Drug Dose.pdf

Aciclovir

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 25 August 2015
Review Date: August 2018
Page 1 of 2

Neonatal Protocol
Description and indication for use
Aciclovir is an anti-viral agent which is used in the treatment of herpes simplex encephalitis and
neonatal herpes simplex and varicella zoster infections with CNS and pulmonary involvement.

Preparations
Injection 250mg/10mL
Tablet 200mg dispersible tablet

Dose

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

IV: 20mg/kg/dose

Interval
CA < 30 weeks 12 hourly
CA ≥ 30 weeks 8 hourly

Consult ID for duration of IV therapy.

Oral suppression after IV treatment: 300mg/m
2
BSA/dose 8 hourly for 6 months
BSA calculator available in http://nicutools.org/MediCalcs/BSA.php3

Consider reducing dose interval if baby has renal impairment.

Reconstitution/Dilution
Ampoule = 250mg/10mL (25mg/mL)

IV: Withdraw 5mL of 25mg/mL solution from ampoule and add to 20mL of Water For Injection
or Sodium Chloride 0.9% in a 50mL syringe = 125mg in 25mL = 5mg/mL.

Mix thoroughly and withdraw required dose.

Route and Method of Administration

Do not give IV preparation orally.
Do not give by IM injection or IV injection as product is highly alkaline.

IV infusion: Give slowly over 1 hour through a syringe infusion pump (Guardrails) – see ‘How to
set up the Pump’.

Oral: Disperse 200mg tablet in 10mL of Water for Injection to give a concentration of 20mg/mL.
Give required dose by oral syringe. Prepare a fresh solution for each dose.

Aciclovir

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 25 August 2015
Review Date: August 2018
Page 2 of 2

Neonatal Protocol
Side Effects
x Phlebitis at IV site. Extravasation may cause skin ulceration
x Rash, urticarial, pruritis
x Acute renal failure, anaemia, thrombocytopenia
x Transient renal dysfunction and crystalluria (minimised by slow infusion and adequate
hydration)
x Neutropenia (may require dose reduction)

Contraindications
x Caution in significant renal impairment. May require extending dose interval.

Drug Interactions

Aminoglycosides (gentamicin,
amikacin, tobramycin) and
vancomycin

May potentiate nephrotoxicity of aciclovir.

Nursing Responsibilities
x Monitor IV site
x Monitor urine output – ensure adequate hydration

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 Amikacin, fluconazole, heparin,
metronidazole, vancomycin, zidovudine
Dopamine, dobutamine, gentamicin, IVN
starter, IVN maintenance, lipid 17%,
midazolam, morphine, phenytoin,
vecuronium

References
1. Young T and Mangum B, Neofax 21
st
Ed, Thomson Reuters, 2010
2. Australian Injectable Drugs Handbook, 6
th
Ed., The Society of Hospital Pharmacists of Australia, 2014
3. Neonatal Formulary 7
th
Ed, The Northern Neonatal Network, BMJ publishing, 2015
4. Paediatric Pharmacopoeia 13
th
Ed, Pharmacy Department, The Royal Children’s Hospital, Parkville 3052
5. Aciclovir: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility). Greenwood
Village, Colorado: Thomson Reuters (Healthcare). Accessed: 12/07/15.
6. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
7. Guidelines for Administration of Intravenous Medications to paediatric Patients 5
th
Ed. 1996 ASHSP
8. Paediatric Injectable Guidelines, 4
th
Ed , 2011, Pharmacy Department, RCH
9. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 13/08/2015.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Adenosine.doc
ADENOSINE

DESCRIPTION AND INDICATION FOR USE
Adenosine is a purine nucleoside endogenous to all cells of the body. It activates specific
receptors on the cell membrane to slow impulse generation in the sinoatrial node (negative
chronotropic effect), impair conduction through the atrio-ventricular node (negative dromotropic
effect) and dilate the coronary arteries. Adenosine has no negative inotropic effects and does not
cause significant systemic hypotension. It can therefore be used safely in infants with impaired
cardiac function.
Adenosine has a rapid onset (response should occur within 2 minutes of the dose) and a short
duration of action, with a serum half-life of approximately 10 seconds.
Adenosine is the drug of choice in the acute treatment of sustained paroxysmal supra-ventricular
tachycardia.

DOSE
IV: 0.05mg/kg/dose.
Dose may be increased by 0.05mg/kg/dose every 2 minutes until tachycardia is
terminated, to a maximum of 0.25mg/kg/dose.
5

RECONSTITUTION/DILUTION
Ampoule = 6mg in 2mL (3mg/mL)

IV Bolus: To be diluted to a 1mg/mL solution to enable measurement of dose.
Withdraw 1.0mL of 3mg/mL solution and add to 2mL of sodium chloride 0.9% in a
5mL syringe = 3mg in 3.0mL = 1mg/mL.
Withdraw required dose.

ROUTE AND METHOD OF ADMINISTR ATION
IV Bolus: TO BE ADMINISTERED BY MEDICAL STAFF ONLY
Give by rapid IV push into a large peripheral vein.
Infuse as close to IV site as possible.
1

Flush immediately with 2.0mL of sodium chloride 0.9%.

SIDE EFFECTS
Flushing
Dyspnoea
Transient arrhythmias may occur between termination of SVT and onset of normal sinus
rhythm
Irritability

CONTRAINDICATIONS
Patients with 2
nd
or 3
rd
degree AV block or sick sinus syndrome

DRUG INTERACTIONS
Theophylline, caffeine Diminish the effects of adenosine by competitive antagonism.
Verapamil Possibility of prolonged bradycardia occurring if adenosine is
used together with high doses of verapamil.
Dipyridamole Protects against degradation and can potentiate the clinical
effects of adenosine.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Adenosine.doc

NURSING RESPONSIB ILITIES
Continuous cardio/respiratory monitoring
Monitor BP

COMPATIBILITY INFORMATION
3

Compatible Incompatible
Fluids Sodium chloride 0.9% No information
Drugs No information No information
Y-Site No information No information

References:

1. Neofax 12
th
Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 10
th
Ed, The Northern Neonatal Network. 1998
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998

RWH Neonatal Intensive and Special Care Nurseries
Adrenaline IV Protocol

ADRENALINE
(Epinephrine – USA)
DESCRIPTION AND INDICATION FOR USE
Adrenaline is a sympathomimetic agent, that acts on α and β adrenergic receptors. Its main effects
include an increase in heart rate, myocardial contractility and conduction velocity. Adrenaline increases
systemic vascular resistance through constriction of the arterioles. It increases blood flow to skeletal
muscle, brain, liver and the myocardium, but decreases renal blood flow.
Adrenaline is used in resuscitation and as a continuous infusion for refractory hypotension or circulatory
collapse not due to hypovolaemia.
DOSE
Resuscitation/Cardiac Arrest
IV: 10 to 30micrograms/kg/dose = 0.1 to 0.3mL/kg/dose of 1:10,000. Dose may be repeated
every 3 minutes PRN

ETT: 50 to 100micrograms/kg/dose = 0.5 to 1mL/kg/dose of 1:10,000. Dose may be repeated
every 3 minutes PRN

Hypotension/Circulatory Collapse
IV Infusion: 50 nanograms/kg/minute to 1000 nanograms/kg/minute. Correct hypovolaemia and
acidosis before commencing adrenaline as an infusion.
RECONSTITUTION/DILUTION
Ampoule: 1 in 10,000 (1mg in 10mL), 1 in 1,000 (1mg in 1mL)

IV, ETT: Use 1 in 10,000. No dilution necessary

IV Infusion: Use 1 in 1,000 (1mg/mL). Add 600microgram/kg (0.6mL/kg of 1:1,000) to infusion solution
to make 50mL. Total volume should equal 50mL.
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Adrenaline
SINGLE
600micrograms/kg to 50mL 1mL/hr = 200nanograms/kg/min
50 nanograms/kg/min to
1000 nanograms/kg/min
Adrenaline
CONC × 5
3mg/kg to 50mL 1mL/hr = 1microgram/kg/min

ROUTE AND METHOD OF ADMINISTRATION
IV, ETT: Give 1 in 10,000 undiluted.
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of adrenaline.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose/amount in syringe then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
(amount and volume shown is the same as in syringe)
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘ng/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

RWH Neonatal Intensive and Special Care Nurseries
Adrenaline IV Protocol

SIDE EFFECTS
x Cardiac arrhythmias (ventricular tachycardia)
x Hypokalaemia
x Tremor
x Severe hypertension and increased risk of intraventricular haemorrhage
x Renal vascular ischaemia with decreased urine output
x Restlessness
x Hyperglycaemia (inhibition of insulin secretion and conversion of glycogen reserves)
x Extravasation causes tissue ischaemia and necrosis
CONTRAINDICATIONS
x Hyperthyroidism
x Hypertension

DRUG INTERACTIONS
Isoprenaline Combination may cause serious arrhythmia
Propranolol Adrenaline ‘resistance’ may occur

NURSING RESPONSIBILITIES
x Cardio/respiratory monitor
x Monitor BP with an arterial line
x Observe IV site carefully for signs of extravasation
x Measure urine output
x Change syringe and tubing every 24 hours.
x Protect from light, cover syringe with foil
x Do not give boluses via the adrenaline
infusion line
x Do not stop or interrupt infusion suddenly,
dose must be weaned slowly

COMPATIBILITY INFORMATION

IMPORTANT: Contact 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
chloride 0.9%
Sodium bicarbonate 5%
Drugs Amikacin, dobutamine, flucloxacillin,
frusemide, ranitidine, verapamil

Benzylpenicillin, calcium chloride, calcium
gluconate, diazepam, digoxin, noradrenaline,
sodium bicarbonate, vancomycin,
Y-Site Amiodarone, caffeine citrate
1
,
dobutamine, dopamine, fentanyl,
glyceryl trinitrate, heparin,
hydrocortisone, midazolam
1
, morphine,
pancuronium, potassium chloride,
ranitidine, vecuronium, PG
1

References:
1. Young T, Mangum B, 2008, Neofax 2008, 21
st
Ed, New Jersey: Thomson Reuters.
2. Fary R, Smtih R, David P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia, 2
nd
Ed, Melbourne:
Pharmacy Department The Royal Women's Hospital.
3. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4
th
Ed., Melbourne: The Society of Hospital
Pharmacists of Australia.
4. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5
th
Ed, Massachusetts: Blackwell
Publishing Inc, 2007.
5. BNF for children, London: BMJ Publishing Group Ltd, 2005.
6. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13
th
Ed, Melbourne: Pharmacy
Department, Royal Childrens Hospital.
7. Trissell LA, 2009, Handbook on Injectable drugs, 15
th
Ed, Bethesda, American Society of Health-System
Pharmacists.
8. Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122;S516-S538.

RWH Neonatal Intensive and Special Care Nurseries
Adrenaline Inhale Protocol

ADRENALINE INHALE
(Epinephrine – USA)
DESCRIPTION AND INDICATION FOR USE
Adrenaline is a sympathomimetic agent, that acts on α and β adrenergic receptors. Its main effects
include an increase in heart rate, myocardial contractility and conduction velocity. Adrenaline increases
systemic vascular resistance through constriction of the arterioles. It increases blood flow to skeletal
muscle, brain, liver and the myocardium, but decreases renal blood flow.
Adrenaline is used in resuscitation and as a continuous infusion for refractory hypotension or circulatory
collapse not due to hypovolaemia.

DOSE
Post extubation Stridor/Bronchospasm
NEB: 0.5mL of 1:1,000/kg/dose every 4 to 6 hours.

RECONSTITUTION/DILUTION
Ampoule: 1 in 10,000 (1mg in 10mL), 1 in 1,000 (1mg in 1mL)

INH: Use 1 in 1,000 (1mg in 1mL). If volume to be nebulised is less than 2mL, make volume up to at
least 2mL using sodium chloride 0.9%

ROUTE AND METHOD OF ADMINISTRATION
INH: Nebulise as directed.

SIDE EFFECTS
Cardiac arrhythmias (ventricular tachycardia)
Hypokalaemia
Tremor
Severe hypertension and increased risk of intraventricular haemorrhage
Renal vascular ischaemia with decreased urine output
Restlessness
Hyperglycaemia (inhibition of insulin secretion and conversion of glycogen reserves)

CONTRAINDICATIONS
Hyperthyroidism
Hypertension

DRUG INTERACTIONS
Isoprenaline Combination may cause serious arrhythmia
Propranolol Adrenaline ‘resistance’ may occur

NURSING RESPONSIBILITIES
Cardio/respiratory monitor
Monitor BP with an arterial line
Measure urine output

References:
1. Young T, Mangum B, 2008, Neofax 2008, 21
st
Ed, New Jersey: Thomson Reuters.
2. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5
th
Ed, Massachusetts: Blackwell
Publishing Inc, 2007.
3. BNF for children, London: BMJ Publishing Group Ltd, 2005.
4. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13
th
Ed, Melbourne: Pharmacy
Department, Royal Childrens Hospital.

RWH Neonatal Intensive and Special Care Nurseries
Alprostadil IV Protocol

ALPROSTADIL (PROSTAGLANDIN E 1)
(Prostin VR
?
)
DESCRIPTION AND INDICATION FOR USE
Alprostadil is a synthetic prostaglandin E1 used to open and/or maintain patency of the ductus arteriosus in early
post-natal life, where a patent ductus is critical for survival (e.g. Pulmonary Atresia, Pulmonary Stenosis, Tricuspid
Atresia and Transposition of the great vessels).
Because the ductus arteriosus rapidly loses its responsiveness to prostaglandin, alprostadil is most effective within
96 hours after birth. Therefore, it is used as palliative therapy until surgery can be performed.

DOSE
To open a closed ductus arteriosus:
IV Infusion: 100 nanogram/kg/minute for 20 to 30 minutes.
Doses greater than 100 nanogram/kg/minute are rarely more effective and may cause serious adverse
effects.

To maintain patency of ductus arteriosus:
IV Infusion: 10 to 20 nanogram/kg/minute

RECONSTITUTION/DILUTION
Ampoule = 500micrograms in 1mL (alcohol as solvent). Refrigerate

IV Infusion: Add 60micrograms/kg to sodium chloride 0.9% to a total volume of 50mL.

If dose ordered is not measurable at 500 micrograms/mL, a dilution can be made. For example, a 1 in 10 dilution:
Take 1mL of 500micrograms/mL solution and add to 9mL of Sodium chloride 0.9% = 50 micrograms/mL.
Withdraw required dose to prepare infusion.

Prepare fresh infusion solution and line every 24 hours.
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Alprostadil 60micrograms/kg to 50mL 1mL/hr = 20 nanograms/kg/min
5mL/hr = 100 nanograms/kg/min
10 to 100 nanograms/kg/min

ROUTE AND METHOD OF ADMINISTRATION
IV Infusion: Give prescribed dose via syringe pump using Guardrails.
x To open a closed ductus arteriosus IV infusion for 20 to 30 minutes.
x To maintain patency of ductus arteriosus continuous IV Infusion.
NB – Use first available venous access for alprostadil administration. A second, separate, venous access site
should also be available for other maintenance fluids and/or bolus doses of other medicines.
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of alprostadil.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose/amount in syringe then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct (amount
and volume shown is the same as in syringe)
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘ng/kg/min then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start infusion:
x To open a closed ductus arteriosus: IV infusion for 20 to 30 minutes.
x To maintain patency of ductus arteriosus: continuous IV Infusion.
Flush the line if
required
Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Alprostadil IV Protocol

SIDE EFFECTS
x Apnoea (usually occurs within the first hour of administration and is more likely during duct opening or with
higher doses)
x Fever
x Flushing (secondary to vasodilation)
x Bradycardia / tachycardia
x Hypotension
x Decreased platelet aggregation, thrombocytopenia
x Oedema
x Prolonged treatment (>120hrs) may cause gastric outlet obstruction and reversible cortical proliferation of
the long bones
x Seizures

CONTRAINDICATIONS
x Respiratory Distress Syndrome
x Total anomalous pulmonary venous return with obstruction
x Caution in patients with bleeding tendencies and seizure disorders

NURSING RESPONSIBILITIES
x Continuous cardio/respiratory monitoring
x Monitor infant's temperature
x Monitor BP preferably with an arterial line or with
non invasive monitoring, as ordered
x Observe IV site carefully to ensure patency of IV
at all times
x DO NOT BOLUS OTHER MEDINES VIA
ALPROSTADIL INFUSION
x Change IV syringe and line every 24 hours. When
changing syringe and line, ensure line is clamped
to prevent administering a bolus. Minimise
interruptions to infusion.

COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for medicines not appearing in the table below. Uncommon medicines
have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Sodium chloride 0.9% No information
Drugs No information No information
Y-Site **Dobutamine, dopamine, heparin,
midazolam, ranitidine
1,4
No information

Notes: ** Only if absolutely necessary, not recommended by manufacturer
References:
1. Neofax 12th Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1st Ed. 1998, Pharmacy Department, The Royal Women's Hospital,
Carlton 3053
3. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of
Australia, 1999
4. Neonatal Formulary 3, 11th Ed, The Northern Neonatal Network. 2000
5. Manual of Neonatal Care 4th Ed., Cloherty J and Stark A. Joint Program in Neonatology,
Boston 1998

RWH Neonatal Intensive and Special Care Nurseries
Amikacin IV Protocol

AMIKACIN
DESCRIPTION AND INDICATION FOR USE
Amikacin is a semi-synthetic aminoglycoside broad-spectrum antibiotic used in the treatment of
gram -ve infections resistant to gentamicin.
Usually used in combination with a penicillin or cephalosporin.
DOSE
Use only following discussion with neonatologist and/or in consultation with clinical
microbiologist
IV, IM: 7.5mg/kg/dose
Interval
CA <28 weeks 36hrly
CA 28 to 29 weeks 24hrly
CA 30 to 35 weeks 18hrly
CA ≥36 weeks 12hrly
CA ≥37 weeks and over 7 days of life, give 8hrly.

Dosage interval may need to be extended in renal impairment.

RECONSTITUTION/DILUTION
Vial = 500mg in 2mL

IV infusion: Withdraw 0.5mL (125mg) from vial and add to 49.5mL of sodium chloride 0.9% in
a 50mL syringe = 125mg in 50mL = 2.5mg/mL
Withdraw required dose.

Unused solution should be discarded.

ROUTE AND METHOD OF ADMINISTRATION
IV infusion: Infuse over 1 hour via syringe pump using Guardrails

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of amikacin.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration’ 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 1 hour:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same
as in syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
Note: 1 hour infusion will show the mg/kg/h of ACTUAL dose.
Flush the
line
Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same
infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Amikacin IV Protocol

SIDE EFFECTS
x Ototoxicity
x Nephrotoxicity (trough levels > 10mg/L)5
x Hepatotoxicity (rare)

CONTRAINDICATIONS
x Caution in renal impairment

DRUG INTERACTIONS
Aminoglycosides, vancomycin Neurotoxic and nephrotoxic potential of amikacin may be
potentiated
Frusemide Potent diuretics may enhance toxicity of amikacin
Pancuronium Increased neuromuscular blockade
Indomethacin, amphotericin May potentiate renal toxicity

NURSING RESPONSIBILITIES
x Monitor urine output
x Large volume injection, record volume given
x Serum levels to be measured on the 3rd dose for all doses
o Pre-level (trough) taken immediately before dose
o Acceptable serum levels: Trough < 10mg/L

Routine assessment of amikacin levels should only occur in infants where it has been decided
antibiotic treatment will continue regardless of blood culture result. Where antibiotic regime is to
be determined by results of blood cultures, antibiotic levels should only be ordered once the
decision to continue treatment beyond 48 hours has been made.
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 chloride 0.9%

Intralipid
1
, PN
Drugs Adrenaline, aminophylline, benzylpenicillin,
calcium, ciprofloxacin, clindamycin,
dexamethasone, fluconazole, frusemide,
hydrocortisone, lignocaine, metronidazole,
midazolam
1
, noradrenaline, phenobarbitone
1
,
ranitidine, sodium bicarbonate, vancomycin,
verapamil

Amphotericin B, heparin, phenytoin,
ticarcillin/clavulanate
1
, erythromycin

Y-Site Aciclovir, amiodarone, dexamethasone,
fluconazole, frusemide, magnesium, midazolam,
morphine, pethidine

References:
1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital,
Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia,
1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network.
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston
1998

RWH Neonatal Intensive and Special Care Nurseries
Amiodarone IV Protocol

AMIODARONE

DESCRIPTION AND INDICATION FOR USE
Amiodarone is a Class III anti-arrhythmic agent. It inhibits adrenergic stimulation, prolongs the
action potential and refractory period in myocardial tissue and decreases AV conduction and
sinus node function.
Amiodarone has slow and variable oral absorption (as low as 50% bioavailability) and an
extremely long half-life (20 to 30 days).
Amiodarone is indicated in severe cases of supraventricular and ventricular tachyarrhythmias.

DOSE
Use only following discussion with neonatologist and/or in consultation with paediatric
cardiologist
ORAL: 4mg/kg/dose 8 hourly for 1 week, then 12 hourly for 1 week, then daily thereafter

IV infusion: 25microgram/kg/minute for 4 hours, then give 5 to 15microgram/kg/minute, titrated
according to response

RECONSTITUTION/DILUTION
Ampoule = 150mg in 3mL (50mg/mL)

IV infusion: Add 30mg/kg to glucose 5% to make 50mL.
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Amiodarone 30mg/kg to 50mL 1mL/hr = 10microgram/kg/minute 5 to 15 microgram/kg/minute

ROUTE AND METHOD OF ADMINISTRATION
If repeated doses are anticipated, where possible, administration via CVC is recommended due
to risk of phlebitis with peripheral administration.
IV infusion: Continuous IV infusion via syringe pump using Guardrails

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of amiodarone.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose/amount in syringe then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is
correct (amount and volume shown is the same as in syringe)
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘mcg/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

RWH Neonatal Intensive and Special Care Nurseries
Amiodarone IV Protocol

SIDE EFFECTS
x Hypotension, bradycardia, atypical ventricular tachycardia
x Hot flushes, sweating
x Nausea, constipation
x Corneal deposits
x Hyperglycaemia
x Hepatotoxicity, abnormal liver function tests. Monitor liver function during and after ceasing therapy.
x Nephrotoxicity, raised serum creatinine
x Abnormal thyroid function tests, hyper and hypo thyroidism. Monitor thyroid function.
x Pulmonary toxicity with long-term use
x Thrombophlebitis (Administration through central line is preferred)
x Photosensitivity. Use protective measures in babies exposed to sunlight
x Blue-grey discoloration of skin
CONTRAINDICATIONS
x CAUTION in patients with left ventricular dysfunction
x CAUTION in patients with hypotension
x Marked cardiomegaly is a relative contra-indication
x Thyroid dysfunction
x CAUTION in patients with liver impairment
DRUG INTERACTIONS
Digoxin Plasma levels of digoxin are increased. Reduce dose of digoxin by 50% during
amiodarone therapy and monitor levels closely.
Phenytoin Plasma levels of phenytoin are increased. Recommended that phenytoin levels be
closely monitored. Effectiveness of amiodarone may also be reduced.
Sotalol, propranolol, esmolol Can result in symptomatic bradycardia and sinus arrest. Hypotension as a side
effect can be severe when the combination is used.
Theophylline, caffeine Plasma levels of theophylline may be increased. Theophylline levels should be
monitored closely.
NURSING RESPONSIBILITIES
x Continuous ECG monitoring
x Continuous respiratory monitoring
x Monitor Q-T interval during commencement of therapy using 12 lead ECG
x Monitor blood pressure
x LFTs and TFTs according to cardiologist
x Protect infusion from light (cover syringe with foil)
x Change infusion solution every 24 hours
x Administer oral doses with food
x Use non DEHP lines and either Terumo or BD syringes to minimise plasticiser exposure
x Serum levels may be monitored - Therapeutic range: 1 to 2.5mg/L
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below. Uncommon drugs have
simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5% Sodium chloride solutions
Drugs No information Aminophylline, cephazolin, flucloxacillin, frusemide, heparin, sodium bicarbonate
Y-Site No information No information
Notes: Amiodarone is considered incompatible with most solutions and drugs when administered
intravenously. Avoid giving amiodarone with other drugs and solutions, including PN and Intralipid.
Amiodarone leaches plasticiser from DEHP containing infusion bags which may affect male reproductive
tract development. Use non DEHP lines and either Terumo or BD syringes and transfer to oral therapy as
soon as possible to minimise exposure.
References:
1. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
2. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of Australia, 1999
3. Neonatal Formulary 4th Ed, The Northern Neonatal Network. 2003
4. Pediatric Dosage Handbook 6th Ed., Taketomo, Hodding, Kraus. 1999-2000
5. Paediatric Pharmacopoeia 12th Ed, Royal Children's Hospital, Pharmacy Department, Parkville, 3052

08/06/05
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Amoxycillin.doc
June 2005
AMOXYCILLIN

DESCRIPTION AND INDICATION FOR USE
Amoxycillin is a broad spectrum penicillin antibiotic. It interferes with bacterial cell wall synthesis
during active multiplication, causing cell wall death and resultant bactericidal activity against
susceptible bacteria.
Amoxycillin is used in the treatment of infection caused by Listeria, beta-lactamase negative
Haemophilus or enterococci, and when indicated by sensitivity testing.

DOSE
Standard infection
IV, IM: 25mg/kg/dose

Severe infection (meningitis or septicaemia)
IV, IM: 50mg/kg/dose

Interval
GA<37 weeks ≤28 days 12hrly
>28 days 8hrly
GA ≥37 weeks ≤7 days 12hrly
>7 days 8 hrly
Dosage interval may be decreased from 8 to 6hrly in suspected meningitis or septicaemia, where
renal function is adequate.

RECONSTITUTION/DILUTION
Vial = 500mg, 1g

IV: For 500mg vial: Add 4.6mL of Water for Injection to vial = 500mg in 5mL = 100mg/mL

For 1g vial: Add 9.2mL WFI to vial = 1000mg in 10ml = 100mg/mL

If further dilution is required to measure dose, take 1 mL of 100mg/mL solution and add to
4mL of sodium chloride 0.9% = 100mg in 5mL = 20mg/mL

IM: Add 2.6mL of Water for Injection to 500mg vial = 500mg in 3mL

Withdraw required dose. Doses should be freshly prepared. Discard any solution remaining.

ROUTE AND METHOD OF ADMINISTRATION
IV: Give slowly over at least 10 minutes

IM: Do not give IM doses greater than 500mg. Consult senior neonatologist prior to prescribing
by IM route.

SIDE EFFECTS
• Rapid IV administration may result in convulsive seizures
• Rash
• Hypersensitivity reactions
• Thrombophlebitis

08/06/05
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Amoxycillin.doc
June 2005
CONTRAINDICATIONS
• Hypersensitivity to amoxycillin or other penicillin antibiotics
• CAUTION in patients with hypersensitivity to cephalosporins
• CAUTION in patients with renal impairment

NURSING RESPONSIBILITIES
• Observe site
• Monitor urine output

COMPATIBILITY INFORMATION
3
IMPORTANT: Contact 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%
1
, sodium
chloride 0.9%

Intralipid
1
, PN
1

Drugs No information Aminoglycosides (amikacin, gentamicin,
tobramycin), midazolam, potassium chloride,
sodium bicarbonate
Y-Site No information

References:

1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network.

AMOXYCILLIN/CLAVULANIC ACID
Penicillin antibiotic/
Beta lactamase inhibitor
Preparations
MIXT 400mg/57mg in 5mL(Augmentin Duo
®
)

Preparation for other routes
ORAL Reconstitute powder with WFI according to
package insert. Store in refrigerator.

Dose
Doses refer to amoxicillin content of Duo product
ORAL: 12.5 to 22.5mg/kg/dose 12hrly

Notes
Contraindicated in patients with a history of penicillin
allergy.
Best given just before a feed.

Amphotericin B – Liposomal (AmBisome
®
)
(NISC IV Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please
remember to read our disclaimer.

Reviewed by: Pharmacy Department, NISC Nursing Staff
Authorised by: Director of Nurseries
Effective Date: March 2012
Review Date: March 2015
Page 1 of 4

Description and indication for use
Amphotericin B is a broad-spectrum anti-fungal agent. It is fungistatic and fungicidal depending on the
concentration achieved in body fluids and the susceptibility of the fungus. It is used in the treatment of
systemic fungal infections.
Ambisome
®
consists of amphotericin B within a single lipid bilayer (liposome). Liposomal amphotericin
is claimed to have less side effects than conventional amphotericin, in particular, nephrotoxicity.
Liposomal amphotericin is indicated in patients who have systemic fungal infections and are intolerant
of conventional amphotericin, or have significant renal impairment/oliguria or liver dysfunction.

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

IV infusion: 3mg/kg/dose 24 hourly.

Doses of 5mg/kg once daily have been used and can be considered if renal function is adequate.

Reconstitution/Dilution
Vial = 50mg (Powder for reconstitution) NOT WARD STOCK (kept in After Hours Cupboard)

Pharmacy will supply preloaded syringes during pharmacy hours.

IV Infusion: Must be reconstituted using Water for Injection
Add 12mL of WFI to the vial containing the 50mg amphotericin dry powder. SHAKE the vial
VIGOROUSLY for at least 30 seconds to completely disperse the liposomal amphotericin. Check for
complete dispersion. Concentration of this solution = 4mg/mL.

USE ONLY GLUCOSE 5% for further dilution according to strength required as below: Withdraw
required volume of the 4mg/mL solution and add to the required volume of Glucose 5% using the 5
micron filter provided to make required strength. Withdraw required dose and discard any unused
solution.

Further dilute as follows:

Strength required Volume of 4mg/mL solution Volume of Glucose 5%
1mg/mL 1mL 3mL

If dose is > 2mg and infant is fluid restricted, the following dilution may be used:
Strength required Volume of 4mg/mL solution Volume of Glucose 5%
2mg/mL (Max) 2mL 2mL

Amphotericin B – Liposomal (AmBisome
®
)
(NISC IV Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please
remember to read our disclaimer.

Reviewed by: Pharmacy Department, NISC Nursing Staff
Authorised by: Director of Nurseries
Effective Date: March 2012
Review Date: March 2015
Page 2 of 4

Route and Method of Administration

If an in-line membrane filter is used, the mean pore size must NOT be less than 1 micron in diameter.
DO NOT INFUSE THROUGH PALL FILTER .

IV infusion: Line should be flushed with Glucose 5% prior to infusion of liposomal amphotericin B.
Give slowly over 1 hour via syringe pump using Guardrails.

Prime line: Use Minimum Volume Extension tubing (volume = 1mL) to prime line with
preloaded syringe containing exact dose of liposomal amphotericin B.

6 steps to infuse safely using Guardrails:

Flush the line: Draw up 1.5mL of Glucose 5% in a 10mL syringe and infuse at the same
infusion rate.

1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe and enter strength required:
Enter medicine dose/amount then press ‘OK’
Enter volume in syringe then press ‘OK’ and check concentration is
correct
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 is the right syringe OR
Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion: over 1 hour:
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.
7. Note: 1 hour infusion will show the mg/kg/h of ACTUAL dose.

Amphotericin B – Liposomal (AmBisome
®
)
(NISC IV Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please
remember to read our disclaimer.

Reviewed by: Pharmacy Department, NISC Nursing Staff
Authorised by: Director of Nurseries
Effective Date: March 2012
Review Date: March 2015
Page 3 of 4

Side Effects

Renal dysfunction: oliguria, decreased glomerular filtration rate, renal tubular acidosis, renal failure.
Anaemia
Coagulation defects, thrombocytopenia, granulocytopenia
Acute liver failure
Vomiting, diarrhoea, rash
Hypokalaemia, hypomagnesia,
Thrombophlebitis
Hearing impairment, neurological effects (seizures)
Hyper/hypotension, arrhythmias, cardiac arrest
Fever/chills

Contraindications

CAUTION in patients with renal impairment.
Hypersensitivity to amphotericin B

Drug Interactions

Corticosteroids (Hydrocortisone) May worsen hypokalaemia
Aminoglycoside antibiotics
(gentamicin, amikacin,
tobramycin) and vancomycin
May increase risk of nephrotoxicity

Digoxin Toxicity may occur due to hypokalaemia induced by amphotericin
Frusemide and
hydrochlorothiazide
May cause excessive loss of serum potassium

Nursing Responsibilities

DO NOT INFUSE THROUGH PALL FILTER.
Monitor urine output
Cardio/respiratory monitor
Monitor BP

Amphotericin B – Liposomal (AmBisome
®
)
(NISC IV Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current. Please
remember to read our disclaimer.

Reviewed by: Pharmacy Department, NISC Nursing Staff
Authorised by: Director of Nurseries
Effective Date: March 2012
Review Date: March 2015
Page 4 of 4

Compatibility Information

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% ONLY Sodium chloride 0.9%, IVN (protein and lipid)
Drugs See notes See notes
Y-Site See notes See notes

Notes: Liposomal amphotericin B must NOT be mixed with other drugs or fluids other than Glucose
5%. NOT compatible with IVN (protein and lipid).

References

1. Neofax 23rd Ed. 2010 A Manual of Drugs Used in Neonatal Care, Young, T.
2. Neonatal Pharmacopoeia. March 2012, Pharmacy Department, The Royal Women's Hospital, Parkville
3. Australian Injectable Drugs Handbook, 3rd Ed., The Society of Hospital Pharmacists of Australia, 2005
4. MIMS Online Prescribing Information for AmBisome
®

5. Gilead Pharmaceutical Medicines Information, accessed 21/03/12

RWH Neonatal Intensive and Special Care Nurseries
Atropine IV Protocol – Jan 2011

ATROPINE

DESCRIPTION AND INDICATION FOR USE
Atropine is an anticholinergic agent with effects on smooth muscle, cardiac muscle and various
glandular cells. It causes increased heart rate, reduced gastrointestinal motility and tone, urinary
retention, cycloplegia (dilated pupil) and reduced salivation and sweating.

Atropine is used with suxamethonium and fentanyl, prior to intubation to reduce the incidence of
bradycardia from vagal stimulation and therefore maintain cerebral perfusion during the procedure.

Reduces bronchial secretions.

Effects of atropine may last up to 6 hours
1
.

Atropine is used occasionally as a mydriatic (to dilate the pupils) before eye surgery.

DOSE
Endotracheal intubation (with fentanyl and suxamethonium)

IV: 10 to 20micrograms/kg/dose (0.02 to 0.03mL/kg/dose) given prior to fentanyl

RECONSTITUTION/DILUTION
Ampoule = 600micrograms in 1mL

IV: No dilution necessary.

ROUTE AND METHOD OF ADMINISTRATION
IV: Give over 1 minute. Effects can be seen within 30 seconds
2
with peak increase in heart rate
occurring in 12 - 16 minutes
1
.

SIDE EFFECTS
Cardiac arrhythmias
Mydriasis and cycloplegia (dilated pupil)
Dry mouth
Abdominal distension with reduced intestinal motility/paralytic ileus
Esophageal reflux

CONTRAINDICATIONS
Thyrotoxicosis
Tachycardia secondary to cardiac insufficiency
Cardiospasm
Paralytic ileus
Obstructive disease of the GI/Urinary tract

RWH Neonatal Intensive and Special Care Nurseries
Atropine IV Protocol – Jan 2011

NURSING RESPONSIBILITIES
Monitor vital signs with cardiorespiratory monitor
Monitor urinary output and stools
Observe for signs of feed intolerance
Strict mouth care

COMPATIBILITY INFORMATION
3,5
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%
1
, glucose 10%
1
, sodium chloride
0.9%

No information
Drugs Dobutamine, frusemide, verapamil Adrenaline, flucloxacillin, noradrenaline, sodium
bicarbonate
Y-Site Fentanyl, heparin, hydrocortisone, potassium
chloride, morphine, PG
1

References:

1. Young T, Mangum B, 2008, Neofax 2008, 21
st
Ed, New Jersey: Thomson Reuters.
2. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5
th
Ed, Massachusetts: Blackwell Publishing Inc,
2007.
3. Trissell LA, 2009, Handbook on Injectable drugs, 15
th
Ed, Bethesda, American Society of Health-System Pharmacists.
4. Fary R, Smtih R, David P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia, 2
nd
Ed, Melbourne: Pharmacy
Department The Royal Women's Hospital.
5. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4
th
Ed., Melbourne: The Society of Hospital Pharmacists
of Australia.
6. Manual of Neonatal Care 6
th
Ed., Cloherty J, Eichenwald E and Stark A. Joint Program in Neonatology, Boston 2008.
7. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13
th
Ed, Melbourne: Pharmacy Department,
Royal Childrens Hospital.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol – Benzylpenicillin.doc

BENZYLPENICILLIN
(PENICILLIN G)
DESCRIPTION AND INDICATION FOR USE
Benzylpenicillin is an antibacterial used in the treatment of most gram +ve and gram -ve
organisms. It is also effective against spirochaetes.
Benzylpenicillin is frequently used in combination with gentamicin for treatment of Group B
Streptococcus infection in neonates and is empirical first line treatment for early onset
sepsis (< 48 hours of age).

