PHENYTOIN

DESCRIPTION AND INDICATION FOR USE

Phenytoin is an anticonvulsant drug.its primary site of action appears to be motor cortex. Where the
spreading of seizure activity is inhibited. The precise mechanism of anticonvulsant activity has not
been determined.it has a rapid onset of action and highly protein bound.it is used as an
anticonfulsant in the treatment of neonatal seizures unresponsive to phenobarbital.

DOSE

Treatment of seizures not controlled by phenobarbitone

Loading dose IV: 15 to 20 mg/dose

Maintenance dose: IV, ORAL

CA < 37 weeks < 14 days 2 mg/kg/dose 12 hrly

> 14 days 5 mg/kg/dose 12 hrly

CA > 37 weeks < 14 days 4 mg/kg/dose 12 hrly

> 14 days 5mg/kg/dose 8 hrly

Commence maintenance dose 12 hours after loading dose.

RECONSTITUTION /DILUTION

Ampoule = 100 mg/2mL(50 mg/ml)

IV: Dilute to at least 5 mg/ml: with draw 1mL of 50 mg/ml.solution and add to 9,0 mL of sodium
chloride 0,9% in a 10 mL syringe = 50 mg in 10 mL withdraw required dose if dose is greater than 50
mg use double quantities.

Diluted solution of 5 mg/mL should be use within 1 hour of preparation.

ROUTE AND METHOD OF ADMINISTRATION

IV loading doses: give slowly over one hour via syringe pump using
guardrails.

IV Maintenace doses: given over at least 15 minutes via syringe pump

using guradrails.

IM administration is not recommended due to pain and possible tissue

Prime line Use minimum volume extension tubing (volume 1mL) prime line
necrosis.Absortion is erratic and delayed.
with preloaded syringe containing exact dose of phenytoin.
6 steps
IV: to infuse
give safely
slowly, at nousing 1. Select the correct medicine to be infused.
greater than 1 mg/kg/minute
Guardrails. 2. Concentration shown 5 mg/mL – No change required.
 3. Weigth of baby: enter weight of baby then press ‘OK’
4. Dose shown in mg/kg/h then press ‘OK’
5. Confirm syringe brand
 Press ‘confirm’ if it is the right syringe OR
 Press ‘Type’ to choose the right syringe brand then
press ‘confrim’.
6. Infuse dose : if all is correct if all is correct to infuse dose
over 1 hour for loading dose and 15 minutes for
maintenance dose.
 Hit? And choose SET VTBI OVER TIME then
press OK.
 Enter actual volume in syringe the press OK.
 Enter duration then press OK
 Press OK to choose STOP infusion when finished.
 It all is correct press green button to start infusing.
Note:1 hour infusion will show the mg/kg/h of actual dose.
15 minutes infusion will show FOUR time the mg/kg/h of
ACTUAL dose.
Draw up 1,5 mL of sodium chloride 0,9% in 10 ML syringe and
Flush the line infuse at the same infusion rate.

SIDE EFFECTS
 Rapid IV infusion may cause
hypotension,arrythmias,bradycardia,cardiovascular,collapse and or respiratory distress
 Vomiting gastric irritation
 Thrombocytopenia,leukopenia,granulocytosis
 Macrocytosis and megaloblastic anemia which respond to folic acid therapy
 Toxicity will cause cardiovascular collapse, CNS deperession or restlessness
 Nystagmus
 Tissue necrosis and inflammation at injection side
 Skin rash drug should be discontinued
 Hypoinsulinaemia, hyperglycaemia, glycosuria
 Long term use: gum, hypertheropy, hirsutism, facial coarsening

CONTRAINDICATIONS
 Heartblock, sinus bradycardia
 Hypoglycemic seizure
 CAUTION in patients with hypebilirubinaemia or jaundice
 CAUTION in patients with renal or hepatic impairment
DRUG INTERACTIONS
Dopamine Combination may result in profound
hypotension,bradycardia,and possibly
cardiac arrest if use together,monitor,blood
pressure and use with EXTREME
CAUTION.
Folid acid,pyridoxine,Rifampicin,and May decrease serum phenytoin levels
chloral hydrate therefore possible loss of effectiveness.
Phenobarbitone Levels may be increased when given
concurrently with penithoin monitor serum
levels of both.
Theophyiline Levels are reduced by phenytoin with
possible loss off effectiveness of both drugs.
Pancuronium Duration of action of pancorium may be
reduced
Frusemide May have reduced diuretic effect
Corticosteroid Metabolism is enhanced by
phenytoin,reducing effectiveness.
Digoxin Serum levels may be decreased,monitor
serum level of digoxin.
Paracetamol High levels of hepatotoxic metabolites may
be produced when use in combination.
Amiodarone May increase serum levels of phenytoin
with phenytoin possibly reducing in the
effectiveness of amidarone.
NURSING RESPONSIBILITIES
 Monitor infant with cardio – respiratory monitor(cardiac rate and rhythm)
 Observe for arythmias during administration
 Record and report effect of drug on seizure activity
 Observe infant for signs of toxicity and side effects
 Monitor infant’s blood pressure
 Observe IV site for phlebitis or tissue inflammation
 Ensure that phenytoin serum levels are monitored,approx. time to steady state 7 days
 Sampel should be taken immendiately before the next dose
 Therapeutic range: 40 to 80 micromol/L

COMPACTIBILILITY INFORMATION
IMPORTANT: Contact pharmacy for drugs not appearing in the table
below.uncommon drugs have simply been omitted and may be incompactible.
Compactib Incompactible
le
Fluids Soidum Glucose 5%,gluocose 10%,PN,intrapillid
chloride
0,9%
(phenytoin
concentrat
ion must
be less
than 6
mg,Ml)
Drugs Not Amikacin,aminophylline,benzylpenisilin,ciprofloxacin,
recommen dobutamine,heparin,insuline,morphine,noradrenaline,po
ded tassium,vanchomysin.
 Y- site Fluconazo
le
Notes: administration of phenytoin with other drugs is not recomneded due to the risk
of precipitation and many incompatibilities.

References:
1. Neofax 16 th Ed.2003 A Manual of Drugs Used in Neonatal care Young
T.Magnum O.
2. Neonatal Pharmacopenia 2nd .Ed 2005 .Pharmacy Departement .The
Royal.Women’s Hospital.Cariton 3053.
3. Australian Injectable Drugs Handbook 2nd Ed society of Hospital Pharmacists of
Austrslia ,1999
4. Neonatal formulary 4 th ed.The Northen Neonatal Network.2003.
5. Manual of Neonatal care 4th E.Cloherty J and Stark A Joint Program in
Neonatology,Boston 1998.

Neonatal protocol
Phosphate
Description and indication for use
Phosphatase deficiency may occur in extremely low birthweight infants (< 1000 g) and
extremely preterm infants (<28 weeks gestation) and may compromise bone development if
not corrected phosphatase supplementation us use in the management of metabolic bone
disease of prematurity and for the treatment of hypophosphatemia. Occasionally growth
restricted preterm infants may require IV phosphatase in addition to IVN solutions this
should be done in consultation with neonatal consultant.
Preparations
Oral solution : 1mmol/mL( as sodium dihydrogen phosphatase 1 mmol/mL
sodium,1mmol/mL phosphatase)
Injection : : 1mmol/mL( as sodium dihydrogen phosphatase 1 mmol/mL sodium,1mmol/mL
phosphatase)
DOSE
Metabolic bone disease prematury
Oral : 2 mmol/kg/day in 2 divided doses
Dose is not adjusted for weight unless phosphatase level is 1.8 mmol/L or ALP > 600 IU/L
Hypoposphaetemia – acute
IV infusion : 1 mmol/kg/dose.repeat dose as required
Hypoposphaetemia – maintenance
IV infusion : 0,5 to 1,5 mmol/kg/day over 24 hours
Dose reduction of at least 50 % is recommended in patients with renal failures
Reconstition/Dilution
Always dilute before intrvenosus administration.
IV Infusions : make up the required dose of sodium dihydrogen phosphatase in compactaible
fluid and dilute according to the table below.
CONCENTRATIO HOW TO FINAL RATE
N DILUTE CONCENTRATIO
N
Sodium dihydrogen 0,5 mmol/kg Infuse over 8 –
phosphatase dilute to 10 24 hours
PERIPHERAL mL/kg
1 mmol/kg 50 MMOL/L
dilute to 20
mL/kg
1.5 mmol /kg
dilute to 30
Ml/Kg
Sodium dihydrogen 0,5 mmol/kg 100 mmol/L Maximum rate
phosphatase dilute to 5 of 0,2
CENTRAL mL/kg mmol/kg/hour
 1 mmol/kg
dilute to 10
mL/kg
1.5 mmol /kg
dilute to 15
ML/Kg

Phosphate
Route and method of administration
Oral: give with feeds
IM,SC,IV Injection: not recomnded
IV Infusion:
 Infuse over at least 8 – 24 hours thourgh a syringe infusion pump maximum rate of
0,2 mmol/kg/hour
 Never push the flush following sodium dihydrogen phosphatase infusion flush at the
same rate as the infusion was given.
SIDE EFFECTS
 Extravasation can cause severe tissue necrosis
 Oral phosphatase may cause loose stools
CONTRAINDICATIONS
 Caution in patients with renal impairment renal excorection of phosphatase isreduced
and dose reduction may be required.
Drug interactions
Calcium Calcium and phosphatase is reduced
absortion of both mineral administer oral
calcium and oral phodpatase supplement at
least 2 hours apart.

Nursing Responsibilities
 Monitoring ALP,calcium and phosphatase level as per the metabolic bone disease of
prematurity guideline or as otherswise indicated by medical staff.
 Monitor sodium(oral solution and intravenous injection contain sodium)
 Monitor renal function
 Administer oral phosphatase at least hours apart from oral calcium
 IV phosphatase must be given in a separate line to IVN solutions
Compatibillty information
IMPORTANT: contact the pharmacticst for medicines not appearing in the table below.
Compactibility informations is for sodium dihydrogen phosphatase

Compactible Incompatible
Fluids Glucose 5 %
sodium
chloride 0,9%
Y- Site Aciclovir,amiodarone,calcium,ciprofloxacin,magnesium,IVN
starter,IVN Maintenace,any other calcium – or magnesium –
containing solutions .

References
1. Australian injectable Drugs Handbook,6 th Edition (online) Victoria
2. Lilley L.Legge D.Paeddiatric Injectable Guideline 5th ed.Flengmington,Vic,The Royal
Children’s Hospital
3. Taketomo CK,Hodding JH,Kraus DM Pediatric & neonatal Dosage Handbook 23th
Ed,Hudson,Ohio American Pharmastic Association Lexicomp,2016.
4. Ryan RSM,Editor BNF for Children,London,BMJ Group,2015.
5. Potassium phosphatase In: micrimedex

PIPERACILIN – TAZOBACTAM
(Tazocin – or Tazopip)

DESCRIPTION AND INDICATIONS FOR USE

Piperacillin is a extended spectrum penicillin.Tazobactam is a beta – lactamase inhibitor
which further extends the spectrum of piperacillin to include many beta – lactamase
producing bacteria normally resistant to it.The combination is eefective against many Gram +
ve and gram – ve aerobic and aeorobic bacteria.

DOSES

Use only following discussion with neonatologist and/ or in consultatition with clinical
microbiologist

Dose ordered according to piperacillin content.

IV: 50 mg/kg/dose

Interval

Age < 7 days :12 hourly

Age > 7 days 6 to 8 hourly

Dose may be increased to 75 mg/kg/dose according to severity of infection and renal

function.

RECONSTITIUTION/DILUTION
Vial: 4 g/500 mg(piperacillin 4 g and tazabactam 500 mg)

IV: Add 16,8 mL of water for injection or sodium chloride 0,9% to the 4 g vial = 4 g in 20
mL= 200 mg/mL.

Withdraw 1 mL of 200 mg/mL solution from vial and add to 9 mL of sodium chloride
0,9% 200 mg in 10 mL.Withdraw required dose.

