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Clinical pharmacy,,, notes

This document provides guidelines for clinical pharmacy including: 1) Infusion guidelines for various drugs like dopamine, dobutamine, heparin etc with recommended doses and diluents. 2) Common CVS abbreviations used in clinical practice along with their meanings. 3) Maximum recommended daily doses for various drug classes like hypoglycemic agents, antihyperlipidemics, antiplatelets etc. 4) Drug interaction tables listing important interactions between various commonly used drugs. 5) Dosing equivalences for corticosteroids and pediatric antimicrobial dosing guidelines based on renal function.

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GUIDELINES TO CLINICAL PHARMACY ‫ا‬‫عداد‬ ..‫رياض‬ ‫دنيا‬ ‫الصيدالنية‬ ..‫فاضل‬ ‫االء‬ ‫الصيدالنية‬
2 Infusions  Dopamineamp. 200 mg Ivac + syr.20cc+ N/S or G/W 5 µ ----------->3 amp. 7 µ----------->4 amp. 10 µ---------->5 amp. 15 µ---------->8 amp.  Dobutamineamp. 250 mg Ivac + syr.10cc+ N/Sor G/W 5 µ------------»2 amp. 10 µ----------»4 amp.  Tridel amp. 5mg/10 mg Ivac + syr.20cc+ N/Sor G/W 5 µ----------->2 amp. 10 µ---------->3 amp.  Heparin vial 25000 UIvac+ syr.5cc+ N/S 5000 UIvac + syr.20cc+ N/S  Meronim vial500 mg(Bolusover 5min& inf. Over 15-30 min while maintenance 10-20 mg/kgq 8 hr) ,Vancomycin vial 1g,Targocid vial 200 mg& Ceftriaxonevial 1g Burette+ syr.5cc+ N/Sor G/W  Aminophyllin amp. 250mg/10ml Burette+ syr.10cc+N/Sor G/W  Mg vial 1g or 4g/20ml & KClvial Burette+ syr.10cc+ N/Sor G/W Mg SO4 conc. 200mg/ml  Ampicloxvial 500mg12×4 Burette+ syr.10/20cc+ N/S  Glucophagedoesn’t suitable in lasix amp inf.  Cordaron amp inf. calc 5mg/kgmaintenancedose Note that 1 mg = 100 IU & Manitol adm. as 1g/kg
3 CVS Abbreviations RCA lesion: right coronary artery lesion ‫با‬ ‫فعالجه‬ ‫شديد‬ ‫بالقسطرة/تضيق‬ ‫عالجه‬ ‫فيكون‬ ‫تضيق‬ ‫ممكن‬‫لون‬ LAD lesion: left anterior descendinglesion ‫هابط‬ ‫امامي‬ ‫شريان‬ AVR: aortic valvereplacement LBBB: left bundlebranch block CHB: complete/ congenital heart block PTCA: ‫شبكة‬ DORV: double outlet right ventriclesurgery Both aorta & pulmonary arteriescome from the sameventricle CoA: co aortication ‫االبهر‬ ‫الشريان‬ ‫تضيق‬ PVA: pulmonary valveatrisia ‫اضمحالل‬ TR: tricuspid regurgitation PA: pulmonary artery L-TGA: transposition of great arteries ‫الشرايين‬ ‫انعكاس‬ ‫انواع‬ ‫من‬ ‫نوع‬ SVT: supraventricular tachycardia LVH: left ventricular hypertrophy TAPVD: total anomalouspulmonaryvenousdrainage PFO: persistent foramin ovali ‫من‬ ‫االذنين‬ ‫بين‬ ‫فتحة‬‫مف‬ ‫تكون‬ ‫االحيان‬ ‫بعض‬ ‫لكن‬ ‫ضعيفة‬ ‫فتح‬ ‫برجة‬ ‫طبيعية‬ ‫تكون‬ ‫الوالدة‬‫اعلى‬ ‫بدرجة‬ ‫توحة‬ ‫الطبيعي‬ ‫من‬---‫مرضية‬ ‫حالة‬ DCM: dilated cardiomyopathy ‫الموضعي‬ ‫القلب‬ ‫عضلة‬ ‫اعتالل‬
4 PDA: patentductusarteriosus ‫الرئوي‬ ‫و‬ ‫االبهر‬ ‫الشريانين‬ ‫بين‬ ‫ناسور‬ TOF: tetralogy of Fallot ‫فالوت‬ ‫رباعية‬ VSD: ventricular septal defect ‫البطينين‬ ‫بين‬ ‫فتحة‬ ASD: arterial septal defect ‫األذينين‬ ‫بين‬ ‫فتحة‬ AR: aortic regretion ‫االبهر‬ ‫الصمام‬ ‫كفاءة‬ ‫عدم‬ Sever MS: mitral stenosis ‫الشديد‬ ‫التاجي‬ ‫الصمام‬ ‫تضيق‬ MVR: mitral valveregurgitation ‫التاجي‬ ‫الصمام‬ ‫كفاءة‬ ‫عدم‬ MVP: mitral valveprolapse ‫التاجي‬ ‫الصمام‬ ‫تهدل‬ SBE: subacute bacterial endocarditis ‫البكتيري‬ ‫القلب‬ ‫غشاء‬ ‫التهاب‬ ACS: acute coronary syndrome(mi) AS: aortic stenosis ‫االبهر‬ ‫الصمام‬ ‫تضيق‬ Valves A: aortic P: pulmonary M: mitral T: tricuspid
5 MaxDoses Hypoglycemicagents Daonil15 mg daily Amaryl6mgdaily Metformin 2 g daily Antihyperlipidemia Avas80 mg daily Lescol 80 mg daily Zocor 80 mg daily Antiplatelets Plavex300 mgdaily Aspirin 4gdaily Others Ibuprofen 2.4 gdaily Ca2+ tab 6mgper course Isordil120-240 mg Antibiotics Ampiclox12gdaily Claforan 12gdaily Ceftriaxone4g daily Rifampicin adult1200 mgdaily &child 600mgdaily (Dose in child 10-20 mg/kgdivided into two equal doses) Piperacillin 4.5g× 4=18 gdaily Imipenem 4gadult/2gchild (not less than 1 yr) β-blockers Propranolol(inderal)HTN 160-320mg/day Angina120-240mg/day
6 Atenolol (tenormin)HTN 25-50 mg/day Angina100 mg/day in 1-2 doses Bisoprolol (concor) HTN+ Angina20 mg/day Heart failure10 mg oncedaily Carvedilol(dilatrand)HTN+HF+Angina50 mg once/bid Metoprololtartarate (betaloc) HTN 400 mg/day Angina50-100 mgbid/tid ACEI Captopril(capoten) HTN 50 mg twice daily [raretid] HF 150 mg/day Enalapril (revatic) HTN 40 mg once/day HF 10-20 mgtwice /day Lisinopril(zestril) HTN 80 mg once/day HF 35 mg once /day Other 40 mg daily Ca2+ channel blockers Amlodipin HTN & Angina 10 mgonce daily Diltiazim Angina360 mgdaily Nifidipen (adalat) 20 mgtid Verpamil [oral] HTN 240-480 mg/day Angina 80-120 mg/day Diuretics Furosemide[oral] Resist. Oedema 80-120mg/day Resist.HTN 40-80 mg/day [I.M/I.V] 1.5 gdaily Spironolacton (lasix) oedemain CHF25-200 mgdaily HF 50 mg/day Resist.HTN 25 mgonce/day Other 400 mgdaily
7 Drug-druginteraction Warfarin + azithromycin=azithromycin isenzymeinhibitor Alteplase + nitroglycerin= increase reperfusion Clopidogrel+ atrovastatin=decreaseclopidogrel activity Clopidogrel+ proton pump inh. (PPI)=PPI areenzymeinh. Pantoprazoleis alternative Methoprim + aldactone =increasehyperkalemia Lasix + amikacin=ototoxicity & nephrotoxicity Amiodaron + lasix =arrhythmia Amiodaron + quinoloneAB=arrhythmia Captopril+allopurinol=hypersensitivity reactions Ceftriaxone+ Ca2+ containingsol. /ring=Ca2+ salt precipitation Digoxin increase plasma conc. Of ACEI, macrolid AB, captopril, amiodaron (cordaron), garamycin, methoprim, diltiazim, nifidipen (adalat) & aldactone Digoxin + β-blockers=increaseAV block & bradycardia Digoxin decrease Neomycin & antacid absorption Rifadine plasmaconc. Epanutinedecrease Vancomycin + lasix=ototoxicity Vancomycin + gentamicin /exacyl=nephrotoxicity Amiodaron + verpamil/diltiazim=sever interaction (HF)
8 Dosing& d. equivalences  Prednisolone5mg = to: Betamethason 750 µg Cortisone acetate 25 mg Deflazacort 6 mg Dexamethason 750 µg Hydrocortisone20 mg Methylprednisolone4 mg Triamciolone 4mg  Clexanedose [S.C]: In DVT; Treatment less than 2 months --------->1.5 mg/kg/12 hr 2 months – 17 years ---------->1 mg/kg/12 hr ; ProphylacticLess than 2 months --------->0.75 mg/kg/12 hr 2 months – 17 years --------->0.5 mg/kg/12 hr Note that:  Verpamil/diltiazim act mainly on heart rather than blood vessels so used to treat tachycardia /angina [Note that diltiazim can be used with lowvasc]  Metoprolol(betaloc) As succinate salt---longer duration of action given single or twice daily (used in HF) As tartarate salt---shorter duration of action (notused in HF)
9 Pediatric Antimicrobial Dosing Guideline for Infants and Children (> 1 Month of Age) Approved by the Antibiotic Advisory Subcommittee and the Pharmacy and Therapeutics Committee 2013 DRUG Creatinine Clearance >50ml/min/1.7 3m2 (Renal Function > 50% of Normal) Creatinine Clearance =10- 50ml/min/1.73 m2 (Renal Function = 10- 50% of Normal) Creatinine Clearance <10ml/min/1 .73m2 (ESRDnot on dialysis) (Renal Function<10 % of Normal) MAXIMU M DAILY DOSE Acyclovir IV Non-CNS HSV infection: 5-10mg/kg/dose q8h 25-50% of normal clearance 5-10mg/kg/dose q12h 10-25% of normal clearance 5-10mg/kg/dose q24h 2.5- 5mg/kg/dose q24h Herpes Zoster 10-20 mg/kg/dose q8h or or 500 mg/m2/doseq8h 25-50% of normal clearance 10- 20mg/kg/dose q12h 5- 10mg/kg/dose q24h or 250 mg/m2/dose q24h
10 (immunocompro mised host) or 500 mg/m2/dose q12h (immunocompro mised host) 10-25% of normal clearance 10- 20mg/kg/dose q24h or 500 mg/m2/dose q24h (immunocompro mised host) (immunocomp romised host) HSV encephalitis, all neonatal infections: 20mg/kg/dose q8h or 500 mg/m2/doseq8h (immunocompro mised host) 25-50% of normal clearance 20mg/kg/dose q12h or 500 mg/m2/dose q12h (immunocompro mised host) 10-25% of normal clearance 20mg/kg/dose q24h 10mg/kg/dose q24h or 250 mg/m2/dose q24h (immunocomp romised host)
11 or 500 mg/m2/dose q24h (immunocompro mised host) Amphoteric in B Liposomal (AmBisome ®; per ID approval except for Heme-Onc) Invasiveyeast infections 3mg/kg/doseIV q24h Invasivemold infections 5mg/kg/doseIV q24h No change No change Dosage reductionsin renal disease are not necessary. However, dueto the nephrotoxic potential of the drug, reducing the doseor holding the drugin the setting of a rising serum creatinine may be warranted. Amoxicillin PO 20mg/kg/dose q12h Otitis Media/Pneumo nia/ Osteomyelitis 45- 50mg/kg/dose q12h 30-50% of normal clearance No change 10-30% of normal clearance 50% normal dose q12h 50% normal dose q24h 4g/DAY Ampicillin IV 50mg/kg/dose q6h 25mg/kg/dose q6h 25mg/kg/dose q8-12h 2gm q4h Meningitis: 100mg/kg/dose q6h 50mg/kg/dose q6h 25mg/kg/dose q8-12h Ampicillin/ sulbactam( Unasyn) 50 mg ampicillin/kg/do se q6h 25 mg ampicillin/kg/do se q6h 25 mg ampicillin/kg/ dose q8-12h 2 gm ampicilli n q6h
12 Caspofungi n IV (per ID approval except Pedatric Heme- Onc/BMT) <3 mo old: 25mg/m2/dose q24h ≥3 mo old: LD 70mg/m2 x1, then 50mg/m2q24h No change No change LD: 70mg MD: 50mg Cefazolin 25mg/kg/dose q8 25mg/kg/dose q12h 25mg/kg/dose q24h 2gm q8h Cephalexin PO 10 mg/kg/dose PO q6-8h Otitis Media 20-25 mg/kg/dose PO q6h Osteomyelitis 25-30 mg/kg/dose PO q6h 10 mg/kg/dose PO q8h-q12h 10mg/kg/dose PO q12h-q24h 4 gm/day Cefepime 50mg/kg/dose q12h >30% of normal clearance 50mg/kg/dose q24h 10-30% of normal clearance 25mg/kg/dose q24h 12.5mg/kg/do se q24h 2gm q12h Febrile neutropenia: 50mg/kg/dose >30% of normal clearance 50mg/kg/dose 25mg/kg/dose q24h 2gm q8h
13 q8h q12h 10-30% of normal clearance 50mg/kg/dose q24h Cystic Fibrosis: 50mg/kg/dose q8h Not documented Not documented 50mg/kg /dose q8h Cefotaxime 50mg/kg/dose q8h 50mg/kg/dose q8-12h 25mg/kg/dose q12h 2gm q6h Meningitis: 50m g/kg/dose q6h 50mg/kg/dose q8h 50mg/kg/dose q12h Ceftazidime 50mg/kg/dose q8h 50mg/kg/dose q12h 50mg/kg/dose q24-48h 2gm q8h Cystic fibrosis: 75mg/kg/dose q8h Not documented Not documented 2gm q8h Burkholderia cepacia co- infected with Pseudomona s aeruginosa: 75mg/kg/dose q8h 3gm q8h Ceftriaxone 50mg/kg/dose q24h No change No change 1gm q24h Meningitis: 50mg/kg/dose No change No change
14 q12h 2gm q12h Cefuroxime IV 50mg/kg/dose q8h 50mg/kg/dose q12h 50mg/kg/dose q24h 1.5gm q8h Ciprofloxaci n IV >30% of normal clearance 10- 15mg/kg/dose q12h 10-30% of normal clearance 7.5mg/kg/dose q12h 7.5mg/kg/dos e q12h 400mg q12h Cystic fibrosis: 15mg/kg/dose q12h Not documented Not documented 600mg q12h Clindamyci n IV 10mg/kg/dose q8h No change No change 900mg q8h Clindamyci n PO 2-8mg/kg/dose q6-8h Osteomyelitis 10-12 mg/kg/dose PO q6-q8h No change 450mg q6h Ertapenem IV 15mg/kg/dose q12h >13 yearsold: 1 gm daily <30ml/min/1.73m2 Decrease dose 50% 1 gm q24h Erythromyc in IV 5-10mg/kg/dose q6h No change No change 1gm q6h Ethambutol PO 15mg/kg/dose q24h 7.5mg/kg/dose q24h 5mg/kg/dose q24h 2.5gm q24h Fluconazole 6-12mg/kg/dose 3-6mg/kg/dose 3- 400mg
15 IV/PO (All patients who are able to tolerate PO should receive PO fluconazole.) q24h q24h 6mg/kg/dose q24h q24h Fungal prophylaxis: 3mg/kg/dose q24h No change No change Ganciclovir IV >80% of normal clearance 5mg/kg/dose q12h 79-50% of normalclearance 2.5mg/kg/dose q12h 25-50% of normal clearance 2.5mg/kg/dose q24h 10-25% of normal clearance1.25mg /kg/dose q24h 1.25mg/kg/do se q24h Gentamicin 2.5mg/kg/dose q8h **consultwith pharmacist for dose adjustment/level assessment** 2.5mg/kg/dose q12h 2.5mg/kg/dos e q24h Imipenem (per ID approval) 20mg/kg/dose q6h 10mg/kg/dose q6-8h 10mg/kg/dose q12h 1gm q6h Isoniazid Treatment: 5mg/kg/dose No change No change 300mg daily
16 daily-bid Prophylaxis: 10mg/kg/dose daily No change No change Levofloxaci n IV-PO < 5 yo: 10mg/kg/dose q12h ≥ 5 yo: 10mg/kg/dose q24h 30-50% of normal clearance No change 10-30% of normal clearance 5-10mg/kg/dose q24h 5- 10mg/kg/dose q48h 750mg q24h Linezolid IV/PO (per ID approval) <5 yo: 10mg/kg/dose q 8h >5 yo: 10mg/kg/dose q 12h No change No change 600mg q12h Meropenem IV 20mg/kg/dose q8h 25-50% of normal clearance 20mg/kg/dose q12h 10-25% of normal clearance 10mg/kg/dose q12h 10mg/kg/dose q24h 1gm q8h