DOSE
Standard infection
IV, IM: 60mg/kg/dose

GBS meningitis
IV, IM: 120mg/kg/dose

Interval
GA<37 weeks 12hrly
GA≥37 weeks ≤7 days 12hrly
7 days 8hrly

RECONSTITUTION/DILUTION
Vial = 600mg
600mg is equivalent to 1,000,000units and contains 1.7mmol of sodium

IV: Add 5.6mL of Water for Injection = 100mg/mL

IM: Add 1.6mL of Water for Injection = 300mg/mL

ROUTE AND METHOD OF ADMINISTRATION
IV: Give slowly over at least 5 minutes.

SIDE EFFECTS
High doses may cause CNS toxicity including lethargy, twitching and seizures
Disturbances to serum electrolytes
8

High doses may cause thrombocytopenia and haemolytic anaemia

CONTRAINDICATIONS
Contraindicated in patients with a history of hypersensitivity to penicillin
CAUTION in patients with significant renal impairment
CAUTION in hypernatraemic patients due to high sodium content of preparation

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol – Benzylpenicillin.doc

NURSING RESPONSIBILITIES
Observe for side effects

COMPATIBILITY INFORMATION
3
IMPORTANT: Contact 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 chloride
0.9%

Intralipid
1
, PN

Drugs Calcium, erythromycin, frusemide, gentamicin,
hydrocortisone, ranitidine, verapamil

Amphotericin B, flucloxacillin, noradrenaline,
phenytoin, sodium bicarbonate, thiopentone,
vancomycin
Y-Site Aciclovir, dopamine, fluconazole, heparin,
metronidazole, morphine
1

References:

1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network.
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
6. Guidelines for Administration of Intravenous Medications to paediatric Patients 5
th
Ed. 1996 ASHSP
7. Paediatric Injectable Guidelines, 2
nd
Ed , 2000, Pharmacy Department, RCH
8. Paediatric Dosage handbook 6
th
Edition 199-2000, Taketomo, Hodding and Kraus

RWH Neonatal Intensive and Special Care Nurseries
Caffeine Citrate IV Protocol

CAFFEINE CITRATE
DESCRIPTION AND INDICATION FOR USE
Caffeine is a methylxanthine derivative used in the management of apnoea of prematurity and to facilitate early
extubation in neonates. It relaxes bronchial smooth muscle and may increase muscle function. It increases cyclic
AMP and also acts as a central nervous system stimulant. It has a wider therapeutic index than aminophylline and
theophylline, which means there is a lower incidence of toxic side effects and blood level monitoring is not
necessary. It has a long half-life, which means that in most neonates it can be given once daily.

DOSE
Doses are expressed as caffeine citrate
NB: 1mg caffeine base = 2mg caffeine citrate (RWH uses caffeine citrate only)

Loading dose: IV infusion, Oral: 20mg/kg/dose

Maintenance dose: IV injection, Oral: 5mg/kg/dose ONCE daily May be increased to 10mg/kg/dose ONCE daily

Maintenance dose is to be given at 2000hrs.
Babies receiving a loading dose prior to 1200hr should receive a maintenance dose the same evening.
Babies receiving a loading dose after 1200hr should receive a maintenance dose the next evening.

Notes
• Occasionally some neonates may require doses up to 20mg/kg/dose ONCE daily to assist with extubation.
5

• Neonates CA > 44 weeks may need up to 10mg/kg /dose 12 hourly.
• IV and oral bioavailability are equivalent, use IV route only if oral route is contraindicated.
• All orders are to be prescribed as caffeine citrate to avoid confusion with caffeine base

RECONSTITUTION/DIL UTION
Caffeine citrate injection 40mg/2mL = 20mg/mL

IV: Babies weight ≥1.5kg: no dilution required. Withdraw required dose from ampoule and administer.

Babies weight <1.5kg : dilution is required and the following procedure may be used:
Withdraw 1mL (20mg) from the ampoule of caffeine citrate and add to 4mL sodium chloride 0.9% in 10mL syringe.
This gives a final concentration of 20mg in 5mL = 4mg/mL. Withdraw required dose.

ROUTE AND METHOD OF ADMINISTRATION
IV: Give doses ≤ 10mg/kg over 10 minutes
Give doses > 10mg/kg slowly over 30 minutes via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of caffeine.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused ‘caffeine LOAD’
2. Choose pump concentration and check it matches syringe concentration then press ‘OK’
3. Enter weight of baby then press ‘OK’
4. Dose shown in ‘mg/kg/h’ then press ‘OK’
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in syringe
then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
x Note: 30minute 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 10mL syringe and infuse at the same infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Caffeine Citrate IV Protocol

SIDE EFFECTS
x Tachycardia
x Irritability
x GI tract upset (feed intolerance, vomiting)
x Hypotension
x Hyperglycaemia

CONTRAINDICATIONS
x Caution in patients with tachycardia (HR > 180 bpm)
x Caution in patients with GI bleeding
x Use with caution in renal or hepatic impairment (decreased metabolism of caffeine)

DRUG INTERACTIONS
Phenobarbitone, Frusemide,
Rifampicin
May reduce caffeine levels.
Propranolol May increase caffeine levels
Erythromycin May increase caffeine levels. Effectiveness may be reduced due
to decreased serum levels of erythromycin.
Pancuronium Reduced effectiveness of pancuronium
Phenytoin May decrease serum levels of caffeine with possible reduced
efficacy

NURSING RESPONSIBILITIES
x Cardio/respiratory monitoring
x Check heart rate prior to giving dose. If HR > 180 bpm consistently, refer to medical staff
prior to administration of dose
x Caffeine levels are not routinely measured
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below. Uncommon
drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9% No information
Drugs No information Aciclovir, frusemide
Y-Site Amikacin,benzyl penicillin, calcium
gluconate, cefotaxime, dexamethasone,
dobutamine, dopamine, fentanyl,
gentamicin, heparin (<1unit/mL), morphine,
vancomycin

References:
1. Neofax 18
th
Ed. 2005 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital,
Carlton 3053
3. Neonatal Formulary 5
th
Ed, The Northern Neonatal Network. 2007
4. BNF for children 2005. BMJ Publishing Group Ltd, RPSGB and RCPCH publications Ltd.
5. Steer P, Flenady V, et al. High dose caffeine citrate for extubation of preterm infants: a
randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2004; 89: F499-F503

CAFFEINE CITRATE
Xanthine derivative
Preparations
INJ 20mg/mL caffeine citrate.
20mg caffeine citrate= 10mg caffeine base

IV preparation and compatibilities
Compatible with G5%.
Give slowly over 30mins.

Dose
Doses expressed as caffeine citrate.

Neonatal apnoea
Loading dose
IV, ORAL: 20mg/kg

Maintenance dose (commence 24hrs after loading dose)
IV, ORAL: 5mg/kg/dose ONCE daily
Maintenance dose can be increased to a maximum of
10mg/kg/DAY.

Notes
Caution in renal and liver impairment.
Give oral doses with feeds.
Signs of toxicity are gastric irritation, agitation, tachycardia
and diuresis. Approx time to steady state is 5 to 6 days.
Monitoring of levels is not required.

CALCITRIOL
Active form of vitamin D3
Preparations
CAP 0.25microgram
MIXT (SAS) 1microgram/mL

Dose
Use only following consultation with renal physician
or endocrinologist.

Hypocalcaemia, hypoparathyroidism, renal
failure
ORAL: 20nanogram/kg/dose ONCE daily

Notes
Liquid inside capsule 0.17mL=0.25microgram
(1.5microgram/mL).
Monitor serum alkaline phosphate, calcium,
phosphate and creatinine.
Content of capsule may be removed by carefully
piercing the capsule at each end and pushing air
through capsule to force liquid out the opposite hole
onto a spoon. Ensure operator safety at all times.

Calcium

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 12 Oct 2017
Review Date: Oct 2020
Page 1 of 3

Neonatal Protocol
Description and indication for use
Hypocalcaemia is physiological in the first few days of life, due to transient hypoparathyroidism.
This is particularly so in premature and growth-restricted babies, and following birth asphyxia. It is
mostly asymptomatic and resolves without treatment. Lower calcium levels are common in infants
< 1500g birth weight and are not usually associated with clinical symptoms unless ionised calcium
is < 0.8 mmol/L. In infants > 1500g birth weight, hypocalcaemia is defined as ionised calcium < 1.1
mmol/L.

Symptoms of hypocalcaemia in neonates may include: muscle twitching, jitteriness, generalized
seizures, hypotonia, apnoea, tachycardia, tachypnea and prolonged QT interval.

Calcium is used for:
- Treatment of hypocalcaemia in infants with cardiovascular instability (hypotension, poor
perfusion, metabolic acidosis, PPHN), encephalopathy, arrhythmias, seizures
- Exchange transfusion where infants have symptomatic hypocalcaemia or ionised calcium <
1.1mmol/L
- Hyperkalaemia with peaked T waves or arrhythmia on ECG
- Metabolic bone disease of prematurity

When treating hypocalcaemia, it should be ensured that hypomagnesaemia is also treated if
present. Correction of hypomagnesaemia may also correct hypocalcaemia.

Preparations
Injection 0.22mmol/mL (as calcium gluconate)
Oral suspension 1mmol/mL (as calcium carbonate)

Dose
Hypocalcaemia

Acute treatment:
IV: 0.22 mmol/kg (1 mL/kg) of elemental calcium as a single dose. May be repeated 6 to 8
hourly if necessary.
For hypocalcaemia with seizures, dose can be increased to 0.44 mmol/kg (2 mL/kg).

Exchange transfusion:
IV: 0.22 mmol (1 mL) [not based on weight] of elemental calcium if ionised calcium < 1.1
mmol/L

Hyperkalaemia with peaked T waves or arrhythmia on ECG:
IV: 0.11 mmol/kg (0.5 mL/kg) of elemental calcium

Hypocalcaemia – Maintenance:
IV infusion: 1.1 mmol/kg/day (5 mL/kg/day) elemental calcium over 24 hours

Metabolic bone disease of prematurity
Oral: 2 mmol/kg/day elemental calcium in 2 divided doses. Dose is not adjusted for weight, unless
phosphate level is < 1.8 mmol/L or ALP > 600 IU/L.

Calcium

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 12 Oct 2017
Review Date: Oct 2020
Page 2 of 3

Neonatal Protocol
Reconstitution/Dilution
IV: Add the required dose of calcium gluconate to an EQUAL volume of compatible fluid to give a
final concentration of 0.11 mmol/mL.

IV infusion: Withdraw the required dose of calcium gluconate and make up to 24mL with
compatible fluid and administer at 1mL/hr.
If current weight > 2.4kg, withdraw the required dose of calcium gluconate and make up to 48mL
with compatible fluid and administer at 2mL/hr.
If current weight > 4.8kg, consider IV injections.

Route and Method of Administration
Do not give by SC or IM injection. Do not give intra-arterially.

Give via a central line where possible.

In emergency situations or exchange transfusion, may be given undiluted over 2-5 minutes via a
central line.

IV: Give diluted solution (0.11 mmol/mL) slowly over 10 minutes

IV infusion: Give diluted solution via syringe pump using Guardrails – see ‘How to set up the
Pump’

Oral: Shake the bottle well before withdrawing the required dose.

Side Effects
x Rapid IV injection may cause vasodilation, hypotension, bradycardia, arrhythmias and cardiac
arrest
x Severe necrosis and sloughing may occur with extravasation
x Constipation may occur with oral therapy

Contraindications
x Do not mix IV solutions containing calcium with ceftriaxone because a precipitate can form.
Deaths have been associated with precipitation of a ceftriaxone-calcium salt in the lungs and
kidneys in neonates.
x In neonates ≤ 28 days old, do not give within 48 hours of administration of ceftriaxone. For
infants over 28 days of age, the FDA states that ceftriaxone and calcium-containing solutions
may be administered sequentially as separate administration solutions ensuring that the
intravenous infusion lines are thoroughly flushed with a compatible solution between
infusions.
9,10

Drug Interactions

Digoxin Calcium enhances the effect of digoxin and may precipitate arrhythmias
Ceftriaxone IV solutions containing calcium and ceftriaxone must NOT be
administered within 48 hours of one another. This includes administration

Calcium

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 12 Oct 2017
Review Date: Oct 2020
Page 3 of 3

Neonatal Protocol
via the SAME or DIFFERENT lines in neonates ≤ 28 days old
Phosphate Calcium may decrease the absorption of phosphate, give oral doses at
least 2 hour apart

Ferrous sulphate Calcium may decrease the absorption of ferrous sulphate, give oral doses
at least 2 hours apart from calcium
2
Hydrochlorothiazide Hydrochlorothiazide may increase calcium levels

Nursing Responsibilities
x Monitor for bradycardia, hypotension and arrhythmias. ECG monitoring required. Observe IV
infusion site closely for extravasation
x Inspect the vial for particles before using as may precipitate in the vial
x Observe solution & complete length of infusion line for precipitation (haziness)
x Monitor serum calcium concentration

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 Aciclovir, amikacin, azithromycin,
benzylpenicillin, cefotaxime, ceftazidime,
ciprofloxacin, digoxin, furosemide,
ganciclovir, heparin, insulin, magnesium
sulphate, midazolam, milrinone,
morphine, piperacillin-tazobactam,
potassium chloride, vancomycin
Amphotericin B liposomal, ceftriaxone
(see contraindications & drug
interactions), indomethacin, lipid
emulsion, IVN starter, IVN maintenance,
phenytoin, potassium dihydrogen
phosphate, sodium bicarbonate, sodium
dihydrogen phosphate

References
1. Neofax® 2016 Truven Health Analytics Inc. Accessed on 22/08/2016
2. Micromedex® Solutions 2016 Truven Health Analytics Inc. Accessed on 16/06/2017.
3. Phelps, Hak, Crill. 2013 Pediatric Injectable Drugs (The Teddy Bear Book), 9th Ed, American Society of
Health-System Pharmacists
4. Burridge N (Ed) 2013 Australian Injectable Drugs Handbook, 6th Ed., Melbourne: The Society of Hospital
Pharmacists of Australia.
5. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5th Ed, Massachusetts: Blackwell
Publishing Inc, 2007.
6. BNF for children, London: BMJ Publishing Group Ltd, 2015-2016.
7. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 23
rd
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2016
8. MIMSOnline. St Leonards, NSW: UBM Medica; 2013. Accessed: 23/08/2016
9. Lilley L, Legge D. Paediatric Injectable Guidelines. 5
th
ed. Flemington, Vic: The Royal Children’s Hospital;
2016.
10. Information for Healthcare Professionals: Ceftriaxone (marketed as Rocephin a nd generics)
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm109
103.htm Accessed: 19/10/2016

CARBAMAZEPINE
Anticonvulsant
Preparations
TAB 100mg, 200mg, 200mg CR, 400mg CR
MIXT 20mg/mL

Preparation for other routes
It is possible to give the suspension rectally to temporarily
replace oral therapy. Give same total daily dose in small
multiple doses. Dilute 1:1 with warm water. May have laxative
effect.

Dose
Experience is limited in neonates.
ORAL: Commence at 2.5mg/kg/dose 12hrly increasing every 2
days to maximum of 15mg/kg/dose 12hrly.

Notes
CR tablets can be halved but not crushed.
Suspension to be given alone. Avoid use in active liver
disease. Increase dose slowly to allow for enzyme induction
upon initiation of therapy.
Serum Levels: Range: 20-40 micromol/L.
Sample immediately before next dose.
Time to steady state approx 1 to 2 weeks.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol – Cefotaxime.doc

CEFOTAXIME

DESCRIPTION AND INDICATION FOR USE
Cefotaxime is a semi-synthetic, third-generation cephalosporin. It is active against both Gram
+ve and Gram -ve organisms. It is used in the treatment of infection when sensitivity testing
indicates susceptibility. It is combined with Amoxycillin for treatment of meningitis until the
organism is identified and sensitivity is confirmed.

DOSE
IV, IM: 50mg/kg/dose

GA < 30 weeks and post natal age
≤ 28 days 12 hourly
> 28 days 8 hourly

GA > 30 weeks and post natal age
≤ 14 days 12 hourly
> 14 days 8 hourly

Dose interval may be reduced from 8 to 6 hourly in severe infections/meningitis

Dose interval may need to be increased in babies with severe renal failure

RECONSTITUTION/DILUTION
Vial = 1g

IV: Add 9.6 mL of Water for Injection to vial
= 1g in 10mL 100mg/mL
May be further diluted with sodium chloride 0.9% to 50mg/mL

IM: Add 3.6mL of Water for Injection = 1g in 4mL 250mg/mL.

ROUTE AND METHO D OF ADMINISTRATION
IV: 100mg/mL or 50mg/ml solution given slowly over at least 10 minutes.

IM: 250mg/mL solution.
NOT RECOMMENDED, but may be useful for larger babies with no IV access.

SIDE EFFECTS
Hypersensitivity (not commonly seen in neonates).
Phlebitis
Diarrhoea
Leukopenia, eosinophilia, granulocytopenia
Transient elevation of BUN and creatinine

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol – Cefotaxime.doc

CONTRAINDICATIONS
Hypersensitivity to cephalosporins and penicillins
CAUTION in patients with renal impairment

DRUG INTERACTIONS
Aminoglycosides Nephrotoxicity of both drugs may be increased.
Cefotaxime is sometimes used together with aminoglycosides as there is
evidence of a synergistic effect when used in combination. Careful monitoring of
aminoglycoside levels should reduce incidence/severity of nephrotoxicity.

NURSING RESPONSIBILITIES
Record volume on IV fluid chart - large volume drug
Observe site for phlebitis

COMPATIBILITY INFORMATION
3
IMPORTANT: Contact 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
chloride 0.9%,

Solutions containing sodium bicarbonate
Drugs Clindamycin, verapamil Aminoglycosides (gentamicin, amikacin,
tobramycin), aminophylline, fluconazole,
vancomycin
Y-Site Aciclovir, heparin, magnesium
sulphate, metronidazole, morphine,
midazolam, PN
1

References:

1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital,
Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia,
1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network. 2003
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston
1998
6. Handbook on Injectable Drugs 11
th
Ed, Trissel L. 2001

RWH Neonatal Intensive and Special Care Nurseries
Ceftazidime IV Protocol

CEFTAZIDIME

DESCRIPTION AND INDICATION FOR USE
Ceftazidime is a third generation cephalosporin antibiotic for use by injection only. It is bactericidal in action, and is
synergistic with aminoglycosides.
Ceftazidime is used in the treatment of single and mixed infections caused by susceptible aerobic organisms with
suspected or documented resistance to other antimicrobials. It is an alternative to aminoglycosides for treatment of
pseudomonas infections in patients for whom aminoglycoside toxicity is a cause for concern.

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

IV: 50mg/kg/dose
Interval
GA <30weeks ≤ 28 days: 12hrly
> 28 days: 8hrly

GA ≥30weeks ≤ 14 days: 12hrly
> 14 days: 8hrly

RECONSTITUTION/DILUTION
Vial = 1g (Powder volume = 1.1mL)

IV: Add 8.9mL of water for injection to the 1g vial = 1g in 10mL = 100mg/mL. Withdraw required dose.

Further dilute if required: add 1mL of100mg/mL solution to 1mL of sodium chloride 0.9% 100mg in 5mL
syringe = 100mg in 2mL = 50mg/mL. Withdraw required dose.

IM: Add 2.9mL of water for injection to the 1g vial = 1g in 4mL = 250mg/mL

ROUTE AND METHOD OF ADMINISTRATION
IM: Not recommended but may be used for larger babies with no IV access.
Give 250mg/mL solution
IV infusion: Give slowly over 30 minutes via syringe pump using Guardrails

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of ceftazidime.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration matches concentration shown on pump then press ‘OK’
For concentration of 100mg/mL, hit ‘Modify’ to ‘select concentration’ of syringe
x Enter 100mg then press ‘OK’
x Enter 1mL then press ‘OK’ and check concentration is correct
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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in syringe
then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.

Note: 30minute 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 10mL syringe and infuse at the same infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Ceftazidime IV Protocol

SIDE EFFECTS
x Thrombophlebitis, pain at injection site
x CNS disturbances with excessive doses (tremors, myodema, convulsions, encephalopathy)
x GI disturbances, diarrhoea, nausea
x May elevate hepatic transaminases
x Eosinophilia, thrombocytosis, positive Coombs test without haemolysis
x

CONTRAINDICATIONS
x Known hypersensitivity
x CAUTION in patients with renal impairment; dose adjustment may be required

DRUG INTERACTIONS
Aminoglycosides Nephrotoxicity of both drugs may be increased.
Ceftazidime is sometimes used together with aminoglycosides as there is evidence
of a synergistic effect when used in combination. Careful monitoring of
aminoglycoside levels should reduce incidence/severity of nephrotoxicity.

NURSING RESPONSIBILITIES
x Observe injection site

COMPATIBILITY INFORMATION

IMPORTANT: Contact 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%
1
, sodium
chloride 0.9%

Sodium bicarbonate, intralipid, PN
Drugs Ciprofloxacin, fluconazole, heparin,
metronidazole, potassium
Aminoglycosides (gentamicin, tobramycin,
amikacin), midazolam, vancomycin
Y-Site Aciclovir, aminophylline, morphine,
ranitidine
-

References:
1. Neofax 16th Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T,
Mangum O.
2. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal
Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital
Pharmacists of Australia, 1999
4. Neonatal Formulary 4th Ed, The Northern Neonatal Network. 2003
5. Manual of Neonatal Care 4th Ed., Cloherty J and Stark A. Joint Program in
Neonatology, Boston 1998

CHLORAL HYDRATE
Sedative / Hypnotic
Preparations
MIXT 100mg/mL

Dose
Sedative
ORAL: 8mg/kg/dose 6 to 8hrly

Hypnotic
ORAL: 25 to 50mg/kg/dose 24hrly (maximum 1g
per dose)
In ventilated patients, higher doses of up to
50mg/kg/dose 6hrly may be used if required.

Notes
May cause nausea, vomiting and diarrhoea. Dose
may be diluted with water or feed to reduce these
side effects. Tolerance may develop after long-
term therapy.

RWH Neonatal Intensive and Special Care Nurseries
Ciprofloxacin IV Protocol

CIPROFLOXACIN
DESCRIPTION AND INDICATION FOR USE
Ciprofloxacin is a synthetic fluoroquinalone with bactericidal antimicrobial activity against a wide
range of gram -ve (Klebsiella, Enterobacter, Salmonella, Proteus and Pseudomonas species)
and gram +ve organisms (Staphyllococcus, Streptococcus and Enterococcus). Ciprofloxacin
may be indicated for the treatment of serious or life-threatening infections due to sensitive
organisms.

Animal studies have shown that ciprofloxacin can produce erosions of cartilage of weight-
bearing joints and other signs of arthropathy in immature animals of various species5. These
effects have not been reported after use of ciprofloxacin in children3.

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

IV, ORAL:
Standard Infection 5mg/kg/dose 12hrly

Severe Infection 10 to 15mg/kg/dose 12hrly

RECONSTITUTION/DILUTION
Vial = 2mg/mL, 50mL and 100mL vial NOT WARD STOCK

IV: No dilution required. Withdraw required dose from vial and administer.

ROUTE AND METHOD OF ADMINISTRATION
NOT TO BE GIVEN BY IM INJECTION
IV infusion: Give slowly over 1 hour via syringe pump using Guardrails

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of ciprofloxacin

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Concentration shown 2mg/mL – No change required
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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 1 hour:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in
syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
Note: 60minute infusion will show the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same
infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Ciprofloxacin IV Protocol

SIDE EFFECTS
x Restlessness
x Rash
x Nausea, vomiting, diarrhoea. Severe diarrhoea should be reported to medical staff immediately,
particularly if GI bleeding occurs. Colitis and pseudomembranous colitis have been reported with
ciprofloxacin.
x Increased liver enzymes
x Anaemia, eosinophilia, neutropenia
x Phlebitis at IV site, particularly if infused to rapidly
x Arthralgia, joint stiffness, tendonitis
x Crystalluria, Elevated serum creatinine and BUN

CONTRAINDICATIONS
x Hypersensitivity to ciprofloxacin or other quinolones

DRUG INTERACTIONS
Theophylline, Caffeine Elevation of theophylline levels may occur, monitor levels on day 3 of
ciprofloxacin treatment. Theophylline dose may need to be decreased by 50%
if levels are elevated. Adverse effects of theophylline may be increased,
particularly those involving the CNS.

NURSING RESPONSIBILITIES
x Oral doses are best given on an empty stomach (between feeds)
x Ensure adequate fluid intake
x Observe IV site for phlebitis
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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
chloride 0.9%
Intralipid, PN
Drugs Amikacin, ceftazidime, gentamicin,
metronidazole, potassium chloride,
ranitidine, tobramycin
Aminophylline, amoxycillin, frusemide,
heparin, hydrocortisone, phenytoin,
dexamethasone, flucloxacillin
Y-Site Calcium gluconate, dobutamine,
dopamine, verapamil

Notes: Manufacturer advises temporarily disconnecting other solutions during the
infusion of ciprofloxacin.
References:
1. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
2. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of Australia, 1999
3. Neonatal Formulary 4th Ed, The Northern Neonatal Network. 2003
4. Paediatric Pharmacopoeia 13th Ed. 2002 The Royal Children's Hospital, Parkville, Victoria
5. Ciproxin IV (Bayer), Product information, APP Guide January 2001
6. Khaneja M, Naprawa J, Kumar A, Piecuch S, 'Clinical Perinatal/Neonatal Case Presentation-Successful Treatment of
Late-Onset Infection due to Resistant Klebsiella pneumoniae in an Extremely Low Birth Weight Infant using
Ciprofloxacin' Journal Of Perinatology 1999 19(4) 311-314.
7. Singh UK, Sinha RK, et al, "Ciprofloxacin in Children: Is Arthropathy a Limitation?" Indian Journal of Pediatrics,
2000:67 (5)
8. Wlazlowski J, et al "Use of the Quinolones in Treatment of Severe Bacterial Infections in Premature Infants"

CLINDAMYCIN
Antibiotic
Preparations
INJ 150mg/mL
CAP 150mg

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Dilute to a maximum concentration of 12mg/mL.
Give over at least 30mins.

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

Age <7days:
BW<2000g 5mg/kg/dose 12hrly
BW≥2000g 7.5mg/kg/dose 12hrly

Age ≥7 days:
CW <1200g 5mg/kg/dose 12hrly
CW 1200-2000g 5mg/kg/dose 8hrly
CW>2000g 5mg/kg/dose 6 to 8hrly

Notes
Risk of hypotension and cardiopulmonary arrest if given quickly.
Discontinue if severe diarrhoea develops and investigate cause. Increase
dosage interval in patients with significant liver dysfunction.

CLONAZEPAM
Benzodiazepine / Anticonvulsant
Preparations
INJ 1mg/mL
MIXT 2.5mg/mL (1drop=0.1mg), 100microgram/mL (RWH)

IV preparation and compatibilities
Compatible with G5%, G10%, NaCl 0.9%.
Dilute with diluent provided immediately before use to give a concentration of
1mg in 2mL.
Give over 5mins.

Preparation for other routes
When giving mixture, count drops onto a spoon before administering. Do not
give directly from bottle to patient as overdosing may occur easily.

Dose
Loading dose
IV, ORAL: 0.1 to 0.25mg
Use lower doses for premature infants. If fitting persists, subsequent doses
may be given.

Maintenance dose
IV, ORAL: 0.01mg/kg/dose 8hrly
Commence maintenance dose 8 hours after loading dose. Maintenance dose
may be increased every 3
rd
day to a maximum of 0.2mg/kg/day.

Notes
Doses should be reduced gradually when treatment is to be ceased to reduce
the risk of withdrawal symptoms. Rapid IV injection may cause respiratory
depression. Possible elevation of phenytoin levels. CNS depression,
hypotension, upper airway hypersecretion and increased salivation may occur.
Therapeutic range: 60 to 150nanomol/L.

COPPER
Supplement
Preparations

MIXT 20micrograms/mL (RWH)

Dose

ORAL: 25micrograms/kg/day

Notes

Mixture prepared by pharmacy
department.

Cyclopentolate 0.5%

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 4 Feb 2015
Review Date: February 2018
Page 1 of 1

Neonatal Protocol

Description and indication for use
Cyclopentolate eye drop is used together with phenylephrine to induce mydriasis (pupil dilation)
prior to Retinopathy of Prematurity (ROP) screening and laser eye surgery in preterm neonates.
The maximum effect is achieved 30 to 60 minutes after instillation.

Preparations
Eye drops Cyclopentolate 0.5%

Note: eye drops are stored in the refrigerator and for single use only.

Dose
Prior to ophthalmologic examination or laser eye surgery
Eye drops: Instil 2 drops into each eye, 30 to 40 minutes prior to ROP screening or laser eye
surgery.

Route and Method of Administration
Intraocular: To be administered 30 to 40 minutes prior to procedure, unless the nurse performing
the eye check indicates the time that the eye drops are to be instilled.

Excessive systemic absorption can be avoided with finger pressure to the lachrymal sac for 1-2
minutes following applications.

Refer to Appendix A for the recommended method of administration.

Side Effects
x May cause transient whitening of the eyelid and, if overflow, of the cheeks also secondary to
local vasoconstriction.
x Transient stinging after instillation
x Tachycardia and urinary retention may occur secondary to systemic absorption

Nursing Responsibilities
x Eye drops are packaged in single use units which are to be used for one patient on one
occasion only.

References
1. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 03/02/2015.
2. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 20
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2013.
4. New Services Clinical Guideline, Aucland Distribution Health Board.
http://www.adhb.govt.nz/newborn/Guidelines/Developmental/ROP.htm#Examination accessed on
03/02/2015.
5. Neofax 23
rd
Ed. 2010, A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.

Dexamethasone

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Sue Jacobs, Clinical Pharmacists, NISC clinical educators
Authorised by: Carl Kuschel
Effective Date: 28 October 2013
Review Date: October 2016
Page 1 of 4

Neonatal Protocol
Description and indication for use
Dexamethasone is a synthetic corticosteroid with basic glucocorticoid actions and effects and with
no mineralocorticoid activity. It has pronounced anti-inflammatory activity and is used in the
treatment of chronic lung disease (CLD)/bronchopulmonary dysplasia (BPD) to facilitate weaning
of mechanical ventilation. It is thought to produce its effect on BPD by increasing surfactant
synthesis, reducing pulmonary oedema and by stabilisation of cell and lysosomal membranes.
Dexamethasone may also be used to treat tracheal oedema before and after extubation.

Dexamethasone has a rapid onset of action, with duration of action between 36 and 54 hours. It is
metabolised in the liver and excreted in the urine as unchanged drug and metabolites. Small
amounts may be excreted in bile.

Preparations
Injection 4mg/mL
Mixture 100micrograms/mL (RWH)

Dose
Chronic Lung Disease / Bronchopulmonary Dysplasia

Note: Doses are to be calculated based on the weight when the course was commenced, not on
the current weight (unless advised by consultant). This weight is to be documented in the medical
information section of the medication order.

DART Regimen
IV, Oral:
Day 1, 2 and 3 75 micrograms/kg/dose 12 hourly (6 doses)
Day 4, 5 and 6 50 micrograms/kg/dose 12 hourly (6 doses)
Day 7 and 8 25 micrograms/kg/dose 12 hourly (4 doses)
Day 9 and 10 10 micrograms/kg/dose 12 hourly (4 doses)

Course may be repeated if necessary.

Medical staff to complete, print and file the DART dosing guide in the notes:
http://intranet.thewomens.loc/departments/clinicaloperations/neonatalservices/Documents/Dexame
thasone%20Dosing%20Tool.xlsx

Cummings Regimen
IV, Oral:
Day 1, 2 and 3 250 micrograms/kg/dose 12 hourly (6 doses)
Day 4, 5 and 6 150 micrograms/kg/dose 12 hourly (6 doses)
Day 7 and after Decrease dose by 10% of the current dose every 3 days until a dose of
50micrograms/kg/dose is reached. Then give on alternate days for 1 week
then cease. Course duration is 42 days.
If initially ineffective, discontinue after 5 days.

Dexamethasone

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Sue Jacobs, Clinical Pharmacists, NISC clinical educators
Authorised by: Carl Kuschel
Effective Date: 28 October 2013
Review Date: October 2016
Page 2 of 4

Neonatal Protocol
Medical staff to complete, print and file the Cummings dosing guide in the notes:
http://intranet.thewomens.loc/departments/clinicaloperations/neonatalservices/Documents/Dexame
thasone%20Dosing%20Tool.xlsx

Shorter courses, with doses starting at up to 500 micrograms/kg/day (in divided doses) may also
be used, with individually designed tapering off periods and dosages.
The length of the course will generally depend on response and the determined weaning schedule.

To prevent failure of ET extubation (with suspected subglottic oedema)
IV, Oral: 250 micrograms/kg/dose every 8 hours for 3 doses

Reconstitution/Dilution
IV: Withdraw 0.25mL of 4mg/mL solution and add to 0.75mL of sodium chloride 0.9% in a
second 1mL syringe = 1mg/mL = 1000micrograms/mL

To dilute for smaller doses: Withdraw 0.1mL (100micrograms) of the above 1mg/mL
solution and add to 9.9mL of sodium chloride 0.9% in a 10mL syringe = 10micrograms/mL

Discard excess volume to obtain required dose or withdraw dose using another syringe.

Route and Method of Administration
IV: Give diluted solution over 1 to 3 minutes. Flush with sodium chloride 0.9%.
IM: Not recommended.

Side Effects
Immunosuppression, increasing the risk of sepsis, especially with prolonged use. May also
mask signs of infection.
Hyperglycaemia
Hypertension
Osteoporosis, inhibition of growth (prolonged use)
Hypokalaemia, hyponatraemia, oedema, glycosuria, hypercalciuria and hypocalcaemia
Acute or rapid withdrawal after more than 7 days of treatment can cause acute adrenal
insufficiency (fever, hypotension, hypoglycaemia and shock)

Contraindications
Untreated systemic bacterial infections
Systemic fungal infections
CAUTION in patients with hypertension
It is recommended that live virus immunisations should be given 1 month after ceasing high
dose, prolonged (>2 weeks) course of dexamethasone
1
. However, live virus vaccines may be
given during treatment with dexamethasone following discussion with consultant.

Dexamethasone

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Sue Jacobs, Clinical Pharmacists, NISC clinical educators
Authorised by: Carl Kuschel
Effective Date: 28 October 2013
Review Date: October 2016
Page 3 of 4

Neonatal Protocol
Drug Interactions

Nursing Responsibilities
Ensure that oral anti-fungal medicine, nystatin drops 1mL 8 hourly is prescribed prophylactically
when prescribing dexamethasone for CLD. Discontinue prophylactic antifungal 3 days after
ceasing dexamethasone.
Observe for signs of infection (including candida)
Monitor blood pressure twice daily for 3 days, then daily during treatment
Monitor blood glucose twice daily for 3 days, then when necessary

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%

Drugs Calcium chloride, calcium gluconate,
ciprofloxacin, dobutamine, erythromycin,
gentamicin, magnesium sulphate,
midazolam, phenytoin, vancomycin
Y-Site Aciclovir, amikacin, benzylpenicillin,
caffeine citrate, cefotaxime, cephazolin,
dopamine, fentanyl, flucloxacillin,
fluconazole, frusemide, heparin, insulin
(neutral), lignocaine, meropenem,
metronidazole, morphine, piperacillin-
tazobactam, potassium chloride, sodium
bicarbonate, ranitidine, PG1, PG2

References
1. Kroger AT, Sumaya CV, Pickering LK, Atkinson WL. General Recommendations on Immunization.
Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep.
2011;60(RR02):1-60.
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm
Accessed: 09/05/2013
2. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 9
th
Ed. Bethesda,
Maryland: American Society of Health-System Pharmacists; 2010.
3. Fary R, Smith R, Davis P, Jacobs S, editors. Neonatal Pharmacopoeia. 2
nd
Ed. Melbourne: Pharmacy
Department, The Royal Women’s Hospital; 2005.
4. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
Phenobarbitone, phenytoin,
rifampicin
May increase the metabolism of dexamethasone
Amphotericin B, frusemide,
hydrochlorothiazide
May have synergistic potassium depleting effect
Ibuprofen Increased risk of gastrointestinal perforation and bleeding

Dexamethasone

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Sue Jacobs, Clinical Pharmacists, NISC clinical educators
Authorised by: Carl Kuschel
Effective Date: 28 October 2013
Review Date: October 2016
Page 4 of 4

Neonatal Protocol
5. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
6. Cummings JJ, D’Eugenio DB, Gross SJ. A Controlled Trial of Dexamethasone in Preterm Infants at High
Risk for Bronchopulmonary Dysplasia. N Engl J Med. 1989;320(23):1505-1510.
7. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 5
th
Ed. Melbourne: The Society of
Hospital Pharmacists of Australia; 2011.
8. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
2011.
9. Dexamethasone sodium phosphate. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral
Compatibility). Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 09/05/2013

Diazoxide

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 26 April 2018
Review Date: April 2021
Page 1 of 2

Neonatal Protocol

Description and indication for use
Diazoxide is used to treat persistent hypoglycaemia secondary to hyperinsulinism by inhibiting
insulin release from the pancreas and by blocking some of the peripheral actions of insulin via the
catecholamine stimulation.
A positive response to diazoxide is usually seen within 48 to 72 hours, with onset of action usually
within 1 hour following oral administration and with a duration of action of approximately 8 hours.
Diazoxide is also an arteriolar vasodilator and may cause hypotension, and fluid retention.
Hydrochlorothiazide is usually prescribed concurrently with diazoxide to minimise fluid retention
and may further increase hyperglycaemia.