ROUTE AND METHOD OF ADMINISTRATION

IV Infusion Give slowly over 30 minutes via syringe
pump using guardrails
Prime line Use minimum volume extension tubing ( 1
Volume = 1Ml) prime line with preloaded
syringe containing exact dose of
pipperacilin – tazobactam.
6 steps to infuse safely using Guardails 1. Select the correct medicine to be
infused.
2. Check syringe concertation
matches concentration shown on
pump then press ‘OK’
3. Weight of baby enter weight of
baby then press ‘OK’
4. Dose shown in mg/kg/h then
press ‘OK’
5. Confirm syringe brand:
  Press confirm if it the
right syringe OR
 Press type tp choose the
right syringe then press
OK
6. Infuse dose : to start infusion
over 30 minutes
 Hit?key and choose SET
VTBI OVER TIME then
press OK
 Enter actual volume in
syringe then press OK
 Enter time to infuse
over,check volume and
amount shown is the
same as in syringe then
press OK
 Press OK to choose
STOP infusion when
finished
 If all is correct press
Green button to start
infusing
Note: 30 minutes infusion will show
DOUBLE the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1,5Ml of sodium chloride 0,9% in
a 10 mL syringe and infuse at the same
infusion ratio.

SIDE EFFECTS
 Thrombophlebitis
 GI Tract upset, diarrhoea
 Transient increases in liver enzymes
 Hyperbilirubinaemia
 Transient leukopenia, neutropenia, thrombocytopaenia(and/or eosinophilia)

CONTRAINDICATIONS
 Known hypersensitivity to penicilins
 CAUTION in patients with significants renal impairment
DRUG INTERACTIONS
Pancuronium Prolongationof neuromuscular blockade

NURSING RESPONSIBILTIES
 Asses IV site carefully
  Observe urine output
 Urine test – may give false positive for glucose
 Tazopip contains 2.35mmol per gram of piperacillin: Tazocin contains 2,79 mmol of
sodium per gram of pipreacillin2.
COMPACTIBILTY INFORMATION
IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompactible.

Compactible Incompatible
Fluids Glucose 5 % sodium chloride 0,9% Albumin and blood
products,alkaline solutions
Drugs Aciclovir, amiodarone,
calcium, ciprofloxacin,
magnesium, IVN starter, IVN
Maintenace, any other calcium
– or magnesium – containing
solutions .
Y-Site Calcium gluconate, dexamethasone, dopamine,
fluconazole, frusemide, heparin, hydrocortisone,
magnesium sulphate, metronidazole, milrinone,
morphine, potassium chloride, ranitidine,
zidovudine P,lipid.

References
1.Australian injectable Drugs Handbook,6 th Edition (online) Victoria
2. Lilley L.Legge D.Paeddiatric Injectable Guideline 5th ed.Flengmington,Vic,The
Royal Children’s Hospital
3. Taketomo CK,Hodding JH,Kraus DM Pediatric & neonatal Dosage Handbook 23th
Ed,Hudson,Ohio American Pharmastic Association Lexicomp,2016.
4. Ryan RSM,Editor BNF for Children,London,BMJ Group,2015.
5. Potassium phosphatase In: micrimedex

Neonatal protocol
 Potassium Chloride
Description and indication for use
Potassium chloride is the main intracellular cation and is mainly excreted by the kidneys.it is
essential for transmission of nerve impuls,cardiac,skeleteal,and smooth muscle contraction
and maintenance of renal function.potassium chloride is used in the treatment of
hypokalemia,symtomps of hypokaelemia in the new born include arrythmias,ECG
changes,metabolic alkalosis,hypoventilation,paralysis,paralytic ileus and urinary retention.
Preparations
Injection: 10 mmol(0.75 g) in 10 mL (1mmol potassium/ML)
Mixture : 1 mmol/mL (RWH)
Dose
Acute depeletion (hypokalaemia)
Iv : 0,6 mmol/kg over 3 hours or 0,6 mmol/kg over 1 hour with ECG monitoring then 2
mmol/kg/day to 6 mmol/kg/day as maintenance infusion.
Usual daily requirements
IV :2 to 6 mmol/kg/days a maintenance infusion
Oral: 2 to 3 mmol/kg/day/ in 2 – 4 divided doses given with or after feeds.
Reconstruction/Dilution
Always dilute before administration.An over dose can be rapidly fatal.
IV infusion for acute depletion MUST be diluted strictly according to protocol and given via
Guardrials.
ECG monitoring is required when concentrated potassium infusions (60 mmol/L) are
administrated and/or when potassium is administrated at a rate . 0,5 mmol/kg/hour.
IV Infusion:
Maintenance infusion: maintenance requirements are added to maintenance fluids and given
over a 24 hour period.
For acute depletion; make up 0,6 mmol/kg in glucose 10 % diluted according to the table
below.mix solution thoroughly after dilution to prevent pooling of potassium chloride.in
critical hypokalemic states,soidum chloride 0,9% may be preferred over glucose 10% as an
infusion fluid to prevent insulin mediated movement of potassium into cells.

CONCENTRATIO HOW TO DILUTE FINAL RATE

N CONCENTRATIO
N
Potassium chloride 0,6mmol/kg dilute to 40 mmol/L Infuse final volume
PERIPHERAL 15 mL/kg over 3 hours (0,2
 mmol/kg/hr) OR
over 1 hour
Potassium chloride 0,6 mmol/kg dilute 60mmol/L 0,6 mmol/kg/hr)only
CENTRAL to 10 ml/kg if necessary
Note:the electrolic version of this documents the version currently in use any printed version
can not be assumed to be current please remember to read our disclamer.

Potassium Chloride
For fluid restricted babies only
CONCENTRATIO HOW TO DILUTE FINAL RATE
N CONCENTRATIO
N
Potassium chloride 0,6mmol/kg dilute to 40 mmol/L Infuse final volume
PERIPHERAL 15 mL/kg over 3 hours (0,2
mmol/kg/hr) OR
over 1 hour
Potassium chloride 0,6 mmol/kg dilute 60mmol/L 0,6 mmol/kg/hr)only
CENTRAL to 10 ml/kg if necessary

Maximun concentration of final solution for peripheral infusion: 60 mmol/L

Maximun concentration of final solution for central infusion: 150 mmol/L
Route and method of administration
Oral: give with or after feeds.
IM,SC: not recommded
IV bolus : contraindicated (must be diluted prior to administration)
IV Infusion:
 administer infusions through a syringe infusion pump(Guardrials) – see how to set up
the Pump.
 Remember to reduce maintenance infusions appropriately
 Never push the flush following potassium infusion.flush at the same rate as the
infusion was given.
Side effects
 Hyperkalaemia,hyperchloraemia
 Weakness,flaccid paralysis
 Arryythmias and ECG abnormalities including heart block and cardiac arrest
 Hypotension ininfused too rapidly
 Thrombophlebitis if in adequately diluted
 Vomiting and diarhhoe may occur with oral doses
Contraindications
  Hyperkalaemia
 Undiluted solution administresed intravenously
 Cocncomintant potassium infusions
 Cation in patients with severe renal impairement or oliguria
Frusemide, hypochlortiaze Reduce potassium levels by renal
potassiu lost
Insuline Reduces potassium level by causing
movement of potassium in to cells
Spironolactone Additive effects resulting in increased
serum levels of potassium

Potassium Chloride
Nursing responsibility
 Monitor potassium level when giving diuretics simultaneosusly
 Assess urine output
 Carefully observe for extravasation
 Mix solution thoroughly after diution to prevent pooling of potassium chloride
 Monitor potassium levels 1 hour after the infusion
 Monitor ECG as requsted by medical staff
 ECG changes include ST segment depression /elevation,low voltage or preaked T
waves,appearance of U waves,heart block with widening QRS complex,arrythmia and
cardiac arrest.
Compactibility
IMPORTANT : contact the pharmachist for medicines not appearing in the table
below.

Compactibel Incompactible
Fl Glucose 5 % glucose 10 % sodium Chloride 10 Lipid emulsion 17 %
ui %m
ds
Dr Amoxyllin,amphotericin
ug B,diazepam,eruthromycin
s ,phenytoin,suxamethoniu
m
Y- Acyclovir, adrenaline,
Sit aminiphyline,benzylpenicili,cefotaxime,digoxin,d
e obutamine,dopamine,fluconazole,frusemide,hepar
in sodium,hydrocortisone sodium
succinate,magnesium sulphate,sodium
bicarbonate,vancomycin,PG1,PG2.

References
 1. Taketomo, Hodding and Kraus, Pediatric Dosage Handbook, 17th Ed., 2010
2. Neonatal Formulary: Drug use in pregnancy and the first year of life. 5th Ed,
Massachusetts: Blackwell Publishing Inc. 2007
3. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4th Melbourne: The
Society of Health-System Pharmacists
4. Trissell LA, 2009, Handbook on Injactable drugs, 15th Ed Bethesda, American
Society of Health-System Pharmacists
5. Cloherty J.P, Eichenwald E.C. Stark A.R. 2008, Manual of Neonatal Care, 6th Ed.,
Philadelphia: Lippincott Williams & Wilkins
6. Fary R. Smith R. Davis P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia,
2nd Ed, Melbourne: Pharmacy Department The Royal Women’s Hospital
7. BNF for Children, London: BMJ Publishing Group Ltd, 2005
8. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13th Ed.
Melbourne: Pharmacy Department, Royal Childrens Hospital
9. CMPmedica, MIMSOnline, CMPmedica; Sydney, Australia, 2010 accessed 20/12/10

Neonatal Protocol
 Probiotics
(Labinic)

Description and indication for use

Probioic a live microoganisms that when administered equate members, confer health
benefict probiotic effects are dose condition-west stran specific.

A variety of different probiotic strains and combinations administresedd to preterm infants of

varying gestational ages and birth weights have been shown to significantly reduce the
incidence of necrotising enterocolitis (Bell stage 2 or more), late onset sepsis and all use
mortality in preterm babies.

Probitoc are reported to be safe, in that they were well tolerated in the randomised trials and
late-onset sepsis by administered probiotic species has not been reported.

Whilst the ProPrams trial of 1099 very preterems babies born less than 12 weeks below
1500 g showed a 54% reduction in NEC 2 Bell stage 2 the formulation used in Preterm is not
curently available . Therefore, RWH NISC will use Labinic containtaining pure live strains
of Lactobatus acidhopilus , Bifidobacterium bifidum and Bifidobacterium infantis.

Preparations
Labinic Oral Drop 4 drops (0.16mL) contains, on average:
Lactobacillus acidophil 0.5 x 10 organisms
Bifidobacterium bifidum 0.5x 10 organisms, and
Bifidobacterium infantis 0.5x10 organisms

Dose

In preterm babies born <32 weeks' gestation AND weighing <1500g commence when:

 Tolerating > 1 mL of enteral milli 4 hourly for 12-24 hours AND

 Vertial parental consent has been obtained and documented in the baby a clinical
notes(see appendix A) AND
 TGA SAS category A form has been completed (Appendix B) AND
 Ordered on neonatal medicines chart

Oral: 4 drops once daily. Continue until 34 weeks CA

Dose is inspective of gestation at birth and is not adjusted for current gestation or weight

Withhold dose when nil orally.

See TGA considerars and parental consents together with Appendices A and B

Route and Method of Administration

Oral : Add drops to milk
Shake well before use. Tip gently to allow drop to form

Note: The electronic version of thisdocuments is the version currently in use any printed
version can not be assumed tobe current please remember to read our disclaimer
Side effects
 Abdominal distension
 Vomiting
 Diarrhoea
 Sepsis with probiotics organisms (potential but no reported)
 Hypersensitivity
Contraindications
 Nil orally
 No documented verbal parenteral consent
 Do not mix with feed thicker
 Hypersensitivity to components of the products
Drugs interaction
Antibiotics Concurrent administration of antibiotics
could kill a large number of probiotics
organisms,reducing the efficacy of the
lactobacillus and Bifidobacterium
species.Admministration of antibiotics
should be separated by at least 2 hours.