17 Meningitis: 40mg/kg/dose q8h 25-50% of normal clearance40mg/ kg/dose q12h 10-25% of normal clearance 20mg/kg/dose q12h 20mg/kg/dose q24h 2gm q8h Metronidaz ole IV/PO 10mg/kg/dose q8h No change 10mg/kg/dose q12h 500mg q6h NafcillinIV 25- 50mg/kg/dose q6h No change No change 2gm q4h PenicillinG IV 100,000- 250,000 units/kg/DAY divided dosesq4- 6h 75,000 -175,000 units/kg/DAY divided doses q8h 50,000- 125,000 units/kg/DAY divided doses q12h 4 million unitsq4h SevereInfection: 250,000-400,000 units/kg/DAY divided doseq4- 6h 175,000- 300,000 units/kg/DAY divided doses q8h 125,000- 200,000 units/kg/DAY divided doses q12h Piperacillin/ Tazobactam IV(Zosyn) 80mg piperacillin/ kg/dose q6-8h* *Serious infections 30-50% of normal clearance 50mg piperacillin kg/dose q6- 50mg piperacillin/ kg/dose q8h 4 gm piperacill in q6h
18 including Pseudomonas: consider q6h 8h 10-30% of normal clearance 50mg piperacillin /kg/dose q8h Cystic fibrosis: 100mg piperacillin/ kg/dose q6h Not documented Not documented 4gm piperacill in q6h Pyrazinamide PO 15- 30mg/kg/dose daily No change No change RifampinIV/PO 5- 10mg/kg/dose daily-bid No change No change 600mg daily TobramycinIV see gentamicin Cystic fibrosis: Once daily dosing 10mg/kg/dose q24h see gentamicin Not documented see gentamicin Not documented TMP/SMX (Septra)IV /PO When switching to oral therapy, consider that a Mild to moderate systemic bacterial infection: 2.5mg TMP/kg/do se q12h 2.5-5mg TMP/kg/do se q24h
19 single-strength tablet has 80mgof TMP, a double-strength tablet 160mgof TMP, oral suspension has 40 mg TMP per 5 ml 5mg TMP/kg/dose q12h Serious systemic bacterial infection: 5mg TMP/kg/dose q6-8h 5mg TMP/kg/do se q8-12h 5mg TMP/kg/do se q12-24h Pneumocystis carinii pneumonia prophylaxis: 2.5mg TMP/kg/dose q12h three daysper week. 2.5mg TMP/kg/do se q12h three days per week. 2.5mg TMP/kg/do se q24h three days per week. 160mg TMP bid Vancomycin Peak levels are not recommended. Troug h levels (< 30 min before next dose) should be 5-20 mg/L dependingon the severity of infection. Specifically, 15-20 for meningitis, sepsis and pneumonia 15mg/kg/dose q6h 15 mg/kg/dose q8-12h 15 mg/kg/dose q12-24h 1 gm IV q8h CNS/Osteo/Seri ous infections: 20mg/kg/dose q6h 20mg/kg/d ose q8h 20mg/kg/d ose q12h 1 gm IV q6h
20 Voriconazole IV/PO (per ID approval except for Heme- Onc/BMT) PO should be used when possible, as oral bioavailability > 95%. Presumed/Empi ric Treatment LD=6mg/kg q12hx2 doses MD=4mg/kg q12h Documented Infections LD=7mg/kg q12hx 2 doses MD=5-7mg/kg q12h Higher doses may be required based on therapeutic drugmonitoring (consultation with Pedi-ID recommended) No change No change
21 DRUG FOR PEDIATRICEMERGENCIES o Adenosine Indication: Supraventricular tachycardia Dosage: Initial dose: 0.05 mg/kg as rapidly as possible followed by flush of the IV catheter. Subsequent doses: If atrioventricular (AV) block occurs or if there is no response within 30 seconds, increase by 0.05 mg/kg (eg, 0.1 mg/kg followed by flush of the IV catheter; if no response, increase to 0.15 mg/kg and flush IV catheter). Maximum single dose, 12 mg. WARNING: Contraindicated in heart transplant patients. Note: Higher doses of adenosine may be needed when a patient is taking methylxanthine preparations. Note: The antidote for profound bradycardia is aminophylline, 5 to 6 mg/kg over 5 minutes.Atropine is contraindicated. A defibrillator must be immediately available. o Albuterol Indication: Status asthmaticus, bronchospasm Dosage: 0.1 to 0.15 mg/kg by nebulization. Repeat as needed. Note: 0.02 to 0.03 mL/kg of 5 mg/mL solution with normal saline to make 3 mL total in nebulizer; maximum single dose, 2.5 mg. Note: Administration can be repeated and doseadjusted until desired clinical effect or symptomatic tachycardia. Note: Oxygen is the preferred gas source for nebulization. Supplemental oxygen should be considered when compressed air driven nebulizersare used or when oxygen flow rate dictated by nebulizer is inadequate. Blended oxygen
22 may be required for premature newborns who are still at risk for retinopathy of prematurity. o Atropine Sulfate Indication: 1) Symptomatic bradycardia Dosage: Intramuscular (IM): 0.02 to 0.04 mg/kg Intratracheal: 0.02 to 0.04 mg/kg IV: 0.02 mg/kg. Minimum single dose, 0.1 mg Maximum single dose, 0.5 mg for child, 1.0 mg for adolescent. This dose may be repeated once. Note: Oxygenation and ventilation are essential first maneuvers in the treatment of symptomatic bradycardia. Epinephrine is the drug of choice if oxygen and adequate ventilation are not effective in the treatment of hypoxia- induced bradycardia. Note: If administered through an endotracheal tube, follow the dose with or dilute in saline flush (1 to 5 mL) based on patient size. Indication: 2) Anticholinesterase poisoning. Dosage: IV: 0.05 mg/kg Repeat as needed for clinical effect. Note: Anticholinesterase poisonings may require large doses of atropine or the addition of pralidoxime. Indication: 3) To prevent succinylcholine-induced bradycardia. Dosage: 0.02 mg/kg IV or 0.02 to 0.04 mg/kg IM just before or simultaneously with succinylcholine o Bicarbonate, Sodium
23 Indication: Metabolic acidosis, Tricyclic antidepressant overdose. Dosage: IV: 1 to 2 mEq/kg WARNING: Only 0.5 mEq/mL concentration should be used for newborns; dilution of available stock solutions may be necessary.Administer slowly because bicarbonate solution is hyperosmotic. Note: Routine initial use of sodium bicarbonate in cardiac arrest is not recommended. However, sodium bicarbonate may be used in cases with documented metabolic acidosisafter effective ventilation has been established. o Calcium Chloride Indication: Ionized hypocalcemia, Hyperkalemia, Hypermagnesemia, Calcium channel blocker toxicity Dosage: IV: 20 mg/kg (if using10% CaCl2, dose is 0.2 mL/kg). Inject slowly. Repeat dose as necessary for desired clinical effect. WARNING: Stop injection if symptomatic bradycardia occurs. Extravascular administration can result in severe skin injuries. Note: Calcium is recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, or calcium channel blocker toxicity. o Calcium Gluconate Indication: Ionized hypocalcemia, Hyperkalemia, Hypermagnesemia, Calcium channel blocker toxicity Ionizes as rapidly as calcium chloride and may be substituted using three times the dose of calcium chloride (mg/kg). Dosage: IV: 60 mg/kg (if using 10% gluconate, dose is 0.6 mL/kg). Inject slowly. Repeat dose as necessary for desired clinical effect.
24 WARNING: Stop injection if symptomatic bradycardia occurs. Extravascular administration can result in severe skin injuries. Note: Calcium is recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, or calcium channel blocker toxicity. o Charcoal, Activated Indication: Acute ingestion of selected toxic substances Dosage: 1 to 2 g/kg Note: Administer as slurry or down a nasogastric tube. Note that iron, lithium, alcohols, ethylene glycol, alkalies, fluoride, mineral acids, and potassium do not bond to activated charcoal. WARNING: Commercially available preparations of activated charcoal often contain a cathartic, such as sorbitol. Fatal hypernatremic dehydration has been reported after repeated doses of charcoal with sorbitol. Nonsorbitol-containing products should be used if repeated doses are necessary. o Dexamethasone Indication: 1) Emergency treatment of elevated intracranial pressure due to brain tumor Dosage: IV: 1 to 2 mg/kg as a loading dose Maintenance dose, 1 mg/kg/24 h Indication: 2) Croup Dosage: IV, IM, or PO: 0.6 mg/kg dexamethasone, 1 dose/d, or 2 mg/kg/24 h of prednisone. Further dosing and route of administration determined by clinical course. o Diazepam Indication: Status epilepticus
25 Dosage: IV: 0.1 mg/kg every 2 minutes. Maximum dose, 0.3 mg/kg (maximum 10 mg/dose). Dosage: Rectal: 0.5 mg/kg up to 20 mg Note: Do not give as IM injection. WARNING: There is an increased incidence of apnea when combined with other sedative agents or when given rapidly. One must be prepared to provide respiratory support. Monitor oxygen saturation. o Diazoxide Indication: Hypertensive crisis Dosage: IV: 1 to 3 mg/kg rapid IV push. Note: Alternative regimen: 3 to 5 mg/kg IV over 30 minutes. This is reported to result in fewer problems with hypotension or hyperglycemia. o Digoxin Immune FAB (Digibind) Indication: Digoxin or digitoxin toxicity Dosage: 1) Administer digoxin immune FAB intravenously in an amount equimolar to the total body load of digoxin or digitoxin. 2) 38 mg digoxin immune FAB binds 0.5 mg digoxin or digitoxin Dosing methods: A: Based on amount ingested: 1) For digoxin tablets, oral solution, IM injection Dose in mg = 2) For digitoxin tablets, digoxin capsules, IV digoxin or IV digitoxin Dose in mg =
26 B: Based on serum digoxin or digitoxin concentration (SDC) 1) Digoxin Dose in mg = 2) Digitoxin Dose in mg = C: If neither amount ingested nor serum concentration is known, 760 mg of digoxin immune FAB should be administered. o Diphenhydramine Indication:Acute hypersensitivity reactions, Dystonic reactions Dosage: V or IM: 1 to 2 mg/kg. Maximum dosage, 50 mg. Note: May cause sedation, especially if other sedative agents are being used. May cause hypotension. o Dopamine Indication: Continued shock after volume resuscitation Dosage: IV infusion: 2 to 20 μg/kg/min. A widely recommended starting dosage is 10 μg/kg/min. Titrate to desired clinical effect. Note: Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mL. Infuse at 10 mL/h = 10 μg/kg/min using a constant infusion pump. WARNING: Extravascular administration can result in severe skin injuries. o Dobutamine
27 Indication: Impaired cardiac contractility Dosage: IV infusion: 5 to 25 μg/kg/min. A widely recommended starting dosage is 10 μg/kg/min. Titrate for desired clinical effect. Note: Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mL. Infuse at 10 mL/h = 10 μg/kg/min using a constant infusion pump. o Epinephrine Indication: 1) Cardiac arrest or profound bradycardia, asystole, ventricular fibrillation, or pulseless electrical activity Initial Dose: IV: 10 μg/kg (0.01 mg/kg) Intraosseous: 10 μg/kg (0.01 mg/kg) Endotracheal: 100 μg/kg (0.10 mg/kg) Note: 10 μg/kg = 0.1 mL/kg of 1:10 000 dilution 100 μg/kg = 0.1 mL/kg of 1:1000 dilution Note: If administered through an endotracheal tube, follow the dose with saline flush or dilute in isotonic saline flush (1 to 5 mL) based on patient size. Subsequent doses: given every 3 to 5 minutes IV: 100 μg/kg (0.1 mg/kg) Intraosseous: 100 μg/kg (0.1 mg/kg) Endotracheal: 100 μg/kg (0.1 mg/kg) Note: For subsequent doses of epinephrine, a dosage up to 200 μg/kg (0.2 mg/kg) may be given. Indication: 2) Anaphylaxis Dosage: Subcutaneous (SC): 10 μg/kg per dose (maximum 3 doses)
28 IV: 10 μg/kg per dose: 10 μg/kg = 0.01 mL/kgof 1:1000 dilution or 0.1 mL/kg of a 1:10 000 dilution Note: Repeat the SC dose every 20 minutes while attempting IV access. Some anaphylactic reactions, eg, latex allergy, require large doses of epinephrine. A continuous infusion of epinephrine may be necessary. Indication: 3) Continued shock after volume resuscitation Dosage: IV infusion: 0.1 to 3.0 μg/kg/min. Start at lowest dose and titrate for desired clinical effect. Note: Preparation of infusion solution: 0.6 mg × body weight (kg) diluted to 100 mL. Infuse at 1 mL/h = 0.1 μg/kg/min using a constant infusion pump. Note: Extravasation can result in tissue necrosis injuries. Indication: 4) Status asthmaticus, bronchospasm Dosage: SC: 10 μg/kg per dose 10 μg/kg = 0.01 mL/kg of 1:1000 dilution Maximum single dose, 300 μg (0.3 mL of 1:1000 dilution). Note: Albuterol administered by inhalation is now considered the agent of choice for treatment of acute exacerbations of asthma. Note: Repeat SC dose every 20 minutes if needed for clinical effect. Total of 3 doses. Indication: 5) Laryngotracheobronchitis: Dosage: Racemic epinephrine, 2.25% inhalation solution 0–20 kg: 0.25 mL in 2 mL with normal saline administered by nebulizer 20–40 kg: 0.50 mL in 2 mL with normal saline administered by nebulizer >40 kg: 0.75 mL in 2 mL with normal saline administered by nebulizer