Preparations
Mixture 10mg/mL (SAS) (RWH)

Dose
Hypoglycaemia secondary to hyperinsulinaemia
Oral: 5 to 15mg/kg/day as recommended by endocrinologist. Can be given in 2 to 3 divided
doses.

Commence when:
Verbal parental consent has been obtained and documented in the baby’s clinical notes, AND
TGA SAS category C form has been completed Appendix A

Route and Method of Administration
Oral: May be given without regard to feeds.

Side Effects
x Hypotension
x Hyperglycaemia
x Tachycardia
x Blood dyscrasias
x Hirsutism and coarse facial features may develop with long term use
x Antidiuretic effect may cause sodium and fluid retention; hydrochlorothiazide may be prescribed
concurrently to counteract these effects.
x Ketoacidosis during intercurrent illness
x Hyperuricaemia
x Pulmonary hypertension has been reported in infants and newborns, monitor patients for
respiratory distress and discontinue diazoxide if pulmonary hypertension is suspected

Contraindications
x CAUTION in heart failure
x CAUTION in mechanical hypertension e.g. aortic coarctation or AV shunt
x CAUTION in pulmonary hypertension
x CAUTION in renal impairment
x CAUTION in hyperbilirubinaemia - diazoxide may displace bilirubin from albumin

Diazoxide

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 26 April 2018
Review Date: April 2021
Page 2 of 2

Neonatal Protocol

Drug Interactions

Antihypertensive agents Diazoxide may potentiate hypotensive effect
Phenytoin Diazoxide may reduce effectiveness of phenytoin

Nursing Responsibilities
x Monitor blood pressure 30 minutes after dose
x Monitor blood sugar levels
x Monitor WCC and platelets with prolonged treatment (> 1 week)

TGA considerations and parental consent
x Diazoxide is not currently listed on the Therapeutics Goods Administration’s (TGA) Australian
Register of Therapeutic Goods.
x Under the TGA Authorised Prescriber Scheme, the NISC prescribers have been authorised by
TGA to prescribe Diazoxide
x Therefore, to prescribe Diazoxide:
o Provide verbal information to the parent(s)/guardian(s)
o Obtain verbal parental consent, and document in the baby’s clinical notes
o Complete the TGA SAS Category C form Appendix A
o Leave copy in pharmacist tray in central work room.

References
1. Diazoxide. In: Lexicomp Online® , Pediatric & Neonatal Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.;
Date accessed 01/03/2018
2. Zenk KE, Sills JH, Koeppel RM. Neonatal Medications & Nutrition: A Comprehensive Guide. 3
rd
Ed. Santa
Rosa, California: NICU Ink; 2003.
3. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press,
and RCPCH Publications <http://www.medicinescomplete.com> [Accessed on 01/03/2018]
4. Diazoxide. In: Micromedex [database on the Internet]. Ann Arbor (MI): Truven Health Analytics;
publication year [cited 01/03/2018]. Available from: www.micromedexsolutions.com. Subscription required
to view.
5. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
6. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
7. Australian Medicines Handbook 2018 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2018
January. Available from: http://amhonline.amh.net.au/

DIGOXIN
Cardiac glycoside
Preparations
INJ 25microgram/mL and MIXT 50microgram/mL
TAB 62.5microgram, 250microgram

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Dilute to 5micrograms/mL.
Withdraw required dose and give slowly over 5 to 10mins.

Dose
Use only after discussion with paediatric cardiologist

Loading dose (total 3 doses) for arrhythmias only
CA <37 weeks
IV, ORAL: 10microgram/kg stat, then 5microgram/kg/dose 8hrly for 2 doses.

CA ≥ 37 weeks
IV, ORAL: 10microgram/kg stat, then 10microgram/kg/dose 8hrly for 2 further
doses.

Maintenance dose
IV, ORAL: 3 to 5microgram/kg/dose 12hrly

Notes
Reduce dose in renal impairment.
Consider lower dose in patients being treated with indomethacin or erythromycin.
Halve dose if given with amiodarone.
Hypokalaemia may increase risk of digoxin toxicity (with or without increased
digoxin levels) therefore drugs which cause hypokalaemia may predispose patients
to digoxin toxicity.
Therapeutic range 1 to 2.5 nanomol/L. Serum level should be taken on 3
rd day but
more frequent levels may be necessary.
Take sample at least 6 hours after dose. Signs of toxicity include vomiting,
diarrhoea, drowsiness, bradycardia and arrhythmias.
Doses must always be prescribed in micrograms.

RWH Neonatal Intensive and Special Care Nurseries
Dobutamine IV Protocol

DOBUTAMINE
DESCRIPTION AND INDICATION FOR USE
Dobutamine is a synthetic catecholamine. It is an inotropic vasopressor, and increases
myocardial contractility, cardiac index, oxygen delivery, and oxygen consumption. Dobutamine
preferentially dilates the coronary beds and does not cause vasodilation in renal and mesenteric
areas. Dobutamine has a greater effect on cardiac output than dopamine, with less tendency to
cause arrhythmias, and with less effect on blood pressure. It is used to increase myocardial
contractility and cardiac output.
Dobutamine may be used in combination with dopamine.
Dobutamine has a serum half-life of 2-3 minutes and must be administered by continuous
infusion due to rapid metabolism.

DOSE
IV Infusion: 5 to 20microgram/kg/minute starting at 5microgram/kg/min and increasing after
10 minutes PRN.

RECONSTITUTION/DILUTION
Vial = 250mg

INF: Reconstitute with 20mL Water for Injection = 250mg in 20mL solution (12.5mg/mL)

Add 30mg/kg to infusion solution ordered (glucose 5 or 10%, sodium chloride 0.9%) to a total
volume of 50mL. (As shown in table below)
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Dobutamine
SINGLE
30mg/kg to 50mL 1mL/hr =
10microgram/kg/min
5 to
20microgram/kg/min
Dobutamine
DOUBLE
60mg/kg to 50mL 1mL/hr =
20microgram/kg/min
10 to
20microgram/kg/min
Dobutamine
QUAD
120mg/kg to 50mL 1mL/hr =
40microgram/kg/min
10 to
20microgram/kg/min

ROUTE AND METHOD OF ADMINISTRATION
Not for IV bolus or IM use
Administration via central line is preferred. Use with caution if given through peripheral line.
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using Guardrails
NOTE: Consider administering fluid volume prior to starting dobutamine infusion.

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of dobutamine.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘mcg/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

RWH Neonatal Intensive and Special Care Nurseries
Dobutamine IV Protocol

SIDE EFFECTS
x May cause hypotension if patient hypovolemic
x Tachycardia
x Arrythmias
x Hypertension
x TISSUE ISCHAEMIA occurs with infiltration
x CUTANEOUS VASODILATION ("flushed" appearance)

CONTRAINDICATIONS
x Hypovolaemia should be corrected before dobutamine administration.
x Caution in patients with hypertension.
x Idiopathic hypertrophic subaortic stenosis
5

NURSING RESPONSIBILITIES
x Carefully prime IV tubing
x USE ATOM PUMP PREFERABLY
x Change infusion fluid and tubing every 24 hours ensuring that pump and 3-way tap
turned off to prevent any inadvertent bolus dose being given.
x Continuous blood pressure monitoring preferably with an arterial line.
x Continuously monitor heart rate and rhythm
x Record vital signs hourly
x Observe and measure urine output
x Observe IV site for inflammation and extravasation of fluid, remove immediately if occurs.
x Avoid interruption of infusion
x DO NOT ADMINISTER ANY BOLUS DOSES
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Sodium chloride 0.9%, sodium chloride 0.45%,
glucose 5%, glucose 10%, glucose/sodium
solutions
Alkaline solutions (sodium bicarbonate)
Drugs Adrenaline, amiodarone, atropine, dopamine,
glyceryl trinitrate, hydralazine, isoprenaline,
lignocaine, meropenem, morphine, noradrenaline,
propranolol, ranitidine
Aciclovir, aminophylline, digoxin, flucloxacillin,
frusemide, heparin, indomethacin
1
, insulin,
phenytoin
Y-Site TPN
1
, calcium, diazepam, fentanyl, fluconazole,
insulin (≤1unit/mL)
6
, magnesium,
midazolam
1
,pancuronium
1
, potassium, sodium
nitroprusside, verapamil

Notes: Dobutamine infusion solution may show a slight pink colour, which is
acceptable. Discard solution if it appears hazy.
References:
1. Neofax 12
th
Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 10
th
Ed, The Northern Neonatal Network. 1998
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
6. Trissel LA. Handbook on injectable drugs. 15
th
edition. Bethesda: American Society of Health-System
Pharmacists 2009

DOPAMINE
Cardiac Inotrope
Preparations
INJ 40mg/mL

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Dilute according to IV drug protocol and give as a continuous
infusion via infusion pump.
Do not mix with strongly alkaline solutions or sodium
bicarbonate.

Dose
Improvement of cardiac output and BP
IV INF: 2 to 20microgram/kg/min

Notes
Use with caution if given through peripheral line due to
vasoconstrictive action.
Correct hypovolaemia before commencing infusion. Observe
IV site for inflammation, extravasation and extreme
vasoconstriction (tracking).
May be used together with dobutamine.
Phenytoin given together with dopamine may cause severe
hypotension.

RWH Neonatal Intensive and Special Care Nurseries
Dopamine IV Protocol

DOPAMINE
DESCRIPTION AND INDICATION FOR USE
Dopamine is a naturally occurring catecholamine with sympathomimetic actions. Dopamine acts
on both alpha and beta adrenergic receptors causing both inotropic and chronotropic responses
(increases rate and force of cardiac contractions).
Low dose infusions stimulate D1-receptors, causing renal, mesenteric and coronary
vasodilatation, that increases renal blood flow, glomerular filtration rate (GFR), and urine flow.
Increasing the dose progressively causes increased heart rate and force due to direct
stimulation of beta-adrenoceptors and release of neuronal noradrenaline, resulting in a rise in
systolic and mean blood pressure, with a smaller increase in diastolic pressure. At high doses,
dopamine stimulates alpha-adrenoceptors, causing vasoconstriction and further rises in blood
pressure, but decreased blood flow to vital organs, including the kidneys.5
Dopamine has a very short-half-life and must be given as a continuous infusion.
Dopamine is used to improve cardiac output, blood pressure and urine output in critically ill
patients with hypotension.
DOSE
Improvement of cardiac output and BP
IV Infusion: 2 to 20 microgram/kg/minute

RECONSTITUTION/DILUTION
Ampoule = 200mg in 5mL
IV: Add 30mg/kg to infusion solution ordered (glucose 5%, glucose 10%, sodium chloride
0.9%) to a total volume of 50mL (as shown in table below)
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Dopamine
SINGLE
30mg/kg to 50mL 1mL/hr = 10microgram/kg/min 2 to 20microgram/kg/min
Dopamine
DOUBLE
60mg/kg to 50mL 1mL/hr = 20microgram/kg/min 2 to 20microgram/kg/min
Dopamine
QUAD
120mg/kg to 50mL 1mL/hr = 40microgram/kg/min 2 to 20microgram/kg/min

ROUTE AND METHOD OF ADMINISTRATION
Not for IV bolus or IM use.
Use with caution if given through peripheral line (vasoconstrictive action). Administration via
central line is preferred, where available.
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of dopamine.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
1. Enter medicine dose then press ‘OK’
2. Enter volume in syringe then press ‘OK’ and check concentration is correct
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘mcg/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start infusion: over 1 hour

RWH Neonatal Intensive and Special Care Nurseries
Dopamine IV Protocol

SIDE EFFECTS
x Hypotension/Hypertension
x Reduced or excessive diuresis
x Tachycardia, Ectopic beats
x Vasoconstriction
x Metabolic acidosis
x Tissue sloughing and necrosis may occur if extravasation of dopamine occurs at infusion site, due to local
vasoconstriction

CONTRAINDICATIONS
x Uncorrected tachyarrhythmias
x Hypovolaemic states should be corrected prior to dopamine administration

DRUG INTERACTIONS
Phenytoin Combination may result in severe hypotension and hypovolaemic shock states. Use with extreme
caution

NURSING RESPONSIBILITIES
x Continuous blood pressure monitoring preferably with an arterial line.
x Continuously monitor heart rate and rhythm
x Record vital signs hourly
x Observe and measure urine output
x Observe IV site for inflammation and extravasation, re-site infusion immediately if extravasation occurs
x DO NOT GIVE BOLUS DOSES
x Avoid interruption to infusion line
x USE ATOM PUMP
x Change infusion fluid and line every 24 hours. When changing syringe and line, ensure pump and 3-way
tap is turned off to avoid giving a bolus.
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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%
6
, sodium chloride 0.9%,

Sodium bicarbonate and alkaline
solutions
Drugs Aminophylline, calcium chloride, dobutamine, glyceryl trinitrate,
heparin, hydrocortisone, meropenem, potassium chloride,
ranitidine, verapamil
Aciclovir, amphotericin B,
frusemide
1
, indomethacin
1
, insulin
(neutral), sodium bicarbonate
Y-Site Adrenaline, amiodarone, benzylpenicillin
1
, ciprofloxacin,
fentanyl, fluconazole, gentamicin, glyceryl trinitrate, heparin,
hydrocortisone, metronidazole, midazolam, morphine,
noradrenaline, pancuronium, piperacillin-tazobactam,
potassium chloride, ranitidine, sodium nitroprusside,
tobramycin
1
, verapamil, PN
1

References:
1. Neofax 12th Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 4th Ed, The Northern Neonatal Network. 2003
5. Therapeutic Guidelines: Cardiovascular, 3rd Ed 1999
6. Handbook on Injectable Drugs, Trissel 11th Ed, 2000

RWH Neonatal Intensive and Special Care Nurseries
Erythromycin IV Protocol

ERYTHROMYCIN
DESCRIPTION AND INDICATION FOR USE
Erythromycin belongs to the macrolide group of antibiotics. It may be bacteriostatic or
bactericidal, depending on the concentration achieved and the organism involved.
It is active against mycoplasma and ureaplasma and is used to treat infection where sensitivity
tests indicate.

DOSE
Standard Infection
IV, ORAL: 10mg/kg/dose 8hrly

Severe Infection
IV, ORAL: 15 to 25mg/kg/dose 8hrly

RECONSTITUTION/DILUTION
Vial = 1g

IV: Reconstitute vial with 20mL of water for injection = 1000mg in 20mL = 50mg/mL

To dilute to 5mg/mL: Withdraw 1mL of 50mg/mL (50mg) solution and add to 9mL of Sodium
Chloride 0.9% in a 10mL syringe = 50mg in 10mL = 5mg/mL. Withdraw required dose.

To dilute to 1mg/mL: Withdraw 0.2mL of 50mg/mL solution (10mg) and add to 9.8mL of Sodium
Chloride 0.9% in a 10mL syringe = 10mg in 10mL = 1mg/mL. Withdraw required dose.

ROUTE AND METHOD OF ADMINISTRATION
IM injection is painful and is not recommended.

IV infusion: Give slowly over 60 to 120 minutes via syringe pump using Guardrails

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with
preloaded syringe containing exact dose of erythromycin.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Choose syringe concentration 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 60 to 120 minutes:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the
same as in syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
Note: 60minute infusion will show the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the
same infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Erythromycin IV Protocol

SIDE EFFECTS
x Thrombophlebitis and pain at injection site
x GI tract disturbances. Erythromycin increases gut motility due to an effect on motilin
receptors.
x Bradycardia with hypotension due to rapid IV administration
x Ventricular arrhythmia, prolongation of the QT interval
x Intrahepatic cholestasis1
x May lead to increased risk of hypertrophic pyloric stenosis in first two weeks of life

CONTRAINDICATIONS
x CAUTION in patients with liver impairment

DRUG INTERACTIONS
Theophylline Decreased clearance of theophylline, resulting in increased serum levels and
possible toxicity. Monitor theophylline levels.
Phenytoin, midazolam Decreased clearance when used together with erythromycin
Digoxin Digoxin levels may be increased due to an alteration in oral absorption

NURSING RESPONSIBILITIES
x Monitor heart rate and blood pressure closely during IV administration1. Two or three
manual readings during administration are sufficient if there is no arterial line.
x Careful observation of infusion site
x Flush line with normal saline before and after administration

COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Sodium chloride 0.9% All glucose containing solutions, intralipid, PN
Drugs Aminophylline, benzylpenicillin,
hydrocortisone, potassium chloride,
ranitidine, sodium bicarbonate, verapamil
Flucloxacillin, fluconazole, frusemide, heparin
Also any drugs that are incompatible due to
their glucose content or that are incompatible
with sodium chloride (e.g. amphotericin B)
Y-Site Aciclovir, heparin, magnesium sulphate,
morphine sulphate

References:
1. Neofax 18th Ed. 2005 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 3rd Ed., The Society of Hospital Pharmacists of Australia, 2005
4. Neonatal Formulary 4th Ed, The Northern Neonatal Network. 2003
5. Manual of Neonatal Care 4th Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
6. APP Guide 2002 p1419
7. Trissell 11th Edition p504

FENTANYL
Opioid analgesic
Preparations
INJ 50microgram/mL

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Dilute with WFI to give a concentration of 10microgram/mL
and give prescribed dose over 10mins.
INF Dilute and administer according to IV drug protocol.

Dose
Analgesia in ventilated patients only
IV: 1 to 5microgram/kg/dose 2 to 3hrly as required.
IV INF: 1 to 5microgram/kg/hour
Naloxone (0.1mg/kg/dose) must be available for reversal.

Notes
Use only in ventilated patients. Potent respiratory depressant.
Monitor chest wall rigidity.
Monitor patient carefully as clearance is highly variable.
Tolerance may develop following constant infusion. Significant
withdrawal symptoms have been reported in patients treated
with continuous infusion longer than 5 days.
Duration of action 30 to 60mins, therefore analgesic effect is
brief unless given by continuous infusion.

RWH Neonatal Intensive and Special Care Nurseries
Fentanyl IV Protocol

FENTANYL
DESCRIPTION AND INDICATION FOR USE
Fentanyl is a synthetic, fat soluble, opioid analgesic used for pain relief, sedation and to enhance anaesthetic
agents during surgery.
Fentanyl has a quicker onset but a shorter duration of action than morphine and is less likely to cause hypotension.
However, it has a prolonged half-life, due to deposition into fat stores around the body. Continuous infusions of
fentanyl are used for short periods only (< 3days), as tolerance develops rapidly and narcotic withdrawal may occur
when infusions are ceased abruptly.
DOSE
Endotracheal intubation (with atropine and suxamethonium)
IV: 5micrograms/kg/dose = 0.1mL/kg/dose

Analgesia in ventilated patients only
IV bolus: 1 to 5micrograms/kg/dose 2 to 3hrly as required

IV INFUSION: 1 to 5micrograms/kg/hour

Naloxone (100micrograms/kg/dose) should be available for reversal of overdose.

RECONSTITUTION/DILUTION
Ampoule = 100micrograms in 2mL = 50micrograms in 1mL (Stored in Drug of Addiction Safe)

Endotracheal intubation (with atropine and suxamethonium)
IV: No dilution necessary

Analgesia in ventilated patients
IV: Withdraw 0.2mL (10micrograms) of 50micrograms/mL solution and add to 0.8mL of sodium chloride 0.9%
in a 1mL syringe = 10micrograms/mL. Discard excess volume to obtain ordered dose or withdraw dose using
another 1mL syringe.

IV Infusion: Dilute according to table below to total volume of 50mL
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Fentanyl
SINGLE
50micrograms/kg in 50mL 1mL/hr = 1microgram/kg/hour 1 to 5micrograms/kg/hour
Fentanyl
5xCONC
250micrograms/kg in 50mL 1mL/hr = 5micrograms/kg/hour

ROUTE AND METHOD OF ADMINISTRATION
IV (endotracheal intubation):
Administer dose slowly over 30 seconds then flush slowly with sodium chloride 0.9%

IV: Administer ordered dose slowly over 10 minutes.
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of fentanyl.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘mcg/kg/h’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

RWH Neonatal Intensive and Special Care Nurseries
Fentanyl IV Protocol

SIDE EFFECTS
x Bradycardia, hypotension, seizures and chest wall rigidity with rapid infusion
x Apnoea, respiratory depression (Naxolone should be available for reversal)
x Muscle rigidity, particularly chest wall rigidity
x Tolerance may develop with prolonged use, requiring increasing doses to achieve
desired effect.

CONTRAINDICATIONS
x Non ventilated patients
x Hypotension
x CAUTION in patients with liver or kidney dysfunction.

DRUG INTERACTIONS
Other CNS depressants (morphine,
diazepam, midazolam, phenobarbitone)
Enhanced effects of both drugs. Risk of respiratory depression
may be increased.

NURSING RESPONSIBILITIES
x Cardiorespiratory monitoring
x Monitor BP
x Transcutaneous O2 /CO2 or oximetry as indicated
x Observe for abdominal distension, loss of bowel sounds and muscle rigidity1
x Change infusion solution every 24 hours
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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%
1
, sodium chloride 0.9%
Drugs Phenobarbitone, phenytoin
Y-Site Adrenaline, atropine, caffeine citrate, dexamethasone,
dobutamine, dopamine, frusemide, heparin,
hydrocortisone, metronidazole, midazolam, milrinone,
morphine, noradrenaline, potassium chloride, ranitidine,
PG, lipid

Notes:
• Tolerance may develop following constant infusion1
• Significant withdrawal symptoms have been reported in patients treated with
continuous infusion for 5 days or longer1
• Duration of action is 30 to 60 minutes4, therefore analgesic action is brief
unless given by continuous infusion
References:
1. Young T, Mangum B, 2008, Neofax 2008, 21
st
Ed, New Jersey: Thomson Reuters.
2. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4
th
Ed., Melbourne: The Society of Hospital Pharmacists of
Australia.
3. Trissell LA, 2009, Handbook on Injectable drugs, 15
th
Ed, Bethesda, American Society of Health-System Pharmacists
4. CMPmedica. MIMSOnline. CMPmedica; Sydney, Australia, 2010 accessed 20/12/10.
5. Cloherty J.P, Eichenwald E.C, Stark A.R. 2008, Manual of Neonatal Care, 6
th
Ed., Philadelphia: Lippincott Williams &
Wilkins
6. Fary R, Smith R, Davis P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia, 2
nd
Ed, Melbourne: Pharmacy
Department The Royal Women's Hospital.
7. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5
th
Ed, Massachusetts: Blackwell Publishing Inc,
2007.
8. BNF for children, London: BMJ Publishing Group Ltd, 2005.
9. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13
th
Ed, Melbourne: Pharmacy Department, Royal
Childrens Hospital.
10. Taketomo, Hodding and Kraus, Pediatric Dosage Handbook, 17
th
Ed., 2010

Ferrous Sulphate
(Iron)

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Effective Date: 21 Jun 2017
Review Date: Jun 2020
Page 1 of 2

Neonatal Protocol
Description and indication for use
Iron salts are compounds used primarily for the prophylaxis and treatment of iron deficiency
anaemia. The body stores iron in ferritin and hemosiderin for future use in the production of
haemoglobin. Haemoglobin is a protein that contains iron and is essential for transporting oxygen
around the body. Iron supplementation replenishes iron stores and helps increase haemoglobin
levels. The ferrous form of inorganic iron is more readily absorbed.

Preparations
Ferro-Liquid
®
containing 30 mg/mL of ferrous sulphate (equivalent to 6 mg/mL of elemental iron)

Dose
Commence iron on day 28 in all babies <32 weeks gestation or <2 kg at birth who are on EBM or
term formula:
ORAL: 0.5 mL/kg once daily (3 mg/kg/day of elemental iron) with feed.

Note: fortified EBM and preterm formula contain iron to meet the baby’s iron requirement, so
supplementation is not required. Iron supplementation should be commenced when fortifier is
ceased or when feeds are switched from preterm formula to term formula.

Ferrous sulphate can be initiated and ceased by pharmacists according to the protocol.
Pharmacists should prescribe and/or cease ferrous sulphate according to the Medicine –
Prescribing and Dispensing guideline.

Side Effects
x Constipation
x Black stools

Notes
x On discharge, families are advised to obtain and administer ferrous sulphate until established
on solids at around 6 months of age if breastfeeding, or 3 months of age if formula fed.
x For babies discharged home < 28 days of age meeting the above criteria for iron
supplementation, families are advised to obtain and administer ferrous sulphate at discharge.
Continue until established on solids at around 6 months of age if breastfeeding, or 3 months of
age if formula fed.
x Families should be provided with the information sheet - Iron supplementation for babies – with
sufficient counselling.
References
1. Jin H, Wang R, Chen S, Wang A, Liu X. Early and late iron supplementation for low birth weight infants: a meta-
analysis. Italian Journal of Pediatrics 2015;41(16):1-10
2. Taylor T, Kennedy KA. Randomised Trial of Iron Supplementation versus Routine Iron Intake in VLBW Infants.
Pediatrics 2013;131(2):e433-e438
3. Franz AR, Mihatsch WA, Sander S, Kron M, Pohlandt F. Prospective Randomised Trial of Early Versus Late Enteral
Iron Supplementation in Infants with a Birth Weight of Less Than 1301 Grams. Pediatrics 2000;106(4):700-706
4. Rao R, Georgieff K. Iron Therapy for Preterm Infants. Clin Perinatol. March 2009; 36(1):27-42

Ferrous Sulphate
(Iron)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 21 Jun 2017
Review Date: Jun 2020
Page 2 of 2

Neonatal Protocol
5. MIMS Online Prescribing Information for Ferro-Liquid
®
.
6. Committee on Nutrition of Preterm Infant, European Society for Paediatric Gastroenterology, Hepatology and
Nutrition. Journal of Pediatric Gastroenterology and Nutrition 2009;50:1-9.

Effective date: 15 Mar 2018

IRON SUPPLEMENTATION
FOR BABIES
Preterm babies born at less than 32 weeks gestation, and babies weighing less than 2kg
at birth may develop anaemia (low levels of haemoglobin in the blood). Haemoglobin is
a protein that contains iron and is essential for transporting oxygen around the body.
Iron supplementation replenishes iron stores and helps increase haemoglobin levels.
Which babies require iron supplementation?
Iron supplementation is recommended for
babies born at less than 32 weeks gestation, or
less than 2kg birth weight.

How long does my baby need an iron
supplement for?
For breastfed babies, iron supplementation
should be continued until your baby is
established on solids, at around 6 months of
age.

For formula-fed babies, iron supplementation
should be continued until 3 months of age.

What is the dose?
The dose for iron supplementation will be
recommended by your baby’s doctor at the time
of discharge.
Dose: ___________ mL once a day.

What iron supplement is available?
Ferro-Liquid
®
is an oral liquid iron supplement
that can be used for your baby.

Where can I purchase Ferro-liquid
®
?
Ferro-Liquid
®
can be purchased from any
pharmacy without a prescription. Ask your
pharmacist for directions on how to give the
recommended dose to your baby.

Further information
For assistance or further information, call the
Royal Women’s Hospital Medicines Information
Line on (03) 8345 3190 or your local
pharmacist.
Disclaimer: The information contained is intended to support not replace discussion
with your doctor or health professionals. The hospital accepts no responsibility for
any inaccuracies, information perceived as misleading, or the success of any
treatment regimen detailed in this leaflet.

Ferro-Liquid
®

Affix patient label here

Flucloxacillin

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Effective Date: 12 June 2015
Review Date: June 2018
Page 1 of 2

Neonatal Protocol
Description and indication for use
Flucloxacillin is a beta-lactamase resistant type of penicillin. It is a narrow spectrum antibiotic used
in the treatment of staphylococcal and other gram positive infections and when sensitivity
indicates. At RWH it is used empirically in combination with gentamicin for late onset sepsis
(> 48 hours of age), until sensitivities are known.

Preparations
Injection 1000 mg
Mixture 25 mg/mL 50 mg/mL

Dose
Standard infection
IV, IM, Oral: 25mg/kg/dose

Severe infection
IV, IM, Oral: 50mg/kg/dose

Interval
≤7 days 12 hourly
8 to 28 days 8 hourly
>28 days 6 hourly

Reconstitution/Dilution
Vial = 1g (1000mg)

IV: Add 5 mL of Water for Injection to the vial. Ensure that the contents of vial are completely
dissolved. Withdraw contents from the vial and make volume to 20 mL with Water for
Injection = 50mg/mL
Withdraw the required dose. Discard any remaining solution.

IM: Add 1.8 mL of Water for Injection = 400 mg/mL

Oral: Reconstitute powder using Water for Injection according to the product information.

Route and Method of Administration
IV: Give over at least 10 minutes.

Oral: Best given on an empty stomach at least half an hour before or two hours after feeds.

Side Effects
x Nausea, vomiting, diarrhoea
x Hepatitis, cholestatic jaundice
x Severe phlebitis
x Displacement of bilirubin from albumin, jaundice in high doses
x Nephritis, haematuria

Flucloxacillin

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 12 June 2015
Review Date: June 2018
Page 2 of 2

Neonatal Protocol
Contraindications
x CONTRAINDICATED in patients with a history of hypersensitivity to penicillin
x Caution in patients with hepatic and renal impairment
x Caution in patients at risk of hyperbilirubinaemia, jaundice

Nursing Responsibilities
x Observe IV site
x Monitor urine output

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

Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9% Lipid emulsion 17%, IVN Starter, IVN
Maintenance
Y-Site Calcium gluconate, ciprofloxacin,
dobutamine, midazolam, morphine,
vancomycin

References

1. Flucloxacillin monograph, IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral
Compatibility). Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 29/05/2015.
2. Trissell LA. Handbook on Injectable drugs. 15
th
Ed. Bethesda, Maryland: American Society of Health-
System Pharmacists; 2009.
3. Burridge N, Collar N, Symons K, editors. Australian Injectable Drugs Handbook. 6
th
Ed. Melbourne: The
Society of Hospital Pharmacists of Australia; 2014.
4. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
5. Australian Medicines Handbook 2015 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2015
January. Available from: http://amhonline.amh.net.au/
6. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 29/05/2015
7. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
8. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
9. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
2011.
10. Flucloxacillin protocol from KEMH WA accessed on 29/05/2015
http://www.kemh.health.wa.gov.au/services/nccu/guidelines/drug_protocols/Flucloxacillin.pdf
11. Flucloxacillin protocol from ADHB Auckland NZ accessed on 29/05/2015
http://www.adhb.govt.nz/newborn/DrugProtocols/FlucloxacillinPharmacology.htm

FLUCONAZOLE
Antifungal
Preparations
INJ 2mg/mL
MIXT 10mg/mL

IV preparation and compatibilities
Administer undiluted over at least 60mins.

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

Systemic infection and/or meningitis
Loading dose
IV, ORAL: 12mg/kg/dose
Maintenance dose
IV, ORAL: 6mg/kg/dose

Cutaneous infections, candidiasis
Loading dose
IV, ORAL: 6mg/kg/dose
Maintenance dose
IV, ORAL: 3mg/kg/dose

Interval
≤ 14 days 72hrly
15 to 28 days 48hrly
> 28 days 24hrly

Notes
Monitor liver function tests and discontinue if liver disease develops. Consider dose
reduction in renal impairment. Do not use to treat C. Krusei or C. Glabrata.
May increase levels of phenytoin, theophylline and caffeine. Consider monitoring
levels.
IV preparation contains 15mmol sodium per 100mL.

FLUCYTOSINE
Antifungal
Preparations
INJ 10mg/mL

IV preparation and compatibilities
Administer undiluted.
Give 10mg/mL over at least 30mins.
Store between 15 and 25°C in original container as precipitation occurs at prolonged
storage under 15°C and conversion to 5-fluorouracil occurs if stored above 25°C.
Flucytosine should be considered a potential carcinogen in humans and must be
handled as a cytotoxic drug.
The pharmacy department will supply preloaded doses as 10mg/mL solutions Monday to
Friday.

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

Use in combination with amphotericin B for systemic fungal infections not
responding to conventional antifungal therapy
Standard infection
IV: 25mg/kg/dose 6hrly

Severe infection
IV: 50mg/kg/dose 6hrly

Notes
Do not use alone. Monitor levels to avoid marrow toxicity. Measure peak 1hr after start of
infusion and trough immediately prior to next dose.
Therapeutic range
Peak: 60 to 80mg/L
Trough: 25 to 40mg/L
Toxic: >100mg/L
Exercise caution in renal impairment and when used in combination with other
nephrotoxic drugs. Monitor liver function tests.
Infusion solution contains 34.4mmol of sodium per 250mL.

FOLIC ACID
Supplement
Preparations
INJ 15mg/mL
TAB 0.5mg, 5mg

IV preparation and compatibilities
Compatible with G5%, G10%, NaCl
0.9%.
Administer over minimum of 1 minute.

Dose
Deficiency
IV, ORAL: 50microgram once daily

Notes
Can be given IM or SC if necessary.

FOLINIC ACID
Calcium leucovorin / Calcium folinate
Preparations
INJ 50mg/5mL, 15mg/2mL
TAB 15mg
MIXT 10mg/mL

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.

Dose
In combination with pyrimethamine for
toxoplasmosis
ORAL: 10mg three times a week (M,W,F).

Bioamine neurotransmitter defects
ORAL: 7.5mg once daily

Notes
Antidote to folic acid antagonists. Used in
combination for toxoplasmosis therapy.

Furosemide (Frusemide)

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Effective Date: 6 March 2018
Review Date: March 2021
Page 1 of 3

Neonatal Protocol
Description and indication for use
Furosemide is a potent loop diuretic with a rapid onset of action. Oral bioavailability is adequate for
maintenance doses, but IV dosing is necessary in acute situations.
Furosemide causes major urinary losses of sodium, potassium and chloride. It also increases
urinary calcium and magnesium excretion, as well as urine ph.
Indications:
1. Chronic Lung Disease
2. Acute episodes of fluid overload
3. Oliguria

Preparations
Injection 20mg/2mL (10mg/mL)
Oral suspension 10mg/mL (RWH)

Dose
IV, IM: 0.5 to 1mg/kg/dose

Oral: 0.5 to 2mg/kg/dose

Interval CA < 31 weeks 24 hourly
CA ≥ 31 weeks 12-24 hourly
Term infant > 30 days 8-12 hourly

IV INFUSION:
50 to 400 micrograms/kg/hour

Higher doses may be required in renal impairment and heart failure in term infants. Oral doses may
be increased to 6mg/kg/dose in resistant cases.

Reconstitution/Dilution
IV Bolus: Withdraw required dose. No dilution necessary.
If dose is unable to be measured, a 1 in 5 dilution can be made. Take 1mL of 10mg/mL solution
and add to 4mL of sodium chloride 0.9% or Water for Injection in a 10mL syringe = 10mg in 5mL =
2mg/mL

IM: No dilution necessary. Withdraw required dose.

