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CHAPTER 10 Pharmacology in Neonatal Care
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239
than expected in normothermic newborns.
In the report on phenobarbital pharmacokinetics for neonates cooled for HIE, C
C
were higher, and half-lives were longer, than
avg
max
, C
min
, and
reported in normothermic newborns in earlier
studies. Clinicians using PB to treat seizures in
such newborns should be aware of the risks of
elevated serum PB concentrations with doses of
40 mg/kg or higher.23 Other antiepileptics with
a better safety profile, such as levetiracetam, may
be used adjunctively to treat refractory seizures in
infants who have been administered PB.84 This may
decrease the need to push PB doses to supratherapeutic levels in this cohort.
Even in noncooling infants, morphine should
be used judiciously in neonatal patients due to
its many known adverse effects. In the Total Body
Hypothermia Study (TOBY), one center measured
and reported morphine pharmacokinetics for the
infants enrolled in the study.69 All of the infants were
treated with a continuous infusion of morphine,
with the rate adjusted according to clinical status.
Serum morphine concentrations reached a steady
state after 24 hours in normothermic infants with
HIE but continued to increase throughout the assessment period in the hypothermia group. The authors
concluded that infants with HIE have reduced
morphine clearance and elevated serum morphine concentrations when morphine infusion
rates are based on the clinical state. Potentially
toxic serum concentrations of morphine are more
likely with the combination of HIE, moderate
hypothermia, and infusion rates greater than 10
micrograms/kg per hour than with HIE not treated
with hypothermia.69 To reduce the accumulation of
morphine, a loading dose of 50 mcg/kg followed
by 5 mcg/kg/hour was predicted to achieve target
serum concentrations in neonates with HIE receiving therapeutic hypothermia.
25
Gentamicin is a common antibiotic used to treat
early-onset sepsis in infants. In a study of 29 infants
treated with hypothermia for HIE, gentamicin
clearance was decreased in neonates with HIE
treated with hypothermia compared with previous
reports in nonasphyxiated, normothermic full-term
neonates. At a 36-hour dosage interval, a dose of 4
to 5 mg/kg was predicted to achieve target gentamicin peak and trough concentrations in more than
90% of neonates.27 In a subsequent study, this group
demonstrated that a gentamicin dosage strategy of
5 mg/kg every 36 hours in neonates with HIE
receiving therapeutic hypothermia improved the
achievement of the target trough concentration of
less than 2 mg l(–1) compared with dosage every 24
hours while still providing high peak concentration
exposure.
26
From these few examples, the effect of hypo-
thermia on the pharmacokinetics of important drugs in a very vulnerable population is
evident.19 An ongoing, multicenter study in the
Netherlands is investigating how therapeutic hypothermia influences the pharmacokinetic and pharmacodynamic time profiles of analgesics, sedatives,
antibiotics, and antiepileptic drugs in infants with
HIE.19 So far, these studies have demonstrated that
therapeutic hypothermia results in significantly
decreased clearance rates for the antibiotics gentamicin, amoxicillin, and benzylpenicillin, resulting in
the need to adjust to lower dosing for all three drugs
during therapeutic hypothermia and rewarming.
9-11
PREVENTION OF
THERAPEUTIC MISHAPS
The Institute of Medicine (IOM) estimates that
more individuals die each year in the United States
from medical error than from motor vehicle accidents, breast cancer, or AIDS-related illness.35 Many
medical errors are medication errors. Neonatal
patients are at a higher risk for errors given the
narrow margin of safety in very small, fragile
patients with an immature organ system and
clinical illness.64 For example, a decimal point
error in dosing that may not cause adverse effects in
an adult could cause significant harm to a preterm
neonate. Between 20% and 50% of neonates in
the NICU experience medication errors, with
the youngest, smallest, and sickest neonates
being the most affected.
69
Medication errors can occur at any stage in
the medication-use process: (1) prescription/
transcription, (2) preparation/dispensing, (3)
administration, and (4) monitoring.