Nursing responsibilities
 If baby possets or vomits do not redose
 Do not administer within 2 hour of antibiotics
 If aspirate contains blood or bile,follow usual feeding guidelines
 If nil orally or feeds is withheld omit dose(s)
 Maybe mixed with breast milk fortifer and artificial infant formula
 Give dose according to medicines chart,maximum of 6 drops per dose can be
administered
Storage
 Kept at room temperature
 Discard contents 30 days after opening(document date of opening on each bottle)
TGA considerations and parental consent
 Labinic not currently listed on the therapeutic goods administrations (TGA) Austalian
Register of Therapeutic Goods
  Under TGA Authorised Prescriber Scheme which has been endorsed by the RWH
Human Research and Ethics Committees, the neonatal consultans have been
authorized by TGA to prescribe Labinic
 Therefore to prescribe Labinic:
o Provide the parent information sheet (Appendix A) and verbal information to
the parent(s)/ guardian (s)
o Obtain verbal parenteral consent and document in the baby clinical notes
o Complete the TGA SAS Category A form (Apendix B) leave copy in
pharmacy tray in central work room and place the original form in the baby’s
clinical notes.
Transfer to level 2 SCN
 If a nenonate is to be transferred to a level 2 special care nursery prior to 34 weeks
CA and cessation of labinic discuss continuation of the probiotics at the receiving
paediatrian.
 The following should go with the baby at the time of transfer
o Sufficient supply of labinic (until 34 weeks CA)
o A copy of the NISC protocol
o A copy the signed TGA category SAS A form
Safety
Safety will be monitored by
 Blood culture positive sepsis by the probiotics
 Side effects or intolerance that lead to cessation of administration of labinic
Taxonomy of the pribiotic preparation labinic will be confirmed with spesies – specific PCR
and purity by standart microbiologicaly culture techniques for each new batch of labinic.

References
1. Deshpande G, Rao S, Oatike S, Bulsara M. Updated meta-analysis of probiotics for
preventing necrotizing enterocolitis in preterm neonates. Pediatr. 2010; 125(5): 921-
930
2. Alfaleh K, Anabrees J. Bassler D, Al-Kharfi T. Probiotics for prevention of
necrotizing enterocolitis in preterm infants. Conchrane Database Syst. Rev. 2011(3):
CD005496
3. Wang Q. Dong J. Zhu Y. Probiotic supplement reduces risk of necrotizing
enterocolitis and mortality in preterm very-low-birth-weight infants: an update meta-
analysis of 20 randomized, controlled trials. J. Pediatr Surg. 2012; 47 : 241-248
4. Jacobs SE, Tobin JM, Opie GF, Donath S, Tabrizi SN, Pirotta M. Morley CJ, Garland
SM. The ProPrems randomised trial investigating the effects of probiotics on late
sepsis in very preterm infants. PAS Washington 2013 E-PAS2013: 1165.1 and
PSANZ Adelaide 2013
5. Garland SM, Tobin JM, Pirotta M, Tabrizi SN, Opie G, Donath S, Tang MLK,
Morley CJ, Hickey L, Ung L, Jacobs SE. The ProPerms trial: investigating the effects
 of probiotics on late onset sepsis in very preterm infants. BMC Infect Dis.
2011;11:210
6. Hickey L, Jacobs SE, Garland SM, on behalf of the ProPrems Study G. Probiotics in
neonatology Journal of Paediatrics and Child Health 2012;48: 777-83
7. Lin HC, Hsu CH, Chen HL, Chung MY, Hsu JF, Lien R, et al. Oral probiotics prevent
necrotizing enterocolitis in very low birth weight preterm infants: a multicenter,
randomized, controlled trial. Pediatr. 2008; 122:693-700
8. Deshpande GC, Rao SC, Keil AD, Patole SK. Evidence-based guidelines for use of
probiotics in preterm neonates. BMC Med; 9:92
9. Deshpande. Probiotics for preterm neonates – a prospective observational strudy
(POP study). Version 2, May 2011
10. Williams NT. Probiotics. Am J Health Syst Pharm. 2010; 67 (6): 449-458
11. Probiotics for very preterm infants, Royal Hobart Hospital, NPCUI June 2013
12. Probiotics, Infloran, Newborn Services Drug Protocol, Auckland District health
Board, http://www.adhb.govt.nz/newborn/drugprotocols/probiotics.htm.July2012
13. Labinic Paediatric Drop product information Sept 2016
14. NHS Labinic probiotic information pack Oct 2016
PROTAMINE
Heparin agonist
Preparations
INJ 10 mg/Ml
IV preparations and compatilibities
Compactible with G5%, Nacl 0,9%
No dilution required give over 10 mins.
Dose
Treatment of heparin overdose
If< 1 hour since heparin dose
IV STAT: 1 mg/100 units heparin
Subsequent doses 1 mg/kg(max 50 mg)
Notes
Check APTT 15 mins post dos.hypotension bradycardia and flushing may occur with rapid
IV injection.
Protamine has an anticoagulant effect at high dose protamine has an anticoagulant effects at
high doses.
Protamine 1 mg also neutralises the anti thrombin activity of 100 units of enoxaparin and
may partially neutralise the anti Xa factor effects.
Neonatal protocol
Pyridoxine
(Vitamin B6)
Description and indication for use
Pyridoxine (Vit B6) is used in the diagnosis and treatment of pyridoxine dependent seizures a
single dose of 100 mg can stop most pyridoxine dependent clinical seizures within minutes.
A corespondening change in the EEG should also occur but may be delayed by several hours.
Preparations
IV: 100 mg as test close the dose may be repated if necessary
Maintenance doses is given orally if a definite response is seen
Oral: 50 mg tp 100 mg once daily
Reconstitution/dilution
IV : no dilution required
Route and method administration
IV: give slowly over 5 minutes
Side effects
 Irritation at administration site
 Irritability
 Sedation,hypotonia and apnoea
 Hypersensitivity and anaphylactic reactions may occur espesiality if very large dosse
ae administresed intravenously resusutacion facilities must be available and monitor
closely
Contraindications
CAUTIONS in patients with enchephalopaty – muscle relaxation may mask seizures making
assessment difficult
Drug interactions
Phenobarbitone.phenitoin Serum levels may be reduced by pyridoxine
if large doses are use monitor level and
adjust dose if necessary

Nursing responsibilitas
  Monitor respiratory rate heart rate and blood pressure
 Monitor hypotonia,sedation and apnoea
 Observe for and document seizure activity

Compatibility information
IMPORTANT: contact pharmacist for medicines not appearing in the table below.
Compactibel Incompactible
Fliuds Glucose 5 % ,sodium Chloride 0,9 %
Y- site Adrenaline, amikacin, benzylpeniclin, Phenobarbitone, phenytoin,
calcium gluconate cetotaxime, ceftazidime, furosemide, ganciclovir,
dexamethasone, digoxin, dobutamine, indomethachin.
dopamine, erythromycin, heparin, insulin,
magnesium sulphate, midazolam, morphine,
ranitidne, soidum bicarnonate, vancomycin.

References
1. Young T, Mangum B. Neofax 2010. 23rd Ed. New Jersey: Thomson Reuters; 2010
2. Ryan RSM, editor. BNF for children. London: BMJ Group; 2015
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 17th Ed Hudson,
Ohio: American Pharmacists Association. Lexicomp; 2016
4. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First year
of Life. 7th Ed. Chichester, West Sussex: John Wiley & Sons, Ltd; 2015
5. Stockley’s Drug Interactions on Medicines Complete [online via Clinican’s Health
Channel]. Accessed on 2016
6. Paediatric Injectable Guidelines. 5th Ed Melbourne: The Royal Children’s Hospital
Pharmacy Department Australia 2016
7. Australian Injectable Drugs Handbook, 7th Ed., Melbourne: The Society of Hospital
Pharmacists of Australia 2017. Accessed on 30/06/2017
8. Pyridoxine In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral
Compatibility) Greenwood Village, Colorado: Thomson Reuters (Healthcare).
Accessed: 2/06/17
9. Gospe SM Jr. Pyridoxine-Dependent Epilepsy. 2001 Dec 7 [Updated 2012 Jun 7]. In:
Pagon RA, Bird TD, Dolan CR, et al., editors. GeneReviews [Internet]. Seattle (WA):
University of Washington, Seattle; 1993. Available from:
http://www.ncbi.nlm.nih.gov/books/NBK1486/
 PYRIMETHAMINE
Preparations
Tab 25 mg
SUSP 2 mg/mL(RWH)
Dose
Use only following discusions with neonatologist and / or in consultation with clinical
microbiologist.
Treatment of toxoplasma infection
ORAL: 2 mg/kg/day for 2 days then 1 mg/kg/DAY
Duration of treatment to be advised by ID/clinical Microbiologist.

Notes
Give in combination with sulphadiazine
Weekly FBC should be carried out to monitor for thrombocytopenia,leucopenia and
megaloblastic anemia.Folinic acid ( 5 to 10 mg) should be given three time per week
(M,W,F) during treatment.
 RANITIDINE
DESCRIPTION AND INDICATION FOR US

Ranitidine hydrochloride is a histamine H-2 Receptor antagonist and is a potent

inhibitor of gastric acid secretion.it used to reduce gastric acid and prevent ulceration
when there is evidence of gastric bleding or hyperadicity.

DOSE

IV: 1 mg/kg/dose every 6 to 8 hours

ORAL : 2 to 4 mg/kg/dose every 8 to 12 hours

Ampoule : 50 mg in 5 mL (10 mg/mL)

IV : withdraw 0,5 mL of 10 mg/Ml solution and ad to 4,5 mL of sodium chloride 0,9 % in

5 mL syringe = 1 Ml discard excess volume until reqired dose is obtained or withdraw
dose using another syringe.

In fluid restricted patients:

The maximum recommended concentration = 2 mg/mL witdraw 0,5 mL of 10 mg/mL

solution and add to 2 mL in a 5 mL syringe = 5 mg in 2,5 mL =2mg/mL discard excess
volume until required dose is obtained or withdraw dose using another syringe.

ROUTE AND METHOD OF ADMINISTRATION

Risk of bradycardia if infusion rate exceeded
Prime line Use minimum volume extension tubing
(volume = 1Ml) prime ine with preloaded
syringe containing exact dose ranitidine
6 steps to infuse safely using Guardrails 1. Select the correct medicine to be
infused
2. Choose pump concentration and
check it matches syringe
 concentration then press OK
3. Weight of baby enter weight of
baby then press OK
4. Dose shown in mg/kg/h then
press OK
5. Confirm syringe brand:
 Press confirm if it id hr
right syringe OR
 Press type to choose the
right syringe brand then
press confirm

6. Infuse dose: to start infusion over

15 minutes:
 Hit key and choose SET
VTBI over tike athen
press OK
 Enter actual volume in
syringe then press OK
 Enter time to infuse over
check volume and amount
shown is the same as in
syringe then press OK
 Press OK to choose STOP
infusion when finished
 If all is correct press green
button to start infusing
Note : 15 minutes
infusion will show FOUR
– TIMES the mg/kg/h of
ACTUAL dose.
Flush the line Draw up 1,5 mL of sodium
chloride 0,9% in a 10 mL syringe
and infuse at the same infusion
rate.

SIDE EFFECTS
 Bradycardia
 Irritability
 Rash
 GI upset (eg.constipation/diarrhoea,nausea/vomiting)
 Elevated hepatic enzymes, hepatitis(rare)
 Tachycardia, premature, ventricular beats, AV blocks (rare)
 Thrombocytopenia (rare)
CONTRAINDICATIONS
  CAUTIONS: - eliminations of ranitidine is prolonged in patients with renal
impairment
 Bioavability of ranitidine may be increased in patients with hepatic impairment.
DRUG INTERACTIONS
Phenytoin Slight chance that ranitidine may increase
phenytoin levels
Ferrous sulphate Oral absortion of iron may be reduced due
to increased gastric PH separate oral dose
by at least 1 hour
Pancuronium, vecurinium May be less effective when used with
ranitidine

NURSING RESPONSIBILITY
 Monitor for adverse reactions
 Liver and renal function tests may be required
 May cause false positive urine test for protein
COMPACTIBILITY INFORMATION
IMPORTANT: Contact pharmacy for drugs not appearing in the table below,uncommon
drugs have simply been omitted and maybe incompactible.
Compactible Incompactible
Fluids Glucose 5%, glucose 10 % No information
sodium chloride 0,9%
Drugs Adrenaline, amikacin, Amphotericin B
benzylpenicillin, phenobarbiton, phenytoin.
dexamethasone, digoxin,
dobutamine, dopamine,
erythromycin, flucoxacilin,
gentamicin, heparin,
meropenem, potassium,
tobramycin, vancomycin
Y – site Asiclovir, ceftazidime,
fentanceftazidime, fentanyl,
fluconazole, glyceryl
trintrate, midazolam,
morphine, pancuronium,
PN.