IV Infusion: Add to infusion solution ordered (sodium chloride 0.9%) to a total volume of 50mL
CONCENTRATION HOW TO DILUTE DOSE EQUIVALENT DOSE RANGE
Furosemide
SINGLE
10mg/kg dilute to
50mL
1mL/hr =
200micrograms/kg/hour

100 to 400
micrograms/kg/hour Furosemide
DOUBLE
20mg/kg dilute to
50mL
1mL/hr =
400micrograms/kg/hour

Furosemide (Frusemide)

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Effective Date: 6 March 2018
Review Date: March 2021
Page 2 of 3

Neonatal Protocol
Route and Method of Administration
Give IM only when no IV access is available. IV administration is recommended.

IV: Give over at least 5 minutes. Do not exceed 500micrograms/kg/min.
If being given in association with a top-up transfusion, dose should be given HALF WAY
THROUGH THE TRANSFUSION.

IV infusion: Administer as a continuous IV infusion at prescribed rate via syringe infusion pump
(Guardrails) – see ‘How to set up the Pump’.

Side Effects
x Hypokalaemia, hyponatraemia, hypomagnesaemia, hypocalcaemia, hyperuricaemia. If used
long-term, monitor serum potassium and consider potassium supplementation.
x Dehydration, hypotension
x Hypercalciuria and renal calculi (long term therapy)
x Bone demineralisation (long term therapy)
x Hypochloraemic metabolic alkalosis
x Risk of ototoxicity is increased with renal impairment, high doses, rapid IV administration and
use of other ototoxic drugs (e.g. aminoglycosides such as gentamicin)

Contraindications
x Anuria
x Hypovolaemia or hypotension
x CAUTION in patients with renal failure
x CAUTION in patients with hyperbilirubinaemia or jaundice

Drug Interactions

Dexamethasone,
Amphotericin B
May enhance hypokalaemia
Gentamicin, Amikacin May enhance nephrotoxicity and ototoxicity
Vancomycin May enhance nephrotoxicity and ototoxicity
Indomethacin,
Ibuprofen
May reduce diuretic response and increase risk of nephrotoxicity
Digoxin Hypokalaemia or hypomagnesamia may predispose to digoxin
induced cardiac arrhythmias

Nursing Responsibilities
x Monitor fluid input and output
x Do not use if the IV solution is yellow in colour

Furosemide (Frusemide)

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Please remember to read our disclaimer.

Effective Date: 6 March 2018
Review Date: March 2021
Page 3 of 3

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

Compatible Incompatible
Fluids Sodium chloride 0.9%, glucose 5%,
glucose 10%, glucose 20%

Y-Site Aciclovir, Adrenaline, amikacin,
benzylpenicillin sodium, calcium
gluconate, cefotaxime, dexamethasone,
digoxin, dopamine, fentanyl, heparin,
hydrocortisone sodium succinate, insulin
neutral, indomethacin, meropenem,
metronidazole, noradrenaline,
piperacillin-tazobactam, potassium
chloride, ranitidine, sodium bicarbonate,
IVN starter, IVN Maintenance,
Azithromycin, caffeine citrate,
erythromycin, fluconazole, gentamicin,
midazolam, milrinone, vancomycin,
vecuronium

References
1. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010
2. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group,
Pharmaceutical Press, and RCPCH Publications <http://www.medicinescomplete.com>
[Accessed February 2018]
3. Lexicomp Online® Pediatric & Neonatal Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.;
January 29, 2015.
4. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book.
10
th
Ed. Bethesda, Maryland: American Society of Health-System Pharmacists; 2013
5. 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.
6. AMH Children’s Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty
Ltd; 2018 January. Available from: https://childrens.amh.net.au/
7. Furosemide. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral
Compatibility). Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed:
February 2018
8. Burridge, Nicolette, (editor.) & Symons, Keli, (editor.) & The Society of Hospital
Pharmacists of Australia 2017, Australian injectable drugs handbook, 7th edition,
Collingwood, Victoria The Society of Hospital Pharmacists of Australia

GANCICLOVIR
Antiviral
Preparations
INJ 500mg

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Ganciclovir should be considered a potential carcinogen in
humans and must be handled as a cytotoxic drug.
The pharmacy department will supply preloaded doses as
5mg/mL solutions Monday to Friday.
Infuse via syringe pump over 1hr.

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

Treatment of life threatening CMV disease
IV: 5mg/kg/dose 12hrly

Notes
Neutropenia and thrombocytopenia may occur requiring dose
reduction. White blood cell and platelet counts should be taken
every 2 days for the first 14 days.
Do not use in combination with imipenem-cilastatin.

RWH Neonatal Intensive and Special Care Nurseries
Ganciclovir IV Protocol

GANCICLOVIR
Please handle according to Cytotoxic Drug Handling Guidelines

DESCRIPTION AND INDICATION FOR USE
Ganciclovir is an acyclic nucleoside that is structurally related to aciclovir and possesses
antiviral activity against herpes viruses, varicellla-zoster virus, and Epstein-Barr virus, as well as
Cytomegalovirus. It is rapidly excreted by the kidneys, with a half-life of 2.5 hours.
Cytomegalovirus resistance to ganciclovir may occur.
Ganciclovir may be used in the treatment of life-threatening CMV disease in neonates, only after
specialist consultation.

DOSE
Treatment of life-threatening CMV disease.
IV: 5mg/kg/dose every 12 hours

RECONSTITUTION/DILUTION
Pharmacy will supply preloaded syringes during pharmacy hours.
Please ensure that syringe is labelled correctly before commencing infusion.

ROUTE AND METHOD OF ADMINISTRATION
Flush line with glucose 5% or sodium chloride 0.9% after dose is completed.
IV infusion: Give slowly over 1 hour via syringe pump using Guardrails

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with
preloaded syringe containing exact dose of ganciclovir.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 1 hour:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the
same as in syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
Note: 60minute infusion will show the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1.5mL of sodium chloride 0.9% or glucose 5% in a 10mL syringe and
infuse at the same infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Ganciclovir IV Protocol

SIDE EFFECTS
x Neutropenia and thrombocytopenia may occur requiring dose reduction. White Blood
Cell and Platelet counts should be taken every 2 days for the first 14 days of treatment.
x Anaemia, leukopenia
x Rarely cardiovascular side effects such as arrhythmia, hypertension, tachycardia
x GI effects
x Hepatotoxicity

CONTRAINDICATIONS
x CAUTION in patients with renal impairment.

DRUG INTERACTIONS
Imipenem-Cilastatin Combination has been associated with generalised seizures
4
Zidovudine Haematologic toxicity is increased when this combination is used.
4

NURSING RESPONSIBILITIES
Handle according to Cytotoxic Drug Handling Guidelines
x Use gloves and goggles during set up, administration and disposal of equipment in
contact with ganciclovir, or the patient's body fluids.
x Use soap and water immediately to wash any accidental contact with skin.
x Dispose of equipment into "purple" cytotoxic container
x Monitor fluid balance
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9%
Drugs
Y-Site
Notes:
x Do not infuse ganciclovir together with any other drugs or with TPN or Intralipid.
x Ganciclovir is only compatible with glucose 5% and sodium chloride 0.9%

References:
1. Neonatal Pharmacopoeia 1st Ed. 1998, Pharmacy Department, The Royal
Women's Hospital, Carlton 3053
2. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital
Pharmacists of Australia, 1999
3. Neonatal Formulary 10th Ed, The Northern Neonatal Network. 1998
4. Micromedex Healthcare Series

Page 1 of 5
Women and Newborn Health Service
Neonatal Directorate

Also refer to NETS WA Clinical Guidelines, Surgical Problems.
Gastroschisis is a congenital anomaly characterised by a full thickness abdominal
wall defect, usually just to the right of an intact umbilical cord, through which a
variable amount of intestine protrudes without a covering membrane; other
abdominal viscera like liver, spleen, gonads etc. may also protrude. The size of the
abdominal wall defect is variable; small defects are a concern and may cause
significant bowel ischaemia.
The term ‘Vanishing Gastroschisis’ is used to describe the apparent foetal ultrasonic
reduction and disappearance of exteriorised bowel due to the abdominal wall defect
spontaneously closing, leading to significant bowel ischaemia and short bowel
syndrome.
Management at Birth
Liaise with the Paediatric Surgeons and PMH NICU
Alert PMH NICU and the on call paediatric surgical team well before delivery. PMH
NICU may need to make room for the admission by moving existing patients and the
paediatric surgeons may wish to be present soon after delivery in order to place the
exposed bowel into a silo before the baby is transferred to PMH NICU.
Management at Birth in Labour Ward
x Standard neonatal resuscitation as per NRP guidelines.
x Double bagging: the first bag covers the legs and lower abdomen i.e. laces
up just below the exposed bowel to prevent the bowel being soiled by urine
and meconium; and the second bag covers the first bag and exposed bowel
and laces up above the bowel close to the axilla (cling film can be loosely
wrapped around the baby when a bowel bag is not available). This protects
the bowel and reduces heat and fluid losses and allows for ongoing careful
inspection of the bowel for discolouration. Lay the infant on the right side
for transport to NICU.
CLINICAL PRACTICE GUIDELINE
Guideline coverage includes NICU KEMH, NICU PMH and NETS WA
Gastroschisis
This document should be read in conjunction with the Disclaimer

Gastroschisis

Page 2 of 5

Neonatal Directorate

x Insert size 8Fg oro-gastric tube and fully aspirate the stomach contents and
leave on free drainage.
On Admission to SCN3 at KEMH and/or PMH
x Immediately upon admission to NICU, contact PMH NICU, NETS WA and the
surgical team and confirm that delivery has occurred (see above). If the
surgeon is unable to attend the infant at KEMH, arrange for transfer to PMH
NICU as soon as the infant is stable for transport.
x Nurse the infant under a radiant warmer. The infant’s legs and torso should
remain inside the impermeable bowel bags in order to limit fluid and heat loss
from the bowel and also to allow easy inspection of the bowel and help protect
the bowel and limit the risk of sepsis.
x Insert size 8Fg oro/nasal gastric tube if not inserted at delivery and fully
aspirate the stomach contents and leave on free drainage.
x Watch bowel colour and report any discolouration that develops; repositioning
the bowel relative to the abdominal opening maybe necessary if the bowel
becomes dusky. Request an urgent surgical review if there is no improvement
in bowel colouring.
x Insert an IV and commence maintenance fluids (7.5 to 10% glucose) at 80
mL/kg/day in neonates > 37 weeks gestation and 100 mL/kg/day in preterm
infants. In addition, commence an infusion of Normal Saline at a rate of 10
mL/kg/hr. The Normal Saline infusion should continue until the surgeons
apply a silo or until a formal reduction of gastroschisis is achieved (whichever
happens first).
Once the Silo is applied make sure to stop the Normal Saline infusion.
x It may be necessary to continue the Normal Saline infusion or give additional
boluses of Normal Saline if hypo-perfusion, hypotension or metabolic/lactic
acidosis is present. Consider early use of Dopamine or Dobutamine if no
improvement in spite of the Normal saline infusion.
x Give IV prophylactic antibiotics Benzyl Penicillin/Gentamicin/Metronidazole
after collecting blood cultures.
x Examine the infant for associated anomalies.
x FBC, blood group and hold or cross-match, blood gas, blood culture. Ensure
that 10mLs of clotted maternal blood for cross-matching is collected.
x Once the baby is stable transfer to PMH NICU.
Management of neonates with gastroschisis during transport
refer to NETS WA Clinical Guidelines
The general management of a gastroschisis infant with a silo
x Nil oral and keep the stomach on free drainage with a large bore catheter.
x Early maintenance parenteral nutrition to ensure adequate weight gain and
metabolic balance.
x Extra IV fluids will be required if gastric losses are greater than 10
mLs/kg/12hour period. The total fluid loss in the previous 12 hour period
should be replaced (half as TPN solution and half as Normal Saline via a side
line). Refer to Replacement of Gastrointestinal Fluid Losses in Surgical
Neonates.

Gastroschisis

Page 3 of 5

Neonatal Directorate

x Surgeons will gradually reduce the intestinal contents as the baby’s condition
permits; usually over 2-5 days.
x Carefully observe the bowel for discolouration. Normal bowel in silo should
look pink. Grey, purple or black looking bowel indicates vascular compromise.
Areas of ‘peel’ may be present and appear discoloured. This situation should
be reviewed by senior neonatal staff.

Post-operative management following complete closure, either
after silo or after primary closure
Some infants may not adapt quickly to the extra amount of gut which has been
reduced into the abdominal cavity. This could result in compression of the
mesenteric blood vessels leading to ischemia of the bowel. This is called
“abdominal compartment syndrome”. If this is not diagnosed and treated quickly, it
can have catastrophic consequences, such as necrosis of the bowel. One or more of
the following clinical features should suggest the possibility of abdominal
compartment syndrome:
x A significant increase in ventilator pressures compared to the pre-reduction
pressures.
x Tense and possibly tender abdomen.
x Discolouration of abdominal wall and lower limbs.
x Very high morphine requirements.
x Progressive worsening of metabolic and or respiratory acidosis, high lactate
levels.
x Hypotension requiring inotropic support.
x Decreased or absent urine output.
If one or more of these clinical features develop, you should seek an urgent senior
neonatal review before contacting the surgical team.
Pain Management
Analgesia should be provided as needed., preferably with intravenous Paracetamol
or Morphine. A balance should be maintained between effective analgesia and side
effects of opiates on respiratory depression and gut motility. Normally infants with a
silo do not require significant analgesia. If an infant needs high dose morphine
infusions, it should alert the clinicians to the possibility of bowel ischemia.

Gastroschisis

Page 4 of 5

Neonatal Directorate

Fluid and electrolyte balance
Frequent blood gas and electrolyte measurements (6-12 hourly) should be
performed to guide fluid therapy. Blood pressure, capillary refill, pulse rate, colour,
amount of gastric aspirates and urine output should be taken into consideration in
adjusting fluid therapy.
Gastric Losses
Refer to Fluid replacement therapy for surgical neonates
A large bore gastric tube (size 8 or 10Fg) on free drainage with 1-2 hourly gentle
aspirations is needed to prevent gastrointestinal distension caused by post-operative
ileus and the reduction process. Monitoring and replacement of losses is necessary
as some infants can lose very large volumes of stomach fluids. Losses are generally
replaced as half normal saline, but are tailored to the baby’s electrolyte status. In
some cases, this may last for weeks until gut motility improves.
Decreased urinary output
A decrease in urine output may be due to renal venous compression as a result of
the raised intra-abdominal pressure or an inadequate intravascular volume (due to
inadequate fluid loss replacement or ‘third’ spacing). Bladder retention is a
frequent problem, often as a side effect of morphine analgesia. A urinary catheter
may be necessary.
Nutrition
Consider early placement of a percutaneous long line. Parenteral nutrition should be
started as soon the baby is stable after birth. Enteral feeding will not start until the
abdominal wall defect has been closed and gastric aspirates are reducing. Trophic
feeds are often given even when there are relatively large gastric aspirates, decided
on a case by case basis. Enteral feeds are increased as tolerated; as judged by the
amount of gastric aspirates/vomits, abdominal distension and bowel actions. Gut
dysmotility can persist for weeks after gastroschisis closure and longer term TPN
may be needed to supplement inadequate enteral intake. Early initiation of enteral
feeding has been shown to improve the gut function in babies with gastroschisis.
Occasionally a prokinetic agent may be helpful in promoting gut motility.
Antibiotics
Antibiotics are routinely started immediately after birth and usually continued until the
abdominal wall defect is closed. Routine antibiotics are Benzyl Penicillin, Gentamicin
and Metronidazole. Vancomycin is frequently added if there is significant abdominal
wall redness. It is reasonable to monitor CRP levels whilst on antibiotics.

Gastroschisis

Page 5 of 5

Neonatal Directorate

References
1. Davies MW, Kimble RM, Woodgate PG. Ward reduction without general anaesthesia versus
reduction and repair under general anaesthesia for gastroschisis in newborn infants. The
Cochrane Database of Systematic Reviews 2002, Issue 3
2. Williams, T, Butler, R, Sundem, T. (2003). Management of the Infant with Gastroschisis: A
comprehensive review of the literature. Newborn and Infant Nursing Reviews. 3 (2): 55-63.
3. Principles and Practice of Pediatric Surgery, 2
nd
Edition. Ch 69 Abdominal Wall Defects. R
Minkes. Available from CAHS library as eBook.

Related WNHS policies, procedures and guidelines
NETS WA Clinical Guidelines
NETS WA Clinical Guidelines: Surgical Problems

Document owner: Neonatal Directorate Management Committee
Author / Reviewer: Neonatal Directorate Management Committee
Date first issued: August 2008
Last reviewed: 26
th
July 2017 Next review date: 26th July 2020
Endorsed by: Neonatal Directorate
Management Committee
Date endorsed: 26
th
September 2017
Standards
Applicable:
NSQHS Standards: 1Governance, 3Infection Control, , 6Clinical
Handover
Printed or personally saved electronic copies of this document are considered uncontrolled.
Access the current version from the WNHS website.

Gentamicin
(NISC Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Page 1 of 3

Description and indication for use
Gentamicin is an aminoglycoside antibiotic. It is bactericidal and acts by inhibiting protein synthesis
in susceptible bacteria. Gentamicin is active against many Gram negative organisms, including
Pseudomonas, Proteus, Serratia, Klebsiella and E.Coli. Gentamicin, when used in combination
with a penicillin antibiotic, has a synergistic effect.

Gentamicin is indicated for the empiric treatment of suspected infection where the organism is
unknown, and in infections where indicated by sensitivity testing.

Preparations
Injection 80mg/2mL

Dose

IV, IM: 5mg/kg/dose

Interval
Birth weight <1200g and postnatal age:
≤ 7 days 48 hourly
8 to 30 days 36 hourly
> 30 days 24 hourly

Birth weight ≥ 1200g and postnatal age:
≤ 7 days 36 hourly
> 7 days 24 hourly

Dose adjustment following therapeutic drug monitoring
Dose or dose interval may need to be adjusted where trough levels are >2mg/L OR there are
concerns regarding side effects or renal impairment. This should be done in consultation with the
NISC pharmacist.

Reconstitution/Dilution
IV: Withdraw 2mL of 40mg/mL solution and dilute with 6mL of sodium chloride 0.9% to make a
solution of 10mg/mL

Babies < 1200g: Withdraw required dose from the 10mg/mL solution and add to 0.5mL of
sodium chloride 0.9% in a 3mL syringe.

Babies ≥ 1200g: Withdraw required dose from the 10mg/mL solution and give undiluted.

IM: No dilution required.

Gentamicin
(NISC Protocol)

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Please remember to read our disclaimer.

Page 2 of 3

Route and Method of Administration
NISC
IV: Give slowly over 30 minutes

Postnatal areas only
IV: Give slowly over 10-15 minutes

Note: A 10-15 minutes infusion time is reserved for term babies in postnatal areas only for
reasons of practicality.

Side Effects
Ototoxicity
Nephrotoxicity
Rarely, leukopenia and thrombocytopenia
Thrombophlebitis at injection site

Contraindications
CAUTION in patients with renal impairment. Monitor levels and adjust dosage interval as
necessary.

Drug Interactions

Amphotericin, ceftazidime,
ibuprofen, vancomycin
Increased risk of nephrotoxicity when used in combination
with gentamicin. Measure urine output.
Gentamicin serum levels may also be altered. Monitor levels.
Frusemide Increased risk of ototoxicity.
Pancuronium Neuromuscular blockade may be enhanced.

Nursing Responsibilities
Monitor urine output
Measure urine output in asphyxiated infants
Trough levels to be measured immediately before the 3
rd
dose
Target trough: < 2mg/L

Gentamicin
(NISC Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Page 3 of 3

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%
PG1, PG2, lipid emulsion 17%
Drugs Amphotericin B, amoxycillin, cefotaxime,
ceftazidime, frusemide, heparin,
hydrocortisone, phenytoin, sodium
bicarbonate
Y-Site Aciclovir, aminophylline, amiodarone,
benzylpenicillin, dopamine, fluconazole,
insulin, magnesium, meropenem,
metronidazole, midazolam, morphine,
ranitidine, tobramycin, verapamil

References
1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999

Glucagon

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Clinical Pharmacists, NISC team Effective Date: 9
th
October 2014
Review Date: October 2017
Page 1 of 2

Neonatal Protocol
Description and indication for use
Glucagon is a pancreatic hormone that stimulates cyclic AMP in the liver and adipose tissue,
initiating gluconeogenesis and glycogenolysis, resulting in an increase in blood sugar levels. At
high doses, glucagon has a cardiac inotropic effect. It also inhibits small-bowel motility and gastric
acid secretion.

Glucagon is effective in the treatment of hypoglycaemia when glucose infusion is unavailable or
when hypoglycaemia is unresponsive to routine treatment. The onset of action of glucagon is 5 to
20 minutes, the half-life being only 3 to 6 minutes, with duration of action usually 1 to 2 hours.
Glucagon is inactivated mainly in the liver and kidney. The use of glucagon in SGA infants is
controversial and should be used with caution in this group.

Preparations
Injection 1mg (1 unit) Supplied with a diluent ampoule of 1mL Water for Injection

Dose
IV, IM, SC: 300micrograms/kg/dose. Dose may be repeated after 20 minutes if necessary.
Maximum dose is 1mg.

IV infusion: 5 to 20 micrograms/kg/hour

Note: 1mg = 1 unit

Reconstitution/Dilution
Reconstitute the contents of the vial with 1mL diluent provided = 1mg/mL

IV, IM, SC: Use 1mg/mL solution

IV infusion: Dilute required dose to 50mL with glucose 10%.

CONCENTRATION HOW TO DILUTE DOSE EQUIVALENT
Glucagon
SINGLE
500micrograms/kg dilute to 50mL 1mL/hour = 10micrograms/kg/hour
Glucagon
DOUBLE
1mg/kg dilute to 50mL 1mL/hour = 20micrograms/kg/hour

Route and Method of Administration
IV, IM, SC: Administer stat dose using 1mg/mL solution

IV infusion: Administer as a continuous IV infusion at prescribed rate via syringe infusion pump
(Guardrails) – see ‘How to set up the Pump’.

Side Effects
x Vomiting
x Diarrhoea
x Tachycardia

Glucagon

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Clinical Pharmacists, NISC team Effective Date: 9
th
October 2014
Review Date: October 2017
Page 2 of 2

Neonatal Protocol
x Rebound hypoglycaemia

Contraindications
x Hypersensitivity to protein compounds
x Patients who have decreased glycogen stores (Caution in IUGR/SGA infants)
x Patients with insulinoma

Drug Interactions

Propranolol Partially inhibits the hyperglycaemic effect of glucagon

Nursing Responsibilities
x Monitor blood glucose levels as required
x Monitor clinical status continuously
x Avoid giving boluses when giving infusion
x Change infusion syringe every 24 hours
x Protect infusion syringe from light
x More than one IM site may be required if max dose is to be given

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%

Drugs
Y-Site

References
1. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
2. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 6
th
Ed. Melbourne: The Society of
Hospital Pharmacists of Australia; 2014.
3. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
4. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
5. Newborn Services Drug Protocol: Glucagon. Auckland District Health Board.
Available at: http://www.adhb.govt.nz/newborn/drugprotocols/Default.htm
Accessed: 11/08/2014.

Glucose Gel
(Glutose 15
TM
)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Clinical pharmacists, Maternity and NISC clinical educators, Sue Jacobs
Authorised by:
Effective Date: 28
th
July 2014
Review Date: July 2017
Page 1 of 1

Neonatal Protocol
Description and indication for use
Glucose is a simple monosaccharide which is a source of energy for the body. The glucose gel is
used to increase blood glucose levels for the treatment of neonatal hypoglycaemia.

Preparations
Oral gel 15g of glucose in 37.5g (d-glucose/dextrose USP 40%)

Dose
Buccal 0.5mL/kg (200mg/kg)

Postnatal ward: Maximum of 6 doses in the first 48 hours after birth
NISC: Only in infants ≥34 weeks’ gestation when the TBG is <1.5 mmol/L
whilst preparing for insertion of an intravenous cannula.
Route and Method of Administration
Buccal Dry the inside of the infant’s mouth with gauze.
Measure the required amount of glucose gel with oral dispenser.
Use clean finger, with gloves, to apply small amounts of gel at a time to the
buccal mucosa (inside the cheek) and massage gently to ensure absorption.

Do not put the gel in the back of the mouth and make sure that the throat
does not become blocked by the gel.
Side Effects
x Gag
x Vomiting
x Hyperglycaemia
Contraindications
x Hypersensitivity to ingredients of the gel

Nursing/Midwifery Responsibilities
x Initiate up to 2 doses of glucose gel on the ‘Once Only Medicines’ section of the neonatal
medicines chart according to the Hypoglycaemia: Infant Management Guideline
x Ensure safe administration of the gel
x Monitor blood glucose levels as required
x Twist tip of tube off and squeeze contents into a measuring cup to withdraw dose. Cover the tip
of the tube with an oral dispenser cap. This tube can be used for the same baby until
discharged from the ward or expiry (whichever comes first). Label the tube with the baby’s
identification sticker.
x The tube should not be shared between babies.

References
1. Harris DL, Weston PJ, Signal M, Chase JG, Harding JE. Dextrose gel for neonatal hypoglycaemia (the
Sugar Babies Study): a randomised, double-blind, placebo-controlled trial. Lancet 2013;382:2077-83.
2. Glutose15
TM
product information online http://www.perrigo.com/business/product.aspx?ID=138 accessed
on 1
st
April 2014.

Glucose
(Dextrose)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 22 May 2017
Review Date: May 2020
Page 1 of 2

Neonatal Protocol
Description and indication for use
Glucose is a monosaccharide that provides the principal source of energy for the body. It is also
involved in many additional areas of protein and fat metabolism.

Intravenous fluid therapy is commonly used to provide a source of energy, correct and prevent
hypoglycaemia. The solutions may also be used as solvents for intravenously administered
medicines where compatibility has been established.

Preparations
IV Bag Glucose 5% (500mL) Glucose 10% (500mL)
Vial Glucose 50% (50mL)

Dose
IV: Dose (mg/kg/min) is titrated according to blood glucose levels as necessary.

Reconstitution/Dilution

TO PREPARE 50mL
Fluid to be prepared
ADDITIONS
Water For
Injections
Glucose 5% Glucose 10% Glucose 50%
Glucose 2.5% 25mL 25mL - -
Glucose 7.5% 13mL - 37mL -
Glucose 12.5% - - 47mL 3mL
Glucose 15% - - 44mL 6mL
Glucose 17.5% - - 41mL 9mL
Glucose 20% - - 37mL 13mL
Glucose 25% 25mL - - 25mL

TO PREPARE 500mL
Fluid to be prepared Fluid bag (500mL) Volume to withdraw Addition Glucose 50%
Glucose 7.5% Glucose 5% 29 mL 29 mL
Glucose 12.5% Glucose 10% 33 mL 33 mL
Glucose 15% Glucose 10% 66 mL 66 mL
Glucose 17.5% Glucose 10% 100 mL 100 mL
Glucose 20% Glucose 10% 132 mL 132 mL
Glucose 25% Glucose 10% 200 mL 200 mL
Note: The volumes are calculated to allow for the average volume contained in 500mL intravenous fluid bags (530mL).

The actual concentration obtained may not be the exact concentration listed in the table.

Glucose
(Dextrose)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 22 May 2017
Review Date: May 2020
Page 2 of 2

Neonatal Protocol
Additives to glucose solutions
If electrolytes are to be added to maintenance glucose infusions, the amount of sodium and
potassium to be added to a 500mL bag is:

Glucose solutions
(500mL)
Sodium Chloride
(NaCl)
Potassium Chloride
(KCl)
Glucose 5%

22 mmol

(6.5mL of NaCl
34mmol/10mL)

10 mmol

(10mL of KCl
10mmol/10mL)
Glucose 7.5%
Glucose 10%
Glucose 12.5%
Glucose 15%
Glucose 17.5%
Glucose 20%
Glucose 25%

Route and Method of Administration
IV: Glucose concentrations greater than 12.5% should ONLY be administered through a
central or umbilical line.

Glucose concentrations less than or equal to 12.5% may be administered via peripheral
line.

Nursing Responsibilities
x Monitor blood glucose levels as necessary
x Administer glucose concentrations greater than 12.5% via a central or umbilical line
x Bags without additives (Glucose 5% and Glucose 10%) should be changed every 48 hours
x Bags with additives (e.g.: Glucose 12.5%, Glucose with NaCl and KCl) should be changed
every 24 hours

Compatibility Information
IMPORTANT: Refer to individual medicine monograph or contact pharmacist for compatibility
information when glucose concentrations greater than 10% are used.

References
1. Baxter Clinical Information Sheet: Overfill Volumes for Solutions Packaged in Viaflex Plastic Containers.
Baxter Healthcare Pty Ltd. Date of revision: 31/08/04.
2. Ryan RSM, editor. BNF for children. London: BMJ Group; 2015-2016.
3. Online calculator (access via the following website): www.nicutools.org
4. Neonatal Handbook. Available at: https://www2.health.vic.gov.au/hospitals-and-health-services/patient-
care/perinatal-reproductive/neonatal-ehandbook/conditions/hypoglycaemia. Accessed: 07/04/2017.

HEPARIN SODIUM
Anticoagulant
Preparations
INJ 1000units/mL, 5000units/0.2mL, 5000units/mL

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Give over at least one minute.
Dilute to appropriate volume and infuse via syringe pump.

Dose
Systemic anticoagulation
Use only following discussion with paediatric haematologist.

Low dose treatment
IV, INF: Loading dose 75units/kg, then 5 to 15units/kg/hr. Adjust
dose according to clotting times.
SC: 75units/kg 12hrly.

Full dose treatment
IV, INF: Loading dose 50 to 200units/kg, then 15 to 30units/kg/hr.
Adjust according to clotting times.

Notes
Incompatible with many drugs. Flush line with saline before giving
other drugs. Protamine 1mg neutralises approximately 100units of
heparin.

RWH Neonatal Intensive and Special Care Nurseries
Heparin – patency of lines IV Protocol

HEPARIN
(to maintain patency of central venous and arterial lines)

DESCRIPTION AND INDICATION FOR USE
Heparin is used to maintain catheter patency and may be used to manage venous thromboembolism.
Heparin has little thrombolytic activity and is generally used to prevent further clot formation.
1

DOSE
To maintain patency of umbilical and peripheral arterial lines
IA: Babies with current weight <2kg: 2units/mL (100units/50mL) at a rate of 0.5mL/hr
(1unit/mL (50units/50mL) can be used in certain circumstances, e.g.: for peripheral arterial line at
1mL/hr)

Babies with current weight ≥2kg: 5units/mL (250units/50mL) at a rate of 1mL/hr

To maintain patency of central venous catheter (e.g.: long line) if no parenteral nutrition running
IV: 1unit/mL (50units/50mL) at a rate of 0.5mL/hr or 1mL/hr

NOTE: 1mg protamine neutralises approximately 100units of heparin.
2

RECONSTITUTION/DILUTION
Heparin sodium vial = 1000units/mL, Heparinised saline ampoule = 50units/5mL (10units/mL)

Solution
concentration
Drug

Infusion diluent** How to make up
1unit/mL Heparinised saline
Use 50units/5mL
Sodium chloride
0.45%
Add 50units (5mL) to a 50mL-syringe
and make up to 50mL
2units/mL* Heparin sodium
Use 1000units/mL
Sodium chloride
0.45%
Add 1000units (1mL) to 500mL bag
5units/mL* Heparin sodium
Use 1000units/mL
Sodium chloride 0.9% Add 2500 units (2.5mL) to 500mL bag
*To be made by admissions nurse at 1500hrs daily and invert bag at least 6 times to prevent pooling of
heparin

**May be substituted with sodium chloride 0.45% or sodium chloride 0.9% in certain circumstances
Vial should be discarded after the dose has been withdrawn – do not keep for additional doses.

ROUTE AND METHOD OF ADMINISTRATION
Do not use PAL filter on either peripheral or umbilical arterial line. PAL filter should be used on long lines
IA and IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of heparin.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose/amount in syringe then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘unit/h’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

RWH Neonatal Intensive and Special Care Nurseries
Heparin – patency of lines IV Protocol

SIDE EFFECTS
x Bleeding, bruising, thrombocytopaenia (rare), urticaria

NURSING RESPONSIBILITIES
x Observe infant for bleeding or bruising
x Monitor IV site for extravasation
x Heparin is incompatible with many medicines. Please flush line with normal saline before
giving other medicines.
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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%, glucose 25%, sodium
chloride 0.45%, sodium chloride 0.9%

Drugs Benzylpenicillin, calcium gluconate, dopamine,
flucloxacillin, fluconazole, frusemide, magnesium
sulphate, noradrenaline, potassium chloride,
ranitidine, sodium bicarbonate

Amikacin, amiodarone diazepam,
dobutamine, gentamicin, phenytoin,
vancomycin
Y-Site Aciclovir, adrenaline, atropine, caffeine citrate
5
,
fentanyl, hydrocortisone sodium succinate, insulin
(neutral), meropenem, metronidazole, midazolam,
morphine sulphate, pancuronium, phenobarbitone,
suxamethonium, vecuronium, zidovudine

References:
1. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5
th
Ed, Massachusetts:
Blackwell Publishing Inc, 2007.
2. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13
th
Ed, Melbourne:
Pharmacy Department, Royal Childrens Hospital.
3. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4
th
Ed., Melbourne: The Society of
Hospital Pharmacists of Australia.
4. Trissell LA, 2009, Handbook on Injectable drugs, 15
th
Ed, Bethesda, American Society of Health-
System Pharmacists
5. Young T, Mangum B, 2008, Neofax 2008, 21
st
Ed, New Jersey: Thomson Reuters.
6. Fary R, Smith R, Davis P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia, 2
nd
Ed,
Melbourne: Pharmacy Department, The Royal Women's Hospital.
7. Cloherty J.P, Eichenwald E.C, Stark A.R. 2008, Manual of Neonatal Care, 6
th
Ed., Philadelphia:
Lippincott Williams & Wilkins
8. BNF for children, London: BMJ Publishing Group Ltd, 2005.

Hydrochlorothiazide
(NISC Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by:
Authorised by:
Effective Date: 13 April 2018
Review Date: April 2018
Page 1 of 2

Description and indication for use
Hydrochlorothiazide is a thiazide diuretic that inhibits reabsorption of sodium and chloride in the
distal convoluting tubule, increasing the excretion of sodium, water and potassium into the urine. It
may be used as short term therapy to improve respiratory function in preterm infants with
bronchopulmonary dysplasia and pulmonary oedema. It is also used in conjunction with diazoxide
to counteract associated fluid retention.

Preparations
Mixture 5mg/mL (RWH)
Tablet 25mg

Dose
Oral: 1 to 2 mg/kg/dose 12 hourly

Route and Method of Administration
Oral: Administer with feeds to enhance absorption.

Side Effects
x Hypokalaemia, hyponatraemia, hypochloraemia, hypomagnesaemia, hypercalcaemia,
hyperuricaemia
x Polyuria
x Hypotension
x Hyperglycaemia

Contraindications
x Hepatic or renal impairment

Drug Interactions

ACE inhibitors (e.g. captopril) Hydrochlorothiazide may increase the risk of severe
hypotension with the first dose of an ACEs
Ibuprofen, Indomethacin NSAIDs may reduce renal function, reduce diuretic and
hypotensive effect and increase risk of nephrotoxicity
Furosemide Use of combination has a synergistic effect, increased risk of
side effects (e.g. hypokalaemia and other electrolyte
abnormalities, hypotension)

Nursing Responsibilities
x Monitor electrolytes
x Monitor fluid input and output

Hydrochlorothiazide
(NISC Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by:
Authorised by:
Effective Date: 13 April 2018
Review Date: April 2018
Page 2 of 2

References

1. Lexicomp Online® , Pediatric & Neonatal Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; Date
accessed 17/04/18
2. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010
3. MIMSOnline. St Leonards, NSW: UBM Medica; 2018. Accessed: 12/04/18
4. Australian Medicines Handbook 2018 (online). Adelaide: Australian Medicines Handbook Pty Ltd;
2018 March. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/

12/06/08
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Hydrocortisone.doc

HYDROCORTISONE

DESCRIPTION AND INDICATION FOR USE
Hydrocortisone is the main adrenal corticosteroid and has mainly glucocorticoid effects. These include
enhancement of vascular reactivity to vasoactive substances, stimulation of the production of glucose in
the liver, and increased deposition of glucose as glycogen. Hydrocortisone also decreases peripheral
glucose utilisation, and increases protein breakdown and lipolysis. It also has anti-inflammatory and
immuno-suppressive properties.
Hydrocortisone is used as steroid replacement in adrenal insufficiency, and in the treatment of refractory
hypotension and hypoglycaemia.

