Formulary
Acetylcysteine
ACETYLCYSTEINE
Indications for Use
Antioxidant in acute liver failure and treatment of paracetamol overdose.
Medication safety issu es
Anaphylactoid reactions have been reported, usually between 15-60 minutes after the start of the infusion. Usually, once an adverse reaction is under control (by stopping the infusion and/or using antihistamines/corticosteroids), the infusion can be restarted at the lowest infusion rate.
Dose
Acute liver failure : Initially 4-8 mg/kg/h by IV infusion.
Paracetamol overdose : Initial loading dose of 150mg/kg administered over 1 hour (3 ml/kg in Glucose 5%), then 50mg/kg over 4 hours (7 ml/kg in Glucose 5%) and then 100mg/kg over 16 hours (14 ml/kg in Glucose 5%).
Presentation
Acetylcysteine injection (Parvolex) containing 200mg/ml in 10ml ampoules.
Preparation (for continuous IV infusion)
Use Glucose 5% preferably. Sodium Chloride 0.9% may also be used.
Acute liver failure : Add 4ml of 200mg/ml injection (i.e. 800mg/4ml) to 46ml of Glucose 5%, this gives a solution with a concentration of 800mg in 50ml (16mg per ml).
Paracetamol overdose :
Dose 1: Prepare a 50 mg/mL solution. Dilute each 10mL ampoule of N-acetylcysteine (200 mg/mL) with 30 mL glucose 5% or sodium chloride 0.9% to give a total volume of 40 mL.
Dose 2: Prepare a 6.25 mg/mL solution. Dilute each 10 mL ampoule of N-acetylcysteine (200 mg/mL) with 310 mL glucose 5% or sodium chloride 0.9% to give a total volume of 320 mL.
Dose 3: Prepare a 6.25 mg/mL solution. Dilute each 10 mL ampoule of N-acetylcysteine (200 mg/mL) with 310 mL glucose 5% or sodium chloride 0.9% to give a total volume of 320 mL.
Administration
Administration ideally through central venous catheter .
Flow rate (ml/hour) = Dose (mg/kg/hour) x Weight (kg) / Concentration of solution (mg/ml)
Adverse Effects
Tachycardia, hypotension, rash, bronchospasm, hypokalaemia.
Note
- Monitor potassium levels.
- Each 10ml of N-acetylcysteine for infusion contains 322.6mg sodium.
- A change of colour of solution to light purple has sometimes been noted and is not thought to indicate significant impairment of efficacy.
Reviewed: August 2020.
Aciclovir
ACICLOVIR
Indications for Use
Treatment for neonatal herpes simplex virus (HSV) and neonatal varicella herpes zoster virus (chickenpox) infections.
Medication safety issues
Zovirax (aciclovir) may be confused with Zyvox (linezolid) and Zithromax (azitromycin).
Dose
Neonatal herpes simplex virus (HSV) infection
- Birth to 3 months: 20mg/kg every 8 hours by IV infusion over 60 minutes.
- Treatment duration is 14 days for skin, eyes and mouth HSV.
- Treatment duration is 21 days for HSV encephalitis or disseminated infection.
Neonatal varicella herpes zoster virus (chickenpox) infection
- Birth to 3 months: 10 to 20mg/kg every 8 hours by IV infusion over 60 minutes.
- Treatment duration is 7 days (given for 10-14 days in encephalitis).
Dose adjustments (in renal impairment)
- Mild renal impairment: give normal dose but increase dose interval to every 12 hours.
- Moderate renal impairment: give normal dose but increase dose interval to every 24 hours.
- Severe renal impairment: give 50% of normal dose and increase dose interval to every 24 hours.
Presentation
Aciclovir may come in powder for solution for infusion (Zovirax) or in an already reconstituted form as a concentrate for solution for infusion (250mg/10ml).
Preparation
If using a dry-powder vial containing (250mg of aciclovir), reconstitute by adding 10ml of water for injection or sodium chloride 0.9% to provide 250mg in 10ml (25mg/ml).
If using an already reconstituted solution for injection, this already contains 25mg of aciclovir per ml.
When the dose has been prescribed, proceed as follows: Further dilute 4 mls (100 mg) of the reconstituted solution with 16 mls of sodium chloride 0.9% or glucose 5% . The resulting solution contains 100 mg in 20 mls (5 mg/ml).