References:
1. Young T, Mangum B(2008) Neofax: A Manual of Drugs Used in Neonatal
Care (21ed). Montvale: Thomson Reuters
2. Neonatal Pharmacopoeia 2nd Ed 2005. Melbourne: Pharmacy Department, The
Royal Women’s Hospital
 3. Australian Injectable Drugs Handbook, 4th Ed (2008), Collingwood: The
Society of Hospital Pharmacists of Australia
4. The Northern Neonatal Network (2007) Neonatal Formulary 5th Ed Oxford :
Blackwell Publishing
5. Neonatology 4th edition. T.L Gomella. Lange Medical Books, 1999
6. MIMS Online, last modified September 2007
7. Trissel L. (2009) Handbook on Injectable Drugs. 15th Ed. Bethesda: ASHP
SODIUM POLYSTYRENE SULPHONATE
(RESONIUM A)
DESCRIPTION AND INDICATIONS

Sodium polystryne sulphonate is a cation exchange resin used in the treatment of non – life
theatering hyperkaelemia it has an invitro challenges capacity ofm3,1 mmol of potassium per
gram of resin in vivo this is actually closer to 1 mmolof potassium boun per gram of
resin.sodium polystyrene sulphonste remove potassium from the bodynby exchanging it within
the large intestine for sodium.the efficiency of potassium exchange in unpredictable and
variable.

DOSE

Non life threatening hyperkalaemia

PR: 250 mg/kg/dose 6hrly

Maximum doses of 1 g/kg/doses have been used adjust according to serum electrolyte results

RECONSTITUTION/DILUTION

PR: Insert dose into rectum colon should be irrigated between dose to prevent
impaction of the resin.

ROUTE AND METHODS OF ADMINISTRATION

PR: Insert dose into rectum colon should be irrigated between

dose to prevent impaction of the resin.

SIDE EFFECTS

 Hypokaelemia,hypocalcaemia,hypernatreamia
 Constipation,nausea
 Faecal impaction after rectal administration
CONTRAINDICATIONS

 Serum potassium levels less than 5mmol/L

 Obstructive bowel disease
 Neonates with reduced gut motility NEC

DRUG
INTERACTIONS
Digoxin Toxic effects of digoxin on the heart are
likely to be exaggerated if hypokalaemia
occurs
Magnesium and aluminium hydoxie When used with catioan exchange resins
intestitinal obstruction due to concretions
may occur

NURSING RESPONSIBILITY

 Monitor potassium serum levels at least once daily

 Monitor sodium calcium and magnesium level daily
 Continuously monitor hearth rate and rhytm
 Discontinue if constipation occurs contact medical staff

Notes
 Effective lowering of serum potassium with resonium A may take hour to days
 When hyperkaelemia is life threatening insulin and glucose IV and or sodium
bicarbonate IV should be considrent.

References
1. Neonatal pharmacopecia 2 nd Ed 2005,pharmacy Departement the royal women’s
hospitalcarlton 3053
2. Neonatal formulary 4 th Ed the northem neonatal network 2003.
 RIFAMPICIN
Antibiotic
Preparations
INJ 600 mg
MIXT 100 mg/5mL
IV preparation and compactibilities
Compactible with G5% and further dilute to a concentration of 1 mg/mL withdraw dose and
infusion pump over 1 hour.
Dose
Use only following discussion with neonatologist and or in consultation with clincal
microbiologist.
For serious infections where sensitivities are known
IV,ORAL: 10 mg/kg/dosen24hrly
Neesseria menignitidis prophylaxis
ORAL: 10 mg/kg/dose/24hrly for 4 days

Notes
Oral dose should be given on an empty stomach induces liver enzymes therofer many drug
interactions,may reduce serum levels of
thephyline,dgoxin,dexamethasone,phenytoin,diazepam,and fluconazole.monitor levels of
concomitant drugs in necessary.Brwonish – red discolouration of bodily fluids,including
tears,sweat,urine,faeces and saliva,may occur.
 RIFAMPICIN
DESCRIPTION AND INDICATIONS FOR USE

Rifampicin is a semi syntetic antibiotocs with wide spectrum of antibacterial activity it is used as
adjunctive therapy to treat severe and persistant sthaphylococal infections,including
meningitjs,endocarditis,epidermal abscess,pulmonary infection and septicaemia.it also indicated
for the treatment and retreatment of tuberculosis and prophylaxis of meningococcal
disease.rifampicin is not used as a first line antibiotic in these cases and must only be used as
adjunctive therapy as bacterial resistance develops rapidly.

DOSE

Use only following discussion with neonatologist and or in consultation with clinical microbiologist.

For serious infection where sensitivities known IV ORAL : 10 mg/kg/dose 24 hrly

Neisseria meningitiddis prophylaxis ORAL : 5 mg/kg/dose 24 hrly for 4 dose

Haemophilus influenza Type B prophylaxis ORAL :10 mg/kg/dose 24 hrly for 4 doses

RECONSTITUTION/DILUTION
Vial : 600 mg + DILUENT 10 ML NOT WARD STOCK

IV: to be freshly prepared for use add 10 mL of diluent provident and shake vigorously for at least
30 seconds to dissolve the concentration of this solution is 60mg/mL.

Withdraw 0,5mL of 60 mg/mL solution and add to 29,5 mL of glucose 5 % (OR 1,0 mL to 59mL) in a
50 mL syringe = 30 mg in 300 mL (60mg in 600mL) = 1mg/mL w

ROUTE AND METHOD OF ADMINISTRATION

NOT FOR IM USE
Do not administration through 0,2 micron in
line filters
Prime line Use minimum volume extension
tubing(volume = 1Ml) prime ine with
preloaded syringe containing exact dose
ranitidine
6 steps to infuse safely using Guardrails 7. Select the correct medicine to be
infused
8. Choose pump concentration and
check it matches syringe
concentration then press OK
9. Weight of baby enter weight of
baby then press OK
10. Dose shown in mg/kg/h then
press OK
11. Confirm syringe brand:
 Press confirm if it id hr
right syringe OR
 Press type to choose the
right syringe brand then
press confirm

12. Infuse dose: to start infusion over

15 minutes:
 Hit?key and choose SET
VTBI over tike athen
press OK
 Enter actual volume in
syringe then press OK
 Enter time to infuse over
check volume and amount
shown is the same as in
syringe then press OK
 Press OK to choose STOP
infusion when finished
 If all is correct press green
button to start infusing
Note : 15 minutes
infusion will show FOUR
– TIMES the mg/kg/h of
ACTUAL dose.
Flush the line Draw up 1,5 mL of sodium
chloride 0,9% in a 10 mL syringe
and infuse at the same infusion
rate.

SIDE EFFECTS
 Brownish red or orange discolouration of the skin,urine,sweat,saliva tears and faeces
 GI distrubbances, nausea, vomiting, diarrhoea
  Elevated BUN and serum uric acid
 Thrombocytopenia with or without purpura discontinuous if purpura occurs
 Acute haemolity anemia,eoshinophilia,leucopenia
 Oedema,muscle weaknes and myelophaty
 Acute renal failure
 Shortnes of breath and wheezing
 Overdose may cause liver enlargement and jaundice heparic enzymes may be affected
CONTRAINDICATIONS
 Previous known hypersensitivity to rifampicin
 CAUTION in patients with impaired liver function
DRUG INTERACTION
Rifampicin has many drug interactions the most common are listed below but it is advised
that rug combinations are cheked with the pharmacist.
Dexamethasone Decreased effect due to encahedd
Hydrocortisone metabolism steroid dose may need
adjustement during and after rifampicin
therapy.
Chloramphenicol Serum levels reduced due to increased
metabolism resulting in decreased
chloramphenicol effectivities
Diazepam Clearance of diazepam increased an
increased dose of diazepam may be required
Digoxin Rifampicin significantly reduces digoxin
serum levels which may lead to ineffective
serum level and adjust dosse accordingly.
Fluconazole Reduce effectivite of fluconazole possible
due to enhanced metabolism of fluconazole
an increase in fluconazole an increase in
fluconazole dose may be necessary
Phenobarbitone phenytoin Efectivite of rifampicin may be
compromised due to significantly lowered
serum levels may be reduced,requiring,dose
adjustment with level monitoring
Theopyline Serum levels of theopyline are significantly
reduced due increased metsbolism monitor
levels and adjust dose acrodingly

NURSING RESPONSIBILITIES
 Observe IV site carefully
 Monitor with cardio respiratory monitor
 Monitor BP
 Observe urinary output
 Observe carefully for signs of jaundice
  Protect product from light heat and moisture
 Avoid contact of product with skin (yellowing may occur)
 Record volume on chart as large drug volume
COMPATIBILITY INFORMATION
IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may incompictable.
Compactable Uncompatible
Fluids Glucose 5%,sodium chloride Intralipid, PN
0,9%
Drugs No information Sodium bicarbonate
Y – site Glucose 10 %

Notes : rifampicin induces its own metabolisms the half life

Do not administrater through 0,2 micron in line filters.

References

1. Taketomo, Hodding and Kraus, Pediatric Dosage Handbook, 17th Ed., 2010
2. mNeonatal Formulary: Drug use in pregnancy and the first year of life. 5th Ed,
Massachusetts: Blackwell Publishing Inc. 2007
3. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4th Melbourne: The
Society of Health-System Pharmacists
4. Trissell LA, 2009, Handbook on Injactable drugs, 15th Ed Bethesda, American
Society of Health-System Pharmacists
5. Cloherty J.P, Eichenwald E.C. Stark A.R. 2008, Manual of Neonatal Care, 6th Ed.,
Philadelphia: Lippincott Williams & Wilkins
6. Fary R. Smith R. Davis P (Ed), and Jacobs S (Ed), 2005, Neonatal
Pharmacopoeia, 2nd Ed,
Melbourne: Pharmacy Department The Royal Women’s Hospital
 SALBUTAMOL
DESCRIPTION AND INDICATIONS FOR USE

Salbutamol is a B energic stimulant mainly on the B2 receptors in the bronchial muscle and is used for
its bronchodilator effects.

Salbutamol is also thought to encanche mucoculiary clearance.

DOSE

INH : 1 to 2 puffs every 4 to 6 hours or as necessary

NEB : 0,15 mg/kg up to every 4 hours

DILUTION

Available : 2,5 mg/2,5 mL solution

NEB: dose should be diluted with sodium chloride 0,9% to aid delivery final volume to be
nebulised should be at least 2mL.

ROUTE AND METHOD OF ADMINISTRATION

INH : spacer device must be used when in healer is used.