DOSE
Early Neonatal Hypotension
IV: 2mg/kg/dose stat, then 1mg/kg/dose 8 to12-hourly

Acute adrenal insufficiency
IV: 1 to 2mg/kg/dose stat, then 1 to 2mg/kg/dose 6-hourly

Congenital Adrenal Hyperplasia
IV: 0.5 to 0.7mg/kg/DAY in divided doses initially, then adjust dose according to response.

Anti-inflammatory
IV, IM: 2.5mg/kg/dose 6-hourly

Do not cease suddenly if given in high doses for longer than two weeks

RECONSTITUTION/DILUTION
Vial = 100mg

IV: To reconstitute 100mg vial, add 2mL of Water for Injection to vial = 100mg in 2mL = 50mg/mL
Dilute as required to measure dose:

For dilution to 1mg/mL: Withdraw 0.2mL of 50mg/mL solution from vial and add to 9.8mL of
sodium chloride 0.9% in a 10mL syringe = 10mg in 10mL = 1mg/mL.
For dilution to 5mg/mL: Withdraw 1mL of 50mg/mL solution from vial and add to 9mL of
sodium chloride 0.9% in a 10mL syringe = 50mg in 10mL = 5mg/mL.

Reconstituted vial is stable and may be used for up to 24 hours when stored in refrigerator

ROUTE AND METHOD OF ADMINISTRATION
IV: Give by slow IV push over at least 5 minutes. Flush with sodium chloride 0.9%.

SIDE EFFECTS
x Hyperglycaemia
x Hypertension
x Fluid and electrolyte imbalances
x Immunosuppression, especially with prolonged use. May mask signs/symptoms of infection
x Osteoporosis (prolonged use)

12/06/08
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Hydrocortisone.doc

CONTRAINDICATIONS
x Untreated systemic bacterial infection
x Systemic fungal infection
x CAUTION in hypertension
x CAUTION in hyperglycaemia

DRUG INTERACTIONS
Frusemide,
Hydrochlorothiazide,
Liposomal amphotericin B
Combination may result in excessive potassium loss, resulting in hypokalaemia
Pancuronium Antagonism of neuromuscular blockade
Phenobarbitone, Phenytoin,
Rifampicin
Decreased plasma levels and therapeutic effect of hydrocortisone due to
increased metabolism
Indomethacin Increased risk of gut perforation

NURSING RESPONSIBILITIES
i Monitor blood pressure BD for at least 3 days, then daily during treatment
i Monitor blood glucose BD for 3 days, then PRN
i Monitor sodium, potassium and bone bloods
i Observe for signs of infection

COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 chloride 0.9% No information
Drugs Amikacin, benzylpenicillin, calcium gluconate, dopamine,
erythromycin, flucloxacillin, magnesium, metronidazole,
noradrenaline, potassium, sodium bicarbonate
Diazepam, midazolam, phenobarbitone,
phenytoin, vancomycin
Y-Site Aciclovir, adrenaline, atropine, dexamethasone, digoxin,
fentanyl, frusemide, heparin, insulin, morphine,
suxamethonium

References:

1. Neofax 18
th
Ed. 2005 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 3
rd
Ed., The Society of Hospital Pharmacists of Australia, 2005
4. Neonatal Formulary 5
th
Ed, BMJ Publishing Group. 2007
5. Neonatal Medications & Nutrition 3
rd
Ed. , NICU Ink Book Publishers, 2003
6. Handbook on Injectable Drugs 11
th
Ed, Trissel L, 2001

HYDROCORTISONE
Corticosteroid
Preparations
INJ 100mg
TAB 4mg, 20mg
MIXT 3mg/mL (RWH)
EYE 0.5%, 1%
OC 0.5%, 1%
CRE 0.5%, 1%
OINT 0.5%, 1%

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Reconstitute with diluent provided or 2mL of WFI to give a concentration of 50mg/mL.
Can be further diluted to 1mg/mL with compatible fluid if required.
Give over at least 5mins.

Dose
Anti-inflammatory
IV, IM: 2.5mg/kg/dose 6hrly
ORAL: 1 to 8mg/kg/dose 6 to 8hrly
TOP: Apply sparingly to affected area 1 to 3 times daily
EYE: (After ophthalmology review) 1 drop 2 to 4hrly or when needed
OC: Apply 2 to 4 times daily

Physiological Replacement
ORAL: 0.2mg/kg/dose 8hrly

Acute Adrenal Insufficiency
Loading dose
IV: 1 to 2mg/kg/dose
Maintenance dose
IV, ORAL: 1 to 2mg/kg/dose 6hrly

Congenital Adrenal Hyperplasia
IV, ORAL: Initially 0.5 to 0.7mg/kg/DAY in divided doses

Early Neonatal Hypotension
IV: 2mg/kg stat then 1mg/kg 8 to 12hrly

Notes
Caution in presence of systemic fungal infections. Caution in patients with hypertension
or hyperglycaemia. Monitor BP, blood glucose, sodium, potassium levels and bone
bloods. Do not cease suddenly if given in high doses for longer than two weeks. Finger
pressure applied to lacrimal sac after eye drops will reduce systemic absorption.

Ibuprofen
(Neoprofen
®
)

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Neonatal Protocol
Description and indication for use
Ibuprofen is an inhibitor of prostaglandin synthesis used to treat haemodynamically significant
Patent Ductus Arteriosus (PDA) in premature neonates. It is considered a pharmacologic
alternative to surgical closure of the PDA. Ibuprofen has good oral bioavailability and should be
administered orally in babies tolerating enteral feeds.

Preparations
Injection 10mg/mL (Neoprofen® - Ibuprofen lysine)
Mixture 20mg/mL

Dose
IV, Oral: Three doses given at 24-hour intervals.

1st dose: 10mg/kg/dose
2nd and 3rd doses: 5mg/kg/dose

Commence when:
Platelets, urea and creatinine levels are within the normal limits
Verbal parental consent has been obtained and documented in the baby’s clinical notes,
AND
TGA SAS category A form has been completed (Appendix A)
Reconstitution/Dilution
IV infusion: Withdraw 2mL of 10mg/mL solution and add to 8mL of sodium chloride 0.9% = 20mg
in 10mL = 2mg/mL. Withdraw required dose from the 2mg/mL solution.

Visually inspect final product for particulate matter and discolouration prior to administration.

Withdraw required dose. Doses should be freshly prepared. Discard any solution remaining.

Route and Method of Administration
Oral: Give after a feed

IV infusion: Infuse over 15 minutes via syringe pump (administer within 30 minutes of
preparation). See ‘How to set up the Pump’.

Side Effects
Transient impairment of renal function which may result in hyponatraemia
Oliguria
Fluid retention
Haematuria
Thrombocytopenia
Neutropenia

Ibuprofen
(Neoprofen
®
)

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Neonatal Protocol
Intraventricular haemorrhage
Pulmonary haemorrhage
Intestinal perforation, GI tract bleeding

Contraindications
Cardiac defects where patency of ductus is necessary for pulmonary or systemic blood flow.
Active GI bleeding, NEC or other haemorrhagic disease.
Thrombocytopenia, coagulation defect (platelets should be checked before commencing
treatment).
Significant renal impairment (renal function should be checked before commencing treatment).
Severe liver impairment.
CAUTION in patients with significant IVH within the previous week.

Drug Interactions

Gentamicin, vancomycin and
other renally excreted drugs
May accumulate due to reduction in renal function caused by
ibuprofen.
Diuretics Diuretic effect may be reduced. Diuretics can increase the risk
of nephrotoxicity of ibuprofen in dehydrated patients.
Dexamethasone Increased risk of gastrointestinal perforation.

Nursing Responsibilities
Measure urine output during treatment and for 24 hours after treatment ceased
Cardiac and BP monitoring
Observe for signs of bleeding including GIT bleeding
Daily urinalysis for blood
Ensure platelets, urea and creatinine levels are within normal limits prior to commencing
ibuprofen
For oral administration when baby is tolerating enteral feeds

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

Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9%

PG1, PG2, lipid emulsion 17%
Drugs Amikacin, caffeine citrate, dobutamine,
dopamine, midazolam, morphine,
vancomycin, vecuronium
Y-Site Adrenaline, frusemide, heparin,
insulin, phenobarbitone, potassium,
sodium bicarbonate

Ibuprofen
(Neoprofen
®
)

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Please remember to read our disclaimer.

Page 3 of 3

Neonatal Protocol
References
1. Neoprofen® (Ibuprofen 10mg/mL) Product Information March 2012.
2. Ibuprofen lysine. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 26/09/2013.
3. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
4. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
5. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
6. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 17
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2010.

Indomethacin

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Please remember to read our disclaimer.

Effective Date: 1 Nov 2017
Review Date: Nov 2020
Page 1 of 3

Neonatal Protocol
Description and indication for use
Indomethacin is a prostaglandin synthetase inhibitor used to treat Patent Ductus Arteriosus (PDA)
and for prophylaxis of intraventricular haemorrhage (IVH) in the neonate at high risk of severe IVH.

Preparations
Injection 1mg powder for injection

Dose
PDA treatment
IV: 200 micrograms/kg/dose 24-hourly for THREE doses

NOTE: Check platelets, urea and creatinine before commencing indomethacin.

IVH Prophylaxis
In babies < 26 weeks’ gestation at birth (inborn and outborn) and mother received her first dose of
antenatal steroids less than 24 hours prior to birth (or did not receive any antenatal steroids).

IV: 100 micrograms/kg/dose 24-hourly for THREE doses

NOTE: First dose should be given as soon as possible after birth once a platelet count is
obtained, ideally prior to 12 hours of age. Indomethacin should not be given if
platelet count is < 50 x10
9
/L. A creatinine level is not required, but measurement of
urine output is essential.

Doses should be withheld if anuria or marked oliguria (urine output < 0.5mL/kg/hr). Delay further
doses until urine output is >1mL/kg/hr.

Commence when:
x Verbal parental consent has been obtained and documented in the baby’s clinical notes,
AND
x TGA SAS category A form has been completed (Appendix A)
Reconstitution/Dilution
Vial = 1mg (Powder for reconstitution)

IV: Reconstitute with 2mL of Water for Injection = 500 micrograms/mL.
Withdraw required dose from vial and add to 1mL of sodium chloride 0.9%.

Route and Method of Administration
Not for IM or SC use

IV infusion: Give slowly over 30 minutes.

Administer infusions through a syringe infusion pump (Guardrails) – see ‘How to set up the Pump’.

Indomethacin

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Please remember to read our disclaimer.

Effective Date: 1 Nov 2017
Review Date: Nov 2020
Page 2 of 3

Neonatal Protocol
Side Effects

x Transient impairment of renal function which may result in hyponatraemia and hyperkalaemia
x Reduced platelet aggregation
x GI tract bleeding
x Hypoglycaemia
x Indomethacin may mask symptoms of infection

Contraindications

x Cardiac defects where patency of ductus is necessary for pulmonary blood flow
x Active GI bleeding, NEC or other haemorrhagic disease
x Thombocytopenia, coagulation defect
x Significant renal impairment (renal function should be checked before commencing treatment)

Drug Interactions

Digoxin May have prolonged half-life or raised serum levels
Gentamicin, vancomycin and other
drugs relying on renal excretion
These drugs may accumulated due to reduction in renal
function caused by indomethacin
Diuretics (e.g.: frusemide and
hydrochlorothiazide)
Diuretic effect may be reduced

Dexamethasone Increased risk of gastrointestinal perforation
Propranolol Impaired anti-hypertensive effect

Nursing Responsibilities

x Measure urine output during treatment and for 24 hours after treatment ceased
x Cardiac and BP monitoring
x Observe for signs of bleeding including G.I.T.
x Daily urinalysis for blood
x Observe for signs of increasing jaundice

TGA considerations and parental consent
x Ductaclose
®
is not currently listed on the Therapeutics Goods Administration’s (TGA)
Australian Register of Therapeutic Goods.
x Under the TGA Authorised Prescriber Scheme, the NISC prescribers have been authorised by
TGA to prescribe Ductaclose
®
.
x Therefore, to prescribe Ductaclose
®
:
o Provide verbal information to the parent(s)/guardian(s)
o Obtain verbal parental consent, and document in the baby’s clinical notes
o Complete the TGA SAS Category A form (Appendix A), leave copy in pharmacist tray in
central work room.

Indomethacin

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 1 Nov 2017
Review Date: Nov 2020
Page 3 of 3

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

Compatible Incompatible
Fluids Water for Injection, sodium chloride 0.9% Glucose concentration > 5%, IVN starter
and maintenance solutions, lipid 17%
Y-Site Ceftazidime, ceftriaxone, frusemide,
heparin, insulin, potassium, sodium
bicarbonate

References

1. Schmidt B, Davis PG, Moddemann D, et al. Long-term effects of indomethacin prophylaxis in extremely
low-birth-weight infants. N Engl J Med 2001;344:1966-72.
2. Schmidt B, Seshia M, Shankaran S, et al. Effects of prophylactic indomethacin in extremely low birth
weight infants with and without adequate exposure to antenatal steroids. Arch Pediatr Adolesc Med.
2011 July ; 165(7): 642–6.
3. Burridge N, Collar N, Symons K, editors. Australian Injectable Drugs Handbook. 6
th
Ed. Melbourne: The
Society of Hospital Pharmacists of Australia; 2014.
4. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
5. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
6. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
7. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013.
8. Indomethacin. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 01/05/15
9. Ductaclose
®
product information. Accessed: 30/10/2017.

Insulin (Neutral)
(Actrapid
®
)

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Please remember to read our disclaimer.

Effective Date: 25 May 2018
Review Date: May 2021
Page 1 of 4

Neonatal Protocol
Description and indication for use
Insulin is a protein hormone secreted from the β cells of the pancreas into the blood where it
regulates carbohydrate, lipid and amino acid metabolism.
Insulin is used to maintain normoglycaemia in infants with persistent hyperglycaemia. It may also
be used in the treatment of severe hyperkalaemia in critically ill infants.

Preparations
Injection 100units/mL (Actrapid
®
)

Dose
Hyperglycaemia

IV infusion: 0.01 to 0.2units/kg/hour, starting at 0.05units/kg/hour.

Hyperkalaemia

IV infusion: 0.02 to 0.1units/kg/hour, starting at 0.1units/kg/hour.

Reconstitution/Dilution
IV infusion: Use only neutral insulin (Actrapid® 100units/mL)

Ensure dose is ordered in units and NOT in mL.

For hyperglycaemia use glucose 10% as the infusion solution.

For hyperkalaemia use glucose 25% as the infusion solution and administer
through a central line.

Add 0.5mL of neutral insulin 100units/mL to 9.5mL of sodium chloride 0.9% in a 10mL syringe to
make a 5units/mL diluted solution. Withdraw the required dose for the baby and further dilute
according to the table below. The final syringe volume should always equal 50mL.

CONCENTRATION HOW TO DILUTE DOSE EQUIVALENT
Insulin
SINGLE
(suitable only if
weight ≥1000g)
5 units/kg to 50mL 1mL/hr = 0.1units/kg/hour
Insulin
DOUBLE
(suitable if
weight <1000g)
10 units/kg to 50mL 1mL/hr = 0.2units/kg/hour
Insulin
QUADRUPLE
(suitable if <1000g
and fluid restricted)
20 units/kg to 50mL 1mL/hr = 0.4units/kg/hour

Insulin (Neutral)
(Actrapid
®
)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 25 May 2018
Review Date: May 2021
Page 2 of 4

Neonatal Protocol
Insulin infusion solution should be filtered using the standard 0.2 micron filter.

Route and Method of Administration
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using
Guardrails. See ‘How to set up the Pump’.

Insulin adsorbs to the plastic tubing of intravenous infusion sets. This decreases the concentration
of insulin delivered to the baby which may have significant clinical implications. Prior to
administration, flushing the plastic tubing with a set volume of insulin solution decreases adsorption
losses by saturating binding sites within the tubing. This enables a more consistent delivery of
insulin to the baby.

Step 1: Prepare insulin solution using the method described in the Reconstitution/Dilution
section. Prime plastic tubing with this prepared insulin solution and leave to sit for 5
minutes. This is a priming and flushing solution only.

Step 2: After 5 minutes, flush the plastic tubing with the entire 50mL volume of this
prepared insulin solution into a receptacle and discard.

Step 3: Prepare a fresh insulin solution using the method described in the
Reconstitution/Dilution section.

Step 4: Add this fresh insulin solution to the same 50mL syringe and plastic tubing and
re-prime tubing in addition to priming the in-line filter. The insulin infusion is now
ready to commence immediately, without the need for further dwelling time within
the infusion set.

When used to prepare intravenous infusions, each vial of neutral insulin is for SINGLE USE only.
Discard the remaining solution in the vial immediately after use.

Side Effects
x Hypoglycaemia
x Hypokalaemia
x Insulin resistance (prolonged use)

Contraindications
x Caution in renal or hepatic impairment – increased risk of hypoglycaemia, more frequent
monitoring and lower doses may be required.

Drug Interactions

Adrenaline, corticosteroids (dexamethasone,
hydrocortisone), glucagon, hydrochlorothiazide,
May decrease the effect of insulin
Beta-blockers (e.g. propranolol) May increase the effect of insulin

Insulin (Neutral)
(Actrapid
®
)

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Please remember to read our disclaimer.

Effective Date: 25 May 2018
Review Date: May 2021
Page 3 of 4

Neonatal Protocol
Nursing Responsibilities

x DO NOT flush line or give boluses of other drugs via insulin infusion line.
x It is preferable to run the insulin infusion through a dedicated line, with glucose as the infusion
fluid, to ensure that unopposed insulin is not being infused to the baby.
x Monitor True Blood Glucose (TBG) 1-2 hourly until stable and after each change in dose rate
x Once stable monitor TBG (as well as potassium if treating hyperkalaemia) at least 4-6 hourly
throughout duration of insulin infusion
x Check TBG more frequently when a new infusion solution is commenced, or if the rate of
insulin infusion/glucose containing infusions/feeds changes or medicine mixed with glucose
and/or insulin infusion is disrupted
x Notify medical staff if TBG is less than 6mmol/L
x For hyperglycaemia titrate infusion according to blood glucose levels; Aiming for TBG: 4-
10mmol/L
x For hyperkalaemia titrate infusion according to potassium levels; Aiming for K+ 5-7mmol/L

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%, glucose 25%

Y-Site Dobutamine (≤4mg/mL), Heparin,
Midazolam, Morphine, IVN Starter, IVN
Maintenance, Lipid Emulsion 17%
Adrenaline, Dopamine, Noradrenaline

Note:
x The insulin infusion can run through the same line as other glucose-containing infusion
solutions, including intravenous nutrition (IVN).
? When running through the same line as other glucose-containing infusion solutions,
sodium chloride 0.9% can be used as the infusion fluid, if clinically indicated, in order to
reduce glucose load delivered to the baby.

Insulin (Neutral)
(Actrapid
®
)

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Please remember to read our disclaimer.

Effective Date: 25 May 2018
Review Date: May 2021
Page 4 of 4

Neonatal Protocol
References
1. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press,
and RCPCH Publications <http://www.medicinescomplete.com> Accessed April 2018
2. Lexicomp Online® Pediatric & Neonatal Lexi-Drugs®, Hudson, Ohio: Lexi-Comp, Inc.; 2018. Accessed
April 2018
3. Eichenwald E, Hansen A, Martin C, Stark A. Cloherty and Mark’s Manual of Neonatal Care. 8th Edition.
Wolters Kluwer. 2017
4. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 10th Ed.
Bethesda, Maryland: American Society of Health-System Pharmacists; 2013
5. Insulin. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility). Greenwood
Village, Colorado: Thomson Reuters (Healthcare). Accessed: February 2018
6. Australian Injectable Drugs Handbook, 7th Ed., Melbourne: The Society of Hospital Pharmacists of
Australia 2017. Accessed April 2018.
7. Thompson CD, Vital-Carona J, Faustino, EVS: The effect of tubing dwell time on insulin adsorption
during intravenous insulin infusions. Diabetes Technology and Therapeutics 2012;14:912-916.
8. Goldberg PA, Kedves A, Walter K, Groszmann A, Belous A, Inzucchi SE: ‘‘Waste not, want not’’:
determining the optimal priming volume for intravenous insulin infusions. Diabetes Technology and
Therapeutics 2006;8:598–601.
9. Hewson M, Nawadra V, Oliver J, Odgers C, Plummer J, Simmer K: Insulin infusions in the neonatal unit:
delivery variation due to adsorption. Journal of Paediatrics and Child Health 2000;36:216–220.

ISONIAZID
Anti-tuberculosis agent

Preparations
TAB 100mg

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

Prophylaxis
ORAL: 5mg/kg/dose 24hrly

Treatment
ORAL: 10mg/kg/dose 24hrly up to max 20mg/kg/dose
(300mg) 24hrly for severe infections.

Notes
Monitor theophylline and phenytoin levels if used
together with isoniazid. Should be given on an empty
stomach as feed and antacids reduce bioavailability.

ISOPRENALINE
Non-selective beta-receptor agonist
Preparations
INJ 200microgram/mL

IV preparation and compatibilities
Compatible with G5%, G10%, NaCl 0.9%.
Dilute according to IV drug protocol.
Infuse via syringe pump.

Dose
Treatment of severe hypotension and
bradycardia
IV INF: 0.1 to 0.4 microgram/kg/min

Notes
Mainly chronotropic affects with some inotropic
actions. Simultaneous administration of
adrenaline may cause severe arrhythmias.
Tachycardia, arrhythmias and skin flushing may
occur. Correct hypovolaemia before commencing
isoprenaline.

RWH Neonatal Intensive and Special Care Nurseries
Isoprenaline IV Protocol

ISOPRENALINE
DESCRIPTION AND INDICATION FOR USE
Isoprenaline is a synthetic sympathomimetic amine structurally related to adrenaline, which acts
almost exclusively at beta adrenergic receptors.
Isoprenaline increases cardiac output due to its positive inotropic and chronotropic actions and
increasing venous return, as well as lowering peripheral vascular resistance. It also relaxes
smooth muscle, in particular bronchial and gastrointestinal smooth muscle.
Isoprenaline may increase myocardial oxygen consumption out of proportion to the increase in
coronary blood flow, which may result in myocardial hypoxia, so it is not considered the inotropic
agent of choice.

DOSE

IV Infusion: 100 to 400 nanogram/kg/minute

RECONSTITUTION/DILUTION
Ampoule = 1 in 5,000 (200microgram/mL) NOT WARD STOCK

IV: Add 600microgram/kg to infusion solution ordered (glucose 5 or 10%, sodium chloride
0.9%) to a total volume of 50mL (As shown in table below)
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Isoprenaline 600microgram/kg to 50mL 1mL/hr =
200nanogram/kg/min
100 to 400 nanogram/kg/min

ROUTE AND METHOD OF ADMINISTRATION
Not for IV bolus or IM use.

IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using
Guardrails

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with
preloaded syringe containing exact dose of isoprenaline.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘ng/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

RWH Neonatal Intensive and Special Care Nurseries
Isoprenaline IV Protocol

SIDE EFFECTS
x Hypertension/ Hypotension
x Tachycardia, arrhythmias
x Pulmonary oedema
x Hypoglycaemia
x Flushing of the skin

CONTRAINDICATIONS
x Cardiac arrhythmias, tachyarrhythmias
x Tachycardia or heart block caused by digoxin toxicity
x Ventricular arrhythmias
x Hypovolaemia should be corrected prior to commencing isoprenaline infusion

DRUG INTERACTIONS
Adrenaline, digoxin,
theophylline
Do not administer simultaneously due to the combined cardiac
stimulation possibly inducing serious arrhythmias.

NURSING RESPONSIBILITIES
x Continuous blood pressure monitoring preferably with an arterial line.
x Continuously monitor heart rate and rhythm
x Record vital signs hourly
x Observe and measure urine output
x Observe intravenous site for inflammation and extravasation resite infusion immediately
x Avoid interruption to continuous infusion. Do not bolus other drugs via isoprenaline line.
DO NOT GIVE BOLUS DOSES
x Change infusion fluid and line every 24 hours. When changing syringe and line, ensure
pump and 3-way tap turned off to avoid giving bolus.
x Protect from light - Cover syringe with foil.
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids TPN, glucose 5%, dextrose 10%
1
, sodium chloride
0.9%

Drugs Amiodarone, calcium, dobutamine, flucloxacillin,
heparin, hydrocortisone, magnesium, netilmicin,
pancuronium, potassium, ranitidine
Aminophylline, diazepam,
frusemide, sodium bicarbonate
Y-Site Pancuronium

References:
1. Neofax 12
th
Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 10
th
Ed, The Northern Neonatal Network. 1998
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998

KONAKION
?
MM Paediatric
(2mg in 0.2mL)

A. One IM injection at birth
1mg (0.1mL) = HALF an ampoule

OR

B. Three oral doses
At birth 2mg (0.2mL)
At 3 to 5 days 2mg (0.2mL)
At 4 weeks 2mg (0.2mL)

C. Infants < 1.5kg birthweight
One IM injection at birth
0.5mg (0.05mL)

Levetiracetam
(NISC IV Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Pharmacy Department: Charis Lau and Donna Legge
Authorised by: Jeanie Cheong
Effective Date: October 2012
Review Date:October 2015
Page 1 of 2

Description and indication for use
Adjunctive anticonvulsant for seizures refractory to treatment with phenobarbitone, phenytoin,
midazolam and pyridoxine. Levetiracetam has good oral bioavailability so IV administration should
only be used in acute situations when oral administration is not possible.

Dose
Age ≤ 21 days
Loading dose
IV: 10-20mg/kg. May be repeated every 24 hours.

Maintenance dose
IV: 10mg/kg every 12 to 24 hours. May be increased to a maximum of 30mg/kg every 12 hours.

Start maintenance dose 12 to 24 hours after loading dose.

Age >21 days
Loading dose
IV: 20-40mg/kg/dose. May be repeated every 8 hours.

Maintenance dose
IV: 10-20mg/kg/dose every 12 hours. May be increased to a maximum of 30mg/kg every 12 hours

Reconstitution/Dilution
Vial = 500mg/5mL (100mg/mL)

IV: Withdraw 1 mL of 100mg/mL solution and add to 4 mL of sodium chloride 0.9% in a 10 mL
syringe = 100mg in 5 mL = 20 mg/mL.

Discard excess volume to obtain required dose or withdraw dose using another syringe.

Route and Method of Administration
IV: Infuse over 15 minutes

Vial is for single use only.

Side Effects
x Drowsiness, sedation
x Hyperkinesia
x Decreased red blood cell count, haemoglobin, haematocrit, WCC and neutrophils

Contraindications
x CAUTION in patients with severe renal impairment

Levetiracetam
(NISC IV Protocol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Pharmacy Department: Charis Lau and Donna Legge
Authorised by: Jeanie Cheong
Effective Date: October 2012
Review Date:October 2015
Page 2 of 2

Drug Interactions
None known.

Nursing Responsibilities
x Observe IV site
x Observe and document seizure activity
x Cardio-respiratory monitor

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

Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9%

Drugs Phenytoin
Y-Site

References

1. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 17
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2010.
2. Pharmacy department, The Royal Children’s Hospital, Melbourne, Paediatric Injectable Guideliines. 3
rd

ED. 2006
3. MIMSOnline. St Leonards, NSW: UBM Medica; 2012. Accessed: 28/05/2012.
4. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 5
th
Ed. Melbourne: The Society of
Hospital Pharmacists of Australia; 2011.
5. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 9
th
Ed. Bethesda,
Maryland: American Society of Health-System Pharmacists; 2010.
6. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
7. Ramantani G, et al. Levetiracetam: Safety and efficacy in neonatal seizures. European Journal of
Paediatric Neurology 2011;15(1):1-7.
8. Abend NS, et al. Levetiracetam for treatment of neonatal seizures. J Child Neurol. 2011 April ; 26(4):
465–470.

LIGNOCAINE
Local anaesthetic/
Antiarrhythmic
Preparations
INJ 1%, 2%, 10%

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Dilute to appropriate volume and infuse via syringe
pump.

Dose
Ventricular arrhythmia
IV, INF: 1mg/kg slowly over at least 5 mins, follow
within 15mins with an infusion of 10 to
50microgram/kg/min, titrating rate according to
response.

Notes
Symptoms of toxicity include hypertension and
seizures.
Contraindicated in Wolff-Parkinson-White syndrome.
Solutions containing preservatives should not be
given IV.

LOPERAMIDE
Antidiarrhoeal
Preparations
CAP 2mg

Preparation for other routes
ORAL Disperse contents of capsule in 4mL
WFI to give a concentration of 0.5mg/mL.
Prepare a fresh solution for each dose.

Dose
Short gut syndrome diarrhoea
ORAL: Up to 1.25mg/kg/DAY in 2 to 3
divided doses has been used.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Magnesium Sulphate.doc

MAGNESIUM SULPHATE
DESCRIPTION AND INDICATION FOR USE
Magnesium Sulphate can be used in the treatment of hypomagnesaemia (<0.7mmol/L) and
symptomatic hypocalcaemia when it is associated with hypomagnesaemia. It can also be used as
an adjunct to total parenteral therapy.

DOSE
Hypomagnesaemia
IV, IM: 0.2 to 0.4mmol/kg/dose 12hrly

Hypocalcaemia
IM: 0.4mmol/kg 12hrly for two doses

NOTE: Oral administration not recommended due to purgative action
IM injection only given following discussion with consultant neonatologist
SC administration not recommended

RECONSTITUTION/DILUTION

Vial = 5g in 10mL (50%) (20mmol/10mL)

IV: Dilute to 0.4mmol/mL (100 mg/mL)
Take 2mL (4mmol) of Magnesium Sulphate and add 8mL of Sodium Chloride 0.9% to
give 4mmol in 10mL = 0.4mmol/mL.
IM: IM injection only given following discussion with consultant neonatologist
Dilute to 0.8mmol/mL ( 200 mg/mL)
Take 4mL (8mmol) of Magnesium Sulphate and add 6mL of Sodium Chloride 0.9% to
give 8mmol in 10mL = 0.8mmol/mL

Diluted solution stable for 24 hours at 25
0
C

ROUTE AND METHOD OF ADMINISTRATION
IV: Give slowly over 20 minutes

IM: Deep IM injection
Note: Maximum volume of IM injection for weight <1500g is 0.5mL. Therefore neonatologist
must approve of IM route before administration

SIDE EFFECTS
Hypotension
ECG changes
Circulatory collapse
Respiratory depression
CNS depression
Gastro-intestinal upset
Urinary retention
Magnesium toxicity
Tissue necrosis at the injection site

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Magnesium Sulphate.doc

CONTRAINDICATIONS
Patients with heart block or myocardial damage
Caution in patients with impaired renal function or electrolyte imbalance

NURSING RESPONSIBILITIES
Monitor BP, HR and respiratory rate when giving IV infusion.
Have resuscitation and ventilatory support available during and after dose administration
Treat Mg2+ serum levels less than 0.7mmol/L (normal range 0.75 to 1.2mmol/L)
Calcium gluconate is the available antidote
Monitor serum calcium in hypocalcaemia

COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 chloride
0.9%.

Intralipid, PN
Drugs Calcium gluconate, heparin, hydrocortisone
sodium succinate, meropenem, noradrenaline,

Amphotericin, calcium chloride, ciprofloxacin,
dobutamine, sodium bicarbonate. Incompatible
with soluble phosphates and with alkali
hydroxides and carbonates.
Y-Site Aciclovir, amikacin, ampicillin, cefotaxime, co-
trimoxazole, erythromycin lactobionate,
gentamicin, insulin(neutral), metronidazole,
morphine, pethidine, piperacillin-tazobactam,
potassium chloride, tobramycin, vancomycin

Notes:
Neuromuscular blockade of pancuronium may be potentiated by magnesium
sulphate

References:
1. Neonatal Pharmacopoeia (2
nd
ed).(2005) Carlton: Pharmacy department, The Royal Women's Hospital
2. Australian Injectable Drugs Handbook, 4
th
Ed.(2008), Collingwood: The Society of Hospital
Pharmacists of Australia,
3. The Northern Neonatal Network (2007) Neonatal Formulary 5
th
Ed, Oxford: Blackwell Publishing
4. Cloherty J, Eichenwald E, Stark A. (2008) Manual of Neonatal Care 4
th
Ed. Philadelphia: Lippincott
Williams and Wilkins
5. Guidelines for Administration of Intravenous Medications to paediatric Patients 5
th
Ed. 1996 ASHSP
6. King et al. (2002) Guide to Parenteral Admixtures, Napa: King Guide Publications Inc
7. Paediatric Injectable Guidelines, 3
rd
Ed , 2006, Melbourne: Pharmacy Department, Royal Children’s
Hospital
8. Paediatric Dosage handbook 6
th
Edition 1999-2000, Taketomo, Hodding and Kraus
9. Paediatric Pharmacopoeia 13
th
Ed 2002, Melbourne: Pharmacy Department, The Royal Children's
Hospital
10. K. Zenk, J. Sills, R. Koeppel (2003) Neonatal Medications & Nutrition 3
rd
Ed. California: NICU Ink
11. Trissel L. (2009) Handbook on Injectable Drugs.15
th
Ed. Bethesda: ASHP

RWH Neonatal Intensive and Special Care Nurseries
Meropenem IV Protocol

MEROPENEM
DESCRIPTION AND INDICATION FOR USE
Meropenem is a broad-spectrum carbapenem antibiotic that penetrates well into the CSF and
most body tissues.
DOSE
Use only following discussion with neonatologist and/or in consultation with clinical
microbiologist.

Standard Infection - IV: 20mg/kg/dose

Severe Infection - IV: 40mg/kg/dose in meningitis caused by Pseudomonas sp.

Interval
≤ 7 days 12hrly
> 7 days 8hrly
RECONSTITUTION/DILUTION
Vial = 500mg (powder for reconstitution)

IV: Add 10mL of Water for Injection to vial. Once all powder is dissolved solution should be
clear and colourless (may be pale yellow) = 500mg in 10mL = 50mg/mL.

Further dilute solution to 10mg/mL: Withdraw 2mL of 50mg/mL solution from vial and add to
8mL of sodium chloride 0.9% in a 10mL syringe = 100mg in 10mL = 10mg/mL. Discard excess
volume to obtain required dose or withdraw required dose using another syringe.

For fluid restricted babies, a dilution to 25mg/mL can be made as follows: Withdraw 2mL of
50mg/mL solution from vial and add to 2mL of sodium chloride 0.9% in another syringe = 100mg
in 4mL = 25mg/mL. Discard excess volume to obtain required dose or withdraw required dose
using another syringe

Reconstituted solutions range in colour from colourless to pale yellow.

ROUTE AND METHOD OF ADMINISTRATION
IV infusion: Give slowly over 30 minutes via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of meropenem.

6 steps to infuse
safely using
Guardrails
1. Select the correct medicine to be infused
2. Choose pump concentration that matches concentration in syringe 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in
syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
Note: 30minute 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 10mL syringe and infuse at the same infusion
rate.

RWH Neonatal Intensive and Special Care Nurseries
Meropenem IV Protocol

SIDE EFFECTS
x Diarrhoea, nausea/vomiting
x Rash
x Seizures
x Hypotension
5

CONTRAINDICATIONS
x CAUTION in patients with renal impairment. Dose interval may need to be extended.
x CAUTION in patients with history of seizures
5

NURSING RESPONSIBILITIES
x Observe urine output
x BP should be monitored during administration
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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%
1
,sodium chloride 0.9% Intralipid, PN
Drugs Aminophylline, atropine, dexamethasone,
dobutamine, dopamine, fluconazole, frusemide,
gentamicin, heparin, insulin(neutral), magnesium,
morphine, noradrenaline, phenobarbitone,
potassium, ranitidine, vancomycin
Aciclovir, amphotericin B,
diazepam, metronidazole
Y-Site Digoxin
Notes:

x No information available on compatibility with PN or Intralipid. Do not administer
meropenem via PN or Intralipid lines. Flush line before and after administration
with sodium chloride 0.9% or glucose 10%.
x Sodium content: 3.92mmol/1g.

References:
1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T,
Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal
Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital
Pharmacists of Australia, 1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network. 2003
5. Pediatric Dosage Handbook 6
th
Ed 1999-2000, Taketomo, Hodding, Kraus.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Methylene Blue.doc

METHYLENE BLUE

DESCRIPTION AND INDICATION FOR USE
Therapeutic doses of methylene blue can lower levels of methaemoglobin in the red blood cells. It
achieves this by activating a normally dormant reductase enzyme system that reduces the
methylene blue to leucomethylene blue, which in turn is able to reduce methaemoglobin itself to
haemoglobin.
However, in large doses, methylene blue can itself cause methaemoglobinaemia and the
methaemoglobin concentration should be carefully monitored during treatment.

