DRUG THERAPY IN PICU

SPEAKER: Mrs. NEETHU MARIYA MATHEW

TOPICS…
 PHARMACOKINETCIS AND PHARMACODYNAMICS
 DRUG DOSAGES AND CALCULATONS
 DRUG INCOMPATIBILITY
 ANTIBIOTIC STEWARDSHIP
SAFE DRUG ADMINISTRATION-
CHALLENGES
 Lack of data on pharmacokinetics and pharmacodynamics
 Lack of FDA approval for most of the drugs
 Lack of appropriate commercially available drug dosage forms and concentrations
of common drugs
 Inability of patients to communicate with care givers
 Interaction with parents

It was not until the 1970s that the effects of drug on the neonate and young infant was
studied
SKILLS NECESSARY FOR A PEDIATRIC
NURSE
 Dosage calculations
 Dosage form selection
 Specialized drug preparation and administration techniques
 Understanding pharmacokinetics/ pharmacodynamics changes
occurring with age
 Understanding of disease specific conditions affecting drug of choice
and or dose
 Understanding nature of medication errors in pediatric patients
 PHARMACOKINETICS OF THE DRUGS IN
CHILDREN

• Children are more sensitive to drugs than adults - due to organ system
immaturity

• Increased risk for adverse drug reactions

• Young patients show greater individual variation

 ABSORPTION
Gastrointestinal

o Gastric emptying: delayed in infants and reaches adult levels by 6-8 months.

Intramuscular
 During the first few days of life: Slow, Erratic, Delayed absorption

Transdermal absorption: increased during newborn period

 DISTRIBUTIONDISTR

 Blood-brain barrier: Immature at birth. Drugs and other chemicals have relatively

easy access to the CNS.

 Dosage should also be reduced for drugs used for actions outside the CNS if

those drugs are capable of producing CNS toxicity as a side effect.

 METABOLISM
Hepatic metabolism
 The drug-metabolizing capacity of newborns is low.

 Due to reduced metabolism, the doses of drugs such as phenobarbital

and diazepam should be reduced in premature infants.

 From the age of 1 year until puberty, the rate of hepatic metabolism

varies.

Complete liver maturation occurs by 1 year of age.

 EXCRETION EXCRETION

 Significantly reduced at birth due to low renal blood flow, low glomerular filtration,

and low active tubular secretion

 Adult levels of renal function - achieved by 1 year

 In infants if possible avoid use of chloramphenicol and aminoglycosides

 EG: RENAL MODIFIED DOSES

Drugs eliminated primarily by renal excretion must be given in

reduced dosage and/or at longer dosing intervals

9
PAEDIATRIC DOSAGE
APPROXIMATION
DOSING …
Safe pediatric dosages calculated by
Body weight: measured in mg/kg, mcg/kg etc.
Body surface area : measured in m2

Dosage is optimally calculated by using child’s body

weight and appropriate dose in milligram/ kg (mg/kg)
DOSAGE CALCULATION
In case of some drugs( chemotherapy) dosing is based on BSA. The
value can be obtained from either nomograms or by following equation

BSA= HEIGHT*WEIGHT
3600
Approximate dosage for a child =
Body surface area of the child × adult dose
1.73 m²

Dosage is optimally calculated by using child’s body weight

and appropriate dose in milligram/ kg (mg/kg)
MPinson_wi_16 13
 DRUG VOLUME CALCULATION

 FORMULA USED

D(desired dose) WHAT WE WANT

H (amount on hand) in 1 ml WHAT WE HAVE IN 1ML

Eg:-Inj.Amikacin 25 mg
1ml of Amikacin= 250 mg
D(desired dose) / H ( amount in hand ) in 1 ml
D=25 mg H = 250 mg
25 / 250 = 0.01ml
FORMULA FOR CALCULATING DROPS/MT

 Total volume to be infused X Drop factor

Total hour X 60 mins
Drop factor= 60 ( drops / ml)
Eg:- infuse 200ml 5% Dex over 24 hrs
200 X 60 = 8.3 ml/hr
24 X 60
IV FLUID CALCULATION
IV Fluids

• IV fluid maintenance requirements are calculated differently depending

on age, but is always calculated over 24 hrs.