70
Prescription and Transcription
A recent descriptive study of common medication
errors in the NICU found that the majority (98.5%)
occurred in the prescribing phase, with 58.7% due
to calculation errors.62Additionally, wrong-patient
orders are more common in the NICU than in
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non-NICU pediatric settings.2 Dosing references;
administration guidelines, such as IV compatibility and infusion rate guidelines; and other drug
resources should be made available to all clinicians
in the NICU.
12,70
Building dosing recommendations and clinical guidelines into order sets within a
computerized order-entry system (CPOE), even the
use of a “preselected prescription” concept, reduces
errors in prescribing and assists in standardizing
and optimizing clinical outcomes.30 Designing the
ordering system to reduce complexity and provide
rule-based order screening and double-checking of
calculations and developing effective information
delivery may be more effective than traditional education or process-improvement efforts that target
interventions after an error occurs.
22,28
The use of a CPOE system with an approved
neonatal formulary, prompts, and clinical decision support decreases errors by making the pre-
scribing legible, guides the prescriber in the safest
and most cost-effective medications, and enables
the prescriber to become proficient with a selected
number of drugs.70 CPOE systems can be customized to a specific NICU and use only “acceptable”
or no abbreviations, write out or use capital letters
for “look-alike/sound-alike” drugs, and use both
generic and brand names of the drugs in the neonatal formulary. Electronic generation of medication
administration records (MARs) by pharmacists
after checking the medication order improves
accuracy in the transcription process and ensures
legibility compared with handwritten MARs.
Pharmacist participation in NICU patient rounds
enables multidisciplinary communication and clarification of new medications to be ordered and any
therapeutic drug monitoring that needs to be done.
Neonatal clinical pharmacist participation in
NICU rounds and clinical care has been shown
to decrease errors by 80%.
74
Preparation and Dispensing
Medications
Even after making a correct choice of medication,
one must pay attention to the appropriate dose and
interval based on factors that affect a drug’s pharmacokinetics and pharmacodynamics.
Investigators estimate that 8% of drug doses
calculated and administered by competent
NICU nurses are at least 10 times greater or
less than the ordered dose.71 A system in which
BOX
10.2
Right drug
Right patient
Right route
Right dose
Right time
Right response
THE “SIX RIGHTS” OF DRUG
ADMINISTRATION
unit doses are prepared in the pharmacy, labeled,
and delivered to the NICU is a safer system than
having stock medications in the NICU that are
reconstituted and/or diluted by the bedside nurse.
Pharmacist interventions can reduce medication
errors and adverse drug events.
12,59,81,82
In the
pharmacy, unit doses are checked by two phar-
12,36,81,82
macists
to ensure accuracy, scanned using
barcode technology, and placed in the automated
dispensing system (ADS). Emergency medications
are available in the ADS, which is accessed by the
nurse for dispensing; the drug is then prepared
by the nurse (reconstituting or diluting), and the
appropriate dose is measured and double-checked
with a second nurse before administration.
36,57,82,81
When unit-dose patient labels are integrated with
the CPOE system, labels contain the dose, volume,
concentration, route, preparation instructions, and
time of administration.
70
Administration of Medications
Completing the “six rights” of medication
administration (Box 10.2) in the NICU is
essential and may be complicated by the small
doses and dosage adjustments based on infant
weight or body surface area. Many drugs used
in neonatal care must be diluted because they are
ordered in amounts that are not commercially
available. The rate of drug entry, or absorption,
also varies, depending on the route of administration. Even with unit dosing, the calculation
of the medication dose received must be
double-checked by two nurses at the bedside
before administration. This redundancy of
independent double-checking in the pharmacy
and at the bedside is a strategy for reducing
medication errors.
be ensured; this includes appropriately prescribed
12,36,57,80,81
Drug delivery must
CHAPTER 10 Pharmacology in Neonatal Care
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241
orders or transcribed orders, appropriate dose
calculations, appropriate mixing with diluents,
and appropriate method of administration. The
Rule of Six was developed originally for use with
vasopressor agents in code situations, and its use
has extended beyond that. The rule, which allows
nurses to estimate a pediatric dose by using a factor
of 6, is prone to error (Fig. 10.4).