NEB: via inspiratory line of ventilator circuit ( as perinhalation drug therapy by nebulazation
procedure 9W -04 -2-075

Via face mask

SIDE EFFECTS
 Tacycardia, arrythmia
 Tremor
 CNS stimulation,hyperactivity
 Hypokalaemia
CONTRAINDICATIONS
 Tacycardia (HR > 200 bpm)
 Known paradoxical bronchoconastrictor response to salbutamol
NURSING RESPONSIBILITIES
 Cardiomegaly respiratory monitor
 Contine oxygen if infant is currently receving oxygen
 Ensure nebulizer is hanging vertically to ensure adequate misting
 Asses need suctioning pre and post delivery in ventilated neonates

References:
1. Neofax 12th Ed 1999 A manual drugs used in Neonatal care young T.Magnum O
2. Neonatal pharmacopenia 1th Ed 1998 pharmacy department
3. Neonatal formulary 10th Ed The Northem neonatal network 1998.
Neonatal protocol
Sildefanil
Description and indication for use
Sildefanil is a phosphodiesterase 5 inhibitor which enhances the vasodilator effect of nitrit
oxide and is used in the management of persistent pulmonary hypertension of the new born.
Preparation
Suspension 2,5 mg/mL (RWH)
Dose
Oral: 250 – 500 micrograms/kg every 4 – 8 hours.start with the lower dose and adjust dose
according to response of 2 – 3 mg/kg every 6 hours have been used maximum of 30 mg per
day.
Side effects
 Abdominal distension
 Anaemia
 Hypotension
 Diarrhoea,reflux
 Flushing,oedema
 Dry mouth
Contraindications
 CAUTION inpatients with hypotension
 CAUTON in patients with renal or hepatic dysfunction
Drug interactions
Antihypertensive agent Increase risk of hypotension monitor blood
pressure
Erythromycin,fluconazole Increase the risk of side effects by reducing
 clereance sildenafil

Nursing responsibilities
 Monitor heart rate and blood pressure
References
1. Ryan RSM,editor BNF for children,London: BMJ Group 2015
2. Young T,Mangum B.Neofax 2010 23rd Ed.New Jersey Thomson Reutres;2010

Sodium bicarbonate
Description and indication for use
Sodium bicarbonate is an alkalinising agent used in the treatment of metabolic acidosis due to
bicarbonate loss from the kidneys and gastrointestinal tract or in exchange transfusion or
following prolonged resuscitation which may be associated with lactic acidosis it is also used
in the management of non oliguric hyperkalaemia with peaked T waves of arrythmia on
ECG.
Preparations
Injection: 8,4% (1 mmol/m,of sodium and 1 mmol/Ml of bicarbonate)
Mixture : 1 mmol/Ml(RWH)
Dose
Metabolic acidosis and correction of significant metabolic derangement in exchange
transfusion
IV: give HALF the mmol deficit then review
HALF mmol deficit ; base deficit x weight (kg)
Chronic metabolic acidosis
Oral, IV 1 – 2 mmol/kg once daily. Adjust dose according to response
Non oliguric hyperkalaemia with peaked T waves or arrythmia on ECG
IV: 2mmol/kg/dose
Neonatal resuscitation
IV:1 – 2 mmol/kg/dose
Reconstruction/dilution
IV: dilute 1 : 1 with compatible fluid = 0,5 mmol/mL (4,2%)
Ie: mL of sodium bicarbonate 8.4% with 1mL of compactible fluid
Route and method of administration
Administer via a central line or large vein is recommended do not administer via artrerial
(umbilical or peripheral) catheter.
IV: give slowly over 10 – 20 minnutes
Rapid Ivadministration is not recommended as it may cause sudden osmolar shifts and has
been associated with IVH
Side effects
 Hypocalcaemia, hypokalaemia, hypernatremia
 Rapid IV administration has been associated with IVH
 Extravasion causes tissue necrosis
Contraindications
 Do not administer via arterial (umbilical or peripheral) catheter
 Caution in patients with hypernatremia solutions contains 1 mmol/mL sodium
Nursing responsibilities
 Observe for sign of extravasion
 Monitor routine electrolites to ensure serum sodium within the normal range
Compatibility information
IMPORTANT: Contact the pharmacist for medicines for not appearing in the table below.
Compactible Incompactible
Fliud Glucose 5 % ,sodium
s Chloride 0,9 %
Y- Adrenaline, amikacin, Phenobarbitone, phenytoin, furosemide,
site benzylpenicillin, calcium ganciclovir, indomethacin.
gluconate cefotaxime,
ceftazidime, dexamethasone,
digoxin, dobutamine,
dopamine, erythromycin,
heparin, insulin, magnesium
sulphate, midazolam,
morphine, ranitidine, sodium
bicarbonate, vancomycin.

References
 1. Taketomo, Hodding and Kraus, Pediatric Dosage Handbook, 17th Ed., 2010
mNeonatal Formulary: Drug use in pregnancy and the first year of life. 5th Ed,
Massachusetts: Blackwell Publishing Inc. 2007
2. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4th Melbourne: The
Society of Health-System Pharmacists
3. Trissell LA, 2009, Handbook on Injactable drugs, 15th Ed Bethesda, American
Society of Health-System Pharmacists
4. Cloherty J.P, Eichenwald E.C. Stark A.R. 2008, Manual of Neonatal Care, 6th
Ed., Philadelphia: Lippincott Williams & Wilkins
5. Fary R. Smith R. Davis P (Ed), and Jacobs S (Ed), 2005, Neonatal
Pharmacopoeia, 2nd Ed,
Melbourne: Pharmacy Department The Royal Women’s Hospital

SURFACTANT (PORACTANT ALFA)

Pulmonary surfactant
Preparations
SUSP 80mg phospholipids/mL (Curosurf)
Dose
Respiratory Distress Syndrome
Intratracheal administration by medical staff experienced in surfactant administration or
under supervision of Fellow or Consultant.
Rescue and Prophylaxis
Intratracheal: 100mg/kg stat. May be repeated after 12 hours. A third dose may be given only
after consulting a senior neonatologist.
Notes
DO NOT SHAKE VIAL. Warm to room temperature by removing from refrigeration and
packaging 20mins prior to procedure. Invert vial to obtain a uniform suspension. Administer
only to infants who are endotracheally intubated undergoing mechanical ventilation. See
RWH policy 9W-04-2-121 for full administration procedure. Transient adverse events
include bradycardia, hypotension, ETT blockage and oxygen desaturation. Severe adverse
effects may include pneumothorax.

SUXAMETHONIUM
(Synonyms: Succinylcholine chloride, Choline chloride succinate)

DESCRIPTION AND INDICATION FOR USE

Suxamethonium is an ultra-short-acting depolarising-type neuromuscular blocking agent. It is used to

induce skeletal muscle relaxion for procedures requiring only brief paralysis or muscle relaxation, such
as endotracheal intubation.

Onset of effect after IV administration is approximately 30 to 60 seconds, and lasts for 4 to 6 minutes. 1
DOSE

Skeletal muscle relaxation for short procedures such as ET intubation

IV: 1 to 3mg/kg/dose (0.02 to 0.6mL/kg/dose) repeated when required.

RECONSTITUTION/DILUTION
Ampoule = 100mg in 2 mL = 50mg in 1 mL (kept in the refrigerator)

IV: No dilution
ROUTE necessary OF ADMINISTRATION
AND METHOD
IV: MUST BE ADMINISTERED BY MEDICAL STAFF OR NURSING STAFF WITH MEDICAL STAFF IN
ATTENDANCE

Give as a single dose over 10 to 30 seconds and flush afterwards.

SIDE EFFECTS
 Bradycardia, Hyper/hypotension
 Prolonged respiratory depression, Apnoea
 Hyperthermia
 Hyperkalaemia

CONTRAINDICATIONS

 CAUTION in patients with hyperkalaemia, avoid in patients with severe hyperkalaemia.

 Patients with hypokalaemia or hypocalcaemia may require reduced doses of suxamethonium.

DRUG INTERACTIONS
Amikacin, gentamicin, tobramycin, beta- May enhance or prolong the effects of
adrenergic blockers, phenytoin suxamethonium
Diazepam May reduce duration of neuromuscular
blockage
Amphotericin B, hydrochlorothiazide May increase the effects of suxamethonium,
secondary to induced electrolyte imbalance
Digoxin Increased arrhythmias due to potassium
changes
Neostigmine May prolong the depolarising action of
suxamethonium
 Pancuronium Administration of suxamethonium prior to or
with pancuronium can alter the intensity and/or
duration of neuromuscular blockade.

NURSING RESPONSIBILITIES

 Intubation equipment available and ready

 Cardio/respiratory monitor
 Suction available
 Monitor BP
 Serum potassium may need to be monitored when repeated doses are required as
suxamethonium causes a 0.5mmol rise in plasma potassium2

COMPATIBILITY INFORMATION3,4
IMPORTANT: Contact pharmacy for medicines not appearing in the table below.
Uncommon medicines have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5%, glucose 10%, Alkaline solutions
sodium chloride 0.9%
Drugs Amikacin, isoprenaline, Phenobarbitone, sodium
morphine sulphate, bicarbonate
noradrenaline
Y-Site Heparin sodium,
hydrocortisone sodium
succinate, potassium chloride
(≤40mmol/L)

References:
10. Taketomo, Hodding and Kraus, Pediatric Dosage Handbook, 17th Ed., 2010
11. Neonatal Formulary: Drug use in pregnancy and the first year of life. 5th Ed,
Massachusetts: Blackwell Publishing Inc. 2007
12. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4th Melbourne: The
Society of Health-System Pharmacists
13. Trissell LA, 2009, Handbook on Injactable drugs, 15th Ed Bethesda, American
Society of Health-System Pharmacists
14. Cloherty J.P, Eichenwald E.C. Stark A.R. 2008, Manual of Neonatal Care, 6th Ed.,
Philadelphia: Lippincott Williams & Wilkins
15. Fary R. Smith R. Davis P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia,
2nd Ed, Melbourne: Pharmacy Department The Royal Women’s Hospital
16. BNF for Children, London: BMJ Publishing Group Ltd, 2005
17. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13th Ed.
Melbourne: Pharmacy Department, Royal Childrens Hospital
18. CMPmedica, MIMSOnline, CMPmedica; Sydney, Australia, 2010 accessed 20/12/10
 TEICOPLANIN
DESCRIPTION AND INDICATION FOR USE

Teicoplanin is a glycopeptide antibiotic, active against Gram-positive aerobic bacteria (e.g.

staphylococci, streptococci) and Gram-positive anaerobic bacteria (e.g. Clostridium bacteria).
Teicoplanin use is restricted to organisms resistant to penicillin therapy, as is vancomycin, but it is also
used for the above organisms that are resistant to vancomycin.

DOSE

Teicoplanin should only be initiated by a consultant microbiologist and/or consultant neonatologist.

IV: loading dose is 16mg/kg then 8mg/kg/day 24-hourly, starting 24 hours after the loading dose.

RECONSTITUTION/DILUTION
Vial = 400mg powder with diluent (3.14 ml Water for Injection).

NB: Overage
ROUTE ANDincluded
METHOD in vialOF
andADMINISTRATION
diluent to allow for complete removal of the correct drug strength
after reconstitution.

IV :

Add entire contents of diluent provided (3.14mL of WFI) to vial. Add diluent slowly down the side wall of
the vial. Roll gently and avoid shaking or a foam may be formed. If foaming occurs, let the vial stand for
15 minutes to allow the foam to settle before dilution.

Take 0.75ml (100mg) and dilute to 10ml with sodium chloride 0.9% = 10mg/ml. withdraw required dose.

ROUTE AND METHOD OF ADMINISTRATION

IV infusion: Give slowly over 30 minutes via syringe pump using Gyardrails
Prime Use Minimum Volume Extension tubing (Volume = 1mL) prime line with
Line preloaded syringe containing exact dose of teicoplanin.
6 steps to 1. Select the correct medicine to be infused
infuse 2. Check syringe concentration’ matches concentration shown on
safely pump then press “OK”
using 3. Weight of baby: enter weight of baby then press “OK”
Guardrail 4. Dose shown in ‘mg/kg/h’ then press “OK”
s 5. Confirm syringe brand:
 Press ‘confirm’ if it is the right syringe OR
 Press ‘Type’ to choose the right syringe brand then press
‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
 Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press
‘OK’
 Enter actual volume in syringe then press ‘OK’
 Enter time to infuse over. Check volume and amount shown is
the same as in syringe then press ‘OK’
 Press ‘OK’ to choose ‘STOP’ infusion when finished
 If all is correct, press ‘Green’ button to start infusing
Note: 30 minutes infusion will show DOUBLE the mg/kg/h of ACTUAL
dose.
Flush the Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the
line sama infusion rate.

SIDE EFFECTS
 Nephrotoxicity
 Ototoxicity
 Thrombophlebitis
 Leucopoenia
 Thrombocytopoenia
 Alterations of liver function
 Adverse effect seem to occur less frequently with teicoplanin compared with other renally toxic
drugs such as aminoglycosides, amphotericin, or non-steroidal anti-inflammatory agents such as
indomethacin.

