 3mg/mL solution and add to 2mL of sodium chloride 0.9% in a
5mL syringe = 3mg in 3.0mL = 1mg/mL.
Withdraw required dose.
ROUTE AND METHOD OF ADMINISTRATION
IV Bolus: TO BE ADMINISTERED BY MEDICAL STAFF ONLY
Give by rapid IV push into a large peripheral vein.
Infuse as close to IV site as possible.1
Flush immediately with 2.0mL of sodium chloride 0.9%.
SIDE EFFECTS
Flushing
Dyspnoea
Transient arrhythmias may occur between termination of SVT and onset of normal sinus
rhythm
Irritability
CONTRAINDICATIONS
Patients with 2
nd
or 3
rd
degree AV block or sick sinus syndrome
DRUG INTERACTIONS
Theophylline, caffeine Diminish the effects of adenosine by competitive antagonism.
Verapamil Possibility of prolonged bradycardia occurring if adenosine is
used together with high doses of verapamil.
Dipyridamole Protects against degradation and can potentiate the clinical
effects of adenosine.

IV Drug Protocol - Adenosine.doc
NURSING RESPONSIBILITIES
Continuous cardio/respiratory monitoring
Monitor BP
COMPATIBILITY INFORMATION3
Fluids Sodium chloride 0.9% No information
Drugs No information No information
Y-Site No information No information
References:
1. Neofax 12
th
Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
nd
th
Ed, The Northern Neonatal Network. 1998
th

Adrenaline IV Protocol
ADRENALINE
(Epinephrine – USA)
Adrenaline is a sympathomimetic agent, that acts on α and β adrenergic receptors. Its main effects
include an increase in heart rate, myocardial contractility and conduction velocity. Adrenaline increases
systemic vascular resistance through constriction of the arterioles. It increases blood flow to skeletal
muscle, brain, liver and the myocardium, but decreases renal blood flow.
Adrenaline is used in resuscitation and as a continuous infusion for refractory hypotension or circulatory
collapse not due to hypovolaemia.
DOSE
Resuscitation/Cardiac Arrest
IV: 10 to 30micrograms/kg/dose = 0.1 to 0.3mL/kg/dose of 1:10,000. Dose may be repeated
every 3 minutes PRN
ETT: 50 to 100micrograms/kg/dose = 0.5 to 1mL/kg/dose of 1:10,000. Dose may be repeated
every 3 minutes PRN
Hypotension/Circulatory Collapse
IV Infusion: 50 nanograms/kg/minute to 1000 nanograms/kg/minute. Correct hypovolaemia and
acidosis before commencing adrenaline as an infusion.
Ampoule: 1 in 10,000 (1mg in 10mL), 1 in 1,000 (1mg in 1mL)
IV, ETT: Use 1 in 10,000. No dilution necessary
IV Infusion: Use 1 in 1,000 (1mg/mL). Add 600microgram/kg (0.6mL/kg of 1:1,000) to infusion solution
to make 50mL. Total volume should equal 50mL.
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Adrenaline
SINGLE
600micrograms/kg to 50mL 1mL/hr = 200nanograms/kg/min
50 nanograms/kg/min to
1000 nanograms/kg/min
Adrenaline
CONC × 5
3mg/kg to 50mL 1mL/hr = 1microgram/kg/min
IV, ETT: Give 1 in 10,000 undiluted.
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of adrenaline.
6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose/amount in syringe then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
(amount and volume shown is the same as in syringe)
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘ng/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

Adrenaline IV Protocol
SIDE EFFECTS
x Cardiac arrhythmias (ventricular tachycardia)
x Hypokalaemia
x Tremor
x Severe hypertension and increased risk of intraventricular haemorrhage
x Renal vascular ischaemia with decreased urine output
x Restlessness
x Hyperglycaemia (inhibition of insulin secretion and conversion of glycogen reserves)
x Extravasation causes tissue ischaemia and necrosis
CONTRAINDICATIONS
x Hyperthyroidism
x Hypertension
DRUG INTERACTIONS
Isoprenaline Combination may cause serious arrhythmia
Propranolol Adrenaline ‘resistance’ may occur
x Cardio/respiratory monitor
x Monitor BP with an arterial line
x Observe IV site carefully for signs of extravasation
x Measure urine output
x Change syringe and tubing every 24 hours.
x Protect from light, cover syringe with foil
x Do not give boluses via the adrenaline
infusion line
x Do not stop or interrupt infusion suddenly,
dose must be weaned slowly
COMPATIBILITY INFORMATION
IMPORTANT: Contact pharmacy for drugs not appearing in the table below. Uncommon drugs
have simply been omitted and may be incompatible.
Fluids Glucose 5%, glucose 10%, sodium
chloride 0.9%
Sodium bicarbonate 5%
Drugs Amikacin, dobutamine, flucloxacillin,
frusemide, ranitidine, verapamil
Benzylpenicillin, calcium chloride, calcium
gluconate, diazepam, digoxin, noradrenaline,
sodium bicarbonate, vancomycin,
Y-Site Amiodarone, caffeine citrate1
,
dobutamine, dopamine, fentanyl,
glyceryl trinitrate, heparin,
hydrocortisone, midazolam1
, morphine,
pancuronium, potassium chloride,
ranitidine, vecuronium, PG1
References:
1. Young T, Mangum B, 2008, Neofax 2008, 21
st
Ed, New Jersey: Thomson Reuters.
2. Fary R, Smtih R, David P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia, 2
nd
Ed, Melbourne:
Pharmacy Department The Royal Women's Hospital.
3. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4
th
Ed., Melbourne: The Society of Hospital
Pharmacists of Australia.
4. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5
th
Ed, Massachusetts: Blackwell
Publishing Inc, 2007.
5. BNF for children, London: BMJ Publishing Group Ltd, 2005.
6. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13
th
Ed, Melbourne: Pharmacy
Department, Royal Childrens Hospital.
7. Trissell LA, 2009, Handbook on Injectable drugs, 15
th
Ed, Bethesda, American Society of Health-System
Pharmacists.
8. Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122;S516-S538.

Adrenaline Inhale Protocol
ADRENALINE INHALE
(Epinephrine – USA)
Adrenaline is a sympathomimetic agent, that acts on α and β adrenergic receptors. Its main effects
include an increase in heart rate, myocardial contractility and conduction velocity. Adrenaline increases
systemic vascular resistance through constriction of the arterioles. It increases blood flow to skeletal
muscle, brain, liver and the myocardium, but decreases renal blood flow.
Adrenaline is used in resuscitation and as a continuous infusion for refractory hypotension or circulatory
collapse not due to hypovolaemia.
DOSE
Post extubation Stridor/Bronchospasm
NEB: 0.5mL of 1:1,000/kg/dose every 4 to 6 hours.
Ampoule: 1 in 10,000 (1mg in 10mL), 1 in 1,000 (1mg in 1mL)
INH: Use 1 in 1,000 (1mg in 1mL). If volume to be nebulised is less than 2mL, make volume up to at
least 2mL using sodium chloride 0.9%
INH: Nebulise as directed.
SIDE EFFECTS
Cardiac arrhythmias (ventricular tachycardia)
Hypokalaemia
Tremor
Severe hypertension and increased risk of intraventricular haemorrhage
Renal vascular ischaemia with decreased urine output
Restlessness
Hyperglycaemia (inhibition of insulin secretion and conversion of glycogen reserves)
CONTRAINDICATIONS
Hyperthyroidism
Hypertension
DRUG INTERACTIONS
Isoprenaline Combination may cause serious arrhythmia
Propranolol Adrenaline ‘resistance’ may occur
Cardio/respiratory monitor
Monitor BP with an arterial line
Measure urine output
References:
st
th
Ed, Massachusetts: Blackwell
3. BNF for children, London: BMJ Publishing Group Ltd, 2005.
th
Department, Royal Childrens Hospital.

Alprostadil IV Protocol
ALPROSTADIL (PROSTAGLANDIN E1)
(Prostin VR“
)
Alprostadil is a synthetic prostaglandin E1 used to open and/or maintain patency of the ductus arteriosus in early
post-natal life, where a patent ductus is critical for survival (e.g. Pulmonary Atresia, Pulmonary Stenosis, Tricuspid
Atresia and Transposition of the great vessels).
Because the ductus arteriosus rapidly loses its responsiveness to prostaglandin, alprostadil is most effective within
96 hours after birth. Therefore, it is used as palliative therapy until surgery can be performed.
DOSE
To open a closed ductus arteriosus:
IV Infusion: 100 nanogram/kg/minute for 20 to 30 minutes.
Doses greater than 100 nanogram/kg/minute are rarely more effective and may cause serious adverse
effects.
To maintain patency of ductus arteriosus:
IV Infusion: 10 to 20 nanogram/kg/minute
Ampoule = 500micrograms in 1mL (alcohol as solvent). Refrigerate
IV Infusion: Add 60micrograms/kg to sodium chloride 0.9% to a total volume of 50mL.
If dose ordered is not measurable at 500 micrograms/mL, a dilution can be made. For example, a 1 in 10 dilution:
Take 1mL of 500micrograms/mL solution and add to 9mL of Sodium chloride 0.9% = 50 micrograms/mL.
Withdraw required dose to prepare infusion.
Prepare fresh infusion solution and line every 24 hours.
Alprostadil 60micrograms/kg to 50mL 1mL/hr = 20 nanograms/kg/min
5mL/hr = 100 nanograms/kg/min
10 to 100 nanograms/kg/min
IV Infusion: Give prescribed dose via syringe pump using Guardrails.
x To open a closed ductus arteriosus IV infusion for 20 to 30 minutes.
x To maintain patency of ductus arteriosus continuous IV Infusion.
NB – Use first available venous access for alprostadil administration. A second, separate, venous access site
should also be available for other maintenance fluids and/or bolus doses of other medicines.
containing exact dose of alprostadil.
6 steps to
infuse safely
using
Guardrails
x Enter volume in syringe then press ‘OK’ and check concentration is correct (amount
and volume shown is the same as in syringe)
4. Dose shown in ‘ng/kg/min then press ‘OK’
6. Infuse dose: if all is correct, press Green button to start infusion:
x To open a closed ductus arteriosus: IV infusion for 20 to 30 minutes.
x To maintain patency of ductus arteriosus: continuous IV Infusion.
Flush the line if
required
Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same infusion rate.