Standardized drug concentrations are less
error prone and safer for patients than the Rule
of Six.2 Because of medication errors, The Joint
Commission (TJC) requires the use of standardized IV drug concentrations for pediatric
patients prescribed medications for which the
Rule of Six was routinely used.
The use of smart IV pumps reduces IV med-
ication errors by 73%.42 Smart pumps are used
for both continuous and intermittent IV administrations. Smart pumps are programmed with each
IV medication from the neonatal formulary and are
separate from adult medication pumps. Proper training on use of medication pumps is crucial. Errors
occur from poor training on pumps. (https://www.
ncbi.nlm.nih.gov/pmc/articles/PMC6318721/). In
addition to barcode scanning, visual verification
of the medication label to ensure that the medication, dose, concentration, and route match
the electronic order and the MAR information also prevents errors and increases patient
42,70
safety.
Access to medication references with
administration guidelines, compatibilities, dilution
guidelines, diluent information, and administration
time is essential for all NICU staff.
70
Monitoring Medication Effects
After medications are administered, all care providers must evaluate the neonate for drug interactions, incompatibilities, and untoward and
adverse effects. The effects of therapy at the chosen
dose and systematic monitoring for therapeutic and
toxic effects must be included in NICU care when
medications are used.
TDM is necessary for some medications
to measure whether pharmacokinetic and
pharmacodynamics goals are being met.69
Blood is drawn at peak, trough, or random times,
and medication doses are adjusted as necessary.
Therapeutic ranges are specified for each drug,
and doses are adjusted for maximum efficacy
and the prevention of toxicity. NICU staff must
be educated in how and when to accurately
and consistently monitor drug levels, as well
as the appropriate interventions that are to
be expected given laboratory values that are
outside of therapeutic ranges. When clinical
pharmacists participate in patient rounds, they
promote safety by effective monitoring with laboratory values as well as with education of the
NICU staff.
42,70,75,79
Additionally, the bedside
nurse who is constantly with the sick neonate must be familiar with the adverse effects
of all medications that are given so that the
nurse is able to advocate for the patient who
is showing symptoms of toxicity. For example,
a very low-birth-weight (VLBW) infant on caffeine therapy who has a resting heart rate of 180
beats/ minute and is vomiting after gavage feeding is symptomatic of caffeine toxicity and needs
a caffeine level drawn; the next dose of caffeine
should be withheld until results of the caffeine
level are known.
A recent national survey found that of the
164 respondent NICUs, 85% adhered to practices designed to decrease and eliminate medication errors, yet some safety practices were
not used.31 The American Society of HealthSystem Pharmacists has published guidelines
for preventing medication errors in hospitals.12
These such include hospital-wide actions as the
establishment of a clearly defined system for drug
ordering, dispensing, and administration, with
review of the original drug order before dispensing and administration. Confirmations of patient
weight, drug dosage, and strength are also recommended. Avoiding the use of the terminal zero
to the right of the decimal point (e.g., writing
5 instead of 5.0) and using a zero to the left
of a dose less than 1 (e.g., using 0.1 rather
than .1) will help reduce medication errors.
Avoid abbreviations of drug names (e.g., MS
may mean either morphine sulfate or magnesium
sulfate), spell out dosage units rather than using
abbreviations (e.g., units rather than U, or mcg
for microgram rather than μg), and use generic
medication names rather than trade names.
Avoid verbal orders whenever possible; verbal
orders should only be used in emergency situations.81 See Table 10.2 for other interventions
to reduce medication errors. For neonatal/
pediatric nurses, recommendations include the
following:
12,36,57,69,81
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TABLE
10.2
STRATEGY EXAMPLES
Establish an institutional and NICU culture of
safety12:
• Safetyisvalued
• Medicationsafetyleader
• Structureforsafemedicationpractices
• Strategicplan
Multidisciplinary staff education and team-
worktrainingtoestablish,enhance,and/or
sustain a culture of safety in the NICU
QIprojects CollectdatabeforeandafterQIinterventionsrelatedtomedicationsafety,suchasdouble-checkingand
INTERVENTIONS TO REDUCE MEDICATION ERRORS
Medication safety is a priority that is supported by a system of safety that makes it easy to prevent an
error and difficult to make an error12:
• “Just”culturethatevaluatessystemsawsaswellashumanerrors;asupportsystemforsecond
victims: care for health care providers traumatized by being involved in medication error(s)
• Nonpunitiveevent-reportingsystemthatincludes“misses”and“near-misses”thatundergoRCAto
identify causes and devise strategies to prevent a recurrence
• Interdisciplinarymedicationsafetyteamtoproactivelyassessrisk,aswellassystematicallyand
collaboratively address medication safety within the NICU
• Continuousqualityimprovementprocessregardingevaluationoferrors/harm:useoftechnologythat
reduces risk and prevents patient harm.