CONTRAINDICATIONS

 Not indicated for minor infections

 CAUTION in patients with renal impairment
 Ensure close monitoring when giving with other renally toxic drugs such as aminoglycosides,
amphotericin or non-steroidal anti-inflammatory agents such as indomethacin

DRUG INTERACTIONS
Aminoglycoside antibiotics (e.g. gentamicin) Increases the risk of nephrotoxicity and
 ototoxicity when used in conjunction with
teicoplanin. Monitor gentamicin levels, as well
as renal function markers (e.g. creatinine,
creatinine clearance and urine output)
Amphotericin Increases risk of nephrotoxicity
Indomethacin Increases risk of nephrotoxicity, as well as other
non-steroidal anti-inflammatory drugs (e.g.
ibuprofen, ketoprofen)

NURSING RESPONSIBILITIES

 Ensure patency of IV line

 Infuse slowly to avoid flushing of the skin, which may be associated with rapid
infusion
 Visually inspect IV tubing for particulate matter/discolouration
 Observe urine output

COMPATIBILITY INFORMATION
IMPORTANT: Contact pharmacy for medicines not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5%, glucose 4%, Hartmann’s Aminoglycosides,
sodium chloride 0.9%, Sodium Chloride ciprofloxacin
0.18%
Drugs No information No information

Y-Site No information No information

 Thiopentone
DESCRIPTION AND INDICATION FOR USE

Thiopentone is a sulphur analogue of pentobarbitone sodium. It is an ultra-short acting depressant of

the CND, inducing hypnosis and anaesthesia. Occasionally thiopentone is used for the control of seizure
activity when anti-convulsant therapy has been unsuccessful.

DOSE

Therapy to initiated only by or following discussion with consultant neonatologist

Anticonvulsant

Loading Dose

IV : 4mg/kg/dose

Maintenance Dose

IV INFUSION: 2mg/kg/hr

RECONSTITUTION/DILUTION
IV :

Reconstitute
ROUTE AND500mg vial with
METHOD OF20mL of Water for Injection = 25mg/mL
ADMINISTRATION
IV INFUSION:

Withdraw required volume of 25mg/mL solution (as above) and make up to ordered volume with the
infusion solution.

Discard any unused solution 24 hours after reconstitution.

ROUTE AND METHOD OF ADMINISTRATION
IV : Give 25mg/mL solution slowly over at least 5 minutes
IV INF: infuse via syringe pump

SIDE EFFECTS
 Hypotension
 Respiratory depression (usually in highly sensitive patients or in overdose)
 Myocardial depression, cardiac arrhythmias
 Downsiness, prolonged CNS depression
 Involuntary muscle movements have been reported
 Tissue necrosis if extravasation occurs

DRUG INTERACTIONS
Aminophylline May antagonise the effects of thiopentone
Magnesium Sulphate May increase CNS depressant effect
Frusemide, hydrochlorothiazide, May increase risk of hypotension
spironolactone

CONTRAINDICATIONS

 Allergy or hypersensitivity to barbiturates

 CAUTION in hypotension

NURSING RESPONSIBILITIES

 Monitor for hypotension

 Close observation of IV site
 Measure and record urine output

COMPATIBILITY INFORMATION
IMPORTANT: Contact pharmacy for drugs not appearing in the table below. Uncommon
drugs have simple been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5%, Sodium Chloride 0.9% Glucose 10%, intralipid, PN
 Drugs Aminophylline, hydrocortisone, Adrenaline, amikacin,
phenobarbitone, potassium chloride benzypenicillin, calcium,
dobutamine, dopamine,
erythromycin, frusemide,
insulin (neutral), magnesium,
midazolam, morphine,
pancuronium, pethidine,
phenytoin, suxamethonium,
vancomycin
Y-Site Heparin, ranitidine, sodium bicarbonate

NOTES
 IV preparation contains 4.9mmol/1g of sodium
References:

Neonatal Protocol
Thyroxine
Description and indication for use
Thyroxine is a thyroid hormone used for the management of hypothyroidism. Thyroxine is
the medicine of choice for thyroid hormone replacement due to preferential use of thyroxine
by the developing brain, rather than liothyronine (T3).
Preparations
Tablet 50 micrograms (stored in medicine fridge)
Dose
Use only after discussion with paediatric endocrinologist
Oral: 8 – 15 micrograms/kg/dose once daily in the morning.
Adjust dose according to thyroid function tests.
Reconstitution
Oral: Dissolve one 50 micrograms tablet in 10mL of Water for Injection to give a
concentration of 5micrograms/mL.
Withdraw the required dose from the 5micrograms/mL solution.
Prepare a fresh solution for each dose.
Route and Method of Administration
Oral: administer in the morning at least 30 minutes before a feed.
Side Effects
 Side effects are usually associated with excessive doses and correspond to symptoms
of hyperthyroidism, for example: tachycardia, arrhythmia, flushing, tremor, weight
loss, sweating and diarrhoea
 Excessive bone loss may develop in infants treated with excessive doses
Contraindications
 Cardiovascular disorders; risk of arrhythmias
 Hypopituitarism and adrenal insufficiency; risk of acute adrenal crisis if not used in
conjunction with glucocorticoid replacement
Drug Interactions
Calcium, ferrous sulphate Separate from thyroxine by at least 4 to 5
hours, otherwise absorption and
effectiveness of thyroxine is reduced

Nursing Responsibilities
 Monitor thyroid function. Aim to maintain serum thyroxine in the upper half of the
normal range and serum TSH level in the normal range
 Monitor heart rate, blood pressure and for clinical signs of hypo- and hyperthyroidism
 TITARCILLIN/POTASSIUM CLAVULANATE
(TIMENTIN)
DECSRIPTION AND INDICATION FOR USE

Timentin is an antibacterial combination of the semsisyntetic penicillin

antibiotics,titraciclin soidum and the B- lactamase inhibitor,potassium
clavulanate .Titraciklin like other penicillin has a bacterial effects on susceptible bacteria
during active multiplication.The addition of clavulanic acid extends the antibacterial
spectrum of ticarcillin.

DOSE

Use only following dsiscussion with neonatologist and/or it consultation with clinical
microbiologist

Dose is expressed as tircarcilin: IV: 75 mg/kg/dose

Interval

CA< 37 eeks 12 hrly

CA > 37 weeks 8 hrly

RECONSTUTION/DILUTION

Vial: 3 g ticarcillin – 100 mg potassium clavulanate

IV: reconstitute vial with 13 mL of water for injection = 3 mg in 15 mL =200mg/mL

Withdraw 2 mL of 200 mg/mL solution from vial and add to 18 mL of sodium chloride 0,9%
glucose 5 % in a 20 mL syringe = 400 mg in 20 mL withdraw reqired and discard remaining
solution.

If fluid restriction applies a more concentrated solution may be considered but concentration
must not exceed 100 mg/mL
Prime line Use minimum volume extension tubing (volume 1mL) prime line
with preloaded syringe containing exact dose of phenytoin.
6 steps to infuse safely using 7. Select the correct medicine to be infused.
Guardrails. 8. Concentration shown 5 mg/mL – No change required.
9. Weigth of baby: enter weight of baby then press ‘OK’
10. Dose shown in mg/kg/h then press ‘OK’
11. Confirm syringe brand
 Press ‘confirm’ if it is the right syringe OR
 Press ‘Type’ to choose the right syringe brand then
press ‘confrim’.
12. Infuse dose : if all is correct if all is correct to infuse dose
over 1 hour for loading dose and 15 minutes for
maintenance dose.
 Hit? And choose SET VTBI OVER TIME then
press OK.
 Enter actual volume in syringe the press OK.
 Enter duration then press OK
 Press OK to choose STOP infusion when finished.
 It all is correct press green button to start infusing.
Note:1 hour infusion will show the mg/kg/h of actual dose.
15 minutes infusion will show FOUR time the mg/kg/h of
ACTUAL dose.
Draw up 1,5 mL of sodium chloride 0,9% in 10 ML syringe and
Flush the line infuse at the same infusion rate.

Side effects
 Iritability
 Seizures
 GI tract distrubances,severe colitis
 Hypernatremia,leukopenia,neutropenia
 Thrombophlebitis
 Abnormalitic of hepatic and renal function test
CONTRAINDICATIONS
 Cautions in patients with cardiac disease
 Hypersensitivity to penicillin antibiotics

NURSING RESPONSIBILITIES
 Observe injection site carefully
 Monitor sodium level
 Record volume of drug on fluid chart – large volume drug

COMPACTIBILITY INFORMATION
IMPORTANT: contact pharmacy for drugs not appearing in the table below uncommon
drugs have simply been omilted and may incompatible.

Compatible Incompatible f
Fluids Glucose 5 % sodium chloride 0,9% Intralipid,PN
Drugs No information Aminoglucoside,sodium
bicarbonate
Y- site Fluconazole,heparin,insulin,morphin,petidine

References :
1. Neofax 16th Ed 2003 A Manual of drugs used In Neonatal care.Young T Mangum O.
2. Neonatal pharmacopenia 2nd Ed.Pharmacy department,The Royal Womens
Hospital,Carlton 3053.
3. King et al Guide to parenteral admixtures 200
4. Trissel L. Handbook on injectable Drugs 11th Ed.

TOBRAMYCIN
 DESCRIPTION AND INDICATIONS FOR USE

Tobramycin is aminoglycoside antibiotics obtained from cultures of streptomycin

tenebarius ,Tobramycin is bacterial activity and in common with all other aminoglycoside is
primary activite against aerobic gram negative bacilli.Tobramycin is consired more active
than most other aminog;ycoside against pseddudomonas aureuginosa.

Tobramycin ismindicated in the treatment of serious caused bu susceptible micro –

organism.

DOSE

Use only following discussion with neonatologist and or/in consultation with clinical
microbiologist

IV,IM : 5 mg/kg/dose

Interval

Current weight , 1200 g ant post natal age:

< 7 days 48 hrly

8 to 30 days 36 hrly

>30 days 24 hrly

Current weight > 1200 g and post natal age:

< 7 days 36 hrly

>7 days 24 hrly

RECONSTITUTION/DILUTION

Viral : 80 mg in 2 mL(40mg/mL)

IV : withdraw 1 mL of 40 mg/mL solution and add to 19 mL of sodium chloride 0,9% im a 20

mL syringe = 40 mg in 20 mL = 2 mg/mL

IM : No dilution is required to measure dose take 0,5 mL of 40 mg/mL solution and add to
1,5mL of sodium chloride 0,9% in a 5 mL syringe = 20 mg in 2 mL .

ROUTE AND MEETHOD OFF ADMINISTRATION

Prime line Use minimum volume extension tubing
(volume 1mL) prime line with preloaded
syringe containing exact dose of phenytoin.
6 steps to infuse safely using 13. Select the correct medicine to be
Guardrails. infused.
 14. Concentration shown 5 mg/mL – No
change required.
15. Weigth of baby: enter weight of
baby then press ‘OK’
16. Dose shown in mg/kg/h then press
‘OK’
17. Confirm syringe brand
 Press ‘confirm’ if it is the
right syringe OR
 Press ‘Type’ to choose the
right syringe brand then
press ‘confrim’.
18. Infuse dose : if all is correct if all is
correct to infuse dose over 1 hour for
loading dose and 15 minutes for
maintenance dose.
 Hit? And choose SET VTBI
OVER TIME then press
OK.
 Enter actual volume in
syringe the press OK.
 Enter duration then press OK
 Press OK to choose STOP
infusion when finished.
 It all is correct press green
button to start infusing.
Note:1 hour infusion will show the mg/kg/h
of actual dose.
15 minutes infusion will show FOUR time
the mg/kg/h of ACTUAL dose.
Draw up 1,5 mL of sodium chloride 0,9% in
Flush the line 10 ML syringe and infuse at the same
infusion rate.
SIDE EFFECTS
 Ototoxity
 Neprhotoxity
 Increased serum bilirubint
 Electrolyte distrubances
CONTRAINDICATIONS

CAUTIONS in patients with impaired renal function increased dosage interval may be required.