Alprostadil IV Protocol
SIDE EFFECTS
x Apnoea (usually occurs within the first hour of administration and is more likely during duct opening or with
higher doses)
x Fever
x Flushing (secondary to vasodilation)
x Bradycardia / tachycardia
x Hypotension
x Decreased platelet aggregation, thrombocytopenia
x Oedema
x Prolonged treatment (>120hrs) may cause gastric outlet obstruction and reversible cortical proliferation of
the long bones
x Seizures
CONTRAINDICATIONS
x Respiratory Distress Syndrome
x Total anomalous pulmonary venous return with obstruction
x Caution in patients with bleeding tendencies and seizure disorders
x Continuous cardio/respiratory monitoring
x Monitor infant's temperature
x Monitor BP preferably with an arterial line or with
non invasive monitoring, as ordered
x Observe IV site carefully to ensure patency of IV
at all times
x DO NOT BOLUS OTHER MEDINES VIA
ALPROSTADIL INFUSION
x Change IV syringe and line every 24 hours. When
changing syringe and line, ensure line is clamped
to prevent administering a bolus. Minimise
interruptions to infusion.
IMPORTANT: Contact pharmacy for medicines not appearing in the table below. Uncommon medicines
have simply been omitted and may be incompatible.
Fluids Sodium chloride 0.9% No information
Drugs No information No information
Y-Site **Dobutamine, dopamine, heparin,
midazolam, ranitidine
1,4
No information
Notes: ** Only if absolutely necessary, not recommended by manufacturer
References:
1. Neofax 12th Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1st Ed. 1998, Pharmacy Department, The Royal Women's Hospital,
Carlton 3053
3. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of
Australia, 1999
4. Neonatal Formulary 3, 11th Ed, The Northern Neonatal Network. 2000
5. Manual of Neonatal Care 4th Ed., Cloherty J and Stark A. Joint Program in Neonatology,
Boston 1998

Amikacin IV Protocol
AMIKACIN
Amikacin is a semi-synthetic aminoglycoside broad-spectrum antibiotic used in the treatment of
gram -ve infections resistant to gentamicin.
Usually used in combination with a penicillin or cephalosporin.
DOSE
Use only following discussion with neonatologist and/or in consultation with clinical
microbiologist
IV, IM: 7.5mg/kg/dose
Interval
CA <28 weeks 36hrly
CA 28 to 29 weeks 24hrly
CA 30 to 35 weeks 18hrly
CA ≥36 weeks 12hrly
CA ≥37 weeks and over 7 days of life, give 8hrly.
Dosage interval may need to be extended in renal impairment.
Vial = 500mg in 2mL
IV infusion: Withdraw 0.5mL (125mg) from vial and add to 49.5mL of sodium chloride 0.9% in
a 50mL syringe = 125mg in 50mL = 2.5mg/mL
Withdraw required dose.
Unused solution should be discarded.
IV infusion: Infuse over 1 hour via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of amikacin.
6 steps to
infuse
safely
using
Guardrails
2. Check syringe concentration’ matches concentration shown on pump then
press ‘OK’
4. Dose shown in ‘mg/kg/h’ then press ‘OK’
6. Infuse dose: To start infusion over 1 hour:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same
as in syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
Note: 1 hour infusion will show the mg/kg/h of ACTUAL dose.
Flush the
line
Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same
infusion rate.

Amikacin IV Protocol
SIDE EFFECTS
x Ototoxicity
x Nephrotoxicity (trough levels > 10mg/L)5
x Hepatotoxicity (rare)
CONTRAINDICATIONS
x Caution in renal impairment
DRUG INTERACTIONS
Aminoglycosides, vancomycin Neurotoxic and nephrotoxic potential of amikacin may be
potentiated
Frusemide Potent diuretics may enhance toxicity of amikacin
Pancuronium Increased neuromuscular blockade
Indomethacin, amphotericin May potentiate renal toxicity
x Monitor urine output
x Large volume injection, record volume given
x Serum levels to be measured on the 3rd dose for all doses
o Pre-level (trough) taken immediately before dose
o Acceptable serum levels: Trough < 10mg/L
Routine assessment of amikacin levels should only occur in infants where it has been decided
antibiotic treatment will continue regardless of blood culture result. Where antibiotic regime is to
be determined by results of blood cultures, antibiotic levels should only be ordered once the
decision to continue treatment beyond 48 hours has been made.
IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Fluids Glucose 5%, glucose 10%, sodium chloride 0.9% Intralipid
1
, PN
Drugs Adrenaline, aminophylline, benzylpenicillin,
calcium, ciprofloxacin, clindamycin,
dexamethasone, fluconazole, frusemide,
hydrocortisone, lignocaine, metronidazole,
midazolam
1
, noradrenaline, phenobarbitone
1
,
ranitidine, sodium bicarbonate, vancomycin,
verapamil
Amphotericin B, heparin, phenytoin,
ticarcillin/clavulanate
1
, erythromycin
Y-Site Aciclovir, amiodarone, dexamethasone,
fluconazole, frusemide, magnesium, midazolam,
morphine, pethidine
References:
1. Neofax 16
th
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital,
Carlton 3053
nd
Ed., The Society of Hospital Pharmacists of Australia,
1999
th
Ed, The Northern Neonatal Network.
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston
1998

Amiodarone IV Protocol
AMIODARONE
Amiodarone is a Class III anti-arrhythmic agent. It inhibits adrenergic stimulation, prolongs the
action potential and refractory period in myocardial tissue and decreases AV conduction and
sinus node function.
Amiodarone has slow and variable oral absorption (as low as 50% bioavailability) and an
extremely long half-life (20 to 30 days).
Amiodarone is indicated in severe cases of supraventricular and ventricular tachyarrhythmias.
DOSE
Use only following discussion with neonatologist and/or in consultation with paediatric
cardiologist
ORAL: 4mg/kg/dose 8 hourly for 1 week, then 12 hourly for 1 week, then daily thereafter
IV infusion: 25microgram/kg/minute for 4 hours, then give 5 to 15microgram/kg/minute, titrated
according to response
Ampoule = 150mg in 3mL (50mg/mL)
IV infusion: Add 30mg/kg to glucose 5% to make 50mL.
Amiodarone 30mg/kg to 50mL 1mL/hr = 10microgram/kg/minute 5 to 15 microgram/kg/minute
If repeated doses are anticipated, where possible, administration via CVC is recommended due
to risk of phlebitis with peripheral administration.
IV infusion: Continuous IV infusion via syringe pump using Guardrails
syringe containing exact dose of amiodarone.
6 steps to
infuse
safely
using
Guardrails
x Enter volume in syringe then press ‘OK’ and check concentration is
correct (amount and volume shown is the same as in syringe)
4. Dose shown in ‘mcg/kg/min’ then press ‘OK’

Amiodarone IV Protocol
SIDE EFFECTS
x Hypotension, bradycardia, atypical ventricular tachycardia
x Hot flushes, sweating
x Nausea, constipation
x Corneal deposits
x Hyperglycaemia
x Hepatotoxicity, abnormal liver function tests. Monitor liver function during and after ceasing therapy.
x Nephrotoxicity, raised serum creatinine
x Abnormal thyroid function tests, hyper and hypo thyroidism. Monitor thyroid function.
x Pulmonary toxicity with long-term use
x Thrombophlebitis (Administration through central line is preferred)
x Photosensitivity. Use protective measures in babies exposed to sunlight
x Blue-grey discoloration of skin
CONTRAINDICATIONS
x CAUTION in patients with left ventricular dysfunction
x CAUTION in patients with hypotension
x Marked cardiomegaly is a relative contra-indication
x Thyroid dysfunction
x CAUTION in patients with liver impairment
DRUG INTERACTIONS
Digoxin Plasma levels of digoxin are increased. Reduce dose of digoxin by 50% during
amiodarone therapy and monitor levels closely.
Phenytoin Plasma levels of phenytoin are increased. Recommended that phenytoin levels be
closely monitored. Effectiveness of amiodarone may also be reduced.
Sotalol, propranolol, esmolol Can result in symptomatic bradycardia and sinus arrest. Hypotension as a side
effect can be severe when the combination is used.
Theophylline, caffeine Plasma levels of theophylline may be increased. Theophylline levels should be
monitored closely.
x Continuous ECG monitoring
x Continuous respiratory monitoring
x Monitor Q-T interval during commencement of therapy using 12 lead ECG
x Monitor blood pressure
x LFTs and TFTs according to cardiologist
x Protect infusion from light (cover syringe with foil)
x Change infusion solution every 24 hours
x Administer oral doses with food
x Use non DEHP lines and either Terumo or BD syringes to minimise plasticiser exposure
x Serum levels may be monitored - Therapeutic range: 1 to 2.5mg/L
IMPORTANT: Contact pharmacy for drugs not appearing in the table below. Uncommon drugs have
simply been omitted and may be incompatible.
Fluids Glucose 5% Sodium chloride solutions
Drugs No information Aminophylline, cephazolin, flucloxacillin, frusemide, heparin, sodium bicarbonate
Y-Site No information No information
Notes: Amiodarone is considered incompatible with most solutions and drugs when administered
intravenously. Avoid giving amiodarone with other drugs and solutions, including PN and Intralipid.
Amiodarone leaches plasticiser from DEHP containing infusion bags which may affect male reproductive
tract development. Use non DEHP lines and either Terumo or BD syringes and transfer to oral therapy as
soon as possible to minimise exposure.
References:
1. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
2. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of Australia, 1999
3. Neonatal Formulary 4th Ed, The Northern Neonatal Network. 2003
4. Pediatric Dosage Handbook 6th Ed., Taketomo, Hodding, Kraus. 1999-2000
5. Paediatric Pharmacopoeia 12th Ed, Royal Children's Hospital, Pharmacy Department, Parkville, 3052