• Neonates up to 28 days usually have their maintenance fluids made

up by adding electrolytes depending on their individual requirements.

• Babies over 28days up to 10Kgs the general formula is 100ml/kg/day.
Eg: 6 month old baby weighs 7.3 kg
100 x 7.3 = 730 ml per 24 hrs. then divide by 24 to get 30ml/hr
 Pediatric Calculations
Ratios Some drugs are expressed as ratios, for example Adrenaline
which comes in two strengths, 1:10,000 and 1:1,000

So what does that mean?

1:10,000 is 1 mg in 10 ml
1:1,000 is 1mg in 1 ml

Example: the dose for cardiac arrest is 10mcg / kg

A child weighs 40 kgs the dose = 400 mcg or 0.4 mg 0.4mg is 4.0 ml of the 1:10,000 or 0.4 ml
of 1:1000
However, this would need further dilution to make it safe to administer so the 1:10,000 dose is pre-mixed
to make it quick and safe to administer in an emergency.
For an Adrenaline infusion the same child would need 0.3 mg/kg of adrenaline made up to a total of 50
ml with suitable diluent.
40 kg x 0.3 = 12mg so,
12 mg = 120 ml of 1:10,000 or 12 ml of 1:1000 which is easier to make up in an infusion in a 50 ml
syringe.
 INFUSIONS..
 All infusion devices are based on ml per hour. If a medication
needs to be infused over 1 hour then the hourly rate will be the
total amount.
 For any other duration the following calculation can be used:

Volume to be infused X60 = rate (ml/hr)

duration in minutes
 Eg: give 165 ml over 20 minutes
165*60= 495 ml
20
So setting the infusion pump to run at 495 ml/hr means the 165
ml will be infused over 20 minutes.
 PERCENTAGES

1. Eg: Mannitol, Sodium Bicarbonate, Dextrose

2. Denotes the strength of the solution, and indicates how many
grams of the medication are in every 100 ml of the solution.

3. A 5% solution has 5 gram per 100ml, A 20% solution has 20

gram per 100ml. We can then work out how many grams are in
the amount of the solution we are using