29 Note: L-Epinephrine: An equal volume of 1% L-epinephrine (1:100) is approximately equivalent in biologic activity to 2.25% racemic epinephrine; one can be substituted for the other in equal volumes for inhalation. Alternatively, 5 mL of 1:1,000 L-epinephrine is equivalent to 0.5 mL of 1:100. o Fentanyl Indication: Pain Dosage: IV: 0.5 μg to 2.0 μg/kg. Repeat dose as necessary for clinical effect. Note: Higher doses may be necessary if the patient is tolerant. Note: Rapid administration of fentanyl has been associated with both glottic and chest wall rigidity even with dosages as low as 1 μg/kg. Therefore, fentanyl should be titrated in slowly over several minutes. WARNING: There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support. o Flumazenil Indication: Benzodiazepine intoxication Dosage: IV: 5 to 10 μg/kg (up to 100 μg/kg has been used) Maximum dose, 1 mg Note: Useful only for benzodiazepine intoxication. WARNING: Duration of action is shorter than most clinically important benzodiazepines. Resedation may occur. May precipitate acute withdrawal in dependent patients; use drug with caution as its use may be associated with seizures. Patients who receive flumazenil should be continuously observed for resedation for at least 2 hours after the last dose of flumazenil. o Fosphenytoin
30 Indication: Status epilepticus (same as phenytoin) Dosage: ALWAYS IN PHENYTOIN EQUIVALENTS (PE) 10 to 20 mg PE/kg (same as phenytoin) Route of administration: IM or IV: 1 to 3 mg PE/kg/min; maximum rate 150 mg PE/min Note: Data are currently being collected on children less than 6 years of age. Itching is a common and controllable by reducing flow rate. WARNING: Rate of infusion should not exceed 3 mg PE/kg/min. Heart rate should be monitored and the rate of infusion reduced if the heart rate decreases by 10 beats/minute (same as phenytoin). o Furosemide Indication: Fluid overload, Congestive heart failure Dosage: IV, IM: 1 mg/kg o Glucagon Indication: 1) Hypoglycemia due to insulin excess Dosage: Adult and adolescent: 0.5 to 1.0 mg SC, IM, IV; repeat every 20 minutes Pediatric: 0.025 mg/kg up to 1.0 mg SC, IM, IV; repeat the dose every 20 minutes if needed for clinical effect. Total of 3 doses. Note: An attempt should be made to provide a simultaneous IV glucose infusion. Indication: 2) Beta-blocker or calcium channel blocker overdose Dosage: Adolescent IV: 2 to 3 mg followed by a 5 mg/h infusion. Pediatric IV: 0.025 to 0.05 mg/kg followed by 0.07 mg/kg/h infusion.
31 o Glucose Indication: Hypoglycemia Initial Dose: IV: 250 to 500 mg/kg Maintenance Dose: Constant infusion of 10% dextrose in water at a rate of 100 mL/kg/24 h (7 mg/kg/min). Older children may require a substantially lower dose. The rate should be titrated to appropriate glucose values. Note: 250 to 500 mg/kg = 2.5 to 5.0 mL/kg of D10% 250 to 500 mg/kg = 1.0 to 2.0 mL/kg of D25% 250 to 500 mg/kg = 0.5 to 1.0 mL/kg of D50% Note: Neonates should receive 10% to 12.5% glucose administered slowly. Note: Glucose levels should be determined beforeand during administration. If large volumes of dextrose are administered, include electrolytes to prevent hyponatremia and hypokalemia. o Haloperidol Indication: Psychosis with agitation Dosage: IM, IV: 0.1 mg/kg, may repeat hourly as necessary. Maximum single dose, 5 mg. Note: Hypotension and dystonic reactions may occur. o Insulin, Regular Indication: 1) Diabetic ketoacidosis Dosage: SC: 0.25 to 0.5 unit/kg per dose IV infusion dose: 0.05 to 0.1 unit/kg/h Neonatal dose: 0.05 unit/kg/h
32 Note: Blood glucose levels should be closely monitored. Appropriate fluid and electrolyte therapy are also required in treating diabetic ketoacidosis. Indication: 2) Hyperkalemia Dosage: IV: 0.1 unit/kg with 400 mg/kg glucose. Ratio of 1 unit of insulin for every 4 g of glucose. Note: Potassium levels in blood or serum should be monitored. o Ipecac Syrup Indication: Acute ingestion of selected toxic substances Dosage: Oral (PO): 6-month-old to 1-year-old = 10 mL >1 year old = 15 mL Adolescent/young adult = 30 mL WARNING: Do not use when patient is suffering from central nervous system depression or if having seizures. Contraindicated in caustic and hydrocarbon ingestion. Patients who ingest pesticides or other chemicals that may have a hydrocarbon base may need to have emesis induced. Consult your regional poison control center. Note: Administer with 120 to 180 mL of fluid; 90% effective in inducing vomiting within 25 minutes of first dose. May repeat once. Note: Activated charcoal is now considered the first line therapy for most oral ingestions treated in the hospital setting. o Kayexalate (Sodium Polystyrene Sulfonate) Indication: Treatment of hyperkalemia Dosage: Adults and adolescents PO: 15 g (60 mL) 1 to 4 times/day Rectal: 30 to 50 g every 6 hours
33 Children PO: 1.0 g/kg every 6 hours Rectal: 1.0 g/kg/dose every 2 to 6 hours (for small children and infants use lower doses by using the practical exchange ratio of 1 mEq K+/g of resin). WARNING: Avoid using the commercially available liquid preparation in neonates due to the hyperosmolar preservative (Sorbitol) content. Extremely premature newborns may develop intestinal hemorrhage (hematochezia) from rectal Kayexalate. o Ketamine Indication: 1) Sedation/analgesia Dosage: IM: 1 to 2 mg/kg IV: 0.5 to 1 mg/kg Indication: 2) Adjunct to intubation Dosage: IV: 1 to 2 mg/kg Note: Laryngospasm associated with ketamine is usually reversed with oxygen administration and positive pressure ventilation. Note: Atropine or other antisialogogue should be used to prevent increased salivation. WARNING: Be prepared to provide respiratory support.Monitor oxygen saturation.Avoid use in patients with increased intracranial pressure or increased intraocular pressure. o Lidocaine Indication: 1) Ventricular arrhythmia Dosage: IV: 1 mg/kg as a single dose slowly, repeat every 5 to 10 minutes to desired effect or until maximum dose of 3 mg/kg is given
34 IV infusion: 20 to 50 μg/kg/min Endotracheal: 1 mg/kg Note: If administered through an endotracheal tube, follow the dose with saline flush or dilute in isotonic saline flush (1 to 5 mL) based on patient size. Note: Preparation of infusion solution: add 120 mg (6 mL of a 2.0% concentration) to 100 mL of 5% glucose in water. Infusion of 1.0 to 2.5 mL/kg/h will deliver 20 to 50 μg/kg/min. Note: A reduced infusion rate should be used in patients with a low cardiac output. WARNING: Contraindicated in complete heart block and wide complex tachycardia due to accessory conduction pathways. Note: Excessive dosage may result in myocardial depression, hypotension, central excitation, and seizures. Indication: 2) To attenuate airway reflexes before endotracheal intubation or airway manipulation in patients with elevated intracranial pressure Dosage: 1 mg/kg IV as a single dose 30 seconds before airway instrumentation. o Lorazepam Indication: Status epilepticus, Adjunct for intubation Dosage: IM or IV: 0.05 to 0.1 mg/kg Repeat doses every 10 to 15 minutes for clinical effect. WARNING: There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen saturation. o Mannitol Indication: Increased intracranial pressure
35 Dosage: IV: 0.25 g/kg given over a 15-minute infusion. Note: A larger dose (0.5 g/kg given over 15 minutes) may be appropriate in an acute intracranial hypertensive crisis. In conjunction with mannitol, other measures to control intracranial pressure such as hyperventilation, barbiturates, and muscle relaxation (using a neuromuscular blocking agent) should be considered. WARNING: Rapid administration may cause hypotension, hyperosmolality, and elevated intracranial pressure. o Meperidine Indication: Pain Dosage: IV or IM: 1 to 2 mg/kg Repeat dose is necessary for clinical effect. Note: Higher doses may be necessary if patient is tolerant. WARNING: There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support. o Methylprednisolone Indication: 1) Asthma/allergic reaction Dosage: IV: 1 to 2 mg/kg every 6 hours Indication: 2) Spinal cord injury Dosage: IV: 30 mg/kg over 15 minutes. In 45 minutes begin a continuous infusion of 5 to 6 mg/kg/h for 23 hours. Indication: 3) Croup Dosage: IV: 1 to 2 mg/kg of methylprednisolone, then 0.5 mg/kg every 6 to 8 hours.
36 o Midazolam Indication: Adjunct for endotracheal intubation or for sedation/anxiolysis Dosage: IV: 0.05 to 0.2 mg/kg given over several minutes. WARNING: There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen saturation. o Morphine Sulfate Indication: Pain, infundibular spasm (“Tet Spell”) Dosage: IV (slowly) or IM: 0.05 to 0.1 mg/kg. Repeat dose as necessary for clinical effect. Note: Higher doses may be necessary if patient is tolerant. WARNING: There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support. o Naloxone Indication: Respiratory depression induced by opioid Dosage: IV, IM: 0.1 mg/kg from birth (including premature infants) until age 5 years or 20 kg of weight. Thereafter, the minimum dose is 2.0 mg. Doses may be repeated as needed to maintain opiate reversal. IM absorption may be erratic. Note: This dosage is indicated for acute opiate intoxication. Titration to effect with lower initial doses (0.01 mg/kg or 10 μg/kg) should be considered for other clinical situations, eg, respiratory depression during pain management. WARNING: May induce acute withdrawal in opioid dependency. Patients who receive naloxone should be continuously observed for renarcotization for at least 2 hours after the last dose of naloxone.
37 o Nitroprusside Indication: Hypertensive crisis Dosage: IV: 0.5 to 10 μg/kg/min. Start at the lowest dosage and titrate for the desired clinical effect. Administer through low dead space system or as close to IV catheter as possible to prevent accidental bolus injection. Note: Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mLD5W. Infuseat1 mL/h = 1 μg/kg/min using a constant infusion pump. Note: Bottle, burette, or syringe pump but not the IV tubing should be covered with protective foil to avoid breakdown by light. WARNING: Administration may result in profound hypotension. Patients should be closely monitored. Blood pressure should be continuously monitored with an arterial line. WARNING: Cyanide toxicity can result from large doses and/or prolonged infusions. Patients should be closely monitored for the development of metabolic acidosis. Patients with decreased renal function may be at increased risk. o Oxygen Indication: Hypoxemia and/or respiratory distress, Carbon monoxide poisoning, Shock Dosage: 100% by nonrebreather mask initially or endotracheal tube; wean as tolerated. Note: The administration of supplemental oxygen should be considered during EVERYpediatric emergency.
38 o Pancuronium Indication: Neuromuscular blockade to facilitate mechanical ventilation, Emergency intubation Dosage: IV: 0.1 mg/kg Note: This drugdoesnot alter the level of consciousnessor provide analgesia or amnesia. Note: This agent can be used when succinylcholine is contraindicated. Pancuronium isalong-acting neuromuscular blocker that requires ventilatory assistance for at least 1 hour. Satisfactory conditions for endotracheal intubation will generally occur 2 to 3 minutes after administration. WARNING: Ventilatory support will be necessary. Personnel with skills in advanced airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available. o Phenobarbital Indication: Status epilepticus Dosage: IV: 20 mg/kg. Maximum dose, 1000 mg. Repeat dose once if necessary for clinical effect after 15 minutes. WARNING: There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen satura o Phenylephrine Indication: Infundibular spasm (“Tet Spell”) Dosage: 5 to 20 μg/kg push then followed by infusion at 0.1 to 5.0 μg/kg/min.