08/06/05
IV Drug Protocol - Amoxycillin.doc
June 2005
AMOXYCILLIN
Amoxycillin is a broad spectrum penicillin antibiotic. It interferes with bacterial cell wall synthesis
during active multiplication, causing cell wall death and resultant bactericidal activity against
susceptible bacteria.
Amoxycillin is used in the treatment of infection caused by Listeria, beta-lactamase negative
Haemophilus or enterococci, and when indicated by sensitivity testing.
DOSE
Standard infection
IV, IM: 25mg/kg/dose
Severe infection (meningitis or septicaemia)
Interval
GA<37 weeks ≤28 days 12hrly
>28 days 8hrly
GA ≥37 weeks ≤7 days 12hrly
>7 days 8 hrly
Dosage interval may be decreased from 8 to 6hrly in suspected meningitis or septicaemia, where
renal function is adequate.
Vial = 500mg, 1g
IV: For 500mg vial: Add 4.6mL of Water for Injection to vial = 500mg in 5mL = 100mg/mL
For 1g vial: Add 9.2mL WFI to vial = 1000mg in 10ml = 100mg/mL
If further dilution is required to measure dose, take 1 mL of 100mg/mL solution and add to
4mL of sodium chloride 0.9% = 100mg in 5mL = 20mg/mL
IM: Add 2.6mL of Water for Injection to 500mg vial = 500mg in 3mL
Withdraw required dose. Doses should be freshly prepared. Discard any solution remaining.
IV: Give slowly over at least 10 minutes
IM: Do not give IM doses greater than 500mg. Consult senior neonatologist prior to prescribing
by IM route.
SIDE EFFECTS
• Rapid IV administration may result in convulsive seizures
• Rash
• Hypersensitivity reactions
• Thrombophlebitis

08/06/05
IV Drug Protocol - Amoxycillin.doc
June 2005
CONTRAINDICATIONS
• Hypersensitivity to amoxycillin or other penicillin antibiotics
• CAUTION in patients with hypersensitivity to cephalosporins
• CAUTION in patients with renal impairment
• Observe site
• Monitor urine output
IMPORTANT: Contact pharmacy for drugs not appearing in the table below. Uncommon
drugs have simply been omitted and may be incompatible.
Fluids Glucose 5%, glucose 10%
1
, sodium
chloride 0.9%
Intralipid
1
, PN
1
Drugs No information Aminoglycosides (amikacin, gentamicin,
tobramycin), midazolam, potassium chloride,
sodium bicarbonate
Y-Site No information
References:
1. Neofax 16th
2. Neonatal Pharmacopoeia 2nd
3053
3. Australian Injectable Drugs Handbook, 2nd
4. Neonatal Formulary 4th

AMOXYCILLIN/CLAVULANIC ACID
Penicillin antibiotic/
Beta lactamase inhibitor
Preparations
MIXT 400mg/57mg in 5mL(Augmentin Duo®)
Preparation for other routes
ORAL Reconstitute powder with WFI according to
package insert. Store in refrigerator.
Dose
Doses refer to amoxicillin content of Duo product
ORAL: 12.5 to 22.5mg/kg/dose 12hrly
Notes
Contraindicated in patients with a history of penicillin
allergy.
Best given just before a feed.

Amphotericin B – Liposomal (AmBisome®
)
(NISC IV Protocol)
Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please
remember to read our disclaimer.
Reviewed by: Pharmacy Department, NISC Nursing Staff
Authorised by: Director of Nurseries
Effective Date: March 2012
Review Date: March 2015
Page 1 of 4
Amphotericin B is a broad-spectrum anti-fungal agent. It is fungistatic and fungicidal depending on the
concentration achieved in body fluids and the susceptibility of the fungus. It is used in the treatment of
systemic fungal infections.
Ambisome®
consists of amphotericin B within a single lipid bilayer (liposome). Liposomal amphotericin
is claimed to have less side effects than conventional amphotericin, in particular, nephrotoxicity.
Liposomal amphotericin is indicated in patients who have systemic fungal infections and are intolerant
of conventional amphotericin, or have significant renal impairment/oliguria or liver dysfunction.
Dose
microbiologist
IV infusion: 3mg/kg/dose 24 hourly.
Doses of 5mg/kg once daily have been used and can be considered if renal function is adequate.
Vial = 50mg (Powder for reconstitution) NOT WARD STOCK (kept in After Hours Cupboard)
Pharmacy will supply preloaded syringes during pharmacy hours.
IV Infusion: Must be reconstituted using Water for Injection
Add 12mL of WFI to the vial containing the 50mg amphotericin dry powder. SHAKE the vial
VIGOROUSLY for at least 30 seconds to completely disperse the liposomal amphotericin. Check for
complete dispersion. Concentration of this solution = 4mg/mL.
USE ONLY GLUCOSE 5% for further dilution according to strength required as below: Withdraw
required volume of the 4mg/mL solution and add to the required volume of Glucose 5% using the 5
micron filter provided to make required strength. Withdraw required dose and discard any unused
solution.
Further dilute as follows:
Strength required Volume of 4mg/mL solution Volume of Glucose 5%
1mg/mL 1mL 3mL
If dose is > 2mg and infant is fluid restricted, the following dilution may be used:
Strength required Volume of 4mg/mL solution Volume of Glucose 5%
2mg/mL (Max) 2mL 2mL

)
(NISC IV Protocol)
Page 2 of 4
If an in-line membrane filter is used, the mean pore size must NOT be less than 1 micron in diameter.
DO NOT INFUSE THROUGH PALL FILTER.
IV infusion: Line should be flushed with Glucose 5% prior to infusion of liposomal amphotericin B.
Give slowly over 1 hour via syringe pump using Guardrails.
Prime line: Use Minimum Volume Extension tubing (volume = 1mL) to prime line with
preloaded syringe containing exact dose of liposomal amphotericin B.
6 steps to infuse safely using Guardrails:
Flush the line: Draw up 1.5mL of Glucose 5% in a 10mL syringe and infuse at the same
infusion rate.
2. Hit ‘Modify’ to ‘select concentration’ of the syringe and enter strength required:
Enter medicine dose/amount then press ‘OK’
Enter volume in syringe then press ‘OK’ and check concentration is
correct
Press ‘confirm’ if it is the right syringe OR
Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion: over 1 hour:
Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
Enter actual volume in syringe then press ‘OK’
Enter time to infuse over. Check volume and amount shown is the
same as in syringe then press ‘OK’.
Press ‘OK’ to choose ‘STOP’ infusion when finished
If all is correct, press ‘Green’ button to start infusing.
7. Note: 1 hour infusion will show the mg/kg/h of ACTUAL dose.

)
(NISC IV Protocol)
Page 3 of 4
Side Effects
Renal dysfunction: oliguria, decreased glomerular filtration rate, renal tubular acidosis, renal failure.
Anaemia
Coagulation defects, thrombocytopenia, granulocytopenia
Acute liver failure
Vomiting, diarrhoea, rash
Hypokalaemia, hypomagnesia,
Thrombophlebitis
Hearing impairment, neurological effects (seizures)
Hyper/hypotension, arrhythmias, cardiac arrest
Fever/chills
Contraindications
CAUTION in patients with renal impairment.
Hypersensitivity to amphotericin B
Drug Interactions
Corticosteroids (Hydrocortisone) May worsen hypokalaemia
Aminoglycoside antibiotics
(gentamicin, amikacin,
tobramycin) and vancomycin
May increase risk of nephrotoxicity
Digoxin Toxicity may occur due to hypokalaemia induced by amphotericin
Frusemide and
hydrochlorothiazide
May cause excessive loss of serum potassium
DO NOT INFUSE THROUGH PALL FILTER.
Monitor urine output
Cardio/respiratory monitor
Monitor BP

)
(NISC IV Protocol)
Page 4 of 4
IMPORTANT: Contact pharmacy for medicines not appearing in the table below. Uncommon
medicines have simply been omitted and may be incompatible.
Fluids Glucose 5% ONLY Sodium chloride 0.9%, IVN (protein and lipid)
Drugs See notes See notes
Y-Site See notes See notes
Notes: Liposomal amphotericin B must NOT be mixed with other drugs or fluids other than Glucose
5%. NOT compatible with IVN (protein and lipid).
References
1. Neofax 23rd Ed. 2010 A Manual of Drugs Used in Neonatal Care, Young, T.
2. Neonatal Pharmacopoeia. March 2012, Pharmacy Department, The Royal Women's Hospital, Parkville
3. Australian Injectable Drugs Handbook, 3rd Ed., The Society of Hospital Pharmacists of Australia, 2005
4. MIMS Online Prescribing Information for AmBisome
®
5. Gilead Pharmaceutical Medicines Information, accessed 21/03/12