DRUG INTERACTIONS
Vancomysine, aminoglycosides Neurotoxic and nephrotoxic potential of
 tobramycin may be increased when given
concomitantly of sequentially
Frusemide May enhance toxicity of tobramycin
Pancuronium Increased neuromuscular blockade may
occur
Indomethacin, Amphotericin May increase adverse renal effects

NURSING RESPONSIBILITIES

 Monitor urine output

 Serum levels to be taken on the 3rd dose
 Pre-dose (trough) level taken immediately prior to dose
 Therapeutic level: Trough <2mg/L

COMPATIBILITY INFORMATION
IMPORTANT: Contract pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.

Compatible Incompatible
Fluids Glucose 5%, glucose 10%, sodium Intralipid, PN
chloride 0.9%
Drugs Calcium gluconate, clindamycin, Amphotericin,
frusemide, metronidazole, flucloxacillin, heparin,
ranitidine, verapamil imipenem/cilastatin1,
indomethacin, magnesium
salts.
Generally, penicillins and
cephalosporins are
considered incompatible
with aminoglycoside
antobiotics.
Y-Site Acyclovir, amiodarone,
ciprofloxacin, dopamine1,
fluconazole, insulin (neutral),
Metronidazole1, midazolam,
morphine

TOLAZOLINE
(PRISCOL)
DESCRIPTION AND INDICATION FOR USE
Tolazoline is a direct peripheral vasodilator with moderate competitive alpha-
adrenergic blocking activity. It decreases peripheral resistance and increases venous
capacitance. It is sympathomimetic and causes cardiac stimulation. It also causes some
gastrointestinal stimulation due to its parasympathomimetic action. It can also stimulate
gastric acid secretion.
Tolazoline is used in the treatment of persistent pulmonary hypertension of then
Newborn (PPHN) when systemic arterial oxygenation cannot be satisfactorily maintained by
supplemental oxygen and mechanical ventilation.

DOSE
IV: Loading dose: 1 to 2 mg/kg
Infusion: 1 to 2 mg/kg/hour
Note: Gradually decrease dose when ceasing
RECONSTITUTION/DILUTION
Ampoule 100mg in 4 mL (25mg/mL) NOT WARD STOCK
IV infusion: Withdraw the required dose and make up to the ordered volume.
Loading dose may be given from this solution.
ROUTE AND METHODE OF ADMINISTRATION
Infuse through scalp vein, pulmonary artery catheter, or right upper extremity vein.
IV: Loading dose: Give infusion solution slowly over at least 10 minutes
Infuse via syringe pump at prescribed rate.
SIDE EFFECTS
 Flushing of the skin
 Hypotension due to peripheral vasodilatation
 Gastric bleeding, ulceration – Consider the use of an H2 antagonist such as ranitidine
prophylactically
 Hypertension
 Tachycardia, cardiac arrhythmias
 Reversible impairment of renal function, oliguria

CONTRAINDICATIONS
Use with CAUTION in patients with mitral stenosis

INCOMPATIBILITIES
Tolazoline must not be mixed together with the following drugs: Indomethacin
Tolazoline is compatible with the following drugs at the Y-site
Gentamicin Dobutamine Aminophylline Frusemide
Vancomycin Dopamine Calcium gluconate Sodium bicarbonate

COMPATIBLE SOLUTIONS
Suitable infusion solutions include: Sodium Chloride 0.9%
Dextrose 5%
Dextrose 10%
Tolazoline is physically compatible in these solutions
Stability in solution is unknown and tolazoline infusion should be changed every 24 hours

DRUG INTERACTIONS

NURSING RESPONSIBILITES

 Continuously monitor condition and response to therapy

 Monitor BP continuously
 Albumin 5% must be available for severe episodes of hypotension
 Observe IV site carefully
 Measure and record urine output and report any decrease. Continue for 24 hours after
tolazoline infusion ceases or until urinary output is normal
 Four hourly gastric aspirates. Record and report if aspirate is blood stained. Return
normal aspirate to stomach.
TRIMETHOPRIM
Antibiotic
Preparations
TAB 300mg
MIXT 10mg/mL (RWH)

Dose
Treatment and prevention of urinary tract infections
Treatment
ORAL : 5mg/kg/dose daily
Prophylaxis
ORAL : 3mg/kg/dose daily
Notes
Single daily doses to be given at night to maximise urinary concentrations, where
appropriate. Trimethoprim may reduce metabolism of phenytoin and digoxin, leading to
increased levels.

THAM (TROMETHAMINE)
 (tris-hydroxymethyl-amino-methane)
DESCRIPTION AND INDICATION FOR USE
Tromethamine is an organic amine proton-acceptor which upon parenteral administration
attracts and combines with hydrogen ions and their associated acid anions. The resulting
salts are excreted in the urine.
Tromethamine is used in the correction of metabolic acidosis. It is used only when sodium
bicarbonate id not appropriate, for example if the infant is hypernatraemic, or has a high
CO2 level.

DOSE
IV: 1mL/kg of 0.3M solution for every 1mmol/L by which it is desired to lower the base deficit
to a maximum of 10mL/kg

OR

IV: Half correction dose

weight ( kg ) x Base deficit ( mmol per L ) x 1.1

mL of 0.3M solution =
2
this dose calculation includes adjustment for the 10% reduction in buffering capacity due to the
presence of acetic acid to lower the solution pH to 8.6

The total dose should not exceed 10mmol/kg/12 hours.1

THAM solution should be used for more than 24 hours.4

RECONSTITUTION/DILUTION
Vial = 0.3M solution 500mL
No dilution is required
Vial may be kept and used for 24 hours. Store in refrigerator after opening.

ROUTE AND METHOD OF ADMINISTRATION

IV: give slowly. Maximum rate of administration should not exceed 1mL/kg/minute.
Due to the risk of apnoea and respiratory depression, ventilation facilities must be
available.
Administer with caution very slowly to non-ventilated babies.
Infusion via umbilical venous catheter (UVC) should be avoided, due to the risk of severe
necrosis.2

SIDE EFFECTS

 Apnoea, respiratory depression

 Hypoglycaemia
 Hypokalaemia
 Alkalosis
 Transient hypocalcaemia
 Venospasm and thrombosis
 Extravasation may cause tissue necrosis
CONTRAINDICATIONS
 Renal failure
 Anuria
 Chronic respiratory acidosis

NURSING RESPONSIBILITES

 Observe IV site closely for signs of extravasation

 Monitor and record urine output
 Cardio-respiratory monitor
 Monitor blood glucose levels for hypoglycaemia

COMPATIBILITY INFORMATION3
Compatible Incompatible
Fluids Dextrose 5%, dextrose 10%, sodium No information
chloride 0.45%, sodium chloride
0.9%
Drugs No information Benzylpenicillin
Y-Site No information No information

Notes:
 Valganciclovir
(NISC Protocol)
Description and indication for use
Valganciclovir is an L-valine ester prodrug of ganciclovir than is rapidly converted to
ganciclovir after oral administration.
Valganciclovir is used to treat cytomegalovirus (CMV) in babies with established feeds and
is considered in newborns aged ≤ 30 days if any of the following are present:
 CNS involvement: microcephaly, suggestive radiological abnormalities on cranial
imaging
 CSF for CMV PCR is not a routine investigation. However, a positive result is
indicative of CNS involvement
 Chorioretinitis
 Sensorineural hearing loss
 Severe organ disease – bone marrow suppression, colitis, pneumonitis, hepatitis.

Preparations
Oral solution 50mg/mL (100mL)

Dose
Use only following discussion with consultant neonatologist and/or in consultation with
clinical infectious diseases team.
Oral: 16mg/kg/dose every 12 hours
Dose may need to be adjusted for infants with renal impairment
Consult ID for duration of treatment, minimum duration of treatment is 6 weeks.

Reconstitution/Dilution
Oral solution valganciclovir to be made up and dispensed by the NISC pharmacist.
Reconstitute power with Water for Injection (WFI) according to package insert. Store in
refrigerator.

Route and Method of Administration

Oral: Administer with feeds

Side Effects
 Anaemia
 Neutropenia
 Thrombocytopenia
 Renal impairment
 Hepatotoxicity
 GI upset
 Gonadal toxicity
 Twice weekly FBE, U&Es, and LFTs during the first 4 weeks, then every 2-4 weeks
once stable.
Contraindications
 Caution in patients with renal impairment
Drug Interactions
Zidovudine Increased risk of profound
myelosuppression, if possible avoid during
concomitant therapy.

Nursing Responsibilites
 Give with feeds
 Since valganciclovir is considered a potential carcinogen or teratogen, but does not
pose the same risks to staff as ganciclovir. Standard precautions should be used during
administration
 As valganciclovir is converted to ganciclovir in the body and excreted in the urine,
nappies from babies on valganciclovir should be managed as cytotoxic waste during
hospital stay.
 Use soap dan water immediately to wash any accidental contact with skin, if eye
contact rinse immediately with water
 Return any unused valganciclovir oral solution to pharmacy for disposal

References

Vancomycin
Description and indication for use
Vancomycin is a glycopeptide antibiotic derived from Niocardia orientalis organism
(formerly Streptomyces orientales). It is bactericidal against may gram +ve bacteria.
It is used in the treatment of staphylococcal infections caused by organisms resistant to
penicillins, and other organisms as indicated by sensitivity tests. Vancomycin is widely
distributed in body fluids. CSF concentrations in premature infants ranged from 26 to 68% of
serum concentrations.1
Preparations
Injection 500mg
Dose
Treatment of known or suspected hospital acquired infection where MRSA (or proven
severe CONS) is a possible causative organism.
IV: 15mg/kg/dose
Interval
CA < 28 weeks 18hrly
CA ≥ 28 to 36 weeks 12hrly
CA ≥ 37 weeks 8 hrly
Dose adjustment following Therapeutic Drug Monitoring
Dose or dose interval may need to be adjusted where trough levels are outside the 10-15mg/L
range OR if there are concerns regarding side effects or renal impairment. This should be
done in consultation with the NISC pharmacist.
Reconstitution/Dilution
Vial = 500mg (powder for reconstitution)
IV: Add 10mL of Water for Injection to vial = 50mg/mL solution
Withdraw 1 mL of 50mg/mL solution from the vial and add to 9 mL of sodium chloride 0.9%
or glucose 5% in a 10mL syringe = 50mg in 10mL = 5 mg/mL
Discard excess volume to obtain required dose or withdraw required dose using another
syringe.
Route and Method of Administration
NOT BE GIVEN BY IM INJECTION
IV Infusion: Give slowly over 1 hour. Administer infusion via the syringe infusion pump
(Guardrails) – see ‘How to set up the Pump’
Side Effects
 Ototoxicity, nephrotoxicity
  Thrombophlebitis
 Rapid bolus administration may cause hypotension, tachycardia, and rarely, cardiac
arrest.
 Transient neutropenia, rarely thrombocytopenia
 Skin flushing or rash (red man syndrome) is associated with rapid bolus injection
 Hypersensitivity (chills, fever, rash)

Contraindications
 Vancomycin is not indicated for the treatment of minor infections
 CAUTION in patients with renal impairment
 Concurrent use of other ototoxic/nephrotoxic medicines, unless clearly indicated and
closely monitored.
Drug Interactions
Aminoglycoside antibiotics (gentamicin, Increased risk of nephrotoxicity and
amikacin) ototoxicity
Ibuprofen Decreases the renal clearance of
vancomycin. A reduction in dose of
vancomycin may be necessary
Amphotericin Increased risk of nephrotoxicity
Frusemide Increased risk of ototoxicity
Pancuronium, suxamethonium Neuromuscular blockade may be enhanced

Nursing Responsibilities
 Ensure trough blood level is taken immediately before 4th dose
Therapeutic range: 10 to 15mg/L
 Ensure patency of IV. Do not inject IM as vancomycin can cause necrosis
 Infuse slowly to avoid rash, hypotension and thrombophlebitis, which may be
associated with rapid infusion
 Visually inspect IV tubing for particulate matter/discoloration
 Monitor urinary output

Compatibility Information
IMPORTANT : Contact the pharmacist for medicines not appearing in the table below

Compatible Incompatible
Fluids Glucose 5%, glucose 10%,
sodium chloride 0.9%
Y-site Acyclovir, adrenaline, Amphotericin B liposomal,
alprostadil, amikacin, cephazolin, cefotaxime,
calcium gluconate, ceftriaxone, frusemide,
 ciprofloxacin, clindamycin, ganciclovir, heparin,
dexamethasone, digoxin, indomethacin, piperacillin-
dobutamine, dopamine, tazobactam
erythromycin, fentanyl,
fluconazole, insulin,
magnesium sulphate,
meropenem, metronidazole,
midazolam, morphine,
noradrenaline, potassium,
pyridoxine, ranitidine,
sodium bicarbonate,
zidovudine, IVN starter,
IVN maintenance, lipid
emulsion 17%

References

Vecuronium
Description and indication for use
Vecuronium is a non-depolarising muscle relaxant (shorter-acting than pancuronium). It
blocks transmission of motor nerve impulses to the striated muscle receptors causing muscle
relaxation and paralysis.
The onset of action for vecuronium is 1-3 minutes. The duration of action varies with dose
and age but is approximately 20-40 minutes in infants.
Vecuronium is less likely to cause cardiovascular effects and does not release clinically
significant amounts of histamine so may be preferable to pancuronium. It is used for unstable
babies in whom it is desirable that they are not breathing against the ventilator. The desirable
effects of vecuronium are improvement of ventilation and minimisation of fluctuations in
cerebral blood flow.
Preparation
Injection 10 mg (powder for reconstitution )
Dose
IV bolus : 100 microgram/kg/dose.repeat 1 -2 hourly or when necessary.
IV infusion : commence at 1- 2 microgram/kg/minute
Antidote :nesotigime 50 micrograms/kgwith atropine 20 microram/kg.
Reconstitution/Dilution
IV: reconstitute 10 mg vial with 5 mL of water for injection = 2 mg/mL,withdraw 5 mLof the
reconstruction solution and add to 5mL of sodium chloride 0,9% glucose 5 % in a 10 mL
syringe = 1mg/mL
IV Infusion: after reconstruction,dilute required dose to 50 mL with a compactible fliud.