4. Eg: mannitol comes in 10% or 20% so to give a dose of 6grams

HOW TO ADMINISTER

 Syringe pump
 Burette set
STORAGE OF LEFT OVER DRUGS
DRUG STORAGE TIME

INJ. AUGMENTIN 20 min after reconstitution 4 hrs. after

dilution: 8hrs in fridge
INJ.AMPHOTERICIN B 24 hours: 7days in fridge

INJ.AZITHROMYCIN 24 hours

INJ.CASPOFUNGIN 24 hours

INJ.CEFPERAZONE 24 hrs. in room temperature; 5 days in

fridge
INJ.CEFRIAXONE 3 days in room temperature

INJ.IMIPENEM 4 hrs. in room temperature: 24 hrs. in

fridge
 EMERGENCY DRUGS IN PICU
Drug Dose (IV) Comment
Adenosine 0.1 mg/Kg Give rapidly; No effect in 2 min:
(Max dose: 6 mg) IV 0.2–0.3 mg/Kg (Max dose: 12mg)
Atropine 0.02 mg/Kg IV Max dose: 0.5 mg (child)
(may give ETT) 1 mg (adolescent)
Calcium Chloride 20 mg/Kg IV Give slowly (Max. rate 100 mg/min);
10%** Max dose: 1 Gm/dose
Give in central line if available**
Dexamethasone 0.6 mg/Kg PO/IM/IV Max dose: 16 mg
Dextrose 500 mg/Kg IV 1–2 ml/Kg D50W Child
2–4 ml/Kg D25W Infant
2–3 ml/Kg D10W NICU
Epinephrine (Code) IV/IO*: 0.01–0.03 mg/ Repeat q 3–5 min. for
Kg 1:10,000 conc code
ETT: 0.1 mg/Kg 1:1,000
concentration
 Congestive heart failure
Furosemide 0.5–1 mg/Kg IV Use lower dose in
furosemide naive patients
Adrenal insuffi ciency,
Hydrocortisone 2 mg/Kg IV bolus catecholamine refractory
shock
0.05–0.1 Units/Kg bolus
IV or SQ Diabetic Ketoacidosis
Insulin (regular)
0.05–0.1 Units/Kg/hr (Infusion preferred to bolus dosing)
infusion
May repeat dose in
Lidocaine 2% 1 mg/Kg IV/IO*
10–20 min.
Give over 10–20 min; faster in Torsades de
Magnesium Sulfate 25 mg/Kg IV/IO* Pointes
Max dose: 2 Gm
Status Asthmaticus,
Anaphylaxis
Methylprednisolone 2 mg/Kg IV/IO/IM
Max dose: 60 mg; use
only acetate salt for IM
Use 1 mEq/ml for > 6 months
Sodium Bicarbonate 1 mEq/Kg IV
Use 0.5 mEq/ml for < 6 months
Vasopressin 0.5 units/Kg IV/IO* Max dose: 40 units
 CONTINUOUS INFUSIONS IN PICURUGS in
picunfusions
Drug Dose (IV) Drug Dose (IV)
10 mg/Kg/day for 4–5 days then 0.3–10 mcg/Kg/min
Amiodarone Nitroprusside
5 mg/Kg/day 0.5–2 mcg/Kg/min typical range
Renal dose: 1–3 mcg/Kg/min; 0.02–2 mcg/Kg/min
Norepinephrine**
Dobutamine** β dose 5–10 mcg/Kg/min; 0.01–0.5 mcg/Kg/min typical range
α dose 10–20 mcg/Kg/min 0.1–10 mcg/Kg/min
Phenylephrine**
0.01–1 mcg/Kg/min 0.5–5 mcg/Kg/min typical range
Epinephrine**
0.01–0.5 mcg/Kg/min typical range Cardiovascular support:
Load: 50–75 mcg/Kg IV over 10 minutes 0.05–2 milli–units/Kg/min

Milrinone 0.25–1 mcg/Kg/min Vasopressin** 0.1–0.5 milli–units/Kg/min typical range

0.5–1 mcg/Kg/min typical range Diabetes Insipidus dose:

0.5–20 mcg/Kg/min 1–10 milli–units/Kg/hr
Nitroglycerin
0.5–5 mcg/Kg/min typical range
 ANTIBIOTIC INCOMPATIBILITY

 Drug Incompatibility refers to

interactions between two or more
substances which lead to changes in
chemical, physical, therapeutic
properties of the pharmaceutical
dosage form. 
TYPES OF DRUG INCOMPATIBILITY

1.PHYSICAL: occurs more commonly with multiple additives. Signs: haze,

precipitation, cloudiness, gas formation. LASIX AND MIDAZOLAM
2.therapeutic:occurs when two or more drugs administered concurrently.
CHLORMPHENICOL AND PENCILLIN
3.CHEMICAL: occurs when mixing two drugs changes the potency of their active
ingredients. NORADRENALINE ADDED TO SODIUM BI CARBONATE
 HOW TO PREVENT… TO PREVENT

 Keep a medication compatibility chart handy for reference

 Dangerous incompatibilities can be prevented by a plausibility check regarding

compatibility information, also considering the material used for therapy (e.g.
diluent, IV container, IV lines) and the infusion regimen. 

 Assessment and planning of regimes to avoid mixing of drugs, which have to be

administered separately.

 Individual labeling for each drug preparation.

 Separating the drug doses by time and place. This can include the

rinsing of the infusion system with a neutral IV solution prior to the

application of another drug.

 Consistently checking alternative modes of administration and/or using

multi-lumen catheters.

 Use of appropriate in-line filters can reduce influx of particles which

result from incompatibilities

 Applications to check drug compatibilities eg: micromedex

 ANTIBIOTIC STEWARDSHIP

“The optimal selection, dosage, and duration of

antimicrobial treatment that results in the best
clinical outcome for the treatment or
prevention of infection, with minimal toxicity to
the patient and minimal impact on subsequent
resistance.
NURSES RESONSIBILITIES
 Be patient advocate
 Questioning the medical necessity of urinary cultures
 Ensuring proper techniques when collecting a culture
 0btaining and recording an accurate penicillin drug allergy history
 Encouraging the prompt transition from IV to PO antibiotics
 Initiating an antibiotic timeout
THANK YOU

THANK YOU