Atropine IV Protocol – Jan 2011
ATROPINE
Atropine is an anticholinergic agent with effects on smooth muscle, cardiac muscle and various
glandular cells. It causes increased heart rate, reduced gastrointestinal motility and tone, urinary
retention, cycloplegia (dilated pupil) and reduced salivation and sweating.
Atropine is used with suxamethonium and fentanyl, prior to intubation to reduce the incidence of
bradycardia from vagal stimulation and therefore maintain cerebral perfusion during the procedure.
Reduces bronchial secretions.
Effects of atropine may last up to 6 hours1
.
Atropine is used occasionally as a mydriatic (to dilate the pupils) before eye surgery.
DOSE
Endotracheal intubation (with fentanyl and suxamethonium)
IV: 10 to 20micrograms/kg/dose (0.02 to 0.03mL/kg/dose) given prior to fentanyl
Ampoule = 600micrograms in 1mL
IV: No dilution necessary.
IV: Give over 1 minute. Effects can be seen within 30 seconds2
with peak increase in heart rate
occurring in 12 - 16 minutes1
.
SIDE EFFECTS
Cardiac arrhythmias
Mydriasis and cycloplegia (dilated pupil)
Dry mouth
Abdominal distension with reduced intestinal motility/paralytic ileus
Esophageal reflux
CONTRAINDICATIONS
Thyrotoxicosis
Tachycardia secondary to cardiac insufficiency
Cardiospasm
Paralytic ileus
Obstructive disease of the GI/Urinary tract

Atropine IV Protocol – Jan 2011
Monitor vital signs with cardiorespiratory monitor
Monitor urinary output and stools
Observe for signs of feed intolerance
Strict mouth care
COMPATIBILITY INFORMATION3,5
IMPORTANT: Contact pharmacy for medicines not appearing in the table below.
Uncommon medicines have simply been omitted and may be incompatible.
Fluids Glucose 5%
1
, glucose 10%
1
, sodium chloride
0.9%
No information
Drugs Dobutamine, frusemide, verapamil Adrenaline, flucloxacillin, noradrenaline, sodium
bicarbonate
Y-Site Fentanyl, heparin, hydrocortisone, potassium
chloride, morphine, PG
1
References:
st
th
Ed, Massachusetts: Blackwell Publishing Inc,
2007.
3. Trissell LA, 2009, Handbook on Injectable drugs, 15
th
Ed, Bethesda, American Society of Health-System Pharmacists.
4. Fary R, Smtih R, David P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia, 2
nd
Department The Royal Women's Hospital.
5. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4
th
Ed., Melbourne: The Society of Hospital Pharmacists
of Australia.
th
Ed., Cloherty J, Eichenwald E and Stark A. Joint Program in Neonatology, Boston 2008.
th
Ed, Melbourne: Pharmacy Department,
Royal Childrens Hospital.

IV Drug Protocol – Benzylpenicillin.doc
BENZYLPENICILLIN
(PENICILLIN G)
Benzylpenicillin is an antibacterial used in the treatment of most gram +ve and gram -ve
organisms. It is also effective against spirochaetes.
Benzylpenicillin is frequently used in combination with gentamicin for treatment of Group B
Streptococcus infection in neonates and is empirical first line treatment for early onset
sepsis (< 48 hours of age).
DOSE
Standard infection
GBS meningitis
Interval
GA<37 weeks 12hrly
GA≥37 weeks ≤7 days 12hrly
7 days 8hrly
Vial = 600mg
600mg is equivalent to 1,000,000units and contains 1.7mmol of sodium
IV: Add 5.6mL of Water for Injection = 100mg/mL
IM: Add 1.6mL of Water for Injection = 300mg/mL
IV: Give slowly over at least 5 minutes.
SIDE EFFECTS
High doses may cause CNS toxicity including lethargy, twitching and seizures
Disturbances to serum electrolytes8
High doses may cause thrombocytopenia and haemolytic anaemia
CONTRAINDICATIONS
Contraindicated in patients with a history of hypersensitivity to penicillin
CAUTION in patients with significant renal impairment
CAUTION in hypernatraemic patients due to high sodium content of preparation

IV Drug Protocol – Benzylpenicillin.doc
Observe for side effects
Fluids Glucose 5%, glucose 10%, sodium chloride
0.9%
Intralipid
1
, PN
Drugs Calcium, erythromycin, frusemide, gentamicin,
hydrocortisone, ranitidine, verapamil
Amphotericin B, flucloxacillin, noradrenaline,
phenytoin, sodium bicarbonate, thiopentone,
vancomycin
Y-Site Aciclovir, dopamine, fluconazole, heparin,
metronidazole, morphine
1
References:
1. Neofax 16
th
nd
3053
nd
th
th
6. Guidelines for Administration of Intravenous Medications to paediatric Patients 5
th
Ed. 1996 ASHSP
7. Paediatric Injectable Guidelines, 2
nd
Ed , 2000, Pharmacy Department, RCH
8. Paediatric Dosage handbook 6
th
Edition 199-2000, Taketomo, Hodding and Kraus

Caffeine Citrate IV Protocol
CAFFEINE CITRATE
Caffeine is a methylxanthine derivative used in the management of apnoea of prematurity and to facilitate early
extubation in neonates. It relaxes bronchial smooth muscle and may increase muscle function. It increases cyclic
AMP and also acts as a central nervous system stimulant. It has a wider therapeutic index than aminophylline and
theophylline, which means there is a lower incidence of toxic side effects and blood level monitoring is not
necessary. It has a long half-life, which means that in most neonates it can be given once daily.
DOSE
Doses are expressed as caffeine citrate
NB: 1mg caffeine base = 2mg caffeine citrate (RWH uses caffeine citrate only)
Loading dose: IV infusion, Oral: 20mg/kg/dose
Maintenance dose: IV injection, Oral: 5mg/kg/dose ONCE daily May be increased to 10mg/kg/dose ONCE daily
Maintenance dose is to be given at 2000hrs.
Babies receiving a loading dose prior to 1200hr should receive a maintenance dose the same evening.
Babies receiving a loading dose after 1200hr should receive a maintenance dose the next evening.
Notes
• Occasionally some neonates may require doses up to 20mg/kg/dose ONCE daily to assist with extubation.
5
• Neonates CA > 44 weeks may need up to 10mg/kg /dose 12 hourly.
• IV and oral bioavailability are equivalent, use IV route only if oral route is contraindicated.
• All orders are to be prescribed as caffeine citrate to avoid confusion with caffeine base
Caffeine citrate injection 40mg/2mL = 20mg/mL
IV: Babies weight ≥1.5kg: no dilution required. Withdraw required dose from ampoule and administer.
Babies weight <1.5kg : dilution is required and the following procedure may be used:
Withdraw 1mL (20mg) from the ampoule of caffeine citrate and add to 4mL sodium chloride 0.9% in 10mL syringe.
This gives a final concentration of 20mg in 5mL = 4mg/mL. Withdraw required dose.
IV: Give doses ≤ 10mg/kg over 10 minutes
Give doses > 10mg/kg slowly over 30 minutes via syringe pump using Guardrails
containing exact dose of caffeine.
6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused ‘caffeine LOAD’
2. Choose pump concentration and check it matches syringe concentration then press ‘OK’
3. Enter weight of baby then press ‘OK’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in syringe
then press ‘OK’.
x Note: 30minute infusion will show DOUBLE the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same infusion rate.

Caffeine Citrate IV Protocol
SIDE EFFECTS
x Tachycardia
x Irritability
x GI tract upset (feed intolerance, vomiting)
x Hypotension
x Hyperglycaemia
CONTRAINDICATIONS
x Caution in patients with tachycardia (HR > 180 bpm)
x Caution in patients with GI bleeding
x Use with caution in renal or hepatic impairment (decreased metabolism of caffeine)
DRUG INTERACTIONS
Phenobarbitone, Frusemide,
Rifampicin
May reduce caffeine levels.
Propranolol May increase caffeine levels
Erythromycin May increase caffeine levels. Effectiveness may be reduced due
to decreased serum levels of erythromycin.
Pancuronium Reduced effectiveness of pancuronium
Phenytoin May decrease serum levels of caffeine with possible reduced
efficacy
x Cardio/respiratory monitoring
x Check heart rate prior to giving dose. If HR > 180 bpm consistently, refer to medical staff
prior to administration of dose
x Caffeine levels are not routinely measured
Fluids Glucose 5%, sodium chloride 0.9% No information
Drugs No information Aciclovir, frusemide
Y-Site Amikacin,benzyl penicillin, calcium
gluconate, cefotaxime, dexamethasone,
dobutamine, dopamine, fentanyl,
gentamicin, heparin (<1unit/mL), morphine,
vancomycin
References:
1. Neofax 18
th
nd
Carlton 3053
th
4. BNF for children 2005. BMJ Publishing Group Ltd, RPSGB and RCPCH publications Ltd.
5. Steer P, Flenady V, et al. High dose caffeine citrate for extubation of preterm infants: a
randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2004; 89: F499-F503

CAFFEINE CITRATE
Xanthine derivative
Preparations
INJ 20mg/mL caffeine citrate.
20mg caffeine citrate= 10mg caffeine base
IV preparation and compatibilities
Compatible with G5%.
Give slowly over 30mins.
Dose
Doses expressed as caffeine citrate.
Neonatal apnoea
Loading dose
IV, ORAL: 20mg/kg
Maintenance dose (commence 24hrs after loading dose)
IV, ORAL: 5mg/kg/dose ONCE daily
Maintenance dose can be increased to a maximum of
10mg/kg/DAY.
Notes
Caution in renal and liver impairment.
Give oral doses with feeds.
Signs of toxicity are gastric irritation, agitation, tachycardia
and diuresis. Approx time to steady state is 5 to 6 days.
Monitoring of levels is not required.