• Strongdesignsthatassessandreduceriskandpatientharm
• reduceriskandpatientharm
• Useofelectronicbarcodescanningsystemsthatreducepreventableadversedrugeventsby50%to
39,53
80%
AdministertheAHRQ’sSurveyonPatientSafetyCulturebeforeandaftercompulsory,multidisciplinary
teamworkandcommunicationtraining;compareunitdatatoAHRQ’snationalsurveydata
signing for all neonatal medications; use of barcode scanning
55
Random safety audits: safety tool to prevent
adverse events
Multidisciplinary team develops a neonatal/
pediatric formulary
Develop written protocols and procedures that
are easily accessible to all NICU staff
Provide up-to-date references easily accessible
to all NICU staff
UseCPOEsystemwithneonataldosing
regimens and order sets
AHRQ, Agency for Healthcare Research and Quality; CPOE, computerized provider order entry; IV, intravenous; NICU, neonatal intensive care unit; QI, quality improvement;
RCA, root cause analysis.
• Familiarizingoneselfwith the system formedi-
cation ordering and documentation
• Accepting only medication orders that specify
not only the amount to be given but also the
intended amount per kilogram so that intended
dosing can be recalculated by the dispenser
(pharmacist) and the administrator (nurse) of the
medication
Collectdatafromsmart(IV)pumpstoassessthefrequencyofappropriateuseofinfusionpumpsafety
7
systems
Neonatal/pediatricdrugstobeusedinNICU,age-specicdosageguidelinesalongwithdilutionsof
commondrugs.Useofstandardizeddrugpreparationanddosage,standardizednomenclatureandCPOEs
with alerts for unusual drug doses
Useofsmartpumps,insulin,skincare;monitoringofIVinfusionsandtherapeuticdruglevels;interven-
tion for IV extravasation
Neonatal/pediatricdrugdosagehandbooks,intranetresources,24-houraccesstopharmacist
Buildnationalandlocalguidelinesintoadmissionordersets,disease-stateordersets,andallcommonly
used neonatal medications
70
70
• Clarifying medication orders before the pre-
scriber leaves the NICU
• Verifyingdrugordersbeforeadministration
• Confirming patient identity by two forms of
identification before each dose
• Using electronic barcode scanning sys-
tem to verify patient and medication before
administration
CHAPTER 10 Pharmacology in Neonatal Care
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243
• Verifying calculations, IV pump programming,
and medication concentrations by using independent double checks with a second individual
• Verifyinganyunusuallylargevolumesordosage
units for a single patient dose
• Verifying verbal orders by “reading back” the
complete order to the prescriber
• Familiarizingoneselfwiththemethods of drug
administration: oral syringes that are unable to be
connected to IV ports, smart pumps, unit dosing,
oral measuring devices in metric system
• Listeningtothepatient,parent,orothercaregiver
• Asking questions as to whether a drug should
be administered—for example, discontinuing
antibiotics after negative laboratory findings,
including cultures in an asymptomatic neonate
• Maintaining familiarity with the operation of
administration devices and the potential for
errors with such devices
METHODS OF
ADMINISTRATION
Once a clinician orders a medication and the
drug and dose are found to be appropriate for
that particular infant, the nurse’s challenge is to
administer the medication correctly. The follow-
ing section addresses methods that help improve the
accuracy of drug delivery.
estimate of the amount lost. For infants receiving oral
medications, documenting the color of the emesis
or residual material helps determine the presence
of medications that have a distinctive color.