Administration
Intravenous infusion over 60 minutes.
Discard if, before or during infusion, turbidity or crystallisation occurs.
Maintain adequate hydration to prevent the risk of renal damage.
In patients who are fluid restricted, the 25 mg/ml concentrate for solution for infusion can be given undiluted through a CVC only.
Monitoring
- Renal function (especially if used with other nephrotoxic drugs) and liver function.
- Monitor infusion site as extravasation can cause severe inflamation and local ulceration due to alkaline pH.
Side Effects
Nausea, vomiting, reduction in haematological indices (anaemia, thrombocytopenia, leucopenia), rash, fever, convulsions.
Incompatibilities
Blood products, parenteral nutrition.
Aztreonam, Caffeine citrate , Diltiazem, Dobutamine, Dopamine, Meropenem, Morphine Sulphate, Piperacillin-Tazobactam.
Storage of reconstituted product
Discard vials immediately after reconstitution.
Reviewed by David Fitzgerald and Montse Corderroura. March 2021.
Adenosine
ADENOSINE
Indications for Use
Antiarrythmic agent used to terminate supraventricular tachycardia (SVT). Slows conduction through the AV node.
Dose
Neonate to 6 months (by intravenous injection):
- Initial dose 150 microgram/kg by rapid IV injection (into a central or large peripheral vein) followed by IV flush with 2 to 5 ml of NaCl 0.9%.
- Wait 1 minute and if unsuccessful, administer a second 250 microgram/kg dose and wait 1 minute . Always follow each dose with NaCl 0.9% flush.
- If unsuccessful, give a 300 microgram/kg dose.
- Stop at any point on the dosing scale if tachycardia is terminated.
- Estimated serum half-life is 10 seconds.
- If SVT persists after the administration of 300 microgram/kg, contact cardiology.
- Other IV antiarrhythmic drugs should only be given following consultation.
- Consider 400 microgram/kg of adenosine or synchronised DCCV.
Presentation
Adenocor 6mg adenosine in 2ml vial.
Preparation
For doses < 600 micrograms (0.2 ml), take 1 ml (3,000 micrograms) of injection and dilute with 9 ml of NaCl 0.9%. This gives a solution with a concentration of 300 micrograms/ml. Withdraw the required dose, use immediately and follow with 2 to 5ml flush with NaCl 0.9%. Solution should be clear at the time of use.
Doses for larger babies can be measured and administered without dilution.
Administration
Inject into a central or large peripheral vein by rapid IV push over 2 seconds. Follow with a rapid IV flush of NaCl 0.9%
Monitoring
Blood pressure and ECG monitoring required.
Side Effects
Dyspnoea, recurrence of SVT (in approximately 30% of treated patients), transient facial flush, arrhythmia, chest pain, choking sensation, hypotension.
Incompatibilities
Blood products, parenteral nutrition.
Notes
Caffeine is a strong inhibitor of adenosine and should not be prescribed simultaneously.
Storage of reconstituted product
Discard injection immediately after use.
Do not refrigerate as crystallization can occur.
Reviewed by David Fitzgerald and Montse Corderroura. March 2021.
Adrenaline for Neonatal Resuscitation
ADRENALINE FOR NEONATAL RESUSCITATION
Indications for use
Adrenaline (Epinephrine) is a potent stimulator of both alpha and beta adrenoreceptors, increasing both heart rate and contractility (beta 1 effects), peripheral vasodilation (beta 2 effect) and vasoconstriction (alpha effect) . The lower the dose, the more beta effects with systemic and pulmonary vasodilation. The higher the dose, the more alpha effect causing intense systemic vasoconstriction. It is used in acute cardiovascular collapse, mainly for its inotropic action. It is also used to treat systemic hypotension.
Medication safety issues
- Adrenaline/EPINEPhrine, can be confused with ePHEDrine.
- Different concentrations of Adrenaline are available (1:10,000-0.1 mg/ml), (1:1,000-1 mg/ml).
Dose for resuscitation (Adrenaline 1:10,000 pre-filled syringe -0.1 mg/ml-)
IV : 0.1 - 0.3 ml/kg (equivalent to 0.01 - 0.03 mg/kg) of 1:10,000 Adrenaline Minijet by IV push followed by 0.5 to 1 ml flush with NaCl 0.9%.