CALCITRIOL
Active form of vitamin D3
Preparations
CAP 0.25microgram
MIXT (SAS) 1microgram/mL
Dose
Use only following consultation with renal physician
or endocrinologist.
Hypocalcaemia, hypoparathyroidism, renal
failure
ORAL: 20nanogram/kg/dose ONCE daily
Notes
Liquid inside capsule 0.17mL=0.25microgram
(1.5microgram/mL).
Monitor serum alkaline phosphate, calcium,
phosphate and creatinine.
Content of capsule may be removed by carefully
piercing the capsule at each end and pushing air
through capsule to force liquid out the opposite hole
onto a spoon. Ensure operator safety at all times.

Calcium
Effective Date: 12 Oct 2017
Review Date: Oct 2020
Page 1 of 3
Neonatal Protocol
Hypocalcaemia is physiological in the first few days of life, due to transient hypoparathyroidism.
This is particularly so in premature and growth-restricted babies, and following birth asphyxia. It is
mostly asymptomatic and resolves without treatment. Lower calcium levels are common in infants
< 1500g birth weight and are not usually associated with clinical symptoms unless ionised calcium
is < 0.8 mmol/L. In infants > 1500g birth weight, hypocalcaemia is defined as ionised calcium < 1.1
mmol/L.
Symptoms of hypocalcaemia in neonates may include: muscle twitching, jitteriness, generalized
seizures, hypotonia, apnoea, tachycardia, tachypnea and prolonged QT interval.
Calcium is used for:
- Treatment of hypocalcaemia in infants with cardiovascular instability (hypotension, poor
perfusion, metabolic acidosis, PPHN), encephalopathy, arrhythmias, seizures
- Exchange transfusion where infants have symptomatic hypocalcaemia or ionised calcium <
1.1mmol/L
- Hyperkalaemia with peaked T waves or arrhythmia on ECG
- Metabolic bone disease of prematurity
When treating hypocalcaemia, it should be ensured that hypomagnesaemia is also treated if
present. Correction of hypomagnesaemia may also correct hypocalcaemia.
Preparations
Injection 0.22mmol/mL (as calcium gluconate)
Oral suspension 1mmol/mL (as calcium carbonate)
Dose
Hypocalcaemia
Acute treatment:
IV: 0.22 mmol/kg (1 mL/kg) of elemental calcium as a single dose. May be repeated 6 to 8
hourly if necessary.
For hypocalcaemia with seizures, dose can be increased to 0.44 mmol/kg (2 mL/kg).
Exchange transfusion:
IV: 0.22 mmol (1 mL) [not based on weight] of elemental calcium if ionised calcium < 1.1
mmol/L
Hyperkalaemia with peaked T waves or arrhythmia on ECG:
IV: 0.11 mmol/kg (0.5 mL/kg) of elemental calcium
Hypocalcaemia – Maintenance:
IV infusion: 1.1 mmol/kg/day (5 mL/kg/day) elemental calcium over 24 hours
Metabolic bone disease of prematurity
Oral: 2 mmol/kg/day elemental calcium in 2 divided doses. Dose is not adjusted for weight, unless
phosphate level is < 1.8 mmol/L or ALP > 600 IU/L.

Calcium
Page 2 of 3
Neonatal Protocol
IV: Add the required dose of calcium gluconate to an EQUAL volume of compatible fluid to give a
final concentration of 0.11 mmol/mL.
IV infusion: Withdraw the required dose of calcium gluconate and make up to 24mL with
compatible fluid and administer at 1mL/hr.
If current weight > 2.4kg, withdraw the required dose of calcium gluconate and make up to 48mL
with compatible fluid and administer at 2mL/hr.
If current weight > 4.8kg, consider IV injections.
Do not give by SC or IM injection. Do not give intra-arterially.
Give via a central line where possible.
In emergency situations or exchange transfusion, may be given undiluted over 2-5 minutes via a
central line.
IV: Give diluted solution (0.11 mmol/mL) slowly over 10 minutes
IV infusion: Give diluted solution via syringe pump using Guardrails – see ‘How to set up the
Pump’
Oral: Shake the bottle well before withdrawing the required dose.
Side Effects
x Rapid IV injection may cause vasodilation, hypotension, bradycardia, arrhythmias and cardiac
arrest
x Severe necrosis and sloughing may occur with extravasation
x Constipation may occur with oral therapy
Contraindications
x Do not mix IV solutions containing calcium with ceftriaxone because a precipitate can form.
Deaths have been associated with precipitation of a ceftriaxone-calcium salt in the lungs and
kidneys in neonates.
x In neonates ≤ 28 days old, do not give within 48 hours of administration of ceftriaxone. For
infants over 28 days of age, the FDA states that ceftriaxone and calcium-containing solutions
may be administered sequentially as separate administration solutions ensuring that the
intravenous infusion lines are thoroughly flushed with a compatible solution between
infusions.9,10
Drug Interactions
Digoxin Calcium enhances the effect of digoxin and may precipitate arrhythmias
Ceftriaxone IV solutions containing calcium and ceftriaxone must NOT be
administered within 48 hours of one another. This includes administration

Calcium
Page 3 of 3
Neonatal Protocol
via the SAME or DIFFERENT lines in neonates ≤ 28 days old
Phosphate Calcium may decrease the absorption of phosphate, give oral doses at
least 2 hour apart
Ferrous sulphate Calcium may decrease the absorption of ferrous sulphate, give oral doses
at least 2 hours apart from calcium2
Hydrochlorothiazide Hydrochlorothiazide may increase calcium levels
x Monitor for bradycardia, hypotension and arrhythmias. ECG monitoring required. Observe IV
infusion site closely for extravasation
x Inspect the vial for particles before using as may precipitate in the vial
x Observe solution & complete length of infusion line for precipitation (haziness)
x Monitor serum calcium concentration
chloride 0.9%
Y-Site Aciclovir, amikacin, azithromycin,
benzylpenicillin, cefotaxime, ceftazidime,
ciprofloxacin, digoxin, furosemide,
ganciclovir, heparin, insulin, magnesium
sulphate, midazolam, milrinone,
morphine, piperacillin-tazobactam,
potassium chloride, vancomycin
Amphotericin B liposomal, ceftriaxone
(see contraindications & drug
interactions), indomethacin, lipid
emulsion, IVN starter, IVN maintenance,
phenytoin, potassium dihydrogen
phosphate, sodium bicarbonate, sodium
dihydrogen phosphate
References
1. Neofax® 2016 Truven Health Analytics Inc. Accessed on 22/08/2016
2. Micromedex® Solutions 2016 Truven Health Analytics Inc. Accessed on 16/06/2017.
3. Phelps, Hak, Crill. 2013 Pediatric Injectable Drugs (The Teddy Bear Book), 9th Ed, American Society of
Health-System Pharmacists
4. Burridge N (Ed) 2013 Australian Injectable Drugs Handbook, 6th Ed., Melbourne: The Society of Hospital
Pharmacists of Australia.
5. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5th Ed, Massachusetts: Blackwell
6. BNF for children, London: BMJ Publishing Group Ltd, 2015-2016.
7. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 23
rd
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2016
8. MIMSOnline. St Leonards, NSW: UBM Medica; 2013. Accessed: 23/08/2016
9. Lilley L, Legge D. Paediatric Injectable Guidelines. 5
th
ed. Flemington, Vic: The Royal Children’s Hospital;
2016.
10.Information for Healthcare Professionals: Ceftriaxone (marketed as Rocephin and generics)
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm109
103.htm Accessed: 19/10/2016

CARBAMAZEPINE
Anticonvulsant
Preparations
TAB 100mg, 200mg, 200mg CR, 400mg CR
MIXT 20mg/mL
It is possible to give the suspension rectally to temporarily
replace oral therapy. Give same total daily dose in small
multiple doses. Dilute 1:1 with warm water. May have laxative
effect.
Dose
Experience is limited in neonates.
ORAL: Commence at 2.5mg/kg/dose 12hrly increasing every 2
days to maximum of 15mg/kg/dose 12hrly.
Notes
CR tablets can be halved but not crushed.
Suspension to be given alone. Avoid use in active liver
disease. Increase dose slowly to allow for enzyme induction
upon initiation of therapy.
Serum Levels: Range: 20-40 micromol/L.
Sample immediately before next dose.
Time to steady state approx 1 to 2 weeks.