If an infant is bottle-fed, it is not recommended
to put the medication in the full bottle. The concern
is that if the infant fails to take the whole volume, he
or she has not received the full dose. One option is
to gently introduce very small portions of a dose into
the cheek pouch and wait for the infant to swallow.
Another method is to put 5 to 10 mL of a feeding, with the medication, in a small bottle and let
the infant take that amount, then continue with
the remainder of the feeding. The medication
also may be placed into a nipple with a small volume of feedings and then offered to the infant.
For breastfeeding infants, medications may be administered into the mouth as described previously, with
or without a small volume of expressed breast milk.
Intramuscular Administration
A newborn infant has relatively little muscle mass to
receive injections. When IM injections are nec-
essary, as with vitamin K, the anterior thigh is
the site of choice. Comfort measures should be
given before and after the injection (see Chapter
12). For an infant weighing less than 1500 grams, the
volume injected into one leg should not exceed 0.5
mL. The final step is to document the administration.
Oral Administration
It must be noted that all oral medications should be
prepared and administered using only oral syringes
and oral orogastric (OG) or nasogastric (NG) tubing. These oral syringes and tubing do not allow
oral medications to be given inadvertently through
an IV line.80 Variations in oral bioavailability and unan-
ticipated and unmeasurable loss of the drug complicate
the administration of oral medications to newborns.
Loss of medication occurs when infants regurgitate or
require gastric suctioning and lose residual fluid that
may include medication. If an infant is receiving
OG or NG feedings, the medication should be
placed into the center of the barrel of a syringe
containing a small portion of the feeding to dilute
the medication, thereby decreasing the osmolality
of the medication and, subsequently, increasing the
tolerance. The nurse should document drug adminis-
tration attempts and any possible loss of drug, with an
Intravenous Administration
IV medications can be given by push or pump
infusion. Although drugs directly enter the
bloodstream, the time necessary to complete
drug delivery to receptors is a function of dosage volume, IV flow rate, and injection site
(depending on particular IV methods).87 Failure
to recognize these potential time lags could result in
inappropriate expectations of the timing of physiologic responses and peak and trough concentrations.
Certain drugs should either be avoided or cautiously administered into the umbilical vein or
artery, and drug incompatibilities should be recognized before setting up multiple medications
through the same IV line. Appropriate flushing is
necessary, especially in between intermittent medications that are incompatible. Careful monitoring for
infiltrates and knowledge of drug-specific treatments
for this complication are essential to safe IV drug
UNIT TWO Support of the Neonate244
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administration. Some medications require central
venous access to safely administer medications,
and stable access may be required before administration. Continuous IV infusion of vasopressors is
common in the NICU, and because of their rapid
clearance and physiologic importance, these infusions should never be interrupted or given by bolus
without orders. A sudden influx of potent medica-
tion and flushes to clear lines with continuous infusions of sympathomimetic amines should be avoided.
PUSH INJECTION
IV push medications must be mixed in appropriate volumes, delivered through appropriately sized syringes,
and followed with an appropriate flush solution.
The IV port closest to the patient should
be used to administer an IV push injection.
Administer a small volume of the appropriate
flush solution, and then administer the medication over 1 to 2 minutes. Slow IV push rates
must be specified by the ordering clinician. A
post-medication flush is given at the same rate
as the medication to clear the line of remaining
medication. IV push administration of many
medications used in the NICU is contraindicated
because of the possibility of immediate adverse
reactions associated with rapid bolus injections.
Opioids and sedatives should be given with
great care and constant attention to respiratory
and cardiovascular parameters. Check a pharmacology reference for any uncertainty.
INTRAVENOUS INFUSION ON THE PUMP
To avoid delay of drug delivery, two methods
of pump infusion using a mechanical infusion
device allow control of drug amount and delivery rate. These devices consist of a pump that can
be set to deliver a specific volume over a specific
time, a syringe or other container that holds the
medication or fluid to be delivered, and connecting
tubing to connect the pump to a port for drug
delivery. Because pumps vary by manufacturer and
some may be used in a variety of ways, each NICU
should have a policy to ensure that each staff
member carries out pump infusions in the same
manner.