DOSE
IV: 1 to 2mg/kg/dose.
A repeat dose may be given after 1 hour if required.

RECONSTITUTION/DILUTION
Ampoule = 1% (10mg/mL), 5mL

IV: No dilution required. Give as 10mg/mL solution.
If dilution is necessary, glucose 5% may be used. Take 1mL of the 10mg/mL solution and
add to 9mL of glucose 5% in a 10mL syringe = 10mg in 10mL = 1mg/mL.
Withdraw required dose.

ROUTE AND METHOD OF ADMINISTRATION
IV: Give over at least 15 minutes.

SIDE EFFECTS
May turn urine, stools and body secretions blue and discolour skin
In overdose, may produce haemolysis and methaemoglobinaemia
Prolonged use may cause anaemia due to increased destruction of erythrocytes.
Haemoglobin concentrations should be checked regularly.
GI disturbances (Nausea, vomiting, abdominal pain)
Elevated BP
Very high doses given IV may cause haemolysis

CONTRAINDICATIONS
G6PD Deficiency
Severe renal impairment

NURSING RESPONSIBILITIES
Avoid extravasation
Cardiorespiratory monitoring
Monitor BP
Pulse oximetry
Monitor urine output

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Methylene Blue.doc

COMPATIBILITY INFORMATION

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

Compatible Incompatible
Fluids Glucose 5%
3
, sodium chloride 0.9% Intralipid, PN
Drugs No information No information
Y-Site No information No information

References:

1. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
2. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network. 2003
3. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
4. Pediatric Dosage Handbook 6
th
Ed, 1999-2000, Taketomo, Hodding and Kraus.

Metronidazole

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 29 Sept 2015
Review Date: Sept 2018
Page 1 of 2

Neonatal Protocol
Description and indication for use
Metronidazole is an antimicrobial effective in vitro against several species of anaerobic bacteria. It
is inactive against aerobic and facultative anaerobic bacteria.
Metronidazole is used only in the treatment of anaerobic infections, predominantly in neonates for
necrotising enterocolitis in conjunction with amoxycillin and gentamicin.

Preparations
Injection 500mg/100mL (5mg/mL)
Mixture 200mg/5mL

Dose
Loading dose
IV, Oral: 15mg/kg

Maintenance dose
IV, Oral: 7.5mg/kg/dose

Interval
≤ 28 days 12 hourly
> 28 days 8 hourly

Commence maintenance dose
CA <37 weeks 24 hours after loading dose
CA ≥37 weeks 12 hours after loading dose

Reconstitution/Dilution
IV: Withdraw required dose from bag. No further dilution required.

Oral: Reconstitute powder using water for irrigation according to the product information.

Route and Method of Administration
Oral: Best given on an empty stomach at least one hour before or two hours after feeds.

IV infusion: Administer infusion over 60 minutes via syringe infusion pump (Guardrails) – see
‘How to set up the Pump’.

Side Effects
x Gastrointestinal tract disturbances
x Thrombophlebitis at injection site
x Red-brown discoloration of urine
x Thrombocytopenia or leucopenia may occur with prolonged treatment
x Hypersensitivity reactions such as rash, flushing or fever

Contraindications
x Caution in patients with renal or hepatic impairment; dosage interval may need to be increased.

Metronidazole

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 29 Sept 2015
Review Date: Sept 2018
Page 2 of 2

Neonatal Protocol
Drug Interactions

Phenobarbitone May reduce effectiveness of metronidazole by increasing its metabolism
Phenytoin Possible increase in serum phenytoin levels. Monitor levels closely.

Nursing Responsibilities
x Observe injection site
x Monitor FBE if duration of treatment is more than 10 days

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 Aciclovir, amikacin, fentanyl, fluconazole,
glucose 10% to glucose 25%, heparin,
midazolam, morphine, vancomycin, IVN
Starter, IVN Maintenance, lipid
Amphotericin liposomal, ganciclovir,
phenytoin

References

1. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
2. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 10
th
Ed.
Bethesda, Maryland: American Society of Health-System Pharmacists; 2013.
3. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
4. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012-2013
5. Metronidazole. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 13/09/2015.
6. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013
7. Australian Injectable Drugs Handbook, 6
th
Edition (online) Victoria. Available from:
http://aidh.hcn.com.au/?acc=36265#browse/about_aidh Accessed 29/09/15

Miconazole
(Oral Gel)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Clinical pharmacists, Clinical NISC educators
Authorised by: Carl Kuschel
Effective Date: 17 Oct 2013
Review Date: October 2016
Page 1 of 1

Neonatal Protocol
Description and indication for use
Miconazole is an antifungal agent used in the treatment of oral candidiasis. It acts on fungal cell
wall membranes to cause fungal cell necrosis. Miconazole oral gel has a low bioavailability
because of the limited absorption from the gastrointestinal tract and oral mucosa.

Preparations
Oral gel 20mg/g (15g gel)

Dose
Treatment of oral candidiasis
Oral: One-quarter (1/4) of a measuring spoon* of gel four times a day. Continue for 2 days after
symptoms resolve.

*Measuring spoon (5mL = 124mg) is provided with the gel. Dose should be measured with the
spoon. One-quarter spoonful contains approximately 31mg of miconazole.

Route and Method of Administration
Oral: Smear the measured dose of the gel around the mouth and front of the tongue using finger
or cotton bud, give after feeds to prolong contact time with mucous membranes.

The measuring spoon is used to measure the dose. The measured dose must be given in
several portions around the mouth and front of the tongue. Do not use the spoon to
administer the dose. Do not put the gel in the back of the mouth. This is to make sure
that the throat does not become blocked by the gel.

Side Effects
Vomiting
Diarrhoea
Loss of appetite

Contraindications
Hypersensitivity to miconazole or to any of the other ingredients of the gel
Liver impairment

Nursing Responsibilities
Ensure safe administration of the gel
Monitor for improvement in symptoms

References
1. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
2. MIMSOnline. St Leonards, NSW: UBM Medica; 2013. Accessed: 10/10/2013.
3. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.

RWH Neonatal Intensive and Special Care Nurseries
Midazolam IV Protocol

MIDAZOLAM
DESCRIPTION AND INDICATION FOR USE
Midazolam is a short-acting benzodiazepine with a rapid onset of action. It is able to induce
sedation, hynosis, amnesia and anaesthesia, depending on the dose administered, the route of
administration and the presence of other medicines. It also has anticonvulsant and muscle
relaxant properties.
Midazolam does not provide analgesia.
DOSE
As a sedative
IV Infusion: 0.5 to 2microgram/kg/minute

IV, IM: 50 to 200microgram/kg/dose
1,7
up to a total of 500microgram/kg. Repeat as
required, usually every 2 to 4 hours.
1

If analgesia is required, and narcotics given concurrently, the dose may need to be lowered.
Flumazenil should be available for reversal of overdose symptoms (respiratory
depression).
RECONSTITUTION/DILUTION
Ampoule = 5mg in 5mL (1mg/mL), 15mg in 3mL (5mg/mL)

IV: Use 1mg/mL solution (5mg in 5mL ampoule) - no further dilution required. Withdraw
required dose from ampoule and discard remaining solution.

INF: Add 3mg/kg to infusion solution ordered (glucose 5 or 10%, sodium chloride 0.9%) to a
total volume of 50mL. (As shown in table below)
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Midazolam
SINGLE
3mg/kg in 50mL
(3000microgram/kg to 50mL)
1mL/hr = 1microgram/kg/min 0.5 to 2microgram/kg/min
Midazolam
DOUBLE
6mg/kg in 50mL
(6000microgram/kg to 50mL)
1mL/hr = 2microgram/kg/min 0.5 to 2microgram/kg/min

ROUTE AND METHOD OF ADMINISTRATION
IV: Give slowly over at least 5 minutes.
IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using
Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of midazolam.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is correct
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown in ‘mcg/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct.
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous infusion

RWH Neonatal Intensive and Special Care Nurseries
Midazolam IV Protocol

SIDE EFFECTS
x Apnoea and respiratory depression
x Hypotension
x Seizure-like myoclonus occurs in approx 8% of premature infants, particularly if given by
rapid IV injection or in infants with underlying CNS abnormalities

CONTRAINDICATIONS
x CAUTION in patients with hepatic impairment
x CAUTION in patients with underlying CNS disorders

DRUG INTERACTIONS
Morphine, fentanyl Respiratory depression and hypotension are more common when used
in combination with narcotics. Additive sedative effects
Theophylline May reduce the effectiveness of midazolam

NURSING RESPONSIBILITIES
x Monitor heart rate and respiratory rate and depth
x Apply transcutaneous monitor and pulse oximeter
x Monitor BP
x Change syringe and IV tubing every 24 hours
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 chloride 0.9%
TPN
1

Drugs No information No information
Y-Site Adrenaline, amikacin, amiodarone, atropine
1
, calcium
gluconate, cefotaxime, cephazolin, digoxin, dobutamine
1
,
dopamine, esmolol, erythromycin, fentanyl, fluconazole,
gentamicin, glyceryl trinitrate, heparin, insulin,
metronidazole, morphine, noradrenaline, pancuronium
1
,
piperacillin, potassium chloride, ranitidine, tobramycin,
vancomycin
Amoxycillin, ceftazidime,
dexamethasone, flucloxacillin,
frusemide, hydrocortisone,
imipenem-cilastatin,
phenobarbitone
1
, ranitidine, sodium
bicarbonate
Notes:
x
Flumazenil is a specific benzodiazepine antagonist and may be used to rapidly
reverse respiratory depression.
3
x
IV: 10micrograms/kg given over 15 seconds, repeated every minute to a maximum of 1mg/kg,
then an infusion of 5 to 10microgram/kg/hour if needed.
6

References:
1. Neofax 12
th
Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 10
th
Ed, The Northern Neonatal Network. 1998
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
6. Pediatric Dosage handbook 6
th
Ed 1999-2000, Taketomo, Hodding & Kraus
7. Drug Doses 10
th
ed 1998, Frank Shan, Intensive Care Unit, Royal Children's Hospital, Parkville 3052

Milrinone
(NISC Protocol)

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Review Date: July 2019
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Description and indication for use
Milrinone is a phosphodiesterase inhibitor which improves cardiac output by enhancing myocardial
contractility, enhancing myocardial diastolic relaxation and decreasing systemic vascular
resistance. It is indicated for severe heart failure and short term (<48hrs) treatment of acute low
cardiac output after cardiac surgery (e.g.: PDA ligation) or septic shock or PPHN resistant to
inhaled nitric oxide. It may be used in combination with adrenaline.

Ensure adequate vascular volume prior to commencement of milrinone to reduce adverse effects.

Elimination is primarily via renal mechanisms. Half-life is quite variable, ranging from approximately
10 hours in ELBW neonates to 3 hours in older and more mature infants.

Preparations
Injection 10mg/10mL (1mg/mL)

Dose
Use only following discussion with consultant neonatologist.

Loading dose
IV: 500-750nanograms/kg/min over 3 hours

Maintenance dose (give immediately after loading dose)
IV infusion: 200 to 750nanograms/kg/minute. Adjust dose according haemodynamic and clinical
responses. Consider initial dose of 200nanograms/kg/minute for GA < 30 weeks.

Note: loading dose can be omitted or reduced if risk of hypotension.

Reconstitution/Dilution
IV: Withdraw 0.5mL of 1mg/mL (1000micrograms/mL) solution and dilute with 19.5mL of
compatible fluid in a 20mL syringe = 500 micrograms in 20mL = 25micrograms/mL.

Babies > 1000g: Withdraw required dose from the 25micrograms/mL solution and
administer.

Babies ≤ 1000g: Dilute 1.5mL of 25microgram/mL solution with 8.5mL of compatible fluid in
a 10mL syringe = 37.5microgram in 10mL = 3.75microgram/mL. Withdraw required dose.
If dose is greater than 37.5microgram, use double quantities.

Note: Loading dose can be given undiluted if fluid restricted

Milrinone
(NISC Protocol)

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IV Infusion: Dilute required dose to 50mL with a compatible fluid.

CONCENTRATION HOW TO DILUTE DOSE EQUIVALENT
Milrinone
SINGLE
3mg/kg to 50mL 1mL/hr = 1000 nanograms/kg/min
Milrinone
DOUBLE
6mg/kg to 50mL 1mL/hr = 2000 nanograms/kg/min

Route and Method of Administration
Not to be given by IM injection.
Administer via central line or peripheral line.

IV: Administer loading dose via syringe pump using Guardrails.

IV infusion: Administer infusions through a syringe infusion pump (Guardrails) – see ‘How to set
up the Pump’.

Flush the line: Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse
at the same infusion rate.

Side Effects
x Hypotension initially then blood pressure normalises. Hypotension may be prolonged in patients
with renal failure
x Ventricular arrythmias, tachycardia
x Thrombocytopaenia
x Anaphylaxis
x Atrial fibrillation
x Liver function abnormalities
x Rash
x Tremor
x Hypokalaemia and hypomagnesaemia
x Spontaneous bronchospasm has been reported

Contraindications
x Decrease dose in patients with renal impairment

Nursing Responsibilities
x Monitor continuous invasive blood pressure and heart rate
x Monitor fluid balance and electrolytes
x Monitor infusion site carefully; avoid extravasation

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

Milrinone
(NISC Protocol)

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Review Date: July 2019
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Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.45%,
sodium chloride 0.9%
Sodium bicarbonate
Y-Site Aciclovir, adrenaline, amikacin,
amiodarone, calcium gluconate,
dexamethasone, digoxin, dobutamine,
dopamine, fentanyl, fluconazole,
gentamicin, heparin, insulin neutral
(regular), magnesium sulphate,
meropenem, metronidazole, midazolam,
morphine sulphate,
noradrenaline,pancuronium, piperacillin
sodium – tazobactam sodium, potassium
chloride, ranitidine, , sodium bicarbonate,
sodium nitroprusside, vecuronium, IVN
starter solution, IVN maintenance solution
Diazepam, frusemide

References
1. Young T, Mangum B, 2010, Neofax 2010, 21st Ed, New Jersey: Thomson Reuters.
2. Phelps, Hak, Crill. 2013 Pediatric Injectable Drugs (The Teddy Bear Book), 9th Ed, American Society of
Health-System Pharmacists
3. Burridge N (Ed) 2013 Australian Injectable Drugs Handbook, 6th Ed., Melbourne: The Society of Hospital
Pharmacists of Australia.
4. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5th Ed, Massachusetts: Blackwell
Publishing Inc, 2007.
5. BNF for children, London: BMJ Publishing Group Ltd, 2015-2016.
6. Micromedex
®
Solutions 2012-2016 Truven Health Analytics Inc. Accessed on 26/07/2016
7. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013

Morphine

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Neonatal Protocol
Description and indication for use
Morphine is the principal alkaloid of opium, acting as an agonist at mu-opioid receptors in the brain,
spinal cord and other tissues. Morphine is used as an analgesic, as a sedative in ventilated infants,
and orally in the treatment of Neonatal Abstinence Syndrome. Doses should be weaned gradually
after prolonged treatment to avoid withdrawal.

Preparations
Injection 10mg/mL
Mixture 1000micrograms/mL

Dose
Analgesia and sedation
IV injection: 50-100 micrograms/kg/dose every 4 to 6 hours

IV infusion: 5 to 20 micrograms/kg/hour. Doses of up to 40 microgram/kg/hour may be used in
ventilated patients. A bolus dose of 50-100micrograms/kg can be given prior to starting the infusion
after discussion with consultant

Note:
x Reduce dose gradually as tolerated after prolonged treatment to minimise withdrawal
x Naloxone (100micrograms/kg/dose) must be available for reversal

Neonatal abstinence syndrome (NAS)
Oral: 500-700 micrograms/kg/day
All doses for the entire period of NAS management are calculated on birth weight and not current
weight.

Oral morphine treatment is commenced when:
Score Morphine Dose
3 consecutive scores average 8 or
more
125 micrograms/kg/dose 6 hourly
or
85 micrograms/kg/dose 4 hourly*

2 consecutive scores average 11
or more (consider higher dosage)
125-175 micrograms/kg/dose 6 hourly
or
85-120 micrograms/kg/dose 4 hourly*

*If NAS symptoms are not assessed as controlled with 6 hourly oral morphine, change
dose frequency to 4 hourly in the first instance before increasing the dosing amount.
Oral doses should be rounded to the nearest 10 micrograms.

Weaning morphine treatment – on 6 hourly dosing
x Reduce by 10% of the initial dose (based on birth weight) every 72 hours (i.e. 12.5-17.5
micrograms/kg/dose)
x When daily dosage is 30micrograms/kg/dose, morphine may be discontinued
x Continue assessment of NAS for a further 72 hours

Morphine

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Neonatal Protocol
Weaning morphine treatment – on 4 hourly dosing
x Reduce by 10% of the initial dose (based on birth weight) every 72 hours (i.e. 8.5-12
micrograms/kg/dose)
x When on 35 micrograms/kg/dose, change dose frequency from 4 hourly to 6 hourly (i.e. 35
micrograms/kg/dose 6 hourly)
x Discontinue treatment after 72 hours
x Continue assessment of NAS for a further 72 hours

Note: Weaning of morphine for NAS is dependent on suitable clinical condition/scoring

To reduce the risk of vomiting the morphine dose:
x Give morphine before a feed
x Ensure the baby is not being overfed
x Ensure the baby is in a semiprone posture during and after feeding
If baby vomits Action
Within 10 minutes of dose Redose
10-30 minutes after dose Give half dose
> 30 minutes after dose Wait until next scheduled dose

Refer to the Clinical Practice Guideline for Babies at Risk of Neonatal Abstinence Syndrome.
http://intranet.thewomens.loc/pgp/Documents/Drug and Alcohol - Neonatal Abstinence Syndrome
(NAS).pdf

Correct prescribing of oral morphine for NAS
Example:

Correct prescribing of morphine for discharge (home based withdrawal program) – Appendix A

Morphine

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Neonatal Protocol
Converting between IV and oral dosing
1mg IV morphine is approximately equivalent to 2mg of oral morphine.

IV to oral: IV infusion dose (micrograms/kg/hour) x 48 = ORAL dose (micrograms/kg/day)
This may be required for babies who have been sedated with continuous IV morphine for more
than 2 weeks and developed tolerance

When converting from continuous intravenous infusion to oral dosing, the first oral dose may be
given at the time the continuous infusion is ceased.

Oral doses should be based on the weight when oral dosing is commenced.

Oral to IV: Discuss with neonatal consultant or NISC pharmacists

Reconstitution/Dilution
IV bolus: Withdraw 0.1mL of 10mg/mL solution and add to 0.9mL of Water for Injection in a
second 1mL syringe = 1mg/mL = 1000micrograms/mL. Discard excess volume to
obtain required dose or withdraw ordered dose using another syringe.

IV Infusion: Dilute required dose to 50mL with a compatible fluid.

Route and Method of Administration
IM: Not recommended in neonates.

IV bolus: Administer over 5 minutes. Flush line after administration.

IV infusion: Administer infusions through a syringe infusion pump (Guardrails) – see ‘How to set
up the Pump’.

Oral: Give before feeds

Side Effects
x Sedation, respiratory depression
x Hypotension, flushing, sweating, bradycardia, tachycardia
x Abdominal distension
x Miosis (pinpoint pupils)
x Muscle rigidity
x Increased intracranial pressure
x Urinary retention, constipation
x Tolerance may develop with continued use. Wean slowly after prolonged morphine use.
CONCENTRATION HOW TO DILUTE DOSE EQUIVALENT
Morphine
SINGLE
500micrograms/kg dilute to 50mL 1mL/hr = 10micrograms/kg/hour
Morphine
DOUBLE
1mg/kg dilute to 50mL 1mL/hr = 20micrograms/kg/hour
Morphine
QUADRUPLE
2mg/kg dilute to 50mL 1mL/hr = 40micrograms/kg/hour

Morphine

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Neonatal Protocol
Contraindications
x Gastrointestinal tract obstruction especially known or suspected paralytic ileus
x Increased intracranial pressure, convulsions
x Caution in patients with shock, hypotension
x Caution in patients with cardiac arrhythmias
x Caution in patients with hepatic or renal impairment
x Caution in patients with urinary retention

Drug Interactions

Benzodiazepines (clonazepam, midazolam), chloral hydrate,
phenobarbitone
Additive sedative effect

Nursing Responsibilities
x Cardio/respiratory monitor
x Monitor blood pressure and pain scores for babies on intravenous therapies
x Have ventilation equipment available
x Medical staff should be on hand when giving STAT doses as ventilation may need to be initiated
or increased.
x Avoid giving other drugs through morphine infusion line to avoid giving bolus doses of
morphine. Refer to medical staff and pharmacist prior to giving bolus drugs through morphine
line. Check medicine compatibilities before giving medicines via morphine infusion line.
x Change syringe and line every 24 hours
x Give oral morphine before a feed

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

Compatible Incompatible
Fluids Glucose 2.5%, glucose 5%, glucose 10%,
sodium chloride 0.45%, sodium chloride 0.9%

Y-Site Adrenaline, amikacin, atropine, benzylpenicillin sodium,
calcium chloride, calcium gluconate, cefotaxime,
dexamethasone, digoxin, dobutamine, dopamine,
erythromycin, fentanyl, fluconazole, gentamicin, heparin,
hydrocortisone sodium succinate, insulin neutral,
magnesium sulfate, meropenem, metronidazole,
midazolam, milrinone, noradrenaline, octreotide,
pancuronium, potassium acetate, potassium phosphate,
pyridoxine, ranitidine, sodium acetate, sodium bicarbonate,
tobramycin, vancomycin, zidovudine, IVN starter and
maintenance solutions, lipid emulsion 17%
Aciclovir, amphotericin B
liposomal, flucloxacillin,
ganciclovir,
indomethacin, phenytoin

Morphine

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Neonatal Protocol
References
1. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 5
th
Ed. Melbourne: The Society of
Hospital Pharmacists of Australia; 2011.
2. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
2011.
3. Morphine. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 18/02/2016.
4. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 9
th
Ed. Bethesda,
Maryland: American Society of Health-System Pharmacists; 2010.
5. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013.
6. eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2013 Mar. Accessed 2013 Jul 04
<http://online.tg.org.au/ip/tgc.htm>.
7. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
8. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
9. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
10. Zenk KE, Sills JH, Koeppel RM. Neonatal Medications & Nutrition: A Comprehensive Guide. 3
rd
Ed. Santa
Rosa, California: NICU Ink; 2003.
11. MIMSOnline. St Leonards, NSW: UBM Medica; 2013. Accessed: 04/07/2013.
12. Micromedex 2.0. Thomson Reuters; 2013. Accessed: 04/07/2013.
13. Rossi S, editor. Australian Medicines Handbook. 15
th
Ed. Adelaide: Australian Medicines Handbook Pty
Ltd. 2014.

Naloxone

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Effective Date: 30 Oct 2016
Review Date: Oct 2019
Page 1 of 3

Neonatal Protocol
Description and indication for use
Naloxone is an opioid receptor antagonist used to reverse respiratory depression, excessive
sedation and hypotension caused by opioids. The onset of action is within 2 minutes and lasts for
20-60 minutes after intravenous administration. Duration of action is shorter than most opioids,
repeated IV doses may be necessary to reverse effects of opioids with longer duration of action.
On the other hand, the onset of action is more gradual (within 2-5 minutes) after IM administration
but the effect is sustained for 24 hours.

Naloxone should NOT be administered to infants of opioid-dependent mothers as it may precipitate
withdrawal (e.g.: seizures).

Preparations
Injection 400 micrograms/mL

Dose
Respiratory depression in babies ≥ 35 weeks gestation in delivery room due to maternal
opioids received < 4 hours prior to birth
IM: 100 micrograms/kg/dose, or
If weight is unknown: 200 – 400 micrograms (i.e: 0.5mL – 1mL) depending on estimate of
baby’s weight

Known opioid overdose
IV: 100 micrograms/kg/dose repeated every 2-3 minutes as necessary, up to a maximum of 2mg
IV infusion: 10 micrograms/kg/hour. Rate of infusion should be titrated to response, as duration of
action is shorter than most opioids.

Reconstitution/Dilution
IM: No dilution required

IV: Can be given undiluted, or dilute to at least 1mL with sodium chloride 0.9% before
administration

IV infusion: dilute to 4 micrograms/mL with compatible fluid

Route and Method of Administration
IV: Administer over 1 minute, flush line with 1mL sodium chloride 0.9% after administration

IV infusion: Administer infusions through a syringe infusion pump (Guardrails) – see ‘How to set
up the Pump’. Protect infusion from light.

Side Effects
x Tachycardia, hypertension
x Lethargy, tremors
x Vomiting

Naloxone

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Neonatal Protocol
Contraindications
x Respiratory depression not caused by opioids
x Naloxone should not be administered to infants of opioid-dependent mothers as it may
precipitate an acute withdrawal syndrome. Symptoms of withdrawal may include tachycardia,
tachypnoea, hypertension and seizures

Drug Interactions

Opioids (morphine, fentanyl) Reversal of analgesic effect (in addition to reversal of
sedation and respiratory depression)

Nursing/midwifery Responsibilities
x Monitor for response to naloxone, including improved respiratory effort
x After administration, reassess the infant every 1-2 hours as repeat doses may be required
x Avoid use in infants of opioid-dependent mothers
x Hourly observations for 4 hours in birth centre or postnatal wards after administration of IM
naloxone for respiratory depression

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 Adrenaline, atropine, benzylpenicillin,
cefotaxime, ceftazidime, ceftriaxone,
dexamethasone, dobutamine, dopamine,
fluconazole, frusemide, gentamicin,
heparin, hydrocortisone sodium
succinate, insulin, isoprenaline,
magnesium sulphate, meropenem,
midazolam, ranitidine, vancomycin,
Amphotericin B liposomal, phenytoin

References
1. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 9
th
Ed. Bethesda,
Maryland: American Society of Health-System Pharmacists; 2010.
2. Naloxone. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 02/08/16
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013.
4. Burridge N, Collar N, Symons K, editors. Australian Injectable Drugs Handbook. 6
th
Ed. Melbourne: The
Society of Hospital Pharmacists of Australia; 2014.
5. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
6. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
7. Australian Medicines Handbook 2016 (online). Available from: http://amhonline.amh.net.au/
8. Naloxone product information (MIMS online) accessed on 01/08/16.

Naloxone

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Page 3 of 3

Neonatal Protocol
9. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
10. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
11. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
2011.
.

RWH Neonatal Intensive and Special Care Nurseries
Noradrenaline IV Protocol

NORADRENALINE
DESCRIPTION AND INDICATION FOR USE
effects include increased vascular resistance through vasoconstriction and increased heart rate
and myocardial contractility.
The main indications for use would be in the uncontrolled hypotensive neonate or to redirect
blood flow more centrally in the peripherally vasodilated septic baby.
Hypovolaemia should always be treated prior to and discussion with consultant necessary
before commencement of noradrenaline.

DOSE
Always given as a continuous infusion via central line

IV Infusion: 50nanogram/kg/min to a maximum 1000nanogram/kg/min

NOTE: Doses greater than 500nanogram/kg/min are rare and must be discussed with a
consultant

RECONSTITUTION/DILUTION
Ampoule: Noradrenaline Base 2mg/2mL (labelled as acid tartrate salt)

IV Infusion: Add 0.3mg/kg (300microgram/kg) to infusion solution (glucose 5%) to a total
volume of 50mL (as shown in table below).
DRUG HOW TO MAKE UP DOSE EQUIVALENT DOSE RANGE
Noradrenaline 0.3mg/kg in 50mL
(300microgram/kg in 50mL)
1mL/hr =
100nanogram/kg/min
50 to
1000nanogram/kg/min

ROUTE AND METHOD OF ADMINISTRATION
Not to be given as IV bolus, IM or SC injection.

Give centrally – never peripherally. Always given as a continuous infusion.

IV infusion: Give as a continuous infusion at the prescribed rate via syringe pump using
Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with
preloaded syringe containing exact dose of noradrenaline.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Hit ‘Modify’ to ‘select concentration’ of the syringe
x Enter medicine dose then press ‘OK’
x Enter volume in syringe then press ‘OK’ and check concentration is
correct
3. Weight of baby: enter weight of baby then press ‘OK’
4. Dose shown is ‘ng/kg/min’ then press ‘OK’
x ‘Adjust’ to required dose as prescribed if needed. Check dose is correct
5. Confirm syringe brand:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: if all is correct, press Green button to start continuous
infusion.

RWH Neonatal Intensive and Special Care Nurseries
Noradrenaline IV Protocol

SIDE EFFECTS
x Arrhythmias, tachycardia, bradycardia
x Anaphylaxis
x Hypertension
x Reduced renal blood flow – renal ischaemia
x Hyperglycaemia

CONTRAINDICATIONS
x Untreated hypovolaemic shock
x Peripheral or mesenteric vascular thrombosis
x Existing tachyarrhythmia
x Asymmetric septal hypertrophy

NURSING RESPONSIBILITIES
x Central line administration only
x Monitor blood pressure and heart rate
x Monitor urine output
x Do not administer bolus doses
x Avoid interruption of infusion
x Change infusion solution every 24 hours
x Protect noradrenaline syringe from light. Cover syringe with foil.
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 Chloride
0.9%
Alkaline solutions*, PN
+
Drugs Amikacin sulphate, magnesium sulphate,
meropenem, ranitidine
Aminophylline, insulin neutral, phenobarbitone
sodium, phenytoin, sodium bicarbonate
Y-Site Adrenaline, amiodarone, calcium salts,
dobutamine, dopamine, fentanyl citrate,
frusemide, glyceryl trinitrate, heparin sodium,
hydrocortisone sodium succinate, midazolam,
morphine sulphate, potassium chloride,
vecuronium, verapamil

#NOTE: There is no compatibility information with Glucose 10%.
*NOTE: Noradrenaline is unstable in alkaline solutions and should not be combined
with alkaline drugs or administered through a line with alkaline solutions.
+NOTE: There is limited information on the compatibility of noradrenaline with
parenteral nutrition (PG1, PG2 and intralipid solutions). For this reason please avoid
mixing the two together or administering via Y-site.
References:
1. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
2. Neonatal Formulary 10
th
Ed, The Northern Neonatal Network. 1998
3. Paediatric Pharmacopoeia, 13
th
Ed, 2002. Royal Children’s Hospital Melbourne
4. Guidelines for Administration of Intravenous Medications to paediatric Patients 5
th
Ed. 1996 ASHSP
5. Paediatric Dosage handbook 6
th
Edition 199-2000, Taketomo, Hodding and Kraus
6. BNF for children 2005, bmfc.org.
7. Handbook on Injectable Drugs, Trissel 11
th
Ed, 2000
8. King Guide to Parenteral Admixtures 2002 Ed, King J, Catania P.
9. Drug Interaction Facts, facts and comparisons. Tatro,D.
10. Neonatal Medications & Nutrition, 3
rd
Ed, 2003, Zenk K et al.

Nystatin

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Sue Jacobs, Clinical Pharmacists, NISC Clinical Educators
Authorised by: Carl Kuschel
Effective Date: 28 October 2013
Review Date: Oct 2016
Page 1 of 2

Neonatal Protocol
Description and indication for use
Nystatin is an antifungal agent used in the treatment of fungal skin infections and oropharyngeal
candidiasis. It is also used for fungal prophylaxis in extremely low birth weight babies with vascular
catheters and for any infant requiring treatment with steroids. Nystatin is poorly absorbed from the
gastrointestinal tract, intact skin and mucous membranes.

Preparations
Oral Drop 100 000units/mL
Cream 100 000units/g

Dose
Fungal prophylaxis for infants with birth weight <1000g and any vascular catheters
(peripheral or central)*
Oral: 1mL 8 hourly (0.5mL applied to oral cavity and 0.5mL through OGT or NGT). Continue until
all vascular catheters are removed.

If any vascular catheters are reinserted and the baby is still <1000g, nystatin should be restarted.
If baby current weight is ≥ 1000g when lines are reinserted, fungal prophylaxis is not necessary.

Fungal prophylaxis during steroid therapy*
Oral: 1mL 8 hourly (0.5mL applied to oral cavity and 0.5mL through OGT or NGT). Continue for 3
days after steroids are ceased.

Treatment of candidal infections of the mucous membranes and intestinal tract
Oral: 1mL 6 hourly. Continue for 3 days after symptoms resolve.

Miconazole oral gel should be used as the first line treatment for oral candidiasis. Refer to the
miconazole neonatal protocol.

Treatment of candidal infections of the skin
Topical: Apply 3 times a day after nappy changes. Continue for 3 days after symptoms resolve.

*Fungal prophylaxis can be initiated and ceased by pharmacist according to the protocol.
Pharmacist should prescribe and/or cease fungal prophylaxis according to the Medicine
Management Guideline.

Route and Method of Administration
Oral: Best administered after feeds when used for treatment of oral candida infection to prolong
contact time with mucous membranes.

When used for fungal prophylaxis in extremely low birth weight infants with vascular
catheters or infants on steroid therapy, administer 0.5mL to the oral cavity and 0.5mL
through the orogastric or nasogastric tube.

Nystatin

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Sue Jacobs, Clinical Pharmacists, NISC Clinical Educators
Authorised by: Carl Kuschel
Effective Date: 28 October 2013
Review Date: Oct 2016
Page 2 of 2

Neonatal Protocol
Side Effects
Diarrhoea
Local irritation to area of application is rare

Contraindications
Hypersensitivity to nystatin or to any of the other ingredients

Nursing Responsibilities
Monitor for improvement in symptoms
Monitor for signs of fungal infection

References
1. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 17
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2010.
2. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
3. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
4. Rossi S, editor. Australian Medicines Handbook. 13
th
Ed. Adelaide: Australian Medicines Handbook Pty
Ltd. 2013.
5. MIMSOnline. St Leonards, NSW: UBM Medica; 2013. Accessed: 02/07/2013.
6. Fary R, Smith R, Davis P, Jacobs S, editors. Neonatal Pharmacopoeia. 2
nd
Ed. Melbourne: Pharmacy
Department, The Royal Women’s Hospital; 2005.
7. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
8. Zenk KE, Sills JH, Koeppel RM. Neonatal Medications & Nutrition: A Comprehensive Guide. 3
rd
Ed. Santa
Rosa, California: NICU Ink; 2003.
9. Austin N, Darlow BA, McGuire W. Prophylactic oral/topical non-absorbed antifungal agents to prevent
invasive fungal infection in very low birth weight infants (Review). The Cochrane Library 2013, Issue 3.
10. Ozturk MA, Gunes T, Koklu E, Cetin N, Koc N. Oral nystatin prophylaxis to prevent invasive candidiasis in
Neonatal Intensive Care Unit. Mycoses 2006;49(6):484–92.
11. Sims M.E., Yoo Y., You H. et al. Prophylactic oral nystatin and fungal infections in very-low birthweight
infants. Am J Perinatol 1988; 5: 33-36.
12. Kaufman D. Strategies for Prevention of Neonatal Invasive Candidiasis. Seminars in Perinatology
2003;27(5):414-424.
13. Kaufman D. Prevention of invasive Candida infections in preterm infants: the time is now. Expert Rev Anti
Infect Ther 2008;6(4):393-399.
14. Howell A, Isaacs D, Halliday R, The Australasian Study Group for Neonatal Infections. Oral nystatin
prophylaxis and neonatal fungal infections. Arch Dis Child Fetal Neonatal Ed 2009;94:F429-F433.
15. Ayedemir C, et al. Randomised controlled trial of prophylactic fluconazole versus nystatin for the
prevention of fungal colonisation and invasive fungal infection in very low birth weight infants. Arch Dis
Child Fetal Neonatal Ed 2011;96:F164-F168.
16. Kaufman D. “Getting to Zero”: Preventing invasive Candida infections and eliminating infection-related
mortality and morbidity in extremely preterm infants. Early Human Development 88S2 2012:S45-S49.

OMEPRAZOLE
Proton pump inhibitor
Preparations

CAP 20mg
MIXT 2mg/mL (RWH)

Dose

Suppression of gastric acid secretion
ORAL: Initially 0.7mg/kg once daily in the
morning, half an hour before feed.
Double dose after 7 to 14 days if
symptoms persist. Doses up to
2.8mg/kg/dose have been used.