CONCENTRATION HOW TO DILUTE DOSE EQUIVALENT

Vecoronium 3 mg/kg to 50 mL 1 mL/hr= 1
SINGLE microgram/kg/min
Vecuronium 6 mg/ kg to 50 mL 1 mL/hr= 20 microgram
DOUBLE /kg/min

Route and method of administration

IV bolus: administer 5 – 10 seconds.flush the line with sodium chloride 0,9%
IV infusion: administer infusions through a syringe infusion pump (Guardrails) – see ‘How to
set’ up the pump.
Side effects
 Fluids retention due immobility
 Dry eyes
  Heart rate blood pressure may decreases when used with opioids
Contraindications
 Non ventilated patients
 Ventilated babies with no analgesia and or sedation
 CAUTION in patients with enchephalopaty muscle relaxation may make neurological
assessment difficult and mask seizures
 CAUTION in patients with anuria and/or worsening (renal failure )
 CAUTION in significant hepatic impairment
Drug interaction
Aminoglycosides( genatmicin,amikacin,tobr May enchace the action of vecuronium
qmicyn)
Corticosteroid May reduce effectivenes of vecuronium
(dexamethasone,hyrocortison)
Frusemide May alter effectivenes of vecuronium
Magnesium sulphate May potentiate the action of veroconium
Phenytoin May alter effectivenes of vecuronium
Vancomycin May enhance the action of vecuronium

Nursing responsibilities
 Monitor hourly heart rate,blood pressure and oxygenation saturation during muscle
relaxation
 Ensure adequate analgelsia and or sedation
 Remain by the bedside until effects of IV bolus vecuronium are complete or et all
times during the administration of continuous IV infusion
 Ensure use of lubricating eye drops 4 – 6 hourly to avoid corneal drying
 Monitor for renal or hepatic impairment dosage reduction may be necessary
 Consider need for blader chateterisasion if urine output decreases
 Monitor for movement
 Protect vecuronium syringe from light.cover syringe with foil
Compactibilty information
IMPORTANT: contact the pharmacist for medicines not appearing in the table below
Compactible Incompactible
Fluid Glucose 5 %, sodium chloride 0,9%
s
Y- Glucose 10 % , adrenaline, calcium Acyclovir, amphotercin B liposomal,
Site gluconate, dobutamine, dopamine, cefotaxime, diazepam, fursemide,
fluconazole,heparin, insulin, ganciclovir, piperacillin, tazobactam,
metronidazole, magnesium sulphate, phenytoin
midazolam, milrinone, morphine, sulphate,
noradrenalin, ranitidine,sodium
bicarbonate, zidovudine
Note: there is no compactibily information available with glucose 10%

VITAMIN E( D-ALPHA TOCOPHERYL ACETATE)

Preparations
MIXT 15.6 units/0,1 mL ( d-alpha tocopherly acetate)
MIXT Combination
Vitamin E = 102 units/mL
Dose
Chronic cholestasis
ORAL: 50 units/kg/dose ONCE daily
Increase in 50 units/kg/DAY increments to 150 to 300 units/kg/DAY.
Notes
Do not give at same time as iron preparations monitor dose by measurement of serum
vitamin E levels,vitamin E/total blood lipid ratio,and/ or measurement of red blood cell
membrane resistance to peroxidation.
Not longer used for supplementation at RWH NISC.
VITAMIN A (RETINOL)
Reparations
MIXT Combinations
Vitamin A = 2210 units/mL
Vitamin E = 102 units/Ml

Dose
Chronic cholestasis
ORAL : 5,000 to 15,000 units/dose ONCE daily

Notes
Adjust dose according to levels,check level regulary in prolonged therapy.1 unit vitamin A =
0,3 microgram retinol.No commercial preparation containing ,Vitamin A alone is available.
 Vitamin D3
(Cholecalcitenol)
Description and indications for use
Vitamin D is positive regulator in calcium homeostasis.it enhances absorption of calcium
from the small intestine and mobilisation of calcium from the bones. It acts on the kidney to
retain calcium and phosphorus.
Vitamin D is important for supporting a large number of physiological processes, including
neuromuscular function and bone mineralisation.
Preparations
Mixture 1000units/0.2mL
Dose
In all babies <32 weeks or <2kg at birth or breastfed babies whose mother is vitamin D
deficient*, commence:
 When lipid is ceased or baby not on lipid, AND
 Tolerating ≥ 1mL of enteral milk 2 hourly for 12-24 hours
Oral: 500 international units once daily with feed
Vitamin D3 can be initiated and ceased by pharmacist according to the protocol. Pharmacist
should prescribe and/or cease vitamin D3 according to the Medicine Management Guideline.
*For breastfed babies of vitamin D deficient mothers, vitamin D is not routinely required
when:
 Maternal 25(OH)D level of 40-50nmol/L and was supplemented after this level and at
least 8 weeks prior to delivery of baby
 Mother tested within 8 weeks prior to delivery and 25 (OH)D level ≥50nmol/L
Refer to Vitamin D Testing and Management – Maternity Patients and Newborns for more
information.
Notes:
 Continue throughout the first 12 months of life
 On discharge, families are advised to obtain a children’s vitamin D supplement
(containing 400IU of vitamin D3) to be administered until 12 months of age. Families
should be provided with the consumer fact sheet – Vitamin D supplementation for
babies (Appendix A) with sufficient counselling.

VITAMIN K
Fat-soluble vitamin / Coagulation factor
Preparations
INJ 10mg/1mL
INJ 2mg/0.2mL
TAB 10mg
IV preparation and compatibilities
Do not mix with infusion fluids
Dose
Vitamin K prophylaxis (prevention of haemorrhagic disease of the newborn)
IM: Preferred route =. Give as a single dose on day 1 of life
BW < 1.5kg 0.5mg
BW ≥ 1.5kg 1mg
ORAL : May be used as an alternative to IM, but must be given as a THREE-dose regimen
Birth: 2mg
Between day 3 to 5 of life: 2mg
At 4 weeks of life: 2mg
Treatment of Vitamin K deficient haemorrhagic disease
IV: 1mg slowly. Urgent replacement of clotting factors may also be necessary.
Notes
Give IV doses slowly due to risk of anaphylaxis.
Use Konakion MM for oral dosing.

Zidovudine
Description and indication for use
Zidovudine is an antiretroviral medicine that inhibits the replication of the human
immunodeficiency virus (HIV). It is used to prevent vertical transmission in all infants born
to HIV infected women.
Preparations
Injection 200mg/20mL (SAS)
Mixture 10mg/mL
Dose
Infant management should always be in consultation with an ID Physician. The following
doses are recommended for HIV-exposed infants.
IV: 1.5mg/kg/dose

Interval
GA ≤ 34 weeks 12hrly
GA > 34 weeks 6hrly
Oral: GA < 30 weeks 2mg/kg/dose 12hrly
GA 30-34 weeks
< 15 days 2mg/kg/dose 12hrly
≥ 15 days 2mg/kg/dose 8hrly
GA > 34 weeks 4mg/kg/dose 12hrly
A 4-week course of oral zidovudine is recommended for all HIV-exposed infants
Note:
Oral zidovudine should be started as soon after birth as possible, and within 6 hours.
If the infant is unable to tolerate oral administration, the zidovudine prophylaxis regimen can
be administered intravenously.
For intravenous zidovudine verbal parental consent to be obtained and documented in baby’s
clinical notes AND TGA SAS category A form to be completed (Appendix A).
Reconstitution/Dilution
Vial = 200mg/20mL (10mg/mL)
IV Infusion: Withdraw 1mL of 10mg/mL solution and dilute with sodium chloride 0.9% to
5mL = 2mg/mL.
Route and Mehode of Administration
IV Infusion: Administer infusions over 60 minutes through a syringe infusion pump
(Guardrails) –
 see ‘How to set up the Pump’
Side Effects
 Neutropenia, leucopenia and anaemia may occur. Blood counts should be monitored
at 2 and 6 weeks of life. Anaemia in the infant generally resolves within 6 weeks after
stopping zidovudine.
 Liver function tests should be monitored at 2 and 6 weeks
 Vomiting, diarrhoea
 Lactic acidosis
Contraindications
 Avoid in infants with very low neutrophil count (less than 0.75 x 109/L) or low
haemoglobin (less than 75g/L)
Drug Interactions
Acyclovir May increase plasma concentration of
zidovudine, and risk of bone marrow
toxicity
Fluconazole May increase plasma concentration of
zidovudine and increase risk of toxicity
Ganciclovir/valganciclovir Increased risk of profound
myelosuppression, if possible avoid during
concomitant therapy, particularly during
initial therapy of ganciclovir/valganciclovir.
Indomethacin, liposomal amphotericin B May increase risk of toxicity. Monitor renal
function and haematological parameters if
concomitant therapy is needed.
Morphine, paracetamol May result in neutropenia or hepatotoxicity,
especially following chronic therapy
Phenytoin May increase or decrease plasma
concentration of phenytoin, consider
monitoring phenytoin levels.

Nursing Responsibilities
 Observe for side effects
 If the infant vomits > 15 minutes after a dose, give the next dose at the next scheduled
time
 If the infant vomits ≤ 15 minutes of a dose, give another dose if possible. If the infant
is unable to tolerate oral feeds, start zidovudine infusion.
Compatibility Information
IMPORTANT: Contact the pharmacist for medicines not appearing in the table below.
Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9%
Y-Site IVN starter, IVN maintenance,
 acyclovir, amikacin, dobutamine,
dopamine, gentamicin, heparin,
metronidazole, morphine, piperacillin-
tazobactam, vancomycin
Zinc
(Zinc Sulfate)
Description and indication for use
Zinc supplementation in babies with low serum zinc level
Preparations
Zinc Sulfate 50mg/mL (equivalent to elemental zinc 11.3mg/mL)
Dose
ORAL: 1mg/kg/dose once daily (dose as elemental zinc)
Route and Method of Administration
Give dose 1 hour before feed
Side Effects
 Abdominal pain
 Diarrhoea
 Gastric irritation
 Irritability
 Lethargy
 Vomiting
Contraindications
 Hypersensitivity to components of the product
Drug Interactions
Calcium Calcium reduces the absorption of zinc, give oral doses at least 2 hours
apart
Ferrous sulphate Iron reduces the absorption of zinc, give oral doses at least 2 hours
apart
Phosphate Phosphate may reduce zinc absorption, give oral doses at least 2 hours
apart