39 WARNING: Blood pressure must be carefully followed and dose titrated to effect. o Phenytoin Indication: Status epilepticus Dosage: IV: 10 to 20 mg/kg initial dose. Maximum initial dose, 1000 mg. Maximum rate of administration, 50 mg/min or 1 mg/kg/min, whichever is less. Note: The lower dose is indicated in neonates because of increased risk of toxicity due to decreased protein binding. Should be diluted in normal saline to avoid precipitation. WARNING: Rate of infusion should not exceed 0.1 mL of undiluted preparation per kg/min. Heart rate should be monitored and the rate of infusion reduced if the heart rate decreases by 10 beats/minute. o Procainamide Indication: Wide complex tachycardia Dosage: IV: Start at 3 to 6 mg/kg/dose over 5 minutes not to exceed 100 mg to a titrated maximum of 15 mg/kg/loading dose. Maintenance dose, 20 to 80 μg/kg/min (0.02 to 0.08 mg/kg/min); maximum, 2 g/24 h. WARNING: If 50% QRS widening or hypotension occurs during loading dose, the remainder of the loading dose is held, and the maintenance dose is delayed until these signs have resolved. o Propranolol Indication: Infundibular spasm (“Tet Spell”)
40 Dosage: IV: 0.01 to 0.02 mg/kg per dose infused over 10 min in 5% dextrose in water. Maximum initial dose, 1.0 mg Note: Oxygen should be administered first. Morphine is also an effective treatment for infundibular spasms. Phenylephrine is another adjunct for reversal of infundibular spasm. Use is contraindicated in congestive heart failure. Avoid in patients with a history of bronchospasm. o Prostaglandin E1 Indication: Possible ductal-dependent cardiac malformation in the neonatal period Dosage: 0.05 to 0.10 μg/kg/min as an infusion in 5% dextrose in water. Note: Preparation of infusion solution: 250 μg in 80 mL of D5W infuse at 1 mL/kg/h = 0.05 μg/kg/min. WARNING: Apnea, hyperthermia, and seizures may occur. Be prepared to provide respiratory support. Monitor oxygen saturation. o Rocuronium Indication: Neuromuscular blockade to facilitate mechanical ventilation, Emergency intubation Dosage: IV: 0.8 to 1.2 mg/kg Note: This drugdoesnot alter the level of consciousnessor provide analgesia or amnesia. Note: Alternative to succinylcholine for rapid intubation when succinylcholine is contraindicated. Duration of block is generally 30 to 45 minutes and is dose-dependent. Satisfactory conditions for endotracheal intubation will generally occur 45 to 60 seconds after administration. WARNING: Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this
41 agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available. o Succinylcholine Indication: Neuromuscular blockade for emergency intubation or treatment of laryngospasm Dosage: 1 to 2 mg/kg IV 4 to 5 mg/kg IM WARNING: Contraindicated with previous history of malignant hyperthermia, severe burns, spinal cord injury, neuromuscular disease, or myopathies. When these contraindications exist use a nondepolarizing muscle relaxant such as rocuronium. Despite reports of acute rhabdomyolysis, hyperkalemia, and cardiac arrest with succinylcholine, this agent remains the drug of choice when immediate securing of an airway is indicated. WARNING: Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available. Note: Atropine, 0.02 mg/kg (minimum dose, 0.1 mg), should be combined with or precede succinylcholine to prevent bradycardia or asystole. Satisfactory conditions for endotracheal intubation generally occur 30 to 45 seconds after IV administration and 3 to 5 minutes after IM administration. Note: If cardiac arrest occurs immediately after administration of succinylcholine, hyperkalemia must be suspected and treatment for this condition initiated. Hyperkalemia is especially likely to be responsible for cardiac arrest occurring in male children 8 years of age or younger. o Thiopental Indication: 1) Adjunct to intubation
42 Dosage: IV: 4 to 6 mg/kg Note: A lower dose may be used if other sedatives/narcotics have been administered. WARNING: IM administration leads to tissue necrosis. WARNING: Be prepared to provide respiratory support.Monitor oxygen saturation. High doses are associated with hypotension and apnea. Use with caution in patients with cardiac compromise or hypovolemia. Indication: 2) Control of intracranial hypertension Dosage: 1 to 2 mg/kg, repeated as necessary o Vecuronium Indication: Neuromuscular blockade to facilitate mechanical ventilation Emergency intubation Dosage: IV: 0.1 mg/kg Note: This drugdoesnot alter the level of consciousnessor provide analgesia or amnesia. Note: This agent may be used for emergency intubation when succinylcholine is contraindicated. Satisfactory conditions for endotracheal intubation generally occur 1.5 to 2.0 minutes after administration. WARNING: Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available.
43 LIST OF LIGHTSENSITIVE MEDICATIONS  Acyclovir cap, tab. (Zovirax®)  Alteplase powder for injection (Activase®)  Allopurinoltab. (Zyloprim®)  Amiodaronetab. (Cordarone®)  Amphotericin B powder for inj. (Fungizone®)  Amrinonelactate inj. (Inocor®)  Amylnitrate inhal.  ApraclonidineHCLophth. Sol. (Iopidine®)  Atenolol inj. (Tenormin®)  Aurothioglucosesusp. for inj. (Solganal®)  Azathioprineinj, tab. (Imuran®)  Bepridiltab. (Vasocor®)  Betamethasone Sod.Phos/Acet.inj. (Celestone®)  BromocriptineMesylate cap, tab. (Parlodel®)  Calcitrol cap. (Rocaltrol®)  Carbidopa/Levodopatab. (Sinemet®)  Cefotaxime inj. (Claforan®)  Ceftazidimeinj. (Fortaz®)  Ceftriaxoneinj. (Rocephin®)  CefuroximeSodium (Zinacef®)  Ciprofloxacin inj. (Cipro®)  Cisplatin inj. (Platinol®)  Clarithromycin tab. (Biaxin®)  Clonidinetab. (Catapres®)  Codeinesol. tab, inj.  Cromolyn sod. Sol. Neb. &nasal sol. (Intal®)  Cyclosporineinj. (Sandimmune®)  Dantroleneinj. (Dantrium®)  DeferoxamineMesylateinj. (Desferal®)  Dexamethasone Sod. Phos. Inj. (Decadron®)  Diazoxideoral susp, inj. (Hyperstat®)
44  Digoxin inj, elixir, tab. (Lanoxin®)  Diphenhydramineinj. (Benadry®l)  Dipyridamoleinj. (Persantine®)  Doxorubicin HCl inj. (Adriamycin®)  Doxycyclinecap. (Vibramycin®)  Droperidol inj. (Inapsine®)  Ephedrineinj.  Ergotaminetartrate tab. (Ergostat®)  Erythromycin cap. (Eryc®)  Ethosuximideoral syrup (Zarontin®)  Felodipinetab. (Plendil®)  Fentanylcitrate inj. (Sublimaze®)  Finasteride tab. (Proscar®)  Flecainide Acetate tab. (Tambocor®)  Fluorouracilinj. (Adrucil®)  Fluoxymesteronetab. (Halotestin®)  Furosemideinj, tab. (Lasix®)  Glipizidetab. (Flucotrol®)  Gold Sodium Thiomalate in (Myochrysine®)  Haloperidolinj. (Haldol®)  Heparin inj.  Hydromorphoneinj, tab. (Dilaudid®)  Isoproterenolinj, inhal. (Isuprel®)  Isotretinoin cap. (Accutane®)  Isradipinecap. (Dynacirc®)  Itraconazole cap. (Sporanox®)  Ketorolac inj, cap. (Toradol®)  Labetalol inj. (Normodyne®)  Lactulose oral syrup (Cephulac®)  Leucovorin calcium inj, tab. (Wellcovorin®)  LeuprolideAcetate inj. (Lupron®)  Levothyroxinetab.  Liotrix tab. (Thyrolar®)
45  Lorazepam inj. (Ativan®)  Lovastatin tab. (Mevacor®)  MesoridazineBesy. inj, oralsol. (Serentil®)  MetaproterenolSul. inj, inhal. sol, syrup, tab. (Alupent®)  Methotrexate inj, tab. (Methotrexate®)  Methsuximidecap. (Celontin®)  Methyldopaoralsusp. (Aldomet®)  Methylergonovineinj, tab. (Methergine®)  Metoclopramideinj. (Reglan®)  Metronidazoleinj, tab. (Flagyl®)  Mivacurium Chlorideinj. (Mivacron®)  MorphineSulfateinj.  Nadololtab. (Corgard®)  Nicardipinecap. (Cardene®)  Nifedipinecap. (Procardia®)  Nimodipinecap (Nimotop®)  Nitrofurantoin cap. (Macrodantin®)  Nitroglycerin inj. (Tridil®)  Nitroprussideinj. (Nitropress®)  Norepinephrine Bitartrateinj. (Levophed®)  Ofloxacin inj. (Floxin®)  Omeprazolecap. (Prilosec®)  Ondansetron inj. (Zofran®)  Pentagastrin inj. (Peptavlon®)  Pentoxifyllinetab. (Trental®)  Perphenazineinj, oral conc. (Trilafon®)  Phenylephrineinj. (Neo-Synephrine®)  Phenytoin Sod inj, cap, oral susp. (Dilantin®)  Phytonadioneinj. (Aquamephyton®)  Potassium Chloridetab. (Slow-K®)  Pravastatin Sodium tab. (Pravachol®)  PrednisoloneSodium Phos. (Hydeltrasol®)  PromethazineHClinj, tab, oral syrup (Phenergan®)
46  Propofolinj. (Diprivan®)  Propranololtab, cap. (Inderal®)  RanitidineHCl inj, tab, oral syr. (Zantac®)  Rifampin inj. (Rifadin®)  Secobarbital Sodium inj. (Seconal®)  SufentanilCitrate inj. (Sufenta®)  Sumatriptan inj. (Imitrex®)  Tamoxifen Citrate tab. (Nolvadex®)  Terbutaline inj. (Bricanyl®)  Tetracaine inj, top. Sol. (Pontocaine®)  Tetracycline tab, cap, syrup (Sumycin®)  Theophyllinecap. (Slo-Bid®)  Thioridazineoral susp. (Mellaril®)  Timolol Maleate ophth. sol, tab. (Timoptic, Blocadren®)  Tolazolineinj. (Priscoline®)  Tolmetin Sodium tab. (Tolectin®)  TriamcinoloneAcet. Susp. for inj. (Kenalog®)  Triamterene cap. (Dyrenium®)  TrifluoperazineHCloralconc. (Stelazine®)  Trimethoprim/sulfamethoxazole tab, oral susp. (Bactrim®)  Verapamil HCltab, inj. (Calan®)  Vecuronium inj. (Norcuron®)  Vitamin A inj, cap. (Aquasol A®)  Warfarin Sodium tab. (Coumadin®)  Zidovudinecap, syrup (Retrovir®)
47 I.V. drugstabilities when added to I.V. solutions Drug Stability at Room Temp Stability Under Refrigerati on Other Information Acetylcysteine (Acetadote) 24 hours 24 hours Amikacin (Amikin) 24 hours 60 days Aminocaproicacid 24 hours 7 days Aminophylline 48 hours n/a Amiodarone (Cordarone) 30 days n/a Mix only in dextrose Amphotericin B Lipid Complex(Abelcet) 6 hours 48 hours ***Protect from Light*** Not Compatiblewith NaCl Ampicillin 1 hour 72 hours Diluted solution is stable for 2-8 hoursat 25 °C Ascorbic acid (Vitamin C) 24 hours n/a Azathioprine 24 hours Bumetanide (Bumex)72 hours n/a ***Protect from Light*** CaffeineCitrate (Cafcit) 24 hours n/a Calcium Gluconate 24 hours n/a Carbencillin 24 hours 72 hours Ceftazidim (Negacef) 18 hours 7 days Ceftizoxime 8 hours 48 hours Color vary from yellow to amber Ceftriaxone (Novocef) 1-3 days 3-10 days Color vary from light yellow to amber Cephalothin 12 hours 6 hours Warm to room temp. & shake to decrease precipitation Chloramphenicol 2-30 days Clindamycin (Cleocin) 16 days 32 days Daptomycin 12
48 (Cubicin) months Dexamethasone (Decadron) 28 days 28 days Diltiazem (Cardizem) 24 hours 24 hours Dobutamine 24 hours 24 hours Dopamine 48 hours 7 days Epinephrine 24 hours 24 hours ***Protect from Light*** Fenoldopam (Corlopam) 24 hours 24 hours Ferric Gluconate Complex(Ferrlicit) Use Immediately Folic Acid 48 hours 48 hours Fomepizole(Antizol) 24 hours 24 hours If drugbecomes solid in vial, hold under warm water to drugback into solution Fosphenytoin (Cerebyx) 30 days 30 days Furosemide(Lasix) 24 hours 24 hours Gentamicin (Garamycin) 7 days 30 days Granisetron (Kytril) 24 hours 24 hours Heparin 12 months 12 months Hepatitis B Vaccine (Engerix-B) 72 hours see exp. date on box Hydrocortison Sod.Succinate 3 days Hydromorphone (Dilaudid) 30 days 60 days ***Protect from Light*** Ibutilite (Corvert) 24 hours 48 hours Iron Dextran (Infed) 24 hours 3 months Mix in NaCl, Dextroseincreases risk of phlebitis Insulin 24 hours 24 hours Adsorbsto glass and plastic surfaces Insulin neutral (Actrapid) 28 days Recommended Temp. is2-8 °C Insulin premixed (Mixtard) 28 days
49 Iron Dextran (Infed) 48 hours 3 months Isoproterenol (Isuprel) n/a 24 hours ***Protect from Light*** Labetalol (Trandate) 72 hours 72 hours ***Protect from Light*** Magnesium Sulfate 60 days 60 days Methylprednisolone Sod. Succinate 48 hours Discard if solution is cloudy or precipitated Metoprolol (Lopressor) 36 hours n/a ***Protect from Light*** Mezlocillin 24-72 hours 1-7 days Reconstituted solution darken duringstorage Morphine 30 days 30 days Multivitamin 24 hours 24 hours Nitroglycerin 48 hours 7 days Mix in glass only Nitroprusside (Nipride) 24 hours 24 hours ***Protect from Light*** Norepinephrine (Levophed) 48 hours 30 days ***Protect from Light*** Octreotide (Sandostatin) 48 hours 7 days ***Protect from Light*** Ondansetron (Zofran) 7 days 7 days Penicillin G 24 hours 7 days Solution diluted for infusion is stable for 1 day Phenylephrine (Neosynephrine) 48 hours 48 hours ***Protect from Light*** Piperacillin 24 hours 7 days Stable for 30 daysif it’s frozen Procainamide Discard if solution markedly discolored or precipitated Dexmedetomidine (Precedex) 48 hours n/a Ranitidine(Zantac) 24 hours 24 hours ***Protect from Light*** Sodium Bicarbonate 7 days 60 days Streptomicin 2-28 days 14 days Sulfamethoxazole/T MP (Bactrim) 4-6 hours 4-6 hours Do NOT Refrigerate Thiamine 24 hours 24 hours ***Protect from Light***
50 Tobramycin (Nebcin) 24 hours 96 hours Torsemide (Demadex) 24 hours n/a Valproic Sodium (Depacon) 6 days 6 days Vitamin K (Aquamephyton) 24 hours 24 hours ***Protect from Light***

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Clinical pharmacy,,, notes

  • 1.