Omnipaque
®
300
(Contrast Agent)

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Review Date: March 2019
Page 1 of 2

Contrast Protocol
Description and indication for use
Omnipaque
®
300 is an iodine containing contrast medium used to confirm the correct position of
percutaneous long lines (PICC).
Preparations
20mL Omnipaque
®
300 (stored in the imprest cupboard)

Dose

IV: 0.5mL of Omnipaque
®
300

Ensure order written in ‘Once Only Administration’ section of the medicines chart:
Contrast order: Omnipaque
®
300 Dose: 0.5mL

Reconstitution/Dilution

IV: Withdraw 0.5mL of Omnipaque
®
300 (undiluted) solution in a 3mL syringe

Note: A 3mL syringe is used to minimise pressure during administration

Route and Method of Administration
x DO NOT USE A FILTER
x RADIOGRAPHER TO BE AT COTSIDE BEFORE ADMINISTRATION
x Flush line with 1mL of Sodium Chloride 0.9%
x Inject 0.5mL of Omnipaque
®
solution - leaving syringe attached
x Request the radiographer to take the X-ray 0-5 seconds after injection
x There is no need to withdraw the Omnipaque
®

x Remove syringe containing Omnipaque
®

x Flush line with 1mL Sodium Chloride 0.9%
Side Effects
x Transient hypothyroidism may occur in preterm infants so minimising the volume of
Omnipaque
®
is important
x Electrolyte disturbances
x Pulmonary hypertension
x Transient increase in creatinine
Contraindications
x Thyrotoxicosis
x Anuria

Omnipaque
®
300
(Contrast Agent)

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Effective Date: 31 March 2016
Review Date: March 2019
Page 2 of 2

Contrast Protocol
Nursing Responsibilities
x Visually inspect Omnipaque
®
for particulate matter or discolouration before use.
x Discard if present.
x CAUTION in patients with impaired renal function
x CAUTION in patients with impaired hepatic function
x Omnipaque
®
300 to be stored away from heat and light
x Inadvertent injection of the Omnipaque
®
solution is unlikely to cause an adverse event however,
baby to be observed as is routine.
Compatibility Information
x Omnipaque
®
should be administered alone and not combined with any medicines.
x The line containing the Omnipaque
®
should only be flushed with Sodium Chloride 0.9%.

References
1. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility) Online. Greenwood Village,
Colorado: Thomson Reuters (Healthcare). Accessed: Feb 2016.
2. MIMS Online, Prescribing Information, 2014

Page 1 of 3
This document should be read in conjunction with the NCCU Disclaimer.

WOMEN AND NEWBORN HEALTH SERVICE
King Edward Memorial Hospital

Section 13: Surgical conditions Neonatology Clinical Guidelines
Exomphalos (Omphalocele) King Edward Memorial/Princess Margaret Hospitals
Date last reviewed: 2006 Perth Western Australia
Date this revision: Sept 2014
Review date: Sept 2017
Authorised by Neonatal Coordinating group
EXOMPHALOS (OMPHALOC ELE)

DEFINITION
An exomphalos is herniation of abdominal viscera through a central abdominal wall
defect
The herniated viscera is covered by 3 layers: peritoneum, amnion and Wharton’s jelly
Exomphalos is different from a gastroschisis in that it has a membrane that covers the
abdominal contents and is more likely to have associated anomalies or be part of a
syndrome
Embryology: During the 6
th
–10
th
week the fetal intestine migrates through the umbilical
ring into the cord, then returns to the abdominal cavity. Failure of viscera to return
results in an exomphalos

TYPES
1. Exomphalos minor where the opening is less than 4cm and only contains the intestine,
2. Exomphalos major where the opening is greater than 4cm and/or with the liver inside
the cord.

ANTENATAL DIAGNOSIS
In most cases, exomphalos is seen on pre-natal ultrasound with associated anomalies
investigated

ASSOCIATED ANOMALIES
Associated anomalies are observed in up to 72% of infants and it is commonly
associated with chromosomal defects or part of a syndrome
Of infants with normal karyotypes, nearly 80% have multiple other anomalies
Multiple anomalies are more common with minor (≤4 cm) versus major exomphalos
(55% vs 36%)

Associations Notes
Chromosomal
abnormalities
Trisomy 13, 14,15, 18 and 21
Syndromes Beckwith-Wiedermann, Pentalogy of Cantrell, lower midline syndrome
(bladder/cloacal extrophy, imperforate anus, meningomyelocele)
Cardiac anomalies Cardiac anomalies seen in up to 20% of cases
Pulmonary hypoplasia Commonly associated with exomphalos major (20%)
VACTERL anomalies
Nervous system Holoprosencephaly and anencephaly

AT BIRTH
Neither vaginal delivery nor caesarean section has been shown to be superior
In exomphalos major, caesarean section may reduce liver injury or sac rupture during
vaginal delivery
Medical staff should attend the resuscitation. A consultant should be present where
possible if a exomphalos major is expected
SURGICAL CONDITIONS

NCCU CLINICAL GUIDELINES
SECTION: 13

Section: 13 Surgical conditions Neonatology Clinical Guidelines
Exomphalos (Omphalocele) King Edward Memorial/Princess Margaret Hospitals
Date revised: Sept 2014 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 2 of 3

These infants may have unsuspected pulmonary hypoplasia requiring early intubation
and ventilation
Fluid resuscitation may be required early especially if there is rupture of the covering sac
Congenital heart disease should be suspected if the infant is cyanosed/not responding to
resuscitation

POST-RESUSCITATION CARE SHOULD FOCUS ON:
1. Care of the exomphalos, covering sac and blood supply
A rupture in the sac should be managed as a gastroschisis with urgent surgical
referral and transfer to 6B
The bowel should be decompressed with a large bore gastric tube
An intact sac can be dressed with saline-soaked gauze and impervious dressing
to minimize fluid loss (discuss with surgical team first)
The underlying viscera should be inspected for perfusion and colour

2. Fluid resuscitation
Despite having a covering sac, these infants have higher fluid losses
If there has been a rupture in the sac then fluid management is the same as
gastroschisis
All infants should be commenced on 80-100mL/kg/day of maintenance fluid (10%
glucose/0.22% saline).
Normal saline boluses may be required if perfusion worsens

3. Temperature regulation
These infants lose heat through the exomphalos so temperature control is very important
INVESTIGATION FOR CHROMOSOMAL AN OMALIES OR SYNDROMES
A full karyotype should be sent
Consider Beckwith Weidermann in infants with hypoglycaemia or are large for
gestational age
The following investigations should be considered – chest X-ray, spinal series,
abdominal & renal ultrasound, head ultrasound, echocardiography, limb X-rays (where
appropriate).
SURGICAL MANAGEMENT
Surgery should be considered electively in all with an intact sac
The infant should have an urgent surgical referral if a rupture of the sac has occurred
Treatment depends on the size of the defect, gestational age and presence of
associated anomalies
Small defects may be repaired with inversion of the sac and primary closure of the fascia
and skin
In larger defects:
o Primary closure may be difficult due to excessive increase in intra-abdominal
pressure
o Options include use of flaps, patches, negative pressure dressing or use of a
silastic pouch (silo) to allow gradual reduction of the defect and scarification.

SURGICAL COMPLICATIO NS
Complications are dependent on the size of the lesion, type of surgery, gestational age and
associated anomalies. These include:

Section: 13 Surgical conditions Neonatology Clinical Guidelines
Exomphalos (Omphalocele) King Edward Memorial/Princess Margaret Hospitals
Date revised: Sept 2014 Perth Western Australia
This document should be read in conjunction with the NCCU Disclaimer Page 3 of 3

Abdominal compartment syndrome (more common with primary closure of larger
defects)
A tear of Glissen’s capsule of the liver may occur when removing the sac covering
the liver
Inadvertent damage of the bladder can occur if it is within the exomphalos.
Infection risk in infants with a patch or mesh.
Bowel adhesions may develop post-operatively.

POSTOPERATIVE COURSE
The majority of infants will require mechanical ventilation for a few days
postoperatively
A nasogastric tube should be utilized for gastric decompression
Feeding can begin when the nasogastric output is decreasing and no longer bilious
(this will be guided by surgeon). GORD is common. 60% of infants with exomphalos
major will have feeding problems.
Survival ranges from 75 to 95% of cases. Asthma and recurrent lung infections can
occur in the postoperative recovery period.
Most infants without associated abnormalities survive with good long-term growth
and neuro-development.

REFERENCES:
Christison-Lagay ER, Kelleher CM, Langer JC. Neonatal abdominal wall defects. Semin Fetal
Neonatal Med. 2011 Jun;16(3):164-72
Poddar R, Hartley L. Exomphalos and gastroschisis. Continuing Education in Anaesthesia, Critical
Care and Pain. 2009; 9(2):48-51

Oxybuprocaine

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Review Date: Nov 2020
Page 1 of 1

Neonatal Protocol

Description and indication for use
Oxybuprocaine is a local anaesthetic eye drop used prior to Retinopathy of Prematurity (ROP)
screening and laser eye surgery in preterm neonates. Local anaesthesia occurs within one minute,
with the maximum response occurring between 1 to 15 minutes after instillation. Duration of effect
is 20 to 30 minutes.

Preparations
Eye drops 0.4%

Note: Eye drops are available as single use bottles and are stored in the refrigerator.

Dose
Prior to ophthalmologic examination of newborns
Eye drops: Instil 1 to 2 drops into each eye immediately prior to ROP screening or laser eye
surgery.

Route and Method of Administration
Intraocular: To be administered immediately prior to eye examination.

Side Effects
x Transient stinging after instillation

Nursing Responsibilities
x Drops are to be administered by ophthalmologist nurse assistants only.
x Eye drops are packaged in single use containers which are to be used for one patient on one
occasion only.

References
1. MIMSOnline. St Leonards, NSW: UBM Medica; 2013. Accessed: 20/08/2013.
2. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.

PANCURONIUM
Long acting non-depolarising
neuromuscular blocker
Preparations
INJ 2mg/mL

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Withdraw 1mg (0.5mL) and dilute to 1mL with WFI to give a
concentration of 1mg/mL.
Withdraw required dose. Administer into IV line and flush with NaCl
0.9%.

Dose
Use only following discussion with neonatologist.

Paralysis of respiratory muscles to improve pulmonary
compliance in patients with assisted ventilation
IV: 50 to 100microgram/kg/dose as required. Adjust dose according to
duration of muscle relaxation.

Antidote
Neostigmine 50microgram/kg/dose with atropine 20microgram/kg/dose.

Notes
Do not use in non-ventilated patients.
Side effects include tachycardia, hypertension and hypothermia.
A rise in CO2 and a drop in PaO2 may be seen with initial dose. May
increase peripheral oedema if used for longer than 24hours. Patients
may require lubricating eye drops.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Pancuronium.doc

PANCURONIUM

DESCRIPTION AND INDICATION FOR USE
Pancuronium is a long-acting, non-depolarising muscle relaxant. It blocks transmission of motor nerve
impulses to the striated muscle receptors causing muscle relaxation/paralysis.
The onset of action for pancuronium is 1 to 2 minutes
1
. Duration of action varies with dose and age
1
, but
is approximately 2 hours
6
.
Pancuronium is used for unstable babies in whom it is desirable that they are not breathing against the
ventilator.
Desirable effects of pancuronium in ventilated infants are: improved oxygenation, reduced barotrauma
and reduced fluctuations in cerebral blood flow.
1

DOSE
IV: 50 to 100 micrograms/kg. Repeat when necessary. Adjust dose according to duration of muscle
relaxation.
1
Antidote: Neostigmine 50 micrograms/kg with Atropine 20 micrograms/kg

RECONSTITUTION/DILUTION
Ampoule = 4mg in 2mL (2mg/mL)

IV: Withdraw 0.5mL of 2mg/mL solution and add to 0.5mL of water for Injection in a second 1mL
syringe = 1mg/mL.
Discard excess volume to obtain required dose or withdraw dose using another 1mL syringe.

ROUTE AND METHOD OF ADMINISTRATION
IV: Give STAT into IV line and flush with sodium chloride 0.9%

SIDE EFFECTS
Tachycardia
A rise in CO2 and drop in PaO2 may be seen with initial dose
Hypertension
Hypothermia
If used for more than 24 hours, may increase peripheral oedema

CONTRAINDICATIONS
Non-ventilated patients (unless for intubation)
CAUTION in patients with fluid and electrolyte imbalance
CAUTION in patients with encephalopathy - muscle relaxation may mask seizures, making
assessment difficult.

DRUG INTERACTIONS
Aminoglycosides (gentamicin, amikacin,
tobramycin) and vancomycin
May enhance the action of pancuronium
Frusemide, chlorothiazide May reduce effectiveness of pancuronium
Theophylline May reduce effectiveness of pancuronium
Phenytoin May reduce effectiveness of pancuronium

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Pancuronium.doc

NURSING RESPONSIBILITIES
With the initial dose apply PULSE OXIMETER
Continuous cardio/respiratory and SaO2 monitoring
Observe chest movement
Observe infant for signs of waking - notify doctor
Monitor urine output, express bladder if necessary
Ensure infant kept comfortable and administer analgesics and sedatives if necessary. Pancuronium
does not alter pain threshold.
May need artificial tears

Antidote: Neostigmine 50micrograms/kg and
Atropine 20micrograms/kg

COMPATIBILITY INFORMATION
3
Compatible Incompatible
Fluids Dextrose 5%, sodium chloride 0.9%
Drugs Phenobarbitone, diazepam,
frusemide
Y-Site Adrenaline, aminophylline, dobutamine, dopamine,
fentanyl, fluconazole, gentamicin, glyceryl trinitrate,
heparin, hydrocortisone, isoprenaline, midazolam,
morphine, ranitidine, sodium nitroprusside, vancomycin,
verapamil
TPN
1

References:

1. Neofax 12
th
Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 10
th
Ed, The Northern Neonatal Network. 1998
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
6. Pediatric Dosage Handbook, 6
th
Ed 1999-2000, Taketomo, Hodding and Kraus.

Paracetamol
(Acetaminophen)

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Please remember to read our disclaimer.

Effective Date: 26 Jul 2017
Review Date: Jul 2020
Page 1 of 2

Neonatal Protocol
Description and indication for use
Paracetamol is an analgesic and antipyretic agent which inhibits prostaglandin synthesis.
Paracetamol is well absorbed following oral administration, with onset of analgesic effect within 1
hour after oral administration.

Paracetamol has also been used for treatment of patent ductus arteriosus (PDA) in neonates
where treatment with a non-steroidal anti-inflammatory medicine (NSAID) has been unsuccessful
(usually after 2 courses of NSAID), or is contraindicated.

Preparations
Oral suspension 24mg/mL
Injection 10mg/mL

Dose
Analgesic, antipyretic
Oral, PR: 15mg/kg/dose

Interval
CA 28 to 32 weeks 12 hourly Maximum 30mg/kg/day
CA > 32 weeks 6-8 hourly Maximum 60mg/kg/day

Patent ductus arteriosus
Oral, IV: 15mg/kg/dose 6 hourly for 3 to 6 days

Echocardiographic evaluation should be performed on the 3
rd
day, if persisting PDA, treatment can
be extended to 6 days.

Reconstitution/Dilution
IV: May be administered undiluted.
If dilution is required, may be diluted to a final concentration of 1mg/mL

Route and Method of Administration
Oral: May be administered without regard to feeds.
PR: Use oral preparation rectally.
IV: Infuse over 15 minutes through a syringe infusion pump

Note: Oral administration is preferred to the rectal route as absorption after rectal administration is
erratic and delayed.

Side Effects
Side effects are rare, but may include:
x Elevated aminotransferases
x Rash
x Neutropenia, thrombocytopenia, pancytopenia
x Flushing, tachycardia, hypotension (with IV administration)

Paracetamol
(Acetaminophen)

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Effective Date: 26 Jul 2017
Review Date: Jul 2020
Page 2 of 2

Neonatal Protocol
Contraindications
x Caution in patients with hepatic impairment or active liver disease
x Caution in patients with G6PD deficiency

Drug Interactions
Phenytoin Induces hepatic metabolism of paracetamol, reducing
paracetamol levels and effect. The risk of hepatotoxicity is
increased. Monitor hepatic function during combined use.
Zidovudine Paracetamol may increase the myelosuppressive and
hepatotoxic effects of zidovudine. Monitor complete blood
count and hepatic function during combined use.

Nursing Responsibilities
x Monitor Premature Infant Pain Profile (PIPP) scores, if being used as an analgesic
x Monitor temperature if being used as an antipyretic
x Monitor for signs of adverse reaction

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 Heparin, hydrocortisone, midazolam,
morphine, vancomycin
Aciclovir

References
1. Hammerman C, Bin-Nun A, Markovitch E, Schimmel MS, Kaplan M, Fink D. Ductal Closure With
Paracetamol: A Surprising New Approach to Patent Ductus Arteriosus Treatment. Pediatrics 2011;128:
e1618-e1621.
2. Ozdemir OM, Doğan M, Küçüktaşçı K, Ergin H, Sahin O. Paracetamol Therapy for Patent Ductus
Arteriosus in Premature Infants: A Chance Before Surgical Ligation. Pediatr Cardiol 2014;35:276-279.
3. Terrin G, Conte F, Oncel MY, Scipione A, McNamara PJ, Simons S, et al. Paracetamol for the treatment
of patent ductus arteriosus in preterm neonates: a systematic review and meta-analysis. Arch Dis Child
Fetal Neonatal Ed 2016;101:F127-F136.
4. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 23
rd
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2016.
5. Australian Injectable Drugs Handbook 7
th
Edition (online). Society of Hospital Pharmacist of Australia.
Accessed: 18/07/2017.
6. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
7. BNF for children. London: BMJ Group; 2015-2016.
8. Lilley L, Legge D. Paediatric Injectable Guidelines. 5
th
Ed. The Royal Children’s Hospital; 2016.
9. Paracetamol. In: Micromedex [database on the Internet]. Accessed on 18/07/2017.

Phenobarbitone

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Effective Date: 31 December 2015
Review Date: December 2018
Page 1 of 3

Neonatal Protocol
Description and indication for use
Phenobarbitone is a long-acting barbiturate with sedative, hypnotic and anti-convulsant properties.
It is used in the management of seizures and neonatal abstinence syndrome. In neonates,
phenobarbitone is the first-line anticonvulsant, with a half-life ranging from 40 to 500 hours. The
half-life decreases with age and prolonged use (1-2 weeks) due to liver enzyme induction.

Preparations
Injection 200mg/mL
Mixture 10mg/mL (RWH)

Dose
Seizures
Loading dose
IV, IM: 20mg/kg/dose

May be repeated up to a maximum of 40mg/kg in total but may depress respiration such that
mechanical ventilation may be required.

Maintenance dose
IV, IM, Oral: 3 to 5mg/kg as a single daily dose

Commence maintenance dose 24 hours after loading dose.

Higher doses may be required depending on blood phenobarbitone levels.

Neonatal abstinence syndrome
Phenobarbitone may be indicated as an additional therapy where the symptoms of NAS are not
adequately suppressed by morphine treatment alone, particularly where there has been
concurrent use of opioid and non-opioid drugs in pregnancy.

Phenobarbitone should be used as the first line treatment if babies with signs of NAS reach
threshold for treatment, and:
- maternal drugs used are unknown
- maternal drugs used are non-opioid drugs
- the mother was intoxicated with alcohol or non-opioid drugs at the time of birth.

If used as a first line treatment, a loading dose is likely to achieve more rapid control of
symptoms

All scores Loading dose:
10-15mg/kg (birthweight) orally or parenterally if
not tolerating oral intake
Then (maintenance doses):
Average 8 or more for 3 consecutive scores 3mg/kg (birthweight)/dose 12-hourly
Average 11 or more for 2 consecutive scores
(consider higher dosage)
3-4 mg/kg (birthweight)/dose 12-hourly

Phenobarbitone

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Effective Date: 31 December 2015
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Page 2 of 3

Neonatal Protocol
Once NAS symptoms have been assessed as controlled (scores less than 8) for 48 hours, the
phenobarbitone dose should be reduced by 2mg per dose every 4th day or longer depending on
neonatal medical assessment of clinical condition until less than 1mg/kg/dose.

Refer to the Clinical Practice Guideline for Drug and Alcohol – Neonatal Abstinence Syndrome
(NAS):
http://intranet.thewomens.loc/pgp/Documents/Drug and Alcohol - Neonatal Abstinence Syndrome
(NAS).pdf

Reconstitution/Dilution
Ampoule = 200mg/mL

IV: Withdraw 1mL of 200mg/mL solution and add to 1mL of Water for Injection in a 2mL syringe
= 200mg in 2mL = 100mg/mL. Withdraw required dose.

IM: Use 200mg/mL solution undiluted.

Route and Method of Administration
IV injection: Administer at a maximum rate of 1mg/kg/minute.

Maximum IV push rate in an emergency is 2mg/kg/minute.

IM: Limit volume to 0.5mL at any one site. Solution is highly alkaline and may cause tissue
damage.

Note: IV or oral are the preferred routes of administration.

Side Effects
x Sedation
x Respiratory depression, apnoea
x Thrombophlebitis
x Tissue necrosis (with extravasation)
x Hypotension, bradycardia
x Hepatitis
x Rash

Note: injection contains propylene glycol and ethanol.
Rapid administration of medicines containing propylene glycol may cause respiratory depression
and cardiac dysrhythmias.

Contraindications
x CAUTION in patients with severe hepatic or renal impairment
x CAUTION in patients with hypotension or respiratory depression
x Term infants with asphyxia

Phenobarbitone

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Effective Date: 31 December 2015
Review Date: December 2018
Page 3 of 3

Neonatal Protocol
Drug Interactions

Dexamethasone, metronidazole,
paracetamol, phenytoin
Phenobarbitone induces liver enzyme production resulting in
increased metabolism and reduced serum levels of several
medicines.
Chloramphenicol May have its effectiveness reduced by phenobarbitone and
may reduce the effectiveness of phenobarbitone.
Rifampicin May reduce the effectiveness of phenobarbitone.

Nursing Responsibilities
x Observe IV site, avoid extravasation
x Observe and document seizure activity
x Cardio-respiratory monitor
x Levels to be taken when necessary. Timing of level sampling with respect to dose is not
necessary because of the long half-life. Therapeutic range is 60-180micromol/L (15-40mg/L).

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

References
1. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 10
th
Ed.
Bethesda, Maryland: American Society of Health-System Pharmacists; 2013.
2. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 20
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2013.
3. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 6
th
Ed. Melbourne: The Society of
Hospital Pharmacists of Australia; 2014.
4. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
5. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
6. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
7. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
8. Phenobarbitone. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 18/12/15
9. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
10. Australian Medicines Handbook 2015 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2015
January. Available from: http://amhonline.amh.net.au/
11. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 18/12/2015

Compatible Incompatible
Fluids Glucose 5%, glucose 10%, sodium
chloride 0.9%

Y-Site Aciclovir, amikacin, calcium, heparin,
meropenem
IVN starter, IVN maintenance, lipid 17%

Phenylephrine 2.5%

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
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Review Date: February 2018
Page 1 of 1

Neonatal Protocol

Description and indication for use
Phenylephrine eye drop is used together with cyclophentolate eye drop to induce mydriasis (pupil
dilation) prior to Retinopathy of Prematurity (ROP) screening and laser eye surgery in preterm
neonates. The maximum effect is achieved 30 to 60 minutes after instillation.

Preparations
Eye drops Phenylephrine 2.5%

Note: Eye drops are stored in the refrigerator and for single use only.

Dose
Prior to ophthalmologic examination or laser eye surgery
Eye drops: Instil 2 drops into each eye, 30 to 40 minutes prior to ROP screening or laser eye
surgery.

Route and Method of Administration
Intraocular: To be administered 30 to 40 minutes prior to procedure, unless the nurse performing
the eye check indicates the time that the eye drops are to be instilled.

Excessive systemic absorption can be avoided with finger pressure to the lachrymal sac for 1-2
minutes following application.

Refer to Appendix A for the recommended method of administration.

Side Effects
x May cause transient whitening of the eyelid and, if overflow, of the cheeks also secondary to
local vasoconstriction.
x Transient stinging after instillation
x Hypertension
x Tachycardia

Nursing Responsibilities
x Eye drops are packaged in single use units which are to be used for one patient on one
occasion only.

References
1. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 03/02/2015.
2. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 20
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2013.
4. New Services Clinical Guideline, Aucland Distribution Health Board.
http://www.adhb.govt.nz/newborn/Guidelines/Developmental/ROP.htm#Examination accessed on
03/02/2015.
5. Neofax 23
rd
Ed. 2010, A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.

PHENYTOIN
Anticonvulsant
Preparations
INJ 50mg/mL
MIXT 30mg/5mL

IV preparation and compatibilities
Compatible with NaCl 0.9% only when concentration is less than 6mg/mL.
Dilute with NaCl 0.9% to give a concentration of 5mg/mL. Withdraw required dose
and give no faster than 1mg/kg/minute.
Diluted solution must be used within 1 hour of preparation.

Dose
Treatment of seizures not controlled by phenobarbitone
Loading dose
IV: 15 to 20mg/kg/dose

Maintenance dose (commence 12 hours after loading dose)
IV, ORAL:
CA < 37 weeks ≤ 14 days 2mg/kg/dose 12hrly
> 14 days 5mg/kg/dose 12hrly

CA ≥37 weeks ≤ 14 days 4mg/kg/dose 12hrly
> 14 days 5mg/kg/dose 8hrly

Notes
Do not administer to patients on dopamine.
Rapid IV injection may cause hypotension, arrhythmias, bradycardia,
cardiovascular collapse and respiratory depression.
Caution in patients with hepatic impairment.
Many drug interactions.
Therapeutic range 40 to 80micromol/L. Sample should be taken immediately before
next dose. Approximate time to steady state is 7 days. Unpredictable
pharmacokinetics, a small increase in dose can have disproportionate increase in
effect. Dose may need to be increased after the 3
rd week of life. Oral route is not
recommended in newborns as absorption is unreliable and may require very high
doses.

RWH Neonatal Intensive and Special Care Nurseries
Phenytoin IV Protocol

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 is highly protein bound.
It is used as an anticonvulsant in the treatment of neonatal seizures unresponsive to phenobarbitone.

DOSE
Treatment of seizures not controlled by phenobarbitone

Loading dose IV: 15 to 20mg/kg/dose

Maintenance dose: IV, ORAL:
CA <37 weeks ≤14 days 2mg/kg/dose 12hrly
>14 days 5mg/kg/dose 12hrly
CA ≥37 weeks ≤14 days 4mg/kg/dose 12hrly
>14 days 5mg/kg/dose 8hrly

Commence maintenance dose12 hours after loading dose

RECONSTITUTION/DILUTION
Ampoule = 100mg/2mL (50mg/mL)

IV: Dilute to at least 5mg/mL: Withdraw 1mL of 50mg/mL solution and add to 9.0mL of sodium chloride 0.9%
in a 10mL syringe = 50mg in 10mL = 5mg/mL. Withdraw required dose. If dose is greater than 50mg, use double
quantities.

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

ROUTE AND METHOD OF ADMINISTRATION
IM administration is not recommended due to pain and possible tissue necrosis. Absorption is erratic and
delayed.

IV: Give slowly, at no greater than 1mg/kg/minute.

IV Loading doses: Give slowly over 1 hour via syringe pump using Guardrails.
IV Maintenance doses: Given over at least 15 minutes via syringe pump using Guardrails.

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
Guardrails
1. Select the correct medicine to be infused
2. Concentration shown 5mg/mL – No change required
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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
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:
x Hit ‘?’ and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe the press ‘OK’
x Enter duration then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If 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 times the mg/kg/h of ACTUAL dose.
Flush the line Draw up 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Phenytoin IV Protocol

SIDE EFFECTS
x Rapid IV infusion may cause hypotension, arrythmias, bradycardia, cardiovascular collapse and/or respiratory distress
x Vomiting, gastric irritation
x Thrombocytopenia, leukopenia, granulocytosis
x Macrocytosis and megaloblastic anaemia which respond to folic acid therapy
x Toxicity will cause cardiovascular collapse, CNS depression or restlessness
x Nystagmus
x Tissue necrosis and inflammation at injection site
x Skin rash * drug should be discontinued
x Hypoinsulinaemia, hyperglycaemia, glycosuria
x Long term use: Gum hypertrophy, hirsuitism, facial coarsening
CONTRAINDICATIONS
x Heartblock, sinus bradycardia
x Hypoglycaemic seizures
x CAUTION in patients with hyperbilirubinaemia or jaundice
x CAUTION in patients with renal or hepatic impairment
DRUG INTERACTIONS
Dopamine Combination may result in profound hypotension, bradycardia and possibly cardiac arrest If
used together, monitor blood pressure and use with EXTREME CAUTION.
Folic acid, Pyridoxine,
Rifampicin & Chloral Hydrate
May decrease serum phenytoin levels therefore possible loss of effectiveness
Phenobarbitone Levels may be increased when given concurrently with phenytoin monitor serum levels of both
drugs
Theophylline Levels are reduced by phenytoin with possible loss of effectiveness of both drugs
Pancuronium Duration of action of pancuronium 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 levels of digoxin.
Paracetamol High levels of hepatotoxic metabolites may be produced when used in combination.
Amiodarone May increase serum levels of phenytoin, with phenytoin possibly reducing the effectiveness of
Amiodarone.
NURSING RESPONSIBILITIES
x Monitor infant with cardio-respiratory monitor (cardiac rate and rhythm)
x Observe for arrythmias during administration
x Record and report effect of drug on seizure activity
x Observe infant for signs of toxicity and side effects.
x Monitor infant's blood pressure
x Observe IV site for phlebitis or tissue inflammation.
x Ensure that phenytoin serum levels are monitored. Approx. time to steady state: 7days.
* Sample should be taken immediately before the next dose.
* Therapeutic range : 40 to 80 micromol/L
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below. Uncommon drugs have
simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Sodium chloride 0.9% (Phenytoin
concentration must be less than 6mg/mL)
Glucose 5%, glucose 10%, PN, Intralipid
Drugs Not recommended Amikacin, aminophylline, benzylpenicillin, ciprofloxacin,
dobutamine, heparin, insulin, morphine, noradrenaline,
potassium, vancomycin
Y-Site Fluconazole
Notes: Administration of phenytoin with other drugs is not recommended due to the risk of
precipitation and many incompatibilities
References:
1. Neofax 16th Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2nd Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
3. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 4th Ed, The Northern Neonatal Network. 2003
5. Manual of Neonatal Care 4th Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998

Phosphate

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
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Effective Date: 13 Jul 2017
Review Date: Jul 2020
Page 1 of 3

Neonatal Protocol
Description and indication for use
Phosphate deficiency may occur in extremely low birthweight infants (<1000g) and extremely
preterm infants (<28 weeks gestation), and may compromise bone development if not corrected.
Phosphate supplementation is used in the management of metabolic bone disease of prematurity,
and for the treatment of hypophosphatemia.
Occasionally growth restricted preterm infants may require IV phosphate in addition to IVN
solutions; this should be done in consultation with neonatal consultant.

Preparations
Oral solution 1mmol/mL (as sodium dihydrogen phosphate: 1mmol/mL sodium, 1mmol/mL
phosphate)
Injection 1mmol/mL (as sodium dihydrogen phosphate: 1mmol/mL sodium, 1mmol/mL
phosphate)

Dose
Metabolic bone disease of prematurity
Oral: 2mmol/kg/day in 2 divided doses

Dose is not adjusted for weight, unless phosphate level is <1.8 mmol/L or ALP > 600 IU/L

Hypophosphataemia - Acute
IV infusion: 1 mmol/kg/dose, repeat dose as required

Hypophosphataemia - 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 failure.

Reconstitution/Dilution
Always dilute before intravenous administration.

IV infusion: Make up the required dose of sodium dihydrogen phosphate in a compatible fluid and
dilute according to the table below.

CONCENTRATION HOW TO DILUTE
FINAL
CONCENTRATION
RATE

Sodium dihydrogen
phosphate
PERIPHERAL

0.5 mmol/kg dilute to 10 mL/kg

50 mmol/L
Infuse over 8 - 24
hours

Maximum rate of
0.2mmol/kg/hour
1 mmol/kg dilute to 20 mL/kg
1.5 mmol/kg dilute to 30 mL/kg
Sodium dihydrogen
phosphate
CENTRAL

0.5 mmol/kg dilute to 5 mL/kg

100 mmol/L
1 mmol/kg dilute to 10 mL/kg
1.5 mmol/kg dilute to 15 mL/kg

Phosphate

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Neonatal Protocol
Route and Method of Administration
Oral: Give with feeds

IM, SC, IV injection: Not recommended

IV infusion:
x Infuse over at least 8 – 24 hours through a syringe infusion pump, maximum rate of
0.2mmol/kg/hour
x Never push the flush following sodium dihydrogen phosphate infusion. Flush at the
same rate as the infusion was given.
Side Effects
x Extravasation can cause severe tissue necrosis
x Oral phosphate may cause loose stools

Contraindications
x Caution in patients with renal impairment; renal excretion of phosphate is reduced, and dose
reduction may be required.

Drug Interactions

Calcium Calcium and phosphate bind together, reducing absorption of
both minerals. Administer oral calcium and oral phosphate
supplements at least 2 hours apart.

Nursing Responsibilities
x Monitor ALP, calcium and phosphate levels as per the Metabolic Bone Disease of Prematurity
guideline or as otherwise indicated by medical staff
x Monitor sodium (oral solution and intravenous injection contain sodium)
x Monitor renal function
x Administer oral phosphate at least 2 hours apart from oral calcium
x IV phosphate must be given in a separate line to IVN solutions

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

Compatibility information is for sodium dihydrogen phosphate.

Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9%
Y-Site Aciclovir, amiodarone, calcium,
ciprofloxacin, magnesium, IVN Starter,
IVN Maintenance, any other calcium- or
magnesium-containing solutions

Phosphate

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
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Review Date: Jul 2020
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Neonatal Protocol
References
1. Australian Injectable Drugs Handbook, 6
th
Edition (online) Victoria.
Available from: http://aidh.hcn.com.au/browse/about_aidh Accessed: 25/05/2017
2. Lilley L, Legge D. Paediatric Injectable Guidelines. 5
th
ed. Flemington, Vic: The Royal Children’s Hospital;
2016.
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 23
rd
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2016.
4. Ryan RSM, editor. BNF for children. London: BMJ Group; 2015.
5. Potassium phosphate. In: Micromedex [database on the Internet]. Ann Arbor (MI): Truven Health
Analytics; publication year [cited 25 May 2017]. Accessed on 16/06/2017.
6. Phelps S, Hagemann TM, Lee KR, Thompson AJ. Pediatric Injectable Drugs. 10
th
Edition. American
Society of Health-System Pharmacists. 2013

RWH Neonatal Intensive and Special Care Nurseries
Piperacillin-Tazobactam IV Protocol

PIPERACILLIN -TAZOBACTAM
(Tazocin
?
or Tazopip
?
)
DESCRIPTION AND INDICATION FOR USE
Piperacillin is a semisynthetic 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 effective against many Gram+ve
and Gram-ve aerobic and anaerobic bacteria.
DOSE
Use only following discussion with neonatologist and/or in consultation with clinical
microbiologist
Dose ordered according to piperacillin content.
IV: 50mg/kg/dose

Interval
Age ≤ 7 days: 12 hourly
Age > 7 days: 6 to 8 hourly

Dose may be increased to 75mg/kg/dose according to severity of infection and renal function.
RECONSTITUTION/DILUTION
Vial = 4g/500mg (piperacillin 4g and tazobactam 500mg)

IV: Add 16.8mL of water for injection or sodium chloride 0.9% to the 4g vial = 4g in 20mL =
200mg/mL
1

Withdraw 1mL of 200mg/mL solution from vial and add to 9mL of sodium chloride 0.9% =
200mg in 10mL = 20mg/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 (Volume = 1mL) prime line with preloaded
syringe containing exact dose of pipperacillin-tazobactam.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration’ 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same
as in syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x 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 10mL syringe and infuse at the same
infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Piperacillin-Tazobactam IV Protocol

SIDE EFFECTS
x Thrombophlebitis
x GI tract upset, diarrhoea
x Transient increases in liver enzymes
x Hyperbilirubinaemia
x Transient leukopenia, neutropenia, thrombocytopenia (and/or eosinophilia)

CONTRAINDICATIONS
x Known hypersensitivity to penicillins
x CAUTION in patients with significant renal impairment

DRUG INTERACTIONS
Pancuronium Prolongation of neuromuscular blockade
NURSING RESPONSIBILITIES
x Assess IV site carefully
x Observe urine output
x Urine test - may give false positive for glucose
x Tazopip® contains 2.35mmol per gram of piperacillin; Tazocin® contains 2.79mmol of
sodium per gram of piperacillin2
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9% Albumin and blood products, alkaline solutions
Drugs Aciclovir, amikacin, amphotericin B, dobutamine,
ganciclovir, gentamicin, sodium bicarbonate
2
,
vancomycin

Y-Site Calcium gluconate, dexamethasone,
dopamine, fluconazole, frusemide, heparin,
hydrocortisone, magnesium sulphate,
metronidazole, milrinone, morphine,
potassium chloride, ranitidine, zidovudine,
PG, lipid
4

References:
1. Burridge N (Ed) 2008 Australian Injectable Drugs Handbook, 4
th
Ed., Melbourne: The Society of Hospital Pharmacists of
Australia.
2. CMPmedica. MIMSOnline. CMPmedica; Sydney, Australia, 2010 accessed 14/12/10.
3. Trissell LA, 2009, Handbook on Injectable drugs, 15
th
Ed, Bethesda, American Society of Health-System Pharmacists
4. Young T, Mangum B, 2008, Neofax 2008, 21
st
Ed, New Jersey: Thomson Reuters.
5. Fary R, Smith R, Davis P (Ed), and Jacobs S (Ed), 2005, Neonatal Pharmacopoeia, 2
nd
Ed, Melbourne: Pharmacy
Department The Royal Women's Hospital.
6. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5
th
Ed, Massachusetts: Blackwell Publishing Inc,
2007.
7. Cloherty J.P, Eichenwald E.C, Stark A.R. 2008, Manual of Neonatal Care, 6
th
Ed., Philadelphia: Lippincott Williams &
Wilkins
8. BNF for children, London: BMJ Publishing Group Ltd, 2005.
9. Kemp C.A and McDowell J.M (Eds), 2002, Paediatric Pharmacopoeia, 13
th
Ed, Melbourne: Pharmacy Department, Royal
Childrens Hospital.