Via ETT (only while awaiting emergency IV access): 0.5 - 1 ml/kg (equivalent to 0.05 - 0.1 mg/kg) of 1:10,000 Adrenaline Minijet. Because of the higher dose administered endotracheally, a large volume of fluid is administered into the endotracheal tube. Administration should be followed with several positive pressure breaths to distribute the drug throughout the lungs for absorption. There is no need to follow the ET dose with a NaCl 0.9% flush.
Presentation
Adrenaline 1:10,000 prefilled syringe (100 microgram/ml).
Preparation
Draw up volume required from pre-filled syringe. Use 1 ml syringe for IV dose and 3 or 5ml for ETT dose.
Administration
IV : Rapid push, preferably into a large central vein followed by Sodium Chloride 0.9% flush. Repeat every 3 - 5 minutes as required.
Via ETT : Rapid push followed by several positive pressure breaths.
Monitoring
Monitor heart rate, rhythm and blood pressure, blood glucose , urinary output, U&E , limb perfusion and IV site.
Side Effects
Tachycardia, tremor, dyspnoea, hyperglycaemia, tissue necrosis . In higher doses arrhythmias, hypertension, cerebral haemorrhage, pulmonary oedema, hypokalaemia and severe metabolic acidosis may occur.
Incompatibilities
Compatible with amiodarone, caffeine citrate, calcium gluconate, dobutamine, dopamine, heparin, hydrocortisone, milrinone, noradrenaline, potassium chloride, standard TPN (aqueous phase only), vasopressin.
Compatible with fentanyl, midazolam and morphine but only if both drugs are mixed with glucose 5%.
Compatible with furosemide and insulin but only if both drugs are mixed with sodium chloride 0.9%.
Incompatible with blood products, parenteral nutrition (lipid phase), prostin, lignocaine, sodium bicarbonate, phenobarbitone or other alkaline solutions.
Notes
Adrenaline should not be given intra-arterially because marked vasocontriction may result in gangrene.
Reviewed by David Fitzgerald and Montse Corderroura. March 2021.
Calcium supplementation
CALCIUM SUPPLEMENTATION
Indications for use
To treat hypocalcaemia and hyperkalaemia (prevention of arrhythmias).
Dose and Administration
Hypocalcaemic crisis with seizures, apnoea or tetany: calcium gluconate 2 ml/kg (=0.45 mmol/kg calcium) of 10% injection given slowly IV over 5 - 10 minutes.
Maintenance treatment of hypocalcaemia :
If corrected serum calcium level > 1.6 mmol/L no treatment is required (unless there are symptoms that can be attributed to hypocalcaemia).
If corrected serum calcium level < 1.6 mmol/L give 2.25 ml/kg per day of Calcium Gluconate 10% injection = 0.5 mmol/kg per day of calcium, preferably infused over 24 hours, adjusted according to response. Consider oral route as soon as possible due to risk of extravasation.
If persistent mild hypocalcaemia occurs consider oral supplements of calcium liquid. Dose is 0.25 mmol/kg = 0.5 ml/kg every six hours orally, adjusted according to response.
Hyperkalaemia:
Give Calcium Gluconate 10% 2 ml/kg (=0.45 mmol of calcium/kg) IV slowly over 5 - 10 minutes. **Watch for extravasation and arrhythmia**
NOTE: Check if baby is on Parenteral Nutrition as calcium is usually included in PN order and calcium level can be corrected as PN is infused.
Presentation
Calcium gluconate 10% is available in 10 ml plastic ampoules containing 0.225 mmol (9 mg) of elemental calcium per 1ml.
Calcium oral liquid contains 20 mg of elemental calcium in 1 ml which is equivalent to 0.5 mmol of calcium in 1 ml.
Preparation
Dilute each 1 ml of Calcium Gluconate 10% injection (=0.225 mmol) up to 5 ml with glucose 5% or sodium chloride 0.9%. Final concentration is 0.045 mmol/ml.
Monitoring
- Rapid IV administration can cause bradycardia and arrhythmias. Monitor ECG.
- Stop infusion is heart rate is less than 100 beats per minute.
- Monitor IV site for signs of infiltration.