    GUIDELINES TO CLINICAL PHARMACY ‫ا‬‫عداد‬ ..‫رياض‬‫دنيا‬ ‫الصيدالنية‬ ..‫فاضل‬ ‫االء‬ ‫الصيدالنية‬
  • 2.
    2 Infusions  Dopamineamp. 200mg Ivac + syr.20cc+ N/S or G/W 5 µ ----------->3 amp. 7 µ----------->4 amp. 10 µ---------->5 amp. 15 µ---------->8 amp.  Dobutamineamp. 250 mg Ivac + syr.10cc+ N/Sor G/W 5 µ------------»2 amp. 10 µ----------»4 amp.  Tridel amp. 5mg/10 mg Ivac + syr.20cc+ N/Sor G/W 5 µ----------->2 amp. 10 µ---------->3 amp.  Heparin vial 25000 UIvac+ syr.5cc+ N/S 5000 UIvac + syr.20cc+ N/S  Meronim vial500 mg(Bolusover 5min& inf. Over 15-30 min while maintenance 10-20 mg/kgq 8 hr) ,Vancomycin vial 1g,Targocid vial 200 mg& Ceftriaxonevial 1g Burette+ syr.5cc+ N/Sor G/W  Aminophyllin amp. 250mg/10ml Burette+ syr.10cc+N/Sor G/W  Mg vial 1g or 4g/20ml & KClvial Burette+ syr.10cc+ N/Sor G/W Mg SO4 conc. 200mg/ml  Ampicloxvial 500mg12×4 Burette+ syr.10/20cc+ N/S  Glucophagedoesn’t suitable in lasix amp inf.  Cordaron amp inf. calc 5mg/kgmaintenancedose Note that 1 mg = 100 IU & Manitol adm. as 1g/kg
  • 3.
    3 CVS Abbreviations RCA lesion:right coronary artery lesion ‫با‬ ‫فعالجه‬ ‫شديد‬ ‫بالقسطرة/تضيق‬ ‫عالجه‬ ‫فيكون‬ ‫تضيق‬ ‫ممكن‬‫لون‬ LAD lesion: left anterior descendinglesion ‫هابط‬ ‫امامي‬ ‫شريان‬ AVR: aortic valvereplacement LBBB: left bundlebranch block CHB: complete/ congenital heart block PTCA: ‫شبكة‬ DORV: double outlet right ventriclesurgery Both aorta & pulmonary arteriescome from the sameventricle CoA: co aortication ‫االبهر‬ ‫الشريان‬ ‫تضيق‬ PVA: pulmonary valveatrisia ‫اضمحالل‬ TR: tricuspid regurgitation PA: pulmonary artery L-TGA: transposition of great arteries ‫الشرايين‬ ‫انعكاس‬ ‫انواع‬ ‫من‬ ‫نوع‬ SVT: supraventricular tachycardia LVH: left ventricular hypertrophy TAPVD: total anomalouspulmonaryvenousdrainage PFO: persistent foramin ovali ‫من‬ ‫االذنين‬ ‫بين‬ ‫فتحة‬‫مف‬ ‫تكون‬ ‫االحيان‬ ‫بعض‬ ‫لكن‬ ‫ضعيفة‬ ‫فتح‬ ‫برجة‬ ‫طبيعية‬ ‫تكون‬ ‫الوالدة‬‫اعلى‬ ‫بدرجة‬ ‫توحة‬ ‫الطبيعي‬ ‫من‬---‫مرضية‬ ‫حالة‬ DCM: dilated cardiomyopathy ‫الموضعي‬ ‫القلب‬ ‫عضلة‬ ‫اعتالل‬
  • 4.
    4 PDA: patentductusarteriosus ‫الرئوي‬‫و‬ ‫االبهر‬ ‫الشريانين‬ ‫بين‬ ‫ناسور‬ TOF: tetralogy of Fallot ‫فالوت‬ ‫رباعية‬ VSD: ventricular septal defect ‫البطينين‬ ‫بين‬ ‫فتحة‬ ASD: arterial septal defect ‫األذينين‬ ‫بين‬ ‫فتحة‬ AR: aortic regretion ‫االبهر‬ ‫الصمام‬ ‫كفاءة‬ ‫عدم‬ Sever MS: mitral stenosis ‫الشديد‬ ‫التاجي‬ ‫الصمام‬ ‫تضيق‬ MVR: mitral valveregurgitation ‫التاجي‬ ‫الصمام‬ ‫كفاءة‬ ‫عدم‬ MVP: mitral valveprolapse ‫التاجي‬ ‫الصمام‬ ‫تهدل‬ SBE: subacute bacterial endocarditis ‫البكتيري‬ ‫القلب‬ ‫غشاء‬ ‫التهاب‬ ACS: acute coronary syndrome(mi) AS: aortic stenosis ‫االبهر‬ ‫الصمام‬ ‫تضيق‬ Valves A: aortic P: pulmonary M: mitral T: tricuspid
  • 5.
    5 MaxDoses Hypoglycemicagents Daonil15 mg daily Amaryl6mgdaily Metformin2 g daily Antihyperlipidemia Avas80 mg daily Lescol 80 mg daily Zocor 80 mg daily Antiplatelets Plavex300 mgdaily Aspirin 4gdaily Others Ibuprofen 2.4 gdaily Ca2+ tab 6mgper course Isordil120-240 mg Antibiotics Ampiclox12gdaily Claforan 12gdaily Ceftriaxone4g daily Rifampicin adult1200 mgdaily &child 600mgdaily (Dose in child 10-20 mg/kgdivided into two equal doses) Piperacillin 4.5g× 4=18 gdaily Imipenem 4gadult/2gchild (not less than 1 yr) β-blockers Propranolol(inderal)HTN 160-320mg/day Angina120-240mg/day
  • 6.
    6 Atenolol (tenormin)HTN 25-50mg/day Angina100 mg/day in 1-2 doses Bisoprolol (concor) HTN+ Angina20 mg/day Heart failure10 mg oncedaily Carvedilol(dilatrand)HTN+HF+Angina50 mg once/bid Metoprololtartarate (betaloc) HTN 400 mg/day Angina50-100 mgbid/tid ACEI Captopril(capoten) HTN 50 mg twice daily [raretid] HF 150 mg/day Enalapril (revatic) HTN 40 mg once/day HF 10-20 mgtwice /day Lisinopril(zestril) HTN 80 mg once/day HF 35 mg once /day Other 40 mg daily Ca2+ channel blockers Amlodipin HTN & Angina 10 mgonce daily Diltiazim Angina360 mgdaily Nifidipen (adalat) 20 mgtid Verpamil [oral] HTN 240-480 mg/day Angina 80-120 mg/day Diuretics Furosemide[oral] Resist. Oedema 80-120mg/day Resist.HTN 40-80 mg/day [I.M/I.V] 1.5 gdaily Spironolacton (lasix) oedemain CHF25-200 mgdaily HF 50 mg/day Resist.HTN 25 mgonce/day Other 400 mgdaily
  • 7.
    7 Drug-druginteraction Warfarin + azithromycin=azithromycinisenzymeinhibitor Alteplase + nitroglycerin= increase reperfusion Clopidogrel+ atrovastatin=decreaseclopidogrel activity Clopidogrel+ proton pump inh. (PPI)=PPI areenzymeinh. Pantoprazoleis alternative Methoprim + aldactone =increasehyperkalemia Lasix + amikacin=ototoxicity & nephrotoxicity Amiodaron + lasix =arrhythmia Amiodaron + quinoloneAB=arrhythmia Captopril+allopurinol=hypersensitivity reactions Ceftriaxone+ Ca2+ containingsol. /ring=Ca2+ salt precipitation Digoxin increase plasma conc. Of ACEI, macrolid AB, captopril, amiodaron (cordaron), garamycin, methoprim, diltiazim, nifidipen (adalat) & aldactone Digoxin + β-blockers=increaseAV block & bradycardia Digoxin decrease Neomycin & antacid absorption Rifadine plasmaconc. Epanutinedecrease Vancomycin + lasix=ototoxicity Vancomycin + gentamicin /exacyl=nephrotoxicity Amiodaron + verpamil/diltiazim=sever interaction (HF)
  • 8.
    8 Dosing& d. equivalences Prednisolone5mg = to: Betamethason 750 µg Cortisone acetate 25 mg Deflazacort 6 mg Dexamethason 750 µg Hydrocortisone20 mg Methylprednisolone4 mg Triamciolone 4mg  Clexanedose [S.C]: In DVT; Treatment less than 2 months --------->1.5 mg/kg/12 hr 2 months – 17 years ---------->1 mg/kg/12 hr ; ProphylacticLess than 2 months --------->0.75 mg/kg/12 hr 2 months – 17 years --------->0.5 mg/kg/12 hr Note that:  Verpamil/diltiazim act mainly on heart rather than blood vessels so used to treat tachycardia /angina [Note that diltiazim can be used with lowvasc]  Metoprolol(betaloc) As succinate salt---longer duration of action given single or twice daily (used in HF) As tartarate salt---shorter duration of action (notused in HF)
  • 9.
    9 Pediatric Antimicrobial DosingGuideline for Infants and Children (> 1 Month of Age) Approved by the Antibiotic Advisory Subcommittee and the Pharmacy and Therapeutics Committee 2013 DRUG Creatinine Clearance >50ml/min/1.7 3m2 (Renal Function > 50% of Normal) Creatinine Clearance =10- 50ml/min/1.73 m2 (Renal Function = 10- 50% of Normal) Creatinine Clearance <10ml/min/1 .73m2 (ESRDnot on dialysis) (Renal Function<10 % of Normal) MAXIMU M DAILY DOSE Acyclovir IV Non-CNS HSV infection: 5-10mg/kg/dose q8h 25-50% of normal clearance 5-10mg/kg/dose q12h 10-25% of normal clearance 5-10mg/kg/dose q24h 2.5- 5mg/kg/dose q24h Herpes Zoster 10-20 mg/kg/dose q8h or or 500 mg/m2/doseq8h 25-50% of normal clearance 10- 20mg/kg/dose q12h 5- 10mg/kg/dose q24h or 250 mg/m2/dose q24h
  • 10.
    10 (immunocompro mised host) or 500 mg/m2/dose q12h (immunocompro misedhost) 10-25% of normal clearance 10- 20mg/kg/dose q24h or 500 mg/m2/dose q24h (immunocompro mised host) (immunocomp romised host) HSV encephalitis, all neonatal infections: 20mg/kg/dose q8h or 500 mg/m2/doseq8h (immunocompro mised host) 25-50% of normal clearance 20mg/kg/dose q12h or 500 mg/m2/dose q12h (immunocompro mised host) 10-25% of normal clearance 20mg/kg/dose q24h 10mg/kg/dose q24h or 250 mg/m2/dose q24h (immunocomp romised host)
  • 11.
    11 or 500 mg/m2/dose q24h (immunocompro mised host) Amphoteric inB Liposomal (AmBisome ®; per ID approval except for Heme-Onc) Invasiveyeast infections 3mg/kg/doseIV q24h Invasivemold infections 5mg/kg/doseIV q24h No change No change Dosage reductionsin renal disease are not necessary. However, dueto the nephrotoxic potential of the drug, reducing the doseor holding the drugin the setting of a rising serum creatinine may be warranted. Amoxicillin PO 20mg/kg/dose q12h Otitis Media/Pneumo nia/ Osteomyelitis 45- 50mg/kg/dose q12h 30-50% of normal clearance No change 10-30% of normal clearance 50% normal dose q12h 50% normal dose q24h 4g/DAY Ampicillin IV 50mg/kg/dose q6h 25mg/kg/dose q6h 25mg/kg/dose q8-12h 2gm q4h Meningitis: 100mg/kg/dose q6h 50mg/kg/dose q6h 25mg/kg/dose q8-12h Ampicillin/ sulbactam( Unasyn) 50 mg ampicillin/kg/do se q6h 25 mg ampicillin/kg/do se q6h 25 mg ampicillin/kg/ dose q8-12h 2 gm ampicilli n q6h
  • 12.
    12 Caspofungi n IV (per ID approval except Pedatric Heme- Onc/BMT) <3mo old: 25mg/m2/dose q24h ≥3 mo old: LD 70mg/m2 x1, then 50mg/m2q24h No change No change LD: 70mg MD: 50mg Cefazolin 25mg/kg/dose q8 25mg/kg/dose q12h 25mg/kg/dose q24h 2gm q8h Cephalexin PO 10 mg/kg/dose PO q6-8h Otitis Media 20-25 mg/kg/dose PO q6h Osteomyelitis 25-30 mg/kg/dose PO q6h 10 mg/kg/dose PO q8h-q12h 10mg/kg/dose PO q12h-q24h 4 gm/day Cefepime 50mg/kg/dose q12h >30% of normal clearance 50mg/kg/dose q24h 10-30% of normal clearance 25mg/kg/dose q24h 12.5mg/kg/do se q24h 2gm q12h Febrile neutropenia: 50mg/kg/dose >30% of normal clearance 50mg/kg/dose 25mg/kg/dose q24h 2gm q8h
  • 13.
    13 q8h q12h 10-30% of normal clearance 50mg/kg/dose q24h CysticFibrosis: 50mg/kg/dose q8h Not documented Not documented 50mg/kg /dose q8h Cefotaxime 50mg/kg/dose q8h 50mg/kg/dose q8-12h 25mg/kg/dose q12h 2gm q6h Meningitis: 50m g/kg/dose q6h 50mg/kg/dose q8h 50mg/kg/dose q12h Ceftazidime 50mg/kg/dose q8h 50mg/kg/dose q12h 50mg/kg/dose q24-48h 2gm q8h Cystic fibrosis: 75mg/kg/dose q8h Not documented Not documented 2gm q8h Burkholderia cepacia co- infected with Pseudomona s aeruginosa: 75mg/kg/dose q8h 3gm q8h Ceftriaxone 50mg/kg/dose q24h No change No change 1gm q24h Meningitis: 50mg/kg/dose No change No change
  • 14.
    14 q12h 2gm q12h Cefuroxime IV 50mg/kg/dose q8h 50mg/kg/dose q12h 50mg/kg/dose q24h 1.5gm q8h Ciprofloxaci n IV >30%of normal clearance 10- 15mg/kg/dose q12h 10-30% of normal clearance 7.5mg/kg/dose q12h 7.5mg/kg/dos e q12h 400mg q12h Cystic fibrosis: 15mg/kg/dose q12h Not documented Not documented 600mg q12h Clindamyci n IV 10mg/kg/dose q8h No change No change 900mg q8h Clindamyci n PO 2-8mg/kg/dose q6-8h Osteomyelitis 10-12 mg/kg/dose PO q6-q8h No change 450mg q6h Ertapenem IV 15mg/kg/dose q12h >13 yearsold: 1 gm daily <30ml/min/1.73m2 Decrease dose 50% 1 gm q24h Erythromyc in IV 5-10mg/kg/dose q6h No change No change 1gm q6h Ethambutol PO 15mg/kg/dose q24h 7.5mg/kg/dose q24h 5mg/kg/dose q24h 2.5gm q24h Fluconazole 6-12mg/kg/dose 3-6mg/kg/dose 3- 400mg
  • 15.