IV Drug Protocol – Cefotaxime.doc
CEFOTAXIME
Cefotaxime is a semi-synthetic, third-generation cephalosporin. It is active against both Gram
+ve and Gram -ve organisms. It is used in the treatment of infection when sensitivity testing
indicates susceptibility. It is combined with Amoxycillin for treatment of meningitis until the
organism is identified and sensitivity is confirmed.
DOSE
GA < 30 weeks and post natal age
≤ 28 days 12 hourly
> 28 days 8 hourly
GA > 30 weeks and post natal age
≤ 14 days 12 hourly
> 14 days 8 hourly
Dose interval may be reduced from 8 to 6 hourly in severe infections/meningitis
Dose interval may need to be increased in babies with severe renal failure
Vial = 1g
IV: Add 9.6 mL of Water for Injection to vial
= 1g in 10mL 100mg/mL
May be further diluted with sodium chloride 0.9% to 50mg/mL
IM: Add 3.6mL of Water for Injection = 1g in 4mL 250mg/mL.
IV: 100mg/mL or 50mg/ml solution given slowly over at least 10 minutes.
IM: 250mg/mL solution.
NOT RECOMMENDED, but may be useful for larger babies with no IV access.
SIDE EFFECTS
Hypersensitivity (not commonly seen in neonates).
Phlebitis
Diarrhoea
Leukopenia, eosinophilia, granulocytopenia
Transient elevation of BUN and creatinine

IV Drug Protocol – Cefotaxime.doc
CONTRAINDICATIONS
Hypersensitivity to cephalosporins and penicillins
CAUTION in patients with renal impairment
DRUG INTERACTIONS
Aminoglycosides Nephrotoxicity of both drugs may be increased.
Cefotaxime is sometimes used together with aminoglycosides as there is
evidence of a synergistic effect when used in combination. Careful monitoring of
aminoglycoside levels should reduce incidence/severity of nephrotoxicity.
Record volume on IV fluid chart - large volume drug
Observe site for phlebitis
Uncommon drugs have simply been omitted and may be incompatible
chloride 0.9%,
Solutions containing sodium bicarbonate
Drugs Clindamycin, verapamil Aminoglycosides (gentamicin, amikacin,
tobramycin), aminophylline, fluconazole,
vancomycin
Y-Site Aciclovir, heparin, magnesium
sulphate, metronidazole, morphine,
midazolam, PN
1
References:
1. Neofax 16
th
nd
Carlton 3053
nd
Ed., The Society of Hospital Pharmacists of Australia,
1999
th
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston
1998
6. Handbook on Injectable Drugs 11
th
Ed, Trissel L. 2001

Ceftazidime IV Protocol
CEFTAZIDIME
Ceftazidime is a third generation cephalosporin antibiotic for use by injection only. It is bactericidal in action, and is
synergistic with aminoglycosides.
Ceftazidime is used in the treatment of single and mixed infections caused by susceptible aerobic organisms with
suspected or documented resistance to other antimicrobials. It is an alternative to aminoglycosides for treatment of
pseudomonas infections in patients for whom aminoglycoside toxicity is a cause for concern.
DOSE
Use only following discussion with neonatologist and/or in consultation with clinical microbiologist
IV: 50mg/kg/dose
Interval
GA <30weeks ≤ 28 days: 12hrly
> 28 days: 8hrly
GA ≥30weeks ≤ 14 days: 12hrly
> 14 days: 8hrly
Vial = 1g (Powder volume = 1.1mL)
IV: Add 8.9mL of water for injection to the 1g vial = 1g in 10mL = 100mg/mL. Withdraw required dose.
Further dilute if required: add 1mL of100mg/mL solution to 1mL of sodium chloride 0.9% 100mg in 5mL
syringe = 100mg in 2mL = 50mg/mL. Withdraw required dose.
IM: Add 2.9mL of water for injection to the 1g vial = 1g in 4mL = 250mg/mL
IM: Not recommended but may be used for larger babies with no IV access.
Give 250mg/mL solution
IV infusion: Give slowly over 30 minutes via syringe pump using Guardrails
containing exact dose of ceftazidime.
6 steps to
infuse safely
using
Guardrails
2. Check syringe concentration matches concentration shown on pump then press ‘OK’
For concentration of 100mg/mL, hit ‘Modify’ to ‘select concentration’ of syringe
x Enter 100mg then press ‘OK’
x Enter 1mL then press ‘OK’ and check concentration is correct
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in syringe
then press ‘OK’.
Note: 30minute infusion will show DOUBLE the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same infusion rate.

Ceftazidime IV Protocol
SIDE EFFECTS
x Thrombophlebitis, pain at injection site
x CNS disturbances with excessive doses (tremors, myodema, convulsions, encephalopathy)
x GI disturbances, diarrhoea, nausea
x May elevate hepatic transaminases
x Eosinophilia, thrombocytosis, positive Coombs test without haemolysis
x
CONTRAINDICATIONS
x Known hypersensitivity
x CAUTION in patients with renal impairment; dose adjustment may be required
DRUG INTERACTIONS
Aminoglycosides Nephrotoxicity of both drugs may be increased.
Ceftazidime is sometimes used together with aminoglycosides as there is evidence
of a synergistic effect when used in combination. Careful monitoring of
aminoglycoside levels should reduce incidence/severity of nephrotoxicity.
x Observe injection site
Fluids Glucose 5%, glucose 10%1, sodium
chloride 0.9%
Sodium bicarbonate, intralipid, PN
Drugs Ciprofloxacin, fluconazole, heparin,
metronidazole, potassium
Aminoglycosides (gentamicin, tobramycin,
amikacin), midazolam, vancomycin
Y-Site Aciclovir, aminophylline, morphine,
ranitidine
-
References:
1. Neofax 16th Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T,
Mangum O.
2. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal
Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital
Pharmacists of Australia, 1999
5. Manual of Neonatal Care 4th Ed., Cloherty J and Stark A. Joint Program in
Neonatology, Boston 1998

CHLORAL HYDRATE
Sedative / Hypnotic
Preparations
MIXT 100mg/mL
Dose
Sedative
ORAL: 8mg/kg/dose 6 to 8hrly
Hypnotic
ORAL: 25 to 50mg/kg/dose 24hrly (maximum 1g
per dose)
In ventilated patients, higher doses of up to
50mg/kg/dose 6hrly may be used if required.
Notes
May cause nausea, vomiting and diarrhoea. Dose
may be diluted with water or feed to reduce these
side effects. Tolerance may develop after long-
term therapy.

Ciprofloxacin IV Protocol
CIPROFLOXACIN
Ciprofloxacin is a synthetic fluoroquinalone with bactericidal antimicrobial activity against a wide
range of gram -ve (Klebsiella, Enterobacter, Salmonella, Proteus and Pseudomonas species)
and gram +ve organisms (Staphyllococcus, Streptococcus and Enterococcus). Ciprofloxacin
may be indicated for the treatment of serious or life-threatening infections due to sensitive
organisms.
Animal studies have shown that ciprofloxacin can produce erosions of cartilage of weight-
bearing joints and other signs of arthropathy in immature animals of various species5. These
effects have not been reported after use of ciprofloxacin in children3.
DOSE
microbiologist
IV, ORAL:
Standard Infection 5mg/kg/dose 12hrly
Severe Infection 10 to 15mg/kg/dose 12hrly
Vial = 2mg/mL, 50mL and 100mL vial NOT WARD STOCK
IV: No dilution required. Withdraw required dose from vial and administer.
NOT TO BE GIVEN BY IM INJECTION
IV infusion: Give slowly over 1 hour via syringe pump using Guardrails
containing exact dose of ciprofloxacin
6 steps to
infuse safely
using
Guardrails
2. Concentration shown 2mg/mL – No change required
6. Infuse dose: To start infusion over 1 hour:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in
syringe then press ‘OK’.
Note: 60minute infusion will show the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same
infusion rate.

Ciprofloxacin IV Protocol
SIDE EFFECTS
x Restlessness
x Rash
x Nausea, vomiting, diarrhoea. Severe diarrhoea should be reported to medical staff immediately,
particularly if GI bleeding occurs. Colitis and pseudomembranous colitis have been reported with
ciprofloxacin.
x Increased liver enzymes
x Anaemia, eosinophilia, neutropenia
x Phlebitis at IV site, particularly if infused to rapidly
x Arthralgia, joint stiffness, tendonitis
x Crystalluria, Elevated serum creatinine and BUN
CONTRAINDICATIONS
x Hypersensitivity to ciprofloxacin or other quinolones
DRUG INTERACTIONS
Theophylline, Caffeine Elevation of theophylline levels may occur, monitor levels on day 3 of
ciprofloxacin treatment. Theophylline dose may need to be decreased by 50%
if levels are elevated. Adverse effects of theophylline may be increased,
particularly those involving the CNS.
x Oral doses are best given on an empty stomach (between feeds)
x Ensure adequate fluid intake
x Observe IV site for phlebitis
chloride 0.9%
Intralipid, PN
Drugs Amikacin, ceftazidime, gentamicin,
metronidazole, potassium chloride,
ranitidine, tobramycin
Aminophylline, amoxycillin, frusemide,
heparin, hydrocortisone, phenytoin,
dexamethasone, flucloxacillin
Y-Site Calcium gluconate, dobutamine,
dopamine, verapamil
Notes: Manufacturer advises temporarily disconnecting other solutions during the
infusion of ciprofloxacin.
References:
1. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
2. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Paediatric Pharmacopoeia 13th Ed. 2002 The Royal Children's Hospital, Parkville, Victoria
5. Ciproxin IV (Bayer), Product information, APP Guide January 2001
6. Khaneja M, Naprawa J, Kumar A, Piecuch S, 'Clinical Perinatal/Neonatal Case Presentation-Successful Treatment of
Late-Onset Infection due to Resistant Klebsiella pneumoniae in an Extremely Low Birth Weight Infant using
Ciprofloxacin' Journal Of Perinatology 1999 19(4) 311-314.
7. Singh UK, Sinha RK, et al, "Ciprofloxacin in Children: Is Arthropathy a Limitation?" Indian Journal of Pediatrics,
2000:67 (5)
8. Wlazlowski J, et al "Use of the Quinolones in Treatment of Severe Bacterial Infections in Premature Infants"

CLINDAMYCIN
Antibiotic
Preparations
INJ 150mg/mL
CAP 150mg
Compatible with G5%, NaCl 0.9%.
Dilute to a maximum concentration of 12mg/mL.
Give over at least 30mins.
Dose
Use only following discussion with neonatologist and/or in consultation with
clinical microbiologist.
Age <7days:
BW<2000g 5mg/kg/dose 12hrly
BW≥2000g 7.5mg/kg/dose 12hrly
Age ≥7 days:
CW <1200g 5mg/kg/dose 12hrly
CW 1200-2000g 5mg/kg/dose 8hrly
CW>2000g 5mg/kg/dose 6 to 8hrly
Notes
Risk of hypotension and cardiopulmonary arrest if given quickly.
Discontinue if severe diarrhoea develops and investigate cause. Increase
dosage interval in patients with significant liver dysfunction.