- Observe IV tubing for precipitates.
- Check calcium levels.
Side Effects
- Bradycardia and arrhythmias.
- Severe tissue necrosis with extravasation - check IV site prior to administration.
- Gastric irritation and diarrhoea with oral administration.
Incompatibilities
Blood products, parenteral nutrition, amphotericin B.
Never add calcium to any solution containing bicarbonate, sulphate or phosphate as precipitation can occur.
Storage
Opened ampoules should be discarded immediately after opening.
Discard reconstituted solution after 24 hours.
Store oral liquid at room temperature.
ACETYLCYSTEINE INJECTION (Parvolex ® )
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ACETYLCYSTEINE INJECTION (Parvolex ® ) |
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Usual Adult Dose |
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Paracetamol overdose: 3 consecutive intravenous infusions receiving a total dose of 300mg/kg over 21 hours. (See adult dosage table )
Treatment of acute hepatic failure not induced by paracetamol (unlicensed indication) Dose: 100mg/kg IV over 16 hours. Repeat dose as required. (Local D&T decision due to risk of anaphylaxis with higher loading dose) Contact specialist liver unit in St. Vincent’s University Hospital as soon as possible for advice. Dosage should be calculated using patients actual weight up to 110kg Obese patients: ceiling weight of 110kg should be used. Pregnant women: use the patient’s actual weight at the time of presentation.
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Available As |
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2g/10ml ampoules (200mg/ml) Concentrate for Solution for Infusion |
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Reconstitution |
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N/A |
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Compatible Infusion Fluid |
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Glucose 5% (first line) Sodium Chloride 0.9% can be used as an alternative |
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Administration |
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Central/ Peripheral |
Central or peripheral (Central line preferable due to high osmolarity - if not available administer via large peripheral vein) |
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Flushing |
Glucose 5% (first line) or Sodium Chloride 0.9% |
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Rate of infusion: See adult dosage table for the Paracetamol Overdose indication ONLY |
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Cautions |
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Side Effects |
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Test
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ACETYLCYSTEINE INJECTION (Parvolex ® ) |
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Usual Adult Dose |
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Paracetamol overdose: 3 consecutive intravenous infusions receiving a total dose of 300mg/kg over 21 hours. (See adult dosage table )
Treatment of acute hepatic failure not induced by paracetamol (unlicensed indication) Dose: 100mg/kg IV over 16 hours. Repeat dose as required. (Local D&T decision due to risk of anaphylaxis with higher loading dose) Contact specialist liver unit in St. Vincent’s University Hospital as soon as possible for advice. Dosage should be calculated using patients actual weight up to 110kg Obese patients: ceiling weight of 110kg should be used. Pregnant women: use the patient’s actual weight at the time of presentation.
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Available As |
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2g/10ml ampoules (200mg/ml) Concentrate for Solution for Infusion |
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Reconstitution |
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N/A |
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Compatible Infusion Fluid |
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Glucose 5% (first line) Sodium Chloride 0.9% can be used as an alternative |
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Administration |
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Central/ Peripheral |
Central or peripheral (Central line preferable due to high osmolarity - if not available administer via large peripheral vein) |
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Flushing |
Glucose 5% (first line) or Sodium Chloride 0.9% |
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Continuous IV Infusion |
(if patient < 40kg use paediatric dosing - see SPC) 1 st infusion: 150mg/kg (max 16.5g) in 200ml over 1 hr. Remove 50mL from a 250mL infusion bag and add the required dose to the remaining 200mL infusion fluid. 2 nd infusion: 50mg/kg (max 5.5g) in 500ml over the next 4 hrs. 3 rd infusion: 100mg/kg (max 11g) in 1L over the next 16hrs . Continued treatment with acetylcysteine (given at the dose and rate as used in the third infusion) may be necessary depending on the clinical evaluation of the individual patient.
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Rate of infusion: See adult dosage table for the Paracetamol Overdose indication ONLY |
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Cautions |
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Side Effects |
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(If any advers reactions develop contact National Poisons Centre (01-8379964) to ensure patient receives adequate treatment of the paracetamol overdose)
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Monitoring |
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Anaphylactoid reaction management:
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References |
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Approval Date: 16/07/2020 Review Date: July 2023 |
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