    15 IV/PO (All patients who areable to tolerate PO should receive PO fluconazole.) q24h q24h 6mg/kg/dose q24h q24h Fungal prophylaxis: 3mg/kg/dose q24h No change No change Ganciclovir IV >80% of normal clearance 5mg/kg/dose q12h 79-50% of normalclearance 2.5mg/kg/dose q12h 25-50% of normal clearance 2.5mg/kg/dose q24h 10-25% of normal clearance1.25mg /kg/dose q24h 1.25mg/kg/do se q24h Gentamicin 2.5mg/kg/dose q8h **consultwith pharmacist for dose adjustment/level assessment** 2.5mg/kg/dose q12h 2.5mg/kg/dos e q24h Imipenem (per ID approval) 20mg/kg/dose q6h 10mg/kg/dose q6-8h 10mg/kg/dose q12h 1gm q6h Isoniazid Treatment: 5mg/kg/dose No change No change 300mg daily
  • 16.
    16 daily-bid Prophylaxis: 10mg/kg/dose daily No change Nochange Levofloxaci n IV-PO < 5 yo: 10mg/kg/dose q12h ≥ 5 yo: 10mg/kg/dose q24h 30-50% of normal clearance No change 10-30% of normal clearance 5-10mg/kg/dose q24h 5- 10mg/kg/dose q48h 750mg q24h Linezolid IV/PO (per ID approval) <5 yo: 10mg/kg/dose q 8h >5 yo: 10mg/kg/dose q 12h No change No change 600mg q12h Meropenem IV 20mg/kg/dose q8h 25-50% of normal clearance 20mg/kg/dose q12h 10-25% of normal clearance 10mg/kg/dose q12h 10mg/kg/dose q24h 1gm q8h
  • 17.
    17 Meningitis: 40mg/kg/dose q8h 25-50% of normal clearance40mg/ kg/dose q12h 10-25%of normal clearance 20mg/kg/dose q12h 20mg/kg/dose q24h 2gm q8h Metronidaz ole IV/PO 10mg/kg/dose q8h No change 10mg/kg/dose q12h 500mg q6h NafcillinIV 25- 50mg/kg/dose q6h No change No change 2gm q4h PenicillinG IV 100,000- 250,000 units/kg/DAY divided dosesq4- 6h 75,000 -175,000 units/kg/DAY divided doses q8h 50,000- 125,000 units/kg/DAY divided doses q12h 4 million unitsq4h SevereInfection: 250,000-400,000 units/kg/DAY divided doseq4- 6h 175,000- 300,000 units/kg/DAY divided doses q8h 125,000- 200,000 units/kg/DAY divided doses q12h Piperacillin/ Tazobactam IV(Zosyn) 80mg piperacillin/ kg/dose q6-8h* *Serious infections 30-50% of normal clearance 50mg piperacillin kg/dose q6- 50mg piperacillin/ kg/dose q8h 4 gm piperacill in q6h
  • 18.
    18 including Pseudomonas: consider q6h 8h 10-30% of normal clearance 50mg piperacillin /kg/dose q8h Cysticfibrosis: 100mg piperacillin/ kg/dose q6h Not documented Not documented 4gm piperacill in q6h Pyrazinamide PO 15- 30mg/kg/dose daily No change No change RifampinIV/PO 5- 10mg/kg/dose daily-bid No change No change 600mg daily TobramycinIV see gentamicin Cystic fibrosis: Once daily dosing 10mg/kg/dose q24h see gentamicin Not documented see gentamicin Not documented TMP/SMX (Septra)IV /PO When switching to oral therapy, consider that a Mild to moderate systemic bacterial infection: 2.5mg TMP/kg/do se q12h 2.5-5mg TMP/kg/do se q24h
  • 19.
    19 single-strength tablet has 80mgofTMP, a double-strength tablet 160mgof TMP, oral suspension has 40 mg TMP per 5 ml 5mg TMP/kg/dose q12h Serious systemic bacterial infection: 5mg TMP/kg/dose q6-8h 5mg TMP/kg/do se q8-12h 5mg TMP/kg/do se q12-24h Pneumocystis carinii pneumonia prophylaxis: 2.5mg TMP/kg/dose q12h three daysper week. 2.5mg TMP/kg/do se q12h three days per week. 2.5mg TMP/kg/do se q24h three days per week. 160mg TMP bid Vancomycin Peak levels are not recommended. Troug h levels (< 30 min before next dose) should be 5-20 mg/L dependingon the severity of infection. Specifically, 15-20 for meningitis, sepsis and pneumonia 15mg/kg/dose q6h 15 mg/kg/dose q8-12h 15 mg/kg/dose q12-24h 1 gm IV q8h CNS/Osteo/Seri ous infections: 20mg/kg/dose q6h 20mg/kg/d ose q8h 20mg/kg/d ose q12h 1 gm IV q6h
  • 20.
    20 Voriconazole IV/PO (per ID approval exceptfor Heme- Onc/BMT) PO should be used when possible, as oral bioavailability > 95%. Presumed/Empi ric Treatment LD=6mg/kg q12hx2 doses MD=4mg/kg q12h Documented Infections LD=7mg/kg q12hx 2 doses MD=5-7mg/kg q12h Higher doses may be required based on therapeutic drugmonitoring (consultation with Pedi-ID recommended) No change No change
  • 21.
    21 DRUG FOR PEDIATRICEMERGENCIES oAdenosine Indication: Supraventricular tachycardia Dosage: Initial dose: 0.05 mg/kg as rapidly as possible followed by flush of the IV catheter. Subsequent doses: If atrioventricular (AV) block occurs or if there is no response within 30 seconds, increase by 0.05 mg/kg (eg, 0.1 mg/kg followed by flush of the IV catheter; if no response, increase to 0.15 mg/kg and flush IV catheter). Maximum single dose, 12 mg. WARNING: Contraindicated in heart transplant patients. Note: Higher doses of adenosine may be needed when a patient is taking methylxanthine preparations. Note: The antidote for profound bradycardia is aminophylline, 5 to 6 mg/kg over 5 minutes.Atropine is contraindicated. A defibrillator must be immediately available. o Albuterol Indication: Status asthmaticus, bronchospasm Dosage: 0.1 to 0.15 mg/kg by nebulization. Repeat as needed. Note: 0.02 to 0.03 mL/kg of 5 mg/mL solution with normal saline to make 3 mL total in nebulizer; maximum single dose, 2.5 mg. Note: Administration can be repeated and doseadjusted until desired clinical effect or symptomatic tachycardia. Note: Oxygen is the preferred gas source for nebulization. Supplemental oxygen should be considered when compressed air driven nebulizersare used or when oxygen flow rate dictated by nebulizer is inadequate. Blended oxygen
  • 22.
    22 may be requiredfor premature newborns who are still at risk for retinopathy of prematurity. o Atropine Sulfate Indication: 1) Symptomatic bradycardia Dosage: Intramuscular (IM): 0.02 to 0.04 mg/kg Intratracheal: 0.02 to 0.04 mg/kg IV: 0.02 mg/kg. Minimum single dose, 0.1 mg Maximum single dose, 0.5 mg for child, 1.0 mg for adolescent. This dose may be repeated once. Note: Oxygenation and ventilation are essential first maneuvers in the treatment of symptomatic bradycardia. Epinephrine is the drug of choice if oxygen and adequate ventilation are not effective in the treatment of hypoxia- induced bradycardia. Note: If administered through an endotracheal tube, follow the dose with or dilute in saline flush (1 to 5 mL) based on patient size. Indication: 2) Anticholinesterase poisoning. Dosage: IV: 0.05 mg/kg Repeat as needed for clinical effect. Note: Anticholinesterase poisonings may require large doses of atropine or the addition of pralidoxime. Indication: 3) To prevent succinylcholine-induced bradycardia. Dosage: 0.02 mg/kg IV or 0.02 to 0.04 mg/kg IM just before or simultaneously with succinylcholine o Bicarbonate, Sodium
  • 23.
    23 Indication: Metabolic acidosis,Tricyclic antidepressant overdose. Dosage: IV: 1 to 2 mEq/kg WARNING: Only 0.5 mEq/mL concentration should be used for newborns; dilution of available stock solutions may be necessary.Administer slowly because bicarbonate solution is hyperosmotic. Note: Routine initial use of sodium bicarbonate in cardiac arrest is not recommended. However, sodium bicarbonate may be used in cases with documented metabolic acidosisafter effective ventilation has been established. o Calcium Chloride Indication: Ionized hypocalcemia, Hyperkalemia, Hypermagnesemia, Calcium channel blocker toxicity Dosage: IV: 20 mg/kg (if using10% CaCl2, dose is 0.2 mL/kg). Inject slowly. Repeat dose as necessary for desired clinical effect. WARNING: Stop injection if symptomatic bradycardia occurs. Extravascular administration can result in severe skin injuries. Note: Calcium is recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, or calcium channel blocker toxicity. o Calcium Gluconate Indication: Ionized hypocalcemia, Hyperkalemia, Hypermagnesemia, Calcium channel blocker toxicity Ionizes as rapidly as calcium chloride and may be substituted using three times the dose of calcium chloride (mg/kg). Dosage: IV: 60 mg/kg (if using 10% gluconate, dose is 0.6 mL/kg). Inject slowly. Repeat dose as necessary for desired clinical effect.
  • 24.
    24 WARNING: Stop injectionif symptomatic bradycardia occurs. Extravascular administration can result in severe skin injuries. Note: Calcium is recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, or calcium channel blocker toxicity. o Charcoal, Activated Indication: Acute ingestion of selected toxic substances Dosage: 1 to 2 g/kg Note: Administer as slurry or down a nasogastric tube. Note that iron, lithium, alcohols, ethylene glycol, alkalies, fluoride, mineral acids, and potassium do not bond to activated charcoal. WARNING: Commercially available preparations of activated charcoal often contain a cathartic, such as sorbitol. Fatal hypernatremic dehydration has been reported after repeated doses of charcoal with sorbitol. Nonsorbitol-containing products should be used if repeated doses are necessary. o Dexamethasone Indication: 1) Emergency treatment of elevated intracranial pressure due to brain tumor Dosage: IV: 1 to 2 mg/kg as a loading dose Maintenance dose, 1 mg/kg/24 h Indication: 2) Croup Dosage: IV, IM, or PO: 0.6 mg/kg dexamethasone, 1 dose/d, or 2 mg/kg/24 h of prednisone. Further dosing and route of administration determined by clinical course. o Diazepam Indication: Status epilepticus
  • 25.
    25 Dosage: IV: 0.1mg/kg every 2 minutes. Maximum dose, 0.3 mg/kg (maximum 10 mg/dose). Dosage: Rectal: 0.5 mg/kg up to 20 mg Note: Do not give as IM injection. WARNING: There is an increased incidence of apnea when combined with other sedative agents or when given rapidly. One must be prepared to provide respiratory support. Monitor oxygen saturation. o Diazoxide Indication: Hypertensive crisis Dosage: IV: 1 to 3 mg/kg rapid IV push. Note: Alternative regimen: 3 to 5 mg/kg IV over 30 minutes. This is reported to result in fewer problems with hypotension or hyperglycemia. o Digoxin Immune FAB (Digibind) Indication: Digoxin or digitoxin toxicity Dosage: 1) Administer digoxin immune FAB intravenously in an amount equimolar to the total body load of digoxin or digitoxin. 2) 38 mg digoxin immune FAB binds 0.5 mg digoxin or digitoxin Dosing methods: A: Based on amount ingested: 1) For digoxin tablets, oral solution, IM injection Dose in mg = 2) For digitoxin tablets, digoxin capsules, IV digoxin or IV digitoxin Dose in mg =
  • 26.
    26 B: Based onserum digoxin or digitoxin concentration (SDC) 1) Digoxin Dose in mg = 2) Digitoxin Dose in mg = C: If neither amount ingested nor serum concentration is known, 760 mg of digoxin immune FAB should be administered. o Diphenhydramine Indication:Acute hypersensitivity reactions, Dystonic reactions Dosage: V or IM: 1 to 2 mg/kg. Maximum dosage, 50 mg. Note: May cause sedation, especially if other sedative agents are being used. May cause hypotension. o Dopamine Indication: Continued shock after volume resuscitation Dosage: IV infusion: 2 to 20 μg/kg/min. A widely recommended starting dosage is 10 μg/kg/min. Titrate to desired clinical effect. Note: Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mL. Infuse at 10 mL/h = 10 μg/kg/min using a constant infusion pump. WARNING: Extravascular administration can result in severe skin injuries. o Dobutamine
  • 27.
    27 Indication: Impaired cardiaccontractility Dosage: IV infusion: 5 to 25 μg/kg/min. A widely recommended starting dosage is 10 μg/kg/min. Titrate for desired clinical effect. Note: Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mL. Infuse at 10 mL/h = 10 μg/kg/min using a constant infusion pump. o Epinephrine Indication: 1) Cardiac arrest or profound bradycardia, asystole, ventricular fibrillation, or pulseless electrical activity Initial Dose: IV: 10 μg/kg (0.01 mg/kg) Intraosseous: 10 μg/kg (0.01 mg/kg) Endotracheal: 100 μg/kg (0.10 mg/kg) Note: 10 μg/kg = 0.1 mL/kg of 1:10 000 dilution 100 μg/kg = 0.1 mL/kg of 1:1000 dilution Note: If administered through an endotracheal tube, follow the dose with saline flush or dilute in isotonic saline flush (1 to 5 mL) based on patient size. Subsequent doses: given every 3 to 5 minutes IV: 100 μg/kg (0.1 mg/kg) Intraosseous: 100 μg/kg (0.1 mg/kg) Endotracheal: 100 μg/kg (0.1 mg/kg) Note: For subsequent doses of epinephrine, a dosage up to 200 μg/kg (0.2 mg/kg) may be given. Indication: 2) Anaphylaxis Dosage: Subcutaneous (SC): 10 μg/kg per dose (maximum 3 doses)
  • 28.