CLONAZEPAM
Benzodiazepine / Anticonvulsant
Preparations
INJ 1mg/mL
MIXT 2.5mg/mL (1drop=0.1mg), 100microgram/mL (RWH)
Compatible with G5%, G10%, NaCl 0.9%.
Dilute with diluent provided immediately before use to give a concentration of
1mg in 2mL.
Give over 5mins.
When giving mixture, count drops onto a spoon before administering. Do not
give directly from bottle to patient as overdosing may occur easily.
Dose
Loading dose
IV, ORAL: 0.1 to 0.25mg
Use lower doses for premature infants. If fitting persists, subsequent doses
may be given.
Maintenance dose
IV, ORAL: 0.01mg/kg/dose 8hrly
Commence maintenance dose 8 hours after loading dose. Maintenance dose
may be increased every 3rd day to a maximum of 0.2mg/kg/day.
Notes
Doses should be reduced gradually when treatment is to be ceased to reduce
the risk of withdrawal symptoms. Rapid IV injection may cause respiratory
depression. Possible elevation of phenytoin levels. CNS depression,
hypotension, upper airway hypersecretion and increased salivation may occur.
Therapeutic range: 60 to 150nanomol/L.

COPPER
Supplement
Preparations
MIXT 20micrograms/mL (RWH)
Dose
ORAL: 25micrograms/kg/day
Notes
Mixture prepared by pharmacy
department.

Cyclopentolate 0.5%
Effective Date: 4 Feb 2015
Review Date: February 2018
Page 1 of 1
Neonatal Protocol
Cyclopentolate eye drop is used together with phenylephrine to induce mydriasis (pupil dilation)
prior to Retinopathy of Prematurity (ROP) screening and laser eye surgery in preterm neonates.
The maximum effect is achieved 30 to 60 minutes after instillation.
Preparations
Eye drops Cyclopentolate 0.5%
Note: eye drops are stored in the refrigerator and for single use only.
Dose
Prior to ophthalmologic examination or laser eye surgery
Eye drops: Instil 2 drops into each eye, 30 to 40 minutes prior to ROP screening or laser eye
surgery.
Intraocular: To be administered 30 to 40 minutes prior to procedure, unless the nurse performing
the eye check indicates the time that the eye drops are to be instilled.
Excessive systemic absorption can be avoided with finger pressure to the lachrymal sac for 1-2
minutes following applications.
Refer to Appendix A for the recommended method of administration.
Side Effects
x May cause transient whitening of the eyelid and, if overflow, of the cheeks also secondary to
local vasoconstriction.
x Transient stinging after instillation
x Tachycardia and urinary retention may occur secondary to systemic absorption
x Eye drops are packaged in single use units which are to be used for one patient on one
occasion only.
References
1. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 03/02/2015.
2. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 20
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2013.
4. New Services Clinical Guideline, Aucland Distribution Health Board.
http://www.adhb.govt.nz/newborn/Guidelines/Developmental/ROP.htm#Examination accessed on
03/02/2015.
5. Neofax 23
rd
Ed. 2010, A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.

Dexamethasone
Reviewed by: Sue Jacobs, Clinical Pharmacists, NISC clinical educators
Authorised by: Carl Kuschel
Effective Date: 28 October 2013
Review Date: October 2016
Page 1 of 4
Neonatal Protocol
Dexamethasone is a synthetic corticosteroid with basic glucocorticoid actions and effects and with
no mineralocorticoid activity. It has pronounced anti-inflammatory activity and is used in the
treatment of chronic lung disease (CLD)/bronchopulmonary dysplasia (BPD) to facilitate weaning
of mechanical ventilation. It is thought to produce its effect on BPD by increasing surfactant
synthesis, reducing pulmonary oedema and by stabilisation of cell and lysosomal membranes.
Dexamethasone may also be used to treat tracheal oedema before and after extubation.
Dexamethasone has a rapid onset of action, with duration of action between 36 and 54 hours. It is
metabolised in the liver and excreted in the urine as unchanged drug and metabolites. Small
amounts may be excreted in bile.
Preparations
Injection 4mg/mL
Mixture 100micrograms/mL (RWH)
Dose
Chronic Lung Disease / Bronchopulmonary Dysplasia
Note: Doses are to be calculated based on the weight when the course was commenced, not on
the current weight (unless advised by consultant). This weight is to be documented in the medical
information section of the medication order.
DART Regimen
IV, Oral:
Day 1, 2 and 3 75 micrograms/kg/dose 12 hourly (6 doses)
Day 7 and 8 25 micrograms/kg/dose 12 hourly (4 doses)
Day 9 and 10 10 micrograms/kg/dose 12 hourly (4 doses)
Course may be repeated if necessary.
Medical staff to complete, print and file the DART dosing guide in the notes:
http://intranet.thewomens.loc/departments/clinicaloperations/neonatalservices/Documents/Dexame
thasone%20Dosing%20Tool.xlsx
Cummings Regimen
IV, Oral:
Day 7 and after Decrease dose by 10% of the current dose every 3 days until a dose of
50micrograms/kg/dose is reached. Then give on alternate days for 1 week
then cease. Course duration is 42 days.
If initially ineffective, discontinue after 5 days.

Dexamethasone
Page 2 of 4
Neonatal Protocol
Medical staff to complete, print and file the Cummings dosing guide in the notes:
http://intranet.thewomens.loc/departments/clinicaloperations/neonatalservices/Documents/Dexame
thasone%20Dosing%20Tool.xlsx
Shorter courses, with doses starting at up to 500 micrograms/kg/day (in divided doses) may also
be used, with individually designed tapering off periods and dosages.
The length of the course will generally depend on response and the determined weaning schedule.
To prevent failure of ET extubation (with suspected subglottic oedema)
IV, Oral: 250 micrograms/kg/dose every 8 hours for 3 doses
IV: Withdraw 0.25mL of 4mg/mL solution and add to 0.75mL of sodium chloride 0.9% in a
second 1mL syringe = 1mg/mL = 1000micrograms/mL
To dilute for smaller doses: Withdraw 0.1mL (100micrograms) of the above 1mg/mL
solution and add to 9.9mL of sodium chloride 0.9% in a 10mL syringe = 10micrograms/mL
Discard excess volume to obtain required dose or withdraw dose using another syringe.
IV: Give diluted solution over 1 to 3 minutes. Flush with sodium chloride 0.9%.
IM: Not recommended.
Side Effects
Immunosuppression, increasing the risk of sepsis, especially with prolonged use. May also
mask signs of infection.
Hyperglycaemia
Hypertension
Osteoporosis, inhibition of growth (prolonged use)
Hypokalaemia, hyponatraemia, oedema, glycosuria, hypercalciuria and hypocalcaemia
Acute or rapid withdrawal after more than 7 days of treatment can cause acute adrenal
insufficiency (fever, hypotension, hypoglycaemia and shock)
Contraindications
Untreated systemic bacterial infections
Systemic fungal infections
CAUTION in patients with hypertension
It is recommended that live virus immunisations should be given 1 month after ceasing high
dose, prolonged (>2 weeks) course of dexamethasone1
. However, live virus vaccines may be
given during treatment with dexamethasone following discussion with consultant.

Dexamethasone
Page 3 of 4
Neonatal Protocol
Drug Interactions
Ensure that oral anti-fungal medicine, nystatin drops 1mL 8 hourly is prescribed prophylactically
when prescribing dexamethasone for CLD. Discontinue prophylactic antifungal 3 days after
ceasing dexamethasone.
Observe for signs of infection (including candida)
Monitor blood pressure twice daily for 3 days, then daily during treatment
Monitor blood glucose twice daily for 3 days, then when necessary
chloride 0.9%
Drugs Calcium chloride, calcium gluconate,
ciprofloxacin, dobutamine, erythromycin,
gentamicin, magnesium sulphate,
midazolam, phenytoin, vancomycin
Y-Site Aciclovir, amikacin, benzylpenicillin,
caffeine citrate, cefotaxime, cephazolin,
dopamine, fentanyl, flucloxacillin,
fluconazole, frusemide, heparin, insulin
(neutral), lignocaine, meropenem,
metronidazole, morphine, piperacillin-
tazobactam, potassium chloride, sodium
bicarbonate, ranitidine, PG1, PG2
References
1. Kroger AT, Sumaya CV, Pickering LK, Atkinson WL. General Recommendations on Immunization.
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.
2011;60(RR02):1-60.
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm
Accessed: 09/05/2013
2. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 9
th
Ed. Bethesda,
Maryland: American Society of Health-System Pharmacists; 2010.
3. Fary R, Smith R, Davis P, Jacobs S, editors. Neonatal Pharmacopoeia. 2
nd
Ed. Melbourne: Pharmacy
Department, The Royal Women’s Hospital; 2005.
4. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
Phenobarbitone, phenytoin,
rifampicin
May increase the metabolism of dexamethasone
Amphotericin B, frusemide,
hydrochlorothiazide
May have synergistic potassium depleting effect
Ibuprofen Increased risk of gastrointestinal perforation and bleeding

Dexamethasone
Page 4 of 4
Neonatal Protocol
5. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
6. Cummings JJ, D’Eugenio DB, Gross SJ. A Controlled Trial of Dexamethasone in Preterm Infants at High
Risk for Bronchopulmonary Dysplasia. N Engl J Med. 1989;320(23):1505-1510.
7. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 5
th
Ed. Melbourne: The Society of
Hospital Pharmacists of Australia; 2011.
8. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
2011.
9. Dexamethasone sodium phosphate. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral
Compatibility). Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 09/05/2013