INTRANASAL ADMINISTRATION
Some medications, such as midazolam or fentanyl, can be given through the intranasal route.
Although the intranasal route of delivery for
these medications has not been approved by
the FDA in neonates, this drug delivery route
has been shown to be useful as a rapid and
less invasive method of administering certain
drugs, especially in neonates who have limited IV
access. The nasal mucosa has a rich vascular bed
that allows rapid absorption of these drugs into
the bloodstream.
OTHER CONSIDERATIONS REGARDING
IV ACCESS AND ADMINISTRATION
Access via Peripherally Inserted Catheters (PICCs) or
Peripheral Intravenous Lines (PIVs). PICCs have been
used in the neonatal world for more than 30 years.
PICC use has decreased mortality and morbidity
and optimized care for infants requiring prolonged stable access for parenteral nutrition or
IV pharmacotherapies. PICCs have proven to be
a reliable, safe method to deliver medications
and fluids with high osmolarity.60 Training for
PICC placement is accomplished through specialized courses that adhere to strict sterile techniques.
IVs may be placed by a bedside nurse without the
specific training course that is needed to place a
PICC. Common sites for IV placement in neo-
nates include the hands, feet, arms, legs, or
scalp veins. A trans-illuminator or ultrasound
machine36 may help locate vessels in extremities. Always use nonpharmacologic comfort mea-
sures and consider local anesthetic or analgesia prior
to attempting access (see Chapter 12).
Some vessels do not provide blood return.
Babies in hemodynamic shock also may not
have blood return. If the needle is thought to be in
the vessel but no blood return is seen, then a small
amount of flushing solution may be injected. If the
needle is not in the vessel, the tissue will swell. If
it blanches, the vessel is most likely an artery.
When securing a line, leave adequate visual
access to the insertion site and allow monitoring for changes in color or edema that indicate
complications such as infiltrates, phlebitis, or
hematomas.
If a medication is to be administered intermittently and the line is not otherwise used, it
may be heparin or saline locked and flushed per
unit protocol with your unit’s standard flush solution. Alternatively, a continuous heparinized fluid
can be infused at a low rate of 0.5 to 1 mL/h to
keep the access patent and can be used as a medication carrier fluid.
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245
COMPLICATIONS OF INTRAVENOUS
THERAPY
Complications of IV therapy include phlebitis,
infiltration, hematomas, chemical burns, compartment syndrome, and emboli.46 Long-term
complications include disfigurement, contractions, and the need for surgical repair or amputation. Frequent (at least hourly) assessment of
IV sites helps reduce, but does not absolutely
prevent, all IV complications (Box 10.3).
Footdrop24 and compartment syndrome, in which
nerves and vessels are damaged by swelling of tissue within a limited space, have been associated
with positioning a footboard along the lateral
aspect of the fibula, with or without an IV infiltration. The use of rolled washcloths as footboards
or extensive padding of IV boards with cotton or
gauze may prevent excessive pressure. Unnoticed
infiltrations may result in significant tissue loss.
Warm soaks are contraindicated because, when
warmed, extravasated fluid may exacerbate
the burn, maceration, and necrosis. In addition,
heat increases oxygen demand in the alreadycompromised tissues.
Elevating the infiltrated area increases venous
and lymphatic drainage, helping to decrease
the edema. Hyaluronidase58 destroys extracellular
barriers, allowing rapid diffusion and absorption
of the infiltrated medication, such as calcium. For
vasoconstrictive substances that extravasate, such as
epinephrine infusion, local use of vasodilators like
phentolamine can aid in reperfusion. Table 10.3 lists
treatment approaches for extravasation.
Clinicians must remain attuned to additional
concerns when administering IV medications.
Medications may require filters or protection
from light sources or may have significant specific gravity osmolarity. A 0.22-micron filter
may provide “cold sterilization” (i.e., remove
particulate matter and bacterial contamination).
Some medications cannot be administered
through a filter because the filter removes the
active ingredient. Medications with a specific
gravity less than that of the IV fluid have a tendency
to accumulate at high points in the IV tubing,
whereas those with a higher specific gravity settle
into low tubing loops, in both cases resulting in
delayed and inaccurate drug delivery.