    28 IV: 10 μg/kgper dose: 10 μg/kg = 0.01 mL/kgof 1:1000 dilution or 0.1 mL/kg of a 1:10 000 dilution Note: Repeat the SC dose every 20 minutes while attempting IV access. Some anaphylactic reactions, eg, latex allergy, require large doses of epinephrine. A continuous infusion of epinephrine may be necessary. Indication: 3) Continued shock after volume resuscitation Dosage: IV infusion: 0.1 to 3.0 μg/kg/min. Start at lowest dose and titrate for desired clinical effect. Note: Preparation of infusion solution: 0.6 mg × body weight (kg) diluted to 100 mL. Infuse at 1 mL/h = 0.1 μg/kg/min using a constant infusion pump. Note: Extravasation can result in tissue necrosis injuries. Indication: 4) Status asthmaticus, bronchospasm Dosage: SC: 10 μg/kg per dose 10 μg/kg = 0.01 mL/kg of 1:1000 dilution Maximum single dose, 300 μg (0.3 mL of 1:1000 dilution). Note: Albuterol administered by inhalation is now considered the agent of choice for treatment of acute exacerbations of asthma. Note: Repeat SC dose every 20 minutes if needed for clinical effect. Total of 3 doses. Indication: 5) Laryngotracheobronchitis: Dosage: Racemic epinephrine, 2.25% inhalation solution 0–20 kg: 0.25 mL in 2 mL with normal saline administered by nebulizer 20–40 kg: 0.50 mL in 2 mL with normal saline administered by nebulizer >40 kg: 0.75 mL in 2 mL with normal saline administered by nebulizer
  • 29.
    29 Note: L-Epinephrine: Anequal volume of 1% L-epinephrine (1:100) is approximately equivalent in biologic activity to 2.25% racemic epinephrine; one can be substituted for the other in equal volumes for inhalation. Alternatively, 5 mL of 1:1,000 L-epinephrine is equivalent to 0.5 mL of 1:100. o Fentanyl Indication: Pain Dosage: IV: 0.5 μg to 2.0 μg/kg. Repeat dose as necessary for clinical effect. Note: Higher doses may be necessary if the patient is tolerant. Note: Rapid administration of fentanyl has been associated with both glottic and chest wall rigidity even with dosages as low as 1 μg/kg. Therefore, fentanyl should be titrated in slowly over several minutes. WARNING: There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support. o Flumazenil Indication: Benzodiazepine intoxication Dosage: IV: 5 to 10 μg/kg (up to 100 μg/kg has been used) Maximum dose, 1 mg Note: Useful only for benzodiazepine intoxication. WARNING: Duration of action is shorter than most clinically important benzodiazepines. Resedation may occur. May precipitate acute withdrawal in dependent patients; use drug with caution as its use may be associated with seizures. Patients who receive flumazenil should be continuously observed for resedation for at least 2 hours after the last dose of flumazenil. o Fosphenytoin
  • 30.
    30 Indication: Status epilepticus(same as phenytoin) Dosage: ALWAYS IN PHENYTOIN EQUIVALENTS (PE) 10 to 20 mg PE/kg (same as phenytoin) Route of administration: IM or IV: 1 to 3 mg PE/kg/min; maximum rate 150 mg PE/min Note: Data are currently being collected on children less than 6 years of age. Itching is a common and controllable by reducing flow rate. WARNING: Rate of infusion should not exceed 3 mg PE/kg/min. Heart rate should be monitored and the rate of infusion reduced if the heart rate decreases by 10 beats/minute (same as phenytoin). o Furosemide Indication: Fluid overload, Congestive heart failure Dosage: IV, IM: 1 mg/kg o Glucagon Indication: 1) Hypoglycemia due to insulin excess Dosage: Adult and adolescent: 0.5 to 1.0 mg SC, IM, IV; repeat every 20 minutes Pediatric: 0.025 mg/kg up to 1.0 mg SC, IM, IV; repeat the dose every 20 minutes if needed for clinical effect. Total of 3 doses. Note: An attempt should be made to provide a simultaneous IV glucose infusion. Indication: 2) Beta-blocker or calcium channel blocker overdose Dosage: Adolescent IV: 2 to 3 mg followed by a 5 mg/h infusion. Pediatric IV: 0.025 to 0.05 mg/kg followed by 0.07 mg/kg/h infusion.
  • 31.
    31 o Glucose Indication: Hypoglycemia InitialDose: IV: 250 to 500 mg/kg Maintenance Dose: Constant infusion of 10% dextrose in water at a rate of 100 mL/kg/24 h (7 mg/kg/min). Older children may require a substantially lower dose. The rate should be titrated to appropriate glucose values. Note: 250 to 500 mg/kg = 2.5 to 5.0 mL/kg of D10% 250 to 500 mg/kg = 1.0 to 2.0 mL/kg of D25% 250 to 500 mg/kg = 0.5 to 1.0 mL/kg of D50% Note: Neonates should receive 10% to 12.5% glucose administered slowly. Note: Glucose levels should be determined beforeand during administration. If large volumes of dextrose are administered, include electrolytes to prevent hyponatremia and hypokalemia. o Haloperidol Indication: Psychosis with agitation Dosage: IM, IV: 0.1 mg/kg, may repeat hourly as necessary. Maximum single dose, 5 mg. Note: Hypotension and dystonic reactions may occur. o Insulin, Regular Indication: 1) Diabetic ketoacidosis Dosage: SC: 0.25 to 0.5 unit/kg per dose IV infusion dose: 0.05 to 0.1 unit/kg/h Neonatal dose: 0.05 unit/kg/h
  • 32.
    32 Note: Blood glucoselevels should be closely monitored. Appropriate fluid and electrolyte therapy are also required in treating diabetic ketoacidosis. Indication: 2) Hyperkalemia Dosage: IV: 0.1 unit/kg with 400 mg/kg glucose. Ratio of 1 unit of insulin for every 4 g of glucose. Note: Potassium levels in blood or serum should be monitored. o Ipecac Syrup Indication: Acute ingestion of selected toxic substances Dosage: Oral (PO): 6-month-old to 1-year-old = 10 mL >1 year old = 15 mL Adolescent/young adult = 30 mL WARNING: Do not use when patient is suffering from central nervous system depression or if having seizures. Contraindicated in caustic and hydrocarbon ingestion. Patients who ingest pesticides or other chemicals that may have a hydrocarbon base may need to have emesis induced. Consult your regional poison control center. Note: Administer with 120 to 180 mL of fluid; 90% effective in inducing vomiting within 25 minutes of first dose. May repeat once. Note: Activated charcoal is now considered the first line therapy for most oral ingestions treated in the hospital setting. o Kayexalate (Sodium Polystyrene Sulfonate) Indication: Treatment of hyperkalemia Dosage: Adults and adolescents PO: 15 g (60 mL) 1 to 4 times/day Rectal: 30 to 50 g every 6 hours
  • 33.
    33 Children PO: 1.0 g/kgevery 6 hours Rectal: 1.0 g/kg/dose every 2 to 6 hours (for small children and infants use lower doses by using the practical exchange ratio of 1 mEq K+/g of resin). WARNING: Avoid using the commercially available liquid preparation in neonates due to the hyperosmolar preservative (Sorbitol) content. Extremely premature newborns may develop intestinal hemorrhage (hematochezia) from rectal Kayexalate. o Ketamine Indication: 1) Sedation/analgesia Dosage: IM: 1 to 2 mg/kg IV: 0.5 to 1 mg/kg Indication: 2) Adjunct to intubation Dosage: IV: 1 to 2 mg/kg Note: Laryngospasm associated with ketamine is usually reversed with oxygen administration and positive pressure ventilation. Note: Atropine or other antisialogogue should be used to prevent increased salivation. WARNING: Be prepared to provide respiratory support.Monitor oxygen saturation.Avoid use in patients with increased intracranial pressure or increased intraocular pressure. o Lidocaine Indication: 1) Ventricular arrhythmia Dosage: IV: 1 mg/kg as a single dose slowly, repeat every 5 to 10 minutes to desired effect or until maximum dose of 3 mg/kg is given
  • 34.
    34 IV infusion: 20to 50 μg/kg/min Endotracheal: 1 mg/kg Note: If administered through an endotracheal tube, follow the dose with saline flush or dilute in isotonic saline flush (1 to 5 mL) based on patient size. Note: Preparation of infusion solution: add 120 mg (6 mL of a 2.0% concentration) to 100 mL of 5% glucose in water. Infusion of 1.0 to 2.5 mL/kg/h will deliver 20 to 50 μg/kg/min. Note: A reduced infusion rate should be used in patients with a low cardiac output. WARNING: Contraindicated in complete heart block and wide complex tachycardia due to accessory conduction pathways. Note: Excessive dosage may result in myocardial depression, hypotension, central excitation, and seizures. Indication: 2) To attenuate airway reflexes before endotracheal intubation or airway manipulation in patients with elevated intracranial pressure Dosage: 1 mg/kg IV as a single dose 30 seconds before airway instrumentation. o Lorazepam Indication: Status epilepticus, Adjunct for intubation Dosage: IM or IV: 0.05 to 0.1 mg/kg Repeat doses every 10 to 15 minutes for clinical effect. WARNING: There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen saturation. o Mannitol Indication: Increased intracranial pressure
  • 35.
    35 Dosage: IV: 0.25g/kg given over a 15-minute infusion. Note: A larger dose (0.5 g/kg given over 15 minutes) may be appropriate in an acute intracranial hypertensive crisis. In conjunction with mannitol, other measures to control intracranial pressure such as hyperventilation, barbiturates, and muscle relaxation (using a neuromuscular blocking agent) should be considered. WARNING: Rapid administration may cause hypotension, hyperosmolality, and elevated intracranial pressure. o Meperidine Indication: Pain Dosage: IV or IM: 1 to 2 mg/kg Repeat dose is necessary for clinical effect. Note: Higher doses may be necessary if patient is tolerant. WARNING: There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support. o Methylprednisolone Indication: 1) Asthma/allergic reaction Dosage: IV: 1 to 2 mg/kg every 6 hours Indication: 2) Spinal cord injury Dosage: IV: 30 mg/kg over 15 minutes. In 45 minutes begin a continuous infusion of 5 to 6 mg/kg/h for 23 hours. Indication: 3) Croup Dosage: IV: 1 to 2 mg/kg of methylprednisolone, then 0.5 mg/kg every 6 to 8 hours.
  • 36.
    36 o Midazolam Indication: Adjunctfor endotracheal intubation or for sedation/anxiolysis Dosage: IV: 0.05 to 0.2 mg/kg given over several minutes. WARNING: There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen saturation. o Morphine Sulfate Indication: Pain, infundibular spasm (“Tet Spell”) Dosage: IV (slowly) or IM: 0.05 to 0.1 mg/kg. Repeat dose as necessary for clinical effect. Note: Higher doses may be necessary if patient is tolerant. WARNING: There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support. o Naloxone Indication: Respiratory depression induced by opioid Dosage: IV, IM: 0.1 mg/kg from birth (including premature infants) until age 5 years or 20 kg of weight. Thereafter, the minimum dose is 2.0 mg. Doses may be repeated as needed to maintain opiate reversal. IM absorption may be erratic. Note: This dosage is indicated for acute opiate intoxication. Titration to effect with lower initial doses (0.01 mg/kg or 10 μg/kg) should be considered for other clinical situations, eg, respiratory depression during pain management. WARNING: May induce acute withdrawal in opioid dependency. Patients who receive naloxone should be continuously observed for renarcotization for at least 2 hours after the last dose of naloxone.
  • 37.
    37 o Nitroprusside Indication: Hypertensivecrisis Dosage: IV: 0.5 to 10 μg/kg/min. Start at the lowest dosage and titrate for the desired clinical effect. Administer through low dead space system or as close to IV catheter as possible to prevent accidental bolus injection. Note: Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mLD5W. Infuseat1 mL/h = 1 μg/kg/min using a constant infusion pump. Note: Bottle, burette, or syringe pump but not the IV tubing should be covered with protective foil to avoid breakdown by light. WARNING: Administration may result in profound hypotension. Patients should be closely monitored. Blood pressure should be continuously monitored with an arterial line. WARNING: Cyanide toxicity can result from large doses and/or prolonged infusions. Patients should be closely monitored for the development of metabolic acidosis. Patients with decreased renal function may be at increased risk. o Oxygen Indication: Hypoxemia and/or respiratory distress, Carbon monoxide poisoning, Shock Dosage: 100% by nonrebreather mask initially or endotracheal tube; wean as tolerated. Note: The administration of supplemental oxygen should be considered during EVERYpediatric emergency.
  • 38.
    38 o Pancuronium Indication: Neuromuscularblockade to facilitate mechanical ventilation, Emergency intubation Dosage: IV: 0.1 mg/kg Note: This drugdoesnot alter the level of consciousnessor provide analgesia or amnesia. Note: This agent can be used when succinylcholine is contraindicated. Pancuronium isalong-acting neuromuscular blocker that requires ventilatory assistance for at least 1 hour. Satisfactory conditions for endotracheal intubation will generally occur 2 to 3 minutes after administration. WARNING: Ventilatory support will be necessary. Personnel with skills in advanced airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available. o Phenobarbital Indication: Status epilepticus Dosage: IV: 20 mg/kg. Maximum dose, 1000 mg. Repeat dose once if necessary for clinical effect after 15 minutes. WARNING: There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen satura o Phenylephrine Indication: Infundibular spasm (“Tet Spell”) Dosage: 5 to 20 μg/kg push then followed by infusion at 0.1 to 5.0 μg/kg/min.
  • 39.
    39 WARNING: Blood pressuremust be carefully followed and dose titrated to effect. o Phenytoin Indication: Status epilepticus Dosage: IV: 10 to 20 mg/kg initial dose. Maximum initial dose, 1000 mg. Maximum rate of administration, 50 mg/min or 1 mg/kg/min, whichever is less. Note: The lower dose is indicated in neonates because of increased risk of toxicity due to decreased protein binding. Should be diluted in normal saline to avoid precipitation. WARNING: Rate of infusion should not exceed 0.1 mL of undiluted preparation per kg/min. Heart rate should be monitored and the rate of infusion reduced if the heart rate decreases by 10 beats/minute. o Procainamide Indication: Wide complex tachycardia Dosage: IV: Start at 3 to 6 mg/kg/dose over 5 minutes not to exceed 100 mg to a titrated maximum of 15 mg/kg/loading dose. Maintenance dose, 20 to 80 μg/kg/min (0.02 to 0.08 mg/kg/min); maximum, 2 g/24 h. WARNING: If 50% QRS widening or hypotension occurs during loading dose, the remainder of the loading dose is held, and the maintenance dose is delayed until these signs have resolved. o Propranolol Indication: Infundibular spasm (“Tet Spell”)
  • 40.