Diazoxide
Effective Date: 26 April 2018
Review Date: April 2021
Page 1 of 2
Neonatal Protocol
Diazoxide is used to treat persistent hypoglycaemia secondary to hyperinsulinism by inhibiting
insulin release from the pancreas and by blocking some of the peripheral actions of insulin via the
catecholamine stimulation.
A positive response to diazoxide is usually seen within 48 to 72 hours, with onset of action usually
within 1 hour following oral administration and with a duration of action of approximately 8 hours.
Diazoxide is also an arteriolar vasodilator and may cause hypotension, and fluid retention.
Hydrochlorothiazide is usually prescribed concurrently with diazoxide to minimise fluid retention
and may further increase hyperglycaemia.
Preparations
Mixture 10mg/mL (SAS) (RWH)
Dose
Hypoglycaemia secondary to hyperinsulinaemia
Oral: 5 to 15mg/kg/day as recommended by endocrinologist. Can be given in 2 to 3 divided
doses.
Commence when:
Verbal parental consent has been obtained and documented in the baby’s clinical notes, AND
TGA SAS category C form has been completed Appendix A
Oral: May be given without regard to feeds.
Side Effects
x Hypotension
x Hyperglycaemia
x Tachycardia
x Blood dyscrasias
x Hirsutism and coarse facial features may develop with long term use
x Antidiuretic effect may cause sodium and fluid retention; hydrochlorothiazide may be prescribed
concurrently to counteract these effects.
x Ketoacidosis during intercurrent illness
x Hyperuricaemia
x Pulmonary hypertension has been reported in infants and newborns, monitor patients for
respiratory distress and discontinue diazoxide if pulmonary hypertension is suspected
Contraindications
x CAUTION in heart failure
x CAUTION in mechanical hypertension e.g. aortic coarctation or AV shunt
x CAUTION in pulmonary hypertension
x CAUTION in renal impairment
x CAUTION in hyperbilirubinaemia - diazoxide may displace bilirubin from albumin

Diazoxide
Effective Date: 26 April 2018
Review Date: April 2021
Page 2 of 2
Neonatal Protocol
Drug Interactions
Antihypertensive agents Diazoxide may potentiate hypotensive effect
Phenytoin Diazoxide may reduce effectiveness of phenytoin
x Monitor blood pressure 30 minutes after dose
x Monitor blood sugar levels
x Monitor WCC and platelets with prolonged treatment (> 1 week)
TGA considerations and parental consent
x Diazoxide is not currently listed on the Therapeutics Goods Administration’s (TGA) Australian
Register of Therapeutic Goods.
x Under the TGA Authorised Prescriber Scheme, the NISC prescribers have been authorised by
TGA to prescribe Diazoxide
x Therefore, to prescribe Diazoxide:
o Provide verbal information to the parent(s)/guardian(s)
o Obtain verbal parental consent, and document in the baby’s clinical notes
o Complete the TGA SAS Category C form Appendix A
o Leave copy in pharmacist tray in central work room.
References
1. Diazoxide. In: Lexicomp Online® , Pediatric & Neonatal Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.;
Date accessed 01/03/2018
2. Zenk KE, Sills JH, Koeppel RM. Neonatal Medications & Nutrition: A Comprehensive Guide. 3rd Ed. Santa
Rosa, California: NICU Ink; 2003.
3. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press,
and RCPCH Publications <http://www.medicinescomplete.com> [Accessed on 01/03/2018]
4. Diazoxide. In: Micromedex [database on the Internet]. Ann Arbor (MI): Truven Health Analytics;
publication year [cited 01/03/2018]. Available from: www.micromedexsolutions.com. Subscription required
to view.
5. Young T, Mangum B. Neofax 2010. 23rd Ed. New Jersey: Thomson Reuters; 2010.
6. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7th Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
7. Australian Medicines Handbook 2018 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2018
January. Available from: http://amhonline.amh.net.au/

DIGOXIN
Cardiac glycoside
Preparations
INJ 25microgram/mL and MIXT 50microgram/mL
TAB 62.5microgram, 250microgram
Dilute to 5micrograms/mL.
Withdraw required dose and give slowly over 5 to 10mins.
Dose
Use only after discussion with paediatric cardiologist
Loading dose (total 3 doses) for arrhythmias only
CA <37 weeks
IV, ORAL: 10microgram/kg stat, then 5microgram/kg/dose 8hrly for 2 doses.
CA ≥ 37 weeks
IV, ORAL: 10microgram/kg stat, then 10microgram/kg/dose 8hrly for 2 further
doses.
Maintenance dose
IV, ORAL: 3 to 5microgram/kg/dose 12hrly
Notes
Reduce dose in renal impairment.
Consider lower dose in patients being treated with indomethacin or erythromycin.
Halve dose if given with amiodarone.
Hypokalaemia may increase risk of digoxin toxicity (with or without increased
digoxin levels) therefore drugs which cause hypokalaemia may predispose patients
to digoxin toxicity.
Therapeutic range 1 to 2.5 nanomol/L. Serum level should be taken on 3rd day but
more frequent levels may be necessary.
Take sample at least 6 hours after dose. Signs of toxicity include vomiting,
diarrhoea, drowsiness, bradycardia and arrhythmias.
Doses must always be prescribed in micrograms.

Dobutamine IV Protocol
DOBUTAMINE
Dobutamine is a synthetic catecholamine. It is an inotropic vasopressor, and increases
myocardial contractility, cardiac index, oxygen delivery, and oxygen consumption. Dobutamine
preferentially dilates the coronary beds and does not cause vasodilation in renal and mesenteric
areas. Dobutamine has a greater effect on cardiac output than dopamine, with less tendency to
cause arrhythmias, and with less effect on blood pressure. It is used to increase myocardial
contractility and cardiac output.
Dobutamine may be used in combination with dopamine.
Dobutamine has a serum half-life of 2-3 minutes and must be administered by continuous
infusion due to rapid metabolism.
DOSE
IV Infusion: 5 to 20microgram/kg/minute starting at 5microgram/kg/min and increasing after
10 minutes PRN.
Vial = 250mg
INF: Reconstitute with 20mL Water for Injection = 250mg in 20mL solution (12.5mg/mL)
Add 30mg/kg to infusion solution ordered (glucose 5 or 10%, sodium chloride 0.9%) to a total
volume of 50mL. (As shown in table below)
Dobutamine
SINGLE
30mg/kg to 50mL 1mL/hr =
10microgram/kg/min
5 to
20microgram/kg/min
Dobutamine
DOUBLE
20microgram/kg/min
10 to
20microgram/kg/min
Dobutamine
QUAD
40microgram/kg/min
10 to
20microgram/kg/min
Not for IV bolus or IM use
Administration via central line is preferred. Use with caution if given through peripheral line.
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using Guardrails
NOTE: Consider administering fluid volume prior to starting dobutamine infusion.
syringe containing exact dose of dobutamine.
6 steps to
infuse
safely
using
Guardrails
x Enter medicine dose then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
4. Dose shown in ‘mcg/kg/min’ then press ‘OK’

Dobutamine IV Protocol
SIDE EFFECTS
x May cause hypotension if patient hypovolemic
x Tachycardia
x Arrythmias
x Hypertension
x TISSUE ISCHAEMIA occurs with infiltration
x CUTANEOUS VASODILATION ("flushed" appearance)
CONTRAINDICATIONS
x Hypovolaemia should be corrected before dobutamine administration.
x Caution in patients with hypertension.
x Idiopathic hypertrophic subaortic stenosis5
x Carefully prime IV tubing
x USE ATOM PUMP PREFERABLY
x Change infusion fluid and tubing every 24 hours ensuring that pump and 3-way tap
turned off to prevent any inadvertent bolus dose being given.
x Continuous blood pressure monitoring preferably with an arterial line.
x Continuously monitor heart rate and rhythm
x Record vital signs hourly
x Observe and measure urine output
x Observe IV site for inflammation and extravasation of fluid, remove immediately if occurs.
x Avoid interruption of infusion
x DO NOT ADMINISTER ANY BOLUS DOSES
Fluids Sodium chloride 0.9%, sodium chloride 0.45%,
glucose 5%, glucose 10%, glucose/sodium
solutions
Alkaline solutions (sodium bicarbonate)
Drugs Adrenaline, amiodarone, atropine, dopamine,
glyceryl trinitrate, hydralazine, isoprenaline,
lignocaine, meropenem, morphine, noradrenaline,
propranolol, ranitidine
Aciclovir, aminophylline, digoxin, flucloxacillin,
frusemide, heparin, indomethacin
1
, insulin,
phenytoin
Y-Site TPN
1
, calcium, diazepam, fentanyl, fluconazole,
insulin (≤1unit/mL)
6
, magnesium,
midazolam
1
,pancuronium
1
, potassium, sodium
nitroprusside, verapamil
Notes: Dobutamine infusion solution may show a slight pink colour, which is
acceptable. Discard solution if it appears hazy.
References:
1. Neofax 12
th
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
nd
th
th
6. Trissel LA. Handbook on injectable drugs. 15
th
edition. Bethesda: American Society of Health-System
Pharmacists 2009

DOPAMINE
Cardiac Inotrope
Preparations
INJ 40mg/mL
Dilute according to IV drug protocol and give as a continuous
infusion via infusion pump.
Do not mix with strongly alkaline solutions or sodium
bicarbonate.
Dose
Improvement of cardiac output and BP
IV INF: 2 to 20microgram/kg/min
Notes
Use with caution if given through peripheral line due to
vasoconstrictive action.
Correct hypovolaemia before commencing infusion. Observe
IV site for inflammation, extravasation and extreme
vasoconstriction (tracking).
May be used together with dobutamine.
Phenytoin given together with dopamine may cause severe
hypotension.

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