BOX
10.3
CRITICAL ASSESSMENT
Intravenous Extravasation
PARENT TEACHING/
COMMUNICATION
IV lines in newborns often frighten the newborn’s
• Checkallindwellinglineshourlyforsignsofextravasation.
• Lookforphlebitis,edema,burns,adequacyofperfusiontosite,hard-
nessoftissue,orinammationatneedlesite.
• Forscalpveins,checkdependentsideofheadfortrauma.
parents, especially lines placed in a scalp vein. (Box
10.4). Family members may need reassurance
that an IV catheter/needle, IV fluids, and possi-
bly medications are going into large veins and not
directly into the infant’s brain. Parents may need
TABLE
10.3
DRUG SUPPLIED DOSAGE/ADMINISTRATION COMMENTS
Hyaluronidase(Amphadase)150
units (mL)
Phentolamine(Regitine)5mg/mL
in 1-mL vial
Modified from Roberts RJ: Intravenous administration of medication in pediatric patients: problems and solutions. Pediatr Clin North Am. 1981;28:23-34.
TREATMENT APPROACH FOR EXTRAVASATION
1mL(150units)givenas4or5intradermal0.2-mL
injectionswitha25-gaugeneedlearoundtheperiphery
of the IV extravasation site
0.5mg/mlgivenas4or5intradermal0.2-mL
injectionswitha25-gaugeneedlearoundtheperiphery
of the IV extravasation site
Use with extravasation of hyperosmolar or extreme
pH drugs.
Administerwithin1hourofevent.
Not for use with vasoactive drugs.
Prepare a dilution.
Use with vasoactive drugs.
May be given up to 12 hours after an event.
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encouragement to touch and hold infants when IVs
are in place.
Parents will need assurance that pain assessment and control are part of the caregiver’s
ongoing efforts and are always addressed during
IV placement and maintenance.
Parents need to be aware that venous fragility,
combined with the types of solutions used, can
make the need to restart IV lines and or the need
for multiple sticks per line relatively commonplace.
The potential for infiltration also should be
addressed, and parents should be included in
the effort to monitor the appearance of IV sites
(see Chapter 12).
As for an infant’s treatment, the parents
should be included in conversations regarding pharmacotherapy and nonpharmacotherapy
choices in the NICU. Parents need not know the
details of medication dosage and significant medications within their infant’s treatment regimen. At
discharge, parents need to know the names,
uses, dosages, frequency of administration, and
side effects of each of their infant’s medications
and how to obtain refills. Some medications for
infants are not readily available. Caregivers must
teach parents to administer prescribed medicines,
BOX
10.4
Talk with parent about indwelling lines. Discuss the following:
• Typeofline,purpose,andanylimitationsonholding,handling,or
• Paincontrolmeasuresfortheplacementoflines
• Needforrestartinglines
• Atdischarge: Thenameof themedications,thedosages,purpose,
• Atdischarge:Medicationadministrationandwhattodoiftheinfant
PARENT/CAREGIVER TEACHING
Indwelling Lines for Parents
feeding the infant
routes,andanypotentialsideeffects
does not receive the full dose of medication
and parents must demonstrate the parent’s ability
to safely and reliably draw up liquid medications
using syringes and administer the prescribed doses
to the infant. The parents need to receive writ-
ten drug information instructions, which may
be developed by the unit for their families or
may be commercially available. Instructions
must include the name of the medication,
treatment indications, dose, route of administration, dosage schedule, and potential side
effects.
Name:
Date of birth:
Drug Strength Dose Route Amount to administer
Epinephrine
Atropine
Volume expanders
Signature of preparer
FIGURE 10.4 Calculationsforneonatalresuscitationmedications.Otherdrugsanddosagescouldbeadded.ET, Endotracheal; IV, intravenous.
1:10,000
0.1 mg/mL
NEONATAL RESUSCITATION MEDICATIONS
Weight:
ET tube size:
0.1 mL/kg
0.1 mL/kg
10 mL/kg
IV, ET
IV
IV
Suction depth:
CHAPTER 10 Pharmacology in Neonatal Care
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