    40 Dosage: IV: 0.01to 0.02 mg/kg per dose infused over 10 min in 5% dextrose in water. Maximum initial dose, 1.0 mg Note: Oxygen should be administered first. Morphine is also an effective treatment for infundibular spasms. Phenylephrine is another adjunct for reversal of infundibular spasm. Use is contraindicated in congestive heart failure. Avoid in patients with a history of bronchospasm. o Prostaglandin E1 Indication: Possible ductal-dependent cardiac malformation in the neonatal period Dosage: 0.05 to 0.10 μg/kg/min as an infusion in 5% dextrose in water. Note: Preparation of infusion solution: 250 μg in 80 mL of D5W infuse at 1 mL/kg/h = 0.05 μg/kg/min. WARNING: Apnea, hyperthermia, and seizures may occur. Be prepared to provide respiratory support. Monitor oxygen saturation. o Rocuronium Indication: Neuromuscular blockade to facilitate mechanical ventilation, Emergency intubation Dosage: IV: 0.8 to 1.2 mg/kg Note: This drugdoesnot alter the level of consciousnessor provide analgesia or amnesia. Note: Alternative to succinylcholine for rapid intubation when succinylcholine is contraindicated. Duration of block is generally 30 to 45 minutes and is dose-dependent. Satisfactory conditions for endotracheal intubation will generally occur 45 to 60 seconds after administration. WARNING: Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this
  • 41.
    41 agent is administered.Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available. o Succinylcholine Indication: Neuromuscular blockade for emergency intubation or treatment of laryngospasm Dosage: 1 to 2 mg/kg IV 4 to 5 mg/kg IM WARNING: Contraindicated with previous history of malignant hyperthermia, severe burns, spinal cord injury, neuromuscular disease, or myopathies. When these contraindications exist use a nondepolarizing muscle relaxant such as rocuronium. Despite reports of acute rhabdomyolysis, hyperkalemia, and cardiac arrest with succinylcholine, this agent remains the drug of choice when immediate securing of an airway is indicated. WARNING: Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available. Note: Atropine, 0.02 mg/kg (minimum dose, 0.1 mg), should be combined with or precede succinylcholine to prevent bradycardia or asystole. Satisfactory conditions for endotracheal intubation generally occur 30 to 45 seconds after IV administration and 3 to 5 minutes after IM administration. Note: If cardiac arrest occurs immediately after administration of succinylcholine, hyperkalemia must be suspected and treatment for this condition initiated. Hyperkalemia is especially likely to be responsible for cardiac arrest occurring in male children 8 years of age or younger. o Thiopental Indication: 1) Adjunct to intubation
  • 42.
    42 Dosage: IV: 4to 6 mg/kg Note: A lower dose may be used if other sedatives/narcotics have been administered. WARNING: IM administration leads to tissue necrosis. WARNING: Be prepared to provide respiratory support.Monitor oxygen saturation. High doses are associated with hypotension and apnea. Use with caution in patients with cardiac compromise or hypovolemia. Indication: 2) Control of intracranial hypertension Dosage: 1 to 2 mg/kg, repeated as necessary o Vecuronium Indication: Neuromuscular blockade to facilitate mechanical ventilation Emergency intubation Dosage: IV: 0.1 mg/kg Note: This drugdoesnot alter the level of consciousnessor provide analgesia or amnesia. Note: This agent may be used for emergency intubation when succinylcholine is contraindicated. Satisfactory conditions for endotracheal intubation generally occur 1.5 to 2.0 minutes after administration. WARNING: Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available.
  • 43.
    43 LIST OF LIGHTSENSITIVEMEDICATIONS  Acyclovir cap, tab. (Zovirax®)  Alteplase powder for injection (Activase®)  Allopurinoltab. (Zyloprim®)  Amiodaronetab. (Cordarone®)  Amphotericin B powder for inj. (Fungizone®)  Amrinonelactate inj. (Inocor®)  Amylnitrate inhal.  ApraclonidineHCLophth. Sol. (Iopidine®)  Atenolol inj. (Tenormin®)  Aurothioglucosesusp. for inj. (Solganal®)  Azathioprineinj, tab. (Imuran®)  Bepridiltab. (Vasocor®)  Betamethasone Sod.Phos/Acet.inj. (Celestone®)  BromocriptineMesylate cap, tab. (Parlodel®)  Calcitrol cap. (Rocaltrol®)  Carbidopa/Levodopatab. (Sinemet®)  Cefotaxime inj. (Claforan®)  Ceftazidimeinj. (Fortaz®)  Ceftriaxoneinj. (Rocephin®)  CefuroximeSodium (Zinacef®)  Ciprofloxacin inj. (Cipro®)  Cisplatin inj. (Platinol®)  Clarithromycin tab. (Biaxin®)  Clonidinetab. (Catapres®)  Codeinesol. tab, inj.  Cromolyn sod. Sol. Neb. &nasal sol. (Intal®)  Cyclosporineinj. (Sandimmune®)  Dantroleneinj. (Dantrium®)  DeferoxamineMesylateinj. (Desferal®)  Dexamethasone Sod. Phos. Inj. (Decadron®)  Diazoxideoral susp, inj. (Hyperstat®)
  • 44.
    44  Digoxin inj,elixir, tab. (Lanoxin®)  Diphenhydramineinj. (Benadry®l)  Dipyridamoleinj. (Persantine®)  Doxorubicin HCl inj. (Adriamycin®)  Doxycyclinecap. (Vibramycin®)  Droperidol inj. (Inapsine®)  Ephedrineinj.  Ergotaminetartrate tab. (Ergostat®)  Erythromycin cap. (Eryc®)  Ethosuximideoral syrup (Zarontin®)  Felodipinetab. (Plendil®)  Fentanylcitrate inj. (Sublimaze®)  Finasteride tab. (Proscar®)  Flecainide Acetate tab. (Tambocor®)  Fluorouracilinj. (Adrucil®)  Fluoxymesteronetab. (Halotestin®)  Furosemideinj, tab. (Lasix®)  Glipizidetab. (Flucotrol®)  Gold Sodium Thiomalate in (Myochrysine®)  Haloperidolinj. (Haldol®)  Heparin inj.  Hydromorphoneinj, tab. (Dilaudid®)  Isoproterenolinj, inhal. (Isuprel®)  Isotretinoin cap. (Accutane®)  Isradipinecap. (Dynacirc®)  Itraconazole cap. (Sporanox®)  Ketorolac inj, cap. (Toradol®)  Labetalol inj. (Normodyne®)  Lactulose oral syrup (Cephulac®)  Leucovorin calcium inj, tab. (Wellcovorin®)  LeuprolideAcetate inj. (Lupron®)  Levothyroxinetab.  Liotrix tab. (Thyrolar®)
  • 45.
    45  Lorazepam inj.(Ativan®)  Lovastatin tab. (Mevacor®)  MesoridazineBesy. inj, oralsol. (Serentil®)  MetaproterenolSul. inj, inhal. sol, syrup, tab. (Alupent®)  Methotrexate inj, tab. (Methotrexate®)  Methsuximidecap. (Celontin®)  Methyldopaoralsusp. (Aldomet®)  Methylergonovineinj, tab. (Methergine®)  Metoclopramideinj. (Reglan®)  Metronidazoleinj, tab. (Flagyl®)  Mivacurium Chlorideinj. (Mivacron®)  MorphineSulfateinj.  Nadololtab. (Corgard®)  Nicardipinecap. (Cardene®)  Nifedipinecap. (Procardia®)  Nimodipinecap (Nimotop®)  Nitrofurantoin cap. (Macrodantin®)  Nitroglycerin inj. (Tridil®)  Nitroprussideinj. (Nitropress®)  Norepinephrine Bitartrateinj. (Levophed®)  Ofloxacin inj. (Floxin®)  Omeprazolecap. (Prilosec®)  Ondansetron inj. (Zofran®)  Pentagastrin inj. (Peptavlon®)  Pentoxifyllinetab. (Trental®)  Perphenazineinj, oral conc. (Trilafon®)  Phenylephrineinj. (Neo-Synephrine®)  Phenytoin Sod inj, cap, oral susp. (Dilantin®)  Phytonadioneinj. (Aquamephyton®)  Potassium Chloridetab. (Slow-K®)  Pravastatin Sodium tab. (Pravachol®)  PrednisoloneSodium Phos. (Hydeltrasol®)  PromethazineHClinj, tab, oral syrup (Phenergan®)
  • 46.
    46  Propofolinj. (Diprivan®) Propranololtab, cap. (Inderal®)  RanitidineHCl inj, tab, oral syr. (Zantac®)  Rifampin inj. (Rifadin®)  Secobarbital Sodium inj. (Seconal®)  SufentanilCitrate inj. (Sufenta®)  Sumatriptan inj. (Imitrex®)  Tamoxifen Citrate tab. (Nolvadex®)  Terbutaline inj. (Bricanyl®)  Tetracaine inj, top. Sol. (Pontocaine®)  Tetracycline tab, cap, syrup (Sumycin®)  Theophyllinecap. (Slo-Bid®)  Thioridazineoral susp. (Mellaril®)  Timolol Maleate ophth. sol, tab. (Timoptic, Blocadren®)  Tolazolineinj. (Priscoline®)  Tolmetin Sodium tab. (Tolectin®)  TriamcinoloneAcet. Susp. for inj. (Kenalog®)  Triamterene cap. (Dyrenium®)  TrifluoperazineHCloralconc. (Stelazine®)  Trimethoprim/sulfamethoxazole tab, oral susp. (Bactrim®)  Verapamil HCltab, inj. (Calan®)  Vecuronium inj. (Norcuron®)  Vitamin A inj, cap. (Aquasol A®)  Warfarin Sodium tab. (Coumadin®)  Zidovudinecap, syrup (Retrovir®)
  • 47.
    47 I.V. drugstabilities whenadded to I.V. solutions Drug Stability at Room Temp Stability Under Refrigerati on Other Information Acetylcysteine (Acetadote) 24 hours 24 hours Amikacin (Amikin) 24 hours 60 days Aminocaproicacid 24 hours 7 days Aminophylline 48 hours n/a Amiodarone (Cordarone) 30 days n/a Mix only in dextrose Amphotericin B Lipid Complex(Abelcet) 6 hours 48 hours ***Protect from Light*** Not Compatiblewith NaCl Ampicillin 1 hour 72 hours Diluted solution is stable for 2-8 hoursat 25 °C Ascorbic acid (Vitamin C) 24 hours n/a Azathioprine 24 hours Bumetanide (Bumex)72 hours n/a ***Protect from Light*** CaffeineCitrate (Cafcit) 24 hours n/a Calcium Gluconate 24 hours n/a Carbencillin 24 hours 72 hours Ceftazidim (Negacef) 18 hours 7 days Ceftizoxime 8 hours 48 hours Color vary from yellow to amber Ceftriaxone (Novocef) 1-3 days 3-10 days Color vary from light yellow to amber Cephalothin 12 hours 6 hours Warm to room temp. & shake to decrease precipitation Chloramphenicol 2-30 days Clindamycin (Cleocin) 16 days 32 days Daptomycin 12
  • 48.
    48 (Cubicin) months Dexamethasone (Decadron) 28days 28 days Diltiazem (Cardizem) 24 hours 24 hours Dobutamine 24 hours 24 hours Dopamine 48 hours 7 days Epinephrine 24 hours 24 hours ***Protect from Light*** Fenoldopam (Corlopam) 24 hours 24 hours Ferric Gluconate Complex(Ferrlicit) Use Immediately Folic Acid 48 hours 48 hours Fomepizole(Antizol) 24 hours 24 hours If drugbecomes solid in vial, hold under warm water to drugback into solution Fosphenytoin (Cerebyx) 30 days 30 days Furosemide(Lasix) 24 hours 24 hours Gentamicin (Garamycin) 7 days 30 days Granisetron (Kytril) 24 hours 24 hours Heparin 12 months 12 months Hepatitis B Vaccine (Engerix-B) 72 hours see exp. date on box Hydrocortison Sod.Succinate 3 days Hydromorphone (Dilaudid) 30 days 60 days ***Protect from Light*** Ibutilite (Corvert) 24 hours 48 hours Iron Dextran (Infed) 24 hours 3 months Mix in NaCl, Dextroseincreases risk of phlebitis Insulin 24 hours 24 hours Adsorbsto glass and plastic surfaces Insulin neutral (Actrapid) 28 days Recommended Temp. is2-8 °C Insulin premixed (Mixtard) 28 days
  • 49.
    49 Iron Dextran (Infed)48 hours 3 months Isoproterenol (Isuprel) n/a 24 hours ***Protect from Light*** Labetalol (Trandate) 72 hours 72 hours ***Protect from Light*** Magnesium Sulfate 60 days 60 days Methylprednisolone Sod. Succinate 48 hours Discard if solution is cloudy or precipitated Metoprolol (Lopressor) 36 hours n/a ***Protect from Light*** Mezlocillin 24-72 hours 1-7 days Reconstituted solution darken duringstorage Morphine 30 days 30 days Multivitamin 24 hours 24 hours Nitroglycerin 48 hours 7 days Mix in glass only Nitroprusside (Nipride) 24 hours 24 hours ***Protect from Light*** Norepinephrine (Levophed) 48 hours 30 days ***Protect from Light*** Octreotide (Sandostatin) 48 hours 7 days ***Protect from Light*** Ondansetron (Zofran) 7 days 7 days Penicillin G 24 hours 7 days Solution diluted for infusion is stable for 1 day Phenylephrine (Neosynephrine) 48 hours 48 hours ***Protect from Light*** Piperacillin 24 hours 7 days Stable for 30 daysif it’s frozen Procainamide Discard if solution markedly discolored or precipitated Dexmedetomidine (Precedex) 48 hours n/a Ranitidine(Zantac) 24 hours 24 hours ***Protect from Light*** Sodium Bicarbonate 7 days 60 days Streptomicin 2-28 days 14 days Sulfamethoxazole/T MP (Bactrim) 4-6 hours 4-6 hours Do NOT Refrigerate Thiamine 24 hours 24 hours ***Protect from Light***
  • 50.
    50 Tobramycin (Nebcin) 24hours 96 hours Torsemide (Demadex) 24 hours n/a Valproic Sodium (Depacon) 6 days 6 days Vitamin K (Aquamephyton) 24 hours 24 hours ***Protect from Light***