Potassium Chloride

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
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Reviewed by: NISC pharmacists, NISC educators, Marta ThioLluch
Authorised by: Carl Kuschel
Effective Date: 12 August 2013
Review Date: August 2016
Page 1 of 3

Neonatal Protocol
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 impulses; cardiac, skeletal and smooth muscle contraction; and
maintenance of normal renal function. Potassium chloride is used in the treatment of
hypokalaemia. Symptoms of hypokalaemia in the newborn include: arrhythmias; ECG changes;
metabolic alkalosis; hypoventilation; paralysis; paralytic ileus and urinary retention.

Preparations
Injection 10mmol (0.75g) in 10mL (1mmol potassium/mL)
Mixture 1mmol/mL (RWH)

Dose
Acute depletion (hypokalaemia)

IV: 0.6mmol/kg over 3 hours or 0.6mmol/kg over 1 hour with ECG monitoring, then 2mmol/kg/day
to 6mmol/kg/day as a maintenance infusion

Usual daily requirements

IV: 2 to 6mmol/kg/day as a maintenance infusion
Oral: 2 to 3mmol/kg/day in 2-4 divided doses given with or after feeds

Reconstitution/Dilution
Always dilute before administration. An overdose can be rapidly fatal.

IV infusion for acute depletion MUST be diluted strictly according to protocol and given via
Guardrails.

ECG monitoring is required when concentrated potassium infusions (>60mmol/L) are
administered and/or when potassium is administered at a rate >0.5mmol/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 0.6mmol/kg in glucose 10% diluted according to the table below.
Mix solution thoroughly after dilution to prevent pooling of potassium chloride. In critical
hypokalaemic states, sodium chloride 0.9% may be preferred over glucose 10% as an infusion
fluid to prevent insulin-mediated movement of potassium into cells.

CONCENTRATION HOW TO DILUTE FINAL CONCENTRATION RATE
Potassium Chloride
PERIPHERAL
0.6 mmol/kg
dilute to 15 mL/kg

40mmol/L Infuse final volume over
3 hours (0.2mmol/kg/hr)
OR over 1 hour
(0.6mmol/kg/hr) only if
necessary

Potassium Chloride
CENTRAL
0.6 mmol/kg
dilute to 10 mL/kg

60mmol/L

Potassium Chloride

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
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Reviewed by: NISC pharmacists, NISC educators, Marta ThioLluch
Authorised by: Carl Kuschel
Effective Date: 12 August 2013
Review Date: August 2016
Page 2 of 3

Neonatal Protocol
For fluid restricted babies only:

CONCENTRATION HOW TO DILUTE FINAL CONCENTRATION RATE
Potassium Chloride
PERIPHERAL

0.6 mmol/kg
dilute to 10 mL/kg
60mmol/L
Infuse final volume over
3 hours (0.2mmol/kg/hr)
OR over 1 hour
(0.6mmol/kg/hr) only if
necessary
Potassium Chloride
CENTRAL

0.6 mmol/kg
dilute to 4 mL/kg
150mmol/L

Maximum concentration of final solution for peripheral infusion: 60mmol/L
Maximum concentration of final solution for central line infusion: 150mmol/L

Route and Method of Administration
Oral: Give with or after feeds.

IM, SC: Not recommended

IV bolus: Contraindicated (must be diluted prior to administration)

IV infusion:
Administer infusions through a syringe infusion pump (Guardrails) – 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
Arrhythmias and ECG abnormalities including heart block and cardiac arrest
Hypotension if infused too rapidly
Thrombophlebitis if inadequately diluted
Vomiting and diarrhoea may occur with oral doses

Contraindications
Hyperkalaemia
Undiluted solution administered intravenously
Concomitant potassium infusions
Caution in patients with severe renal impairment or oliguria

Drug Interactions
Frusemide,
hydrochlorothiazide
Reduce potassium levels by renal potassium loss
Insulin Reduces potassium levels by causing movement of potassium into cells
Spironolactone Additive effect resulting in increased serum levels of potassium

Potassium Chloride

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
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Reviewed by: NISC pharmacists, NISC educators, Marta ThioLluch
Authorised by: Carl Kuschel
Effective Date: 12 August 2013
Review Date: August 2016
Page 3 of 3

Neonatal Protocol
Nursing Responsibilities
Monitor potassium level when giving diuretics simultaneously
Assess urine output
Carefully observe for extravasation
Mix solution thoroughly after dilution to prevent pooling of potassium chloride
Monitor potassium levels 1 hour after the infusion
Monitor ECG as requested by medical staff
o ECG changes include ST segment depression/elevation, low voltage or peaked T
waves, appearance of U wave, heart block with widening QRS complex, arrhythmia and
cardiac arrest
5,8,11,12

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

Compatible Incompatible
Fluids Glucose 5%, glucose 10%, glucose 20%,
sodium chloride 0.9%
Lipid emulsion 17%
Drugs

Amoxycillin, amphotericin B, diazepam,
erythromycin, phenytoin, suxamethonium
Y-Site Aciclovir, adrenaline aminophylline,
benzylpenicillin, cefotaxime, digoxin,
dobutamine (6.25mg/mL or weaker),
dopamine, fluconazole, frusemide,
heparin sodium, hydrocortisone sodium
succinate, magnesium sulphate,
morphine sulphate, sodium bicarbonate,
vancomycin, PG1, PG2

References
1. Trissell LA. Handbook on Injectable drugs. 15
th
Ed. Bethesda, Maryland: American Society of Health-System
Pharmacists; 2009.
2. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 9
th
Ed. Bethesda, Maryland:
American Society of Health-System Pharmacists; 2010.
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 17
th
Ed. Hudson, Ohio: American Pharmacists
Association. Lexicomp; 2010.
4. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital 2011
5. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
6. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 5
th
Ed. Melbourne: The Society of Hospital
Pharmacists of Australia; 2011.
7. Fary R, Smith R, Davis P, Jacobs S, editors. Neonatal Pharmacopoeia. 2
nd
Ed. Melbourne: Pharmacy Department,
The Royal Women’s Hospital; 2005.
8. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton, Victoria:
Blackwell Publishing Asia Pty Ltd; 2007.
9. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
10. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department, Royal
Children’s Hospital; 2002.
11. Zenk KE, Sills JH, Koeppel RM. Neonatal Medications & Nutrition: A Comprehensive Guide. 3
rd
Ed. Santa Rosa,
California: NICU Ink; 2003.
12. Newborn Services Drug Protocol: Potassium Chloride. Auckland District Health Board.
Available at: http://www.adhb.govt.nz/newborn/drugprotocols/KClPharmacology.htm
Accessed: 17/07/2013.

Probiotics
(Labinic)

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Effective Date: 23 January 2017
Review Date: January 2020
Page 1 of 3

Neonatal Protocol
Description and indication for use
Probiotics are live microorganisms that, when administered in adequate numbers, confer health
benefits. Probiotic effects are dose-, condition- and strain-specific.

A variety of different probiotic strains and combinations administered 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-cause mortality in preterm
babies. Probiotics 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 ProPrems trial of 1099 very preterm babies born less than 32 weeks below 1500g
showed a 54% reduction in NEC ≥ Bell stage 2, the formulation used in ProPrems is not currently
available. Therefore, RWH NISC will use Labinic containing pure live strains of Lactobacillus
acidophilus, Bifidobacterium bifidum and Bifidobacterium infantis.

Preparations
Labinic Oral Drop 4 drops (0.16mL) contains, on average:
Lactobacillus acidophilus 0.5 x 10
9
organisms;
Bifidobacterium bifidum 0.5 x 10
9
organisms; and
Bifidobacterium infantis 0.5 x 10
9
organisms

Dose
In preterm babies born <32 weeks’ gestation AND weighing <1500g, commence when:
x Tolerating ≥ 1mL of enteral milk 4 hourly for 12-24 hours, AND
x Verbal parental consent has been obtained and documented in the baby’s clinical notes
(see Appendix A), AND
x TGA SAS category A form has been completed (Appendix B), AND
x Ordered on neonatal medicines chart

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

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

Withhold dose when nil orally.

See ‘TGA considerations and parental consent’ 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.

Probiotics
(Labinic)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 23 January 2017
Review Date: January 2020
Page 2 of 3

Neonatal Protocol
Side Effects
x Abdominal distension
x Vomiting
x Diarrhoea
x Sepsis with probiotic organisms (potential, but not reported)
x Hypersensitivity

Contraindications
x Nil orally
x No documented verbal parental consent
x Do not mix with feed thickener
x Hypersensitivity to components of the product

Drug interactions
Antibiotics Concurrent administration of antibiotics could kill a large
number of probiotics organisms, reducing the efficacy of the
Lactobacillus and Bifidobacterium species. Administration of
antibiotics should be separated by at least 2 hours.

Nursing Responsibilities
x If baby possets or vomits, do not redose
x Do not administer within 2 hours of antibiotics
x If aspirate contains blood or bile, follow usual feeding guidelines
x If nil orally, or feed is withheld, omit dose(s)
x May be mixed with breast milk fortifier and artificial infant formula
x Give dose according to medicines chart, maximum of 6 drops per dose can be administered

Storage
x Kept at room temperature
x Discard contents 30 days after opening (document date of opening on each bottle)
TGA considerations and parental consent
x Labinic is not currently listed on the Therapeutics Goods Administration’s (TGA) Australian
Register of Therapeutic Goods.
x Under the TGA Authorised Prescriber Scheme, which has been endorsed by the RWH Human
Research and Ethics Committees, the neonatal consultants have been authorised by TGA to
prescribe Labinic.
x Therefore, to prescribe Labinic:
o Provide the ‘parent information’ sheet (Appendix A) and verbal information to the
parent(s)/guardian(s)
o Obtain verbal parental consent, and document in the baby’s clinical notes
o Complete the TGA SAS Category A form (Appendix B), leave copy in pharmacy tray in
central work room and place the original form in the baby’s clinical notes.

Probiotics
(Labinic)

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Please remember to read our disclaimer.

Effective Date: 23 January 2017
Review Date: January 2020
Page 3 of 3

Neonatal Protocol
Transfer to Level 2 SCN
x If a neonate is to be transferred to a level 2 special care nursery prior to 34 weeks CA and
cessation of Labinic, discuss continuation of the probiotic at the receiving SCN with the
NISC Team consultant and then receiving paediatrician.
x 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 of the signed TGA Category SAS A form
Safety
Safety will be monitored by:
x Blood culture positive sepsis by the probiotic bacteria
x Side effects or intolerance that lead to cessation of administration of Labinic
Taxonomy of the probiotic preparation Labinic will be confirmed with species-specific PCR and
purity by standard microbiological culture techniques for each new batch of Labinic.

References
1. Deshpande G, Rao S, Patole 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. Cochrane 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 updated 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 onset 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 ProPrems 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 study (POPstudy). 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, NPCIU June 2013
12. Probiotics, Infloran, Newborn Services Drug Protocol, Auckland District Health Board,
http://www.adhb.govt.nz/newborn/drugprotocols/probiotics.htm. July 2012.
13. Labinic Paediatric Drop product information Sept 2016
14. NHS Labinic probiotic information pack Oct 2016

PROPYLTHIOURACIL

Anti thyroid agent

Preparations
TAB 50mg

Dose
Use only after discussion with
paediatric endocrinologist.

Neonatal thyrotoxicosis
ORAL: 5mg/kg/dose 12hrly.

PROTAMINE
Heparin antagonist
Preparations
INJ 10mg/mL

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
No dilution required. Give over 10mins.

Dose
Treatment of heparin overdose
If <1hour since heparin dose
IV STAT: 1mg/100units heparin

If >1hour since heparin dose
IV STAT: 0.5mg/100units heparin

Subsequent doses 1mg/kg (max 50mg).

Notes
Check APTT 15mins post dose.
Hypotension, bradycardia and flushing may occur with rapid IV
injection.
Protamine has an anticoagulant effect at high doses.
Protamine 1mg also neutralises the anti thrombin activity of
100units of enoxaparin, and may partially neutralise the anti-
Xa factor effect.

Pyridoxine
(Vitamin B6)

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Effective Date: 30 Jun 2017
Review Date: Jun 2020
Page 1 of 2

Neonatal Protocol
Description and indication for use
Pyridoxine (Vitamin B6) is used in the diagnosis and treatment of pyridoxine-dependent seizures.
A single dose of 100mg can stop most pyridoxine-dependent clinical seizures within minutes.
A corresponding change in the EEG should also occur but may be delayed by several hours.

Preparations
Injection 100mg/2mL = 50 mg/mL (SAS)
Mixture 50 mg/mL (RWH)

Dose
IV: 100 mg as a test dose. The dose may be repeated if necessary.

Maintenance dose is given orally if a definite response is seen.

Oral: 50 mg to 100 mg once daily.

Reconstitution/Dilution
IV: No dilution required.

Route and Method of Administration
IV: Give slowly over 5 minutes.

Side Effects
x Irritation at administration site
x Irritability
x Sedation, hypotonia and apnoea
x Hypersensitivity and anaphylactic reactions may occur especially if very large doses are
administered intravenously. Resuscitation facilities must be available and monitor closely

Contraindications
x CAUTION in patients with encephalopathy – muscle relaxation may mask seizures, making
assessment difficult.

Drug Interactions

Phenobarbitone, phenytoin Serum levels may be reduced by pyridoxine, if large doses are
used. Monitor levels and adjust dose if necessary.

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

Pyridoxine
(Vitamin B6)

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Please remember to read our disclaimer.

Effective Date: 30 Jun 2017
Review Date: Jun 2020
Page 2 of 2

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

Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9%
Y-Site Adrenaline, amikacin, benzylpenicillin,
calcium gluconate, cefotaxime,
ceftazidime, dexamethasone, digoxin,
dobutamine, dopamine, erythromycin,
heparin, insulin, magnesium sulphate,
midazolam, morphine, ranitidine, sodium
bicarbonate, vancomycin
Phenobarbitone, phenytoin, furosemide,
ganciclovir, indomethacin

References
1. Young T, Mangum B. Neofax 2010. 23
rd
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. 17
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2016.
4. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
5. Stockley’s Drug Interactions on Medicines Complete [online via Clinician’s Health Channel]. Accessed on
30/06/2017.
6. Paediatric Injectable Guidelines. 5
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
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
Antibiotic
Preparations
TAB 25mg
SUSP 2mg/mL (RWH)

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

Treatment of toxoplasma infection
ORAL: 2mg/kg/DAY for 2 days then 1mg/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 megoblastic
anaemia. Folinic acid (5 to 10mg) should be given
three times per week (M,W,F) during treatment.

RWH Neonatal Intensive and Special Care Nurseries
Ranitidine IV Protocol

RANITIDINE
DESCRIPTION AND INDICATION FOR USE
Ranitidine hydrochloride is a histamine H2-receptor antagonist, and is a potent inhibitor of
gastric acid secretion. It is used to reduce gastric acid and prevent ulceration when there is
evidence of gastric bleeding or hyperacidity.

DOSE
IV: 1mg/kg/dose every 6 to 8 hours.
ORAL: 2 to 4mg/kg/dose every 8 to 12 hours.

RECONSTITUTION/DILUTION
Ampoule = 50mg in 5mL (10mg/mL)

IV: Withdraw 0.5mL of 10mg/mL solution and add to 4.5mL of sodium chloride 0.9% in 5mL
syringe = 1mg/mL. Discard excess volume until required dose is obtained or withdraw dose
using another syringe.

In fluid restricted patients: the maximum recommended concentration = 2mg/mL:
Withdraw 0.5mL of 10mg/mL solution and add to 2mL in a 5mL syringe = 5mg in 2.5mL =
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 is exceeded.
IV infusion: Give slowly over 15 minutes via syringe pump using Guardrails.

Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 15 minutes:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same
as in syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x 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 1.5mL of sodium chloride 0.9% in a 10mL syringe and infuse at the same
infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Ranitidine IV Protocol

SIDE EFFECTS
x Bradycardia
x Irritability
x Rash
x GI upset (eg. Constipation/diarrhoea, nausea/vomiting)
x Elevated hepatic enzymes, hepatitis (rare)
x Tachycardia, premature ventricular beats, AV block (rare)
x Thrombocytopenia (rare)

CONTRAINDICATIONS
x CAUTION – Elimination of ranitidine is prolonged in patients with renal impairment
- Bioavailability of ranitidine may be increased in patients with hepatic
impairment

DRUG INTERACTIONS
Phenytoin Slight chance that ranitidine may increase phenytoin levels
Ferrous sulphate Oral absorption of iron may be reduced due to increased gastric pH. Separate
oral doses by at least 1 hour.
Pancuronium, Vecuronium May be less effective when used with ranitidine.

NURSING RESPONSIBILITIES
x Monitor for adverse reactions
x Liver and renal function tests may be required
x May cause false positive urine tests for protein
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 chloride 0.9% No information
Drugs Adrenaline, amikacin, benzylpenicillin, dexamethasone, digoxin,
dobutamine, dopamine, erythromycin, flucloxacillin, frusemide,
gentamicin, heparin, meropenem, potassium, tobramycin,
vancomycin
Amphotericin B,
phenobarbitone, phenytoin

Y-Site Aciclovir, ceftazidime, fentanyl, fluconazole, glyceryl trinitrate,
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 2
nd
Ed. 2005, Melbourne: Pharmacy Department, The Royal Women's Hospital,
3. Australian Injectable Drugs Handbook, 4
th
Ed.(2008), Collingwood: The Society of Hospital Pharmacists of Australia,
4. The Northern Neonatal Network (2007) Neonatal Formulary 5
th
Ed, Oxford: Blackwell Publishing
5. Neonatology 4
th
edition, T.L.Gomella, Lange Medical Books, 1999
6. MIMS Online, last modified September 2007
7. Trissel L. (2009) Handbook on Injectable Drugs.15
th
Ed. Bethesda: ASHP

RWH Neonatal Intensive and Special Care Nurseries
Resonium A.doc

SODIUM POLYSTYRENE SULPHONATE
(RESONIUM A
?
)

DESCRIPTION AND INDICATION FOR USE
Sodium polystyrene sulphonate is a cation exchange resin used in the treatment of non-life threatening
hyperkalaemia. It has an in vitro exchange capacity of 3.1mmol of potassium per gram of resin. In vivo, this is
actually closer to 1mmol of potassium bound per gram of resin.
Sodium polystyrene sulphonate removes potassium from the body by exchanging it within the large intestine
for sodium. The efficiency of potassium exchange is unpredictable and variable.

DOSE
Non life-threatening hyperkalaemia
PR: 250mg/kg/dose 6hrly
Maximum doses of 1g/kg/dose have been used
Adjust dose according to serum electrolyte results.

RECONSTITUTION/DILUTION
PR: Add 3 to 4mL of WFI or glucose 5 or 10% per gram of resin to make a suspension

ROUTE AND METHOD OF ADMINISTRATION
PR: Insert dose into rectum. Colon should be irrigated between doses to prevent impaction of the resin.

SIDE EFFECTS
x Hypokalaemia, hypocalcaemia, hypernatraemia
x Constipation, nausea
x Faecal impaction after rectal administration

CONTRAINDICATIONS
x Serum potassium levels less than 5mmol/L
x Obstructive bowel disease
x 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 hydroxide
When used with cation exchange resins, intestinal obstruction due to concretions may occur

NURSING RESPONSIBILITIES
x Monitor potassium serum levels at least once daily
x Monitor sodium, calcium and magnesium levels daily
x Continuously monitor heart rate and rhythm
x Discontinue if constipation occurs - contact medical staff

Notes:
x Effective lowering of serum potassium with Resonium A may take hours to days.
x When hyperkalaemia is life-threatening, insulin and glucose IV and/or sodium bicarbonate IV should be
considered.

References:
1. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
2. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network. 2003

RIFAMPICIN
Antibiotic
Preparations
INJ 600mg
MIXT 100mg/5mL

IV preparation and compatibilities
Compatible with G5%, NaCl 0.9%.
Reconstitute vial with G5% and further dilute to a concentration of 1mg/mL.
Withdraw dose and infuse via infusion pump over 1 hour.

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

For serious infections where sensitivities are known
IV, ORAL: 10mg/kg/dose 24hrly

Neisseria meningitidis prophylaxis
ORAL: 5mg/kg/dose 12hrly for 4 doses.

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

Notes
Oral doses should be given on an empty stomach.
Induces liver enzymes therefore many drug interactions. May reduce
serum levels of theophylline, digoxin, dexamethasone, phenytoin,
diazepam and fluconazole. Monitor levels of concomitant drugs if
necessary.
Brownish-red discolouration of bodily fluids, including tears, sweat, urine,
faeces and saliva, may occur.

RWH Neonatal Intensive and Special Care Nurseries
Rifampicin IV Protocol

RIFAMPICIN
DESCRIPTION AND INDICATION FOR USE
Rifampicin is a semi-synthetic antibiotic with a wide spectrum of antibacterial activity.
It is used as adjunctive therapy to treat severe and persistant staphylococcal infections, including
meningitis, endocarditis, epidermal abscess, pulmonary infection and septicaemia. It is 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 infections where sensitivities known: IV, ORAL: 10mg/kg/dose 24hrly

Neisseria meningitidis prophylaxis: ORAL: 5mg/kg/dose 12hrly for 4 doses

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

RECONSTITUTION/DILUTION
Vial = 600mg + DILUENT 10mL NOT WARD STOCK

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

Withdraw 0.5mL of 60mg/mL solution and add to 29.5mL of Glucose 5% (OR 1.0mL to 59mL) in a
50mL syringe = 30mg in 30mL (60mg in 60mL) = 1mg/mL. Withdraw required dose. Discard remaining
solution.

Glucose 5% is the ONLY acceptable diluent. Use Glucose 5% from an unopened 50mL syringe.

ROUTE AND METHOD OF ADMINISTRATION
NOT FOR IM USE

Do not administer through 0.2 micron in-line filters
6

IV infusion: Give slowly over 1 hour via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of rifampicin.

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration’ 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 1 hour:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in syringe
then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x If all is correct, press ‘Green’ button to start infusing.
Note: 1 hour infusion will show the mg/kg/h of ACTUAL dose.
Flush the
line
Draw up 1.5mL of Glucose 5% in a 10mL syringe and infuse at the same infusion rate.
Alternatively, may be flushed with sodium chloride 0.9%, but must be at the same rate as the
infusion. When complete, remove IV tubing and discard.

RWH Neonatal Intensive and Special Care Nurseries
Rifampicin IV Protocol

SIDE EFFECTS
x Brownish-red or orange discolouration of the skin, urine, sweat, saliva, tears and faeces
x GI disturbances, nausea, vomiting, diarrhoea
x Elevated BUN and serum uric acid
x Thrombocytopenia, with or without purpura. Discontinue if purpura occurs.
x Acute haemolytic anaemia, eosinophilia, leucopenia
x Oedema, muscle weakness and myopathy (rare)
x Acute renal failure
x Shortness of breath and wheezing
x Overdose may cause liver enlargement and jaundice, hepatic enzymes may be affected
CONTRAINDICATIONS
x Previous known hypersensitivity to rifampicin
x CAUTION in patients with impaired liver function
DRUG INTERACTIONS
Rifampicin has many drug interactions. The most common are listed below, but it is advised that drug
combinations are checked with the pharmacist.
Dexamethasone,
Hydrocortisone
Decreased effect due to enhanced metabolism. Steroid dose may need
adjustment during and after rifampicin therapy.
Chloramphenicol Serum levels reduced due to increased metabolism, resulting in decreased
chloramphenicol effectiveness.
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 levels. Monitor digoxin levels and adjust dose accordingly
Fluconazole Reduced effectiveness of fluconazole possible due to enhanced metabolism
of fluconazole. An increase in fluconazole dose may be necessary
Phenobarbitone, Phenytoin Effectiveness of rifampicin may be compromised due to significantly lowered
serum levels. Phenytoin levels may be reduced, requiring dose adjustments
with level monitoring.
Theophylline Serum levels of theophylline are significantly reduced due to increased
metabolism. Monitor levels and adjust dose accordingly
NURSING RESPONSIBILITIES
x Observe IV site carefully
x Monitor with Cardio-respiratory monitor
x Monitor BP
x Observe urinary output
x Observe carefully for signs of jaundice
x Protect product from light, heat and moisture
x Avoid contact of product with skin (yellowing may occur)
x 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 be incompatible.
Compatible Incompatible
Fluids Glucose 5%, sodium chloride 0.9% Intralipid, PN
Drugs No information Sodium bicarbonate
Y-Site Glucose 10%
Notes:
x Rifampicin induces its own metabolism, the half-life (approx. 7 hours in neonates) falls rapidly
during the first 2 weeks of life.
x Do not administer through 0.2 micron in-line filters
References:
1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed. 2005, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network. 2003
5. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
6. Personal Communication April 2003, PALL Medical, Australia.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol – Salbutamol neb.doc

SALBUTAMOL

DESCRIPTION AND INDICATION FOR USE
Salbutamol is a E adrenergic stimulant, mainly on the E2 receptors in the bronchial muscle, and is
used for its bronchodilator effects.
3

Salbutamol is also thought to enhance mucociliary clearance.
1

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

NEB: 0.15mg/kg up to every 4 hours
2

DILUTION
Available: 2.5mg/2.5mL solution

NEB: Dose should be diluted with sodium chloride 0.9% to aid delivery.
2
Final volume to be
nebulised should be at least 2mL

ROUTE AND METHOD OF ADMINISTRATION
INH: Spacer device must be used when an inhaler is used.

NEB: Via inspiratory line of ventilator circuit (as per inhalation drug therapy by nebulization
procedure 9W-04-2-075)
Via face mask.

SIDE EFFECTS
x Tachycardia, arrhythmias
x Tremor
x CNS Stimulation, hyperactivity
x Hypokalaemia

CONTRAINDICATIONS
x Tachycardia (HR > 200bpm)
x Known parodoxical bronchoconastrictor response to salbutamol

NURSING RESPONSIBILITIES
x Cardiorespiratory monitor
x Continue oxygen if infant is currently receiving oxygen
x Ensure nebulizer is hanging vertically to ensure adequate misting
x Assess need for suctioning pre and post delivery in ventilated neonates

References:

1. Neofax 12
th
Ed. 1999 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 1
st
Ed. 1998, Pharmacy Department, The Royal Women's Hospital, Carlton 3053
3. Neonatal Formulary 10
th
Ed, The Northern Neonatal Network. 1998

Sildenafil

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Review Date: March 2020
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Neonatal Protocol

Description and indication for use
Sildenafil is a phosphodiesterase-5 inhibitor which enhances the vasodilator effect of nitric oxide
and is used in the management of persistent pulmonary hypertension of the newborn.

Preparations
Suspension 2.5 mg/mL (RWH)

Dose
Oral: 250-500 micrograms/kg every 4-8 hours. Start with the lower dosage and adjust dose
according to response. Doses of 2-3 mg/kg every 6 hours have been used. Maximum of 30 mg per
day.

Side Effects
x Abdominal distension
x Anaemia
x Hypotension
x Diarrhoea, reflux
x Flushing, oedema
x Dry mouth

Contraindications
x CAUTION in patients with hypotension
x CAUTION in patients with renal or hepatic dysfunction

Drug Interactions

Antihypertensive agents Increase risk of hypotension; monitor blood pressure.
Erythromycin, fluconazole Increase the risk of side effects by reducing clearance of
sildenafil

Nursing Responsibilities
x 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. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
3. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 23
rd
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013.
4. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.

Sodium Bicarbonate

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Review Date: Jul 2020
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Neonatal Protocol
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 or arrhythmia on ECG

Preparations
Injection 8.4% (1 mmol/mL 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)
6

Chronic metabolic acidosis
Oral, IV: 1 – 2 mmol/kg once daily, adjust dose according to response

Non-oliguric hyperkalaemia with peaked T waves or arrhythmia on ECG
IV: 2 mmol/kg/dose

Neonatal resuscitation
IV: 1 - 2 mmol/kg/dose

Reconstitution/Dilution
IV: Dilute 1:1 with compatible fluid = 0.5 mmol/mL (4.2%)
ie: 1 mL of sodium bicarbonate 8.4% with 1 mL of compatible fluid

Route and Method of Administration
Administer via a central line or large vein is recommended. Do not administer via arterial
(umbilical or peripheral) catheter.

IV: Give slowly over 10 to 20 minutes (Maximum rate is 10 mmol/minute)

Rapid IV administration is not recommended as it may cause sudden osmolar shifts and has been
associated with IVH.

Side Effects
x Hypocalcaemia, hypokalaemia, hypernatremia
x Rapid IV administration has been associated with IVH
x Extravasation causes tissue necrosis

Sodium Bicarbonate

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Neonatal Protocol
Contraindications
x Do not administer via arterial (umbilical or peripheral) catheter
x Caution in patients with hypernatraemia; solution contains 1mmol/mL sodium.

Nursing Responsibilities
x Observe for signs of extravasation
x Monitor routine electrolytes to ensure serum sodium is within the normal range.

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 Aciclovir, amikacin, ceftriaxone,
fluconazole, furosemide, heparin sodium,
hydrocortisone sodium succinate, insulin,
magnesium sulphate, metronidazole,
morphine, naloxone, potassium chloride,
ranitidine, vancomycin, vecuronium

Adrenaline, amphotericin B liposomal,
calcium gluconate, cefotaxime,
dobutamine, dopamine, ganciclovir,
midazolam, noradrenaline, phenytoin

References

1. Sodium Bicarbonate. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 17/07/2017
2. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 23
rd
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2016.
3. Australian Injectable Drugs Handbook online. The Society of Hospital Pharmacists of Australia. Accessed
on 17/07/2017
4. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
5. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
6. Australian Medicines Handbook 2015 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2015
January. Available from: http://amhonline.amh.net.au/
7. BNF for children. London: BMJ Group; 2015-2016
8. Lilley L, Legge D. Paediatric Injectable Guidelines. 5
th
Ed. Melbourne: The Royal Children’s Hospital
Pharmacy Department 2016.

Sodium Chloride

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Reviewed by: Clinical Pharmacists, NISC Clinical Educators, Marta ThioLluch
Authorised by: Carl Kuschel
Effective Date: 1 July 2013
Review Date: July 2016
Page 1 of 3

Neonatal Protocol
Description and indication for use
Used in the treatment of hyponatraemia. Symptoms of hyponatraemia include: cerebral oedema
(with corresponding neurological symptoms) and seizures.
Sodium supplementation is not necessary for patients with hyponatraemia due to fluid overload
(e.g. heart failure, renal failure, liver failure or preterm infants with respiratory distress in the first
48-72 hours of life) as it does not correct the underlying condition.
Sodium chloride 0.9% may be administered as a bolus to correct hypotension secondary to
hypovolaemia.

Preparations
Injection 154mmol/L (sodium chloride 0.9%)
34mmol/10mL (sodium chloride 20%)
Oral solution 2mmol/mL

Dose
Usual daily requirements
IV/Oral: 2 to 8 mmol/kg/day

Acute depletion (hyponatraemia)
IV correction: 6 mmol/kg over 6 hours

Maintenance
IV: 2 to 8 mmol/kg/day added to intravenous fluids
Oral: 2 to 8 mmol/kg/day in divided doses
Higher doses can be given in consultation with consultant.

Hypotension secondary to hypovolaemia
IV bolus: 10-20mL/kg of sodium chloride 0.9% over 5-10 minutes, dose may be repeated up to
80mL/kg during the first hour.

Note:
x 6mmol/kg correction raises serum sodium by approximately 10mmol/L
x Correct serum sodium level slowly; infuse at 1mmol/kg/hr or less to minimise sudden changes in
serum osmolality

Reconstitution/Dilution
IV correction: Use sodium chloride 20% and dilute required dose with glucose 5% or
glucose 10%.

CONCENTRATION HOW TO DILUTE FINAL CONCENTRATION RATE
Sodium Chloride
PERIPHERAL
6mmol/kg dilute to
20mL/kg

300mmol/L
Infuse final volume
over 6 hours
(1mmol/kg/hr)
Sodium Chloride
CENTRAL
6mmol/kg dilute to
10mL/kg

600mmol/L

Sodium Chloride

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Reviewed by: Clinical Pharmacists, NISC Clinical Educators, Marta ThioLluch
Authorised by: Carl Kuschel
Effective Date: 1 July 2013
Review Date: July 2016
Page 2 of 3

Neonatal Protocol

Route and Method of Administration
IV:
x More concentrated saline infusions (≥3% or ≥513mmol/L) should be given via a central line.
x Concentrations of ≥513mmol/L sodium chloride should be infused at a maximum rate of
100mL/hr.
x Administer infusions through a syringe infusion pump (Guardrails) – see ‘How to set up the
Pump’.

Side Effects
x Hypernatraemia

Contraindications
x Hypernatraemia
x Caution in patients receiving concomitant sodium infusions
Drug Interactions
Frusemide, hydrochlorothiazide Increased renal excretion of sodium

Nursing Responsibilities
x Take care when giving diuretics simultaneously
x Monitor sodium levels 1 hour after the 6 hour infusion
Compatibility Information
Refer to pharmacist for compatibilities when using hypertonic (>0.9% OR >154mmol/L) sodium
chloride solutions.

Compatible with sodium chloride 0.9% Compatible with sodium chloride 3%
Fluids PG1, PG2, lipid emulsion 17%, glucose
2.5%, glucose 5%, glucose 10%
Glucose 5%, glucose 10%
Drugs See individual medicine protocol Potassium chloride (up to 80mmol/L)
Y-Site See individual medicine protocol See individual medicine protocol

References
1. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
2. Fary R, Smith R, Davis P, Jacobs S, editors. Neonatal Pharmacopoeia. 2
nd
Ed. Melbourne: Pharmacy
Department, The Royal Women’s Hospital; 2005.
3. Burridge N, Deidun D, editors. Australian Injectable Drugs Handbook. 5
th
Ed. Melbourne: The Society of
Hospital Pharmacists of Australia; 2011.
Concentration Na & Cl (mmoL/L)
0.45% 77
0.9% 154
3% 513
6% 1026
20% 3420

Sodium Chloride

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Reviewed by: Clinical Pharmacists, NISC Clinical Educators, Marta ThioLluch
Authorised by: Carl Kuschel
Effective Date: 1 July 2013
Review Date: July 2016
Page 3 of 3

Neonatal Protocol
4. Hey E, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 5
th
Ed. Carlton,
Victoria: Blackwell Publishing Asia Pty Ltd; 2007.
5. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
2011.
6. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 17
th
Ed. Hudson, Ohio: American
Pharmacists Association. Lexicomp; 2010.
7. Zenk KE, Sills JH, Koeppel RM. Neonatal Medications & Nutrition: A Comprehensive Guide. 3
rd
Ed. Santa
Rosa, California: NICU Ink; 2003.
8. Sodium chloride (additive). In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral
Compatibility). Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 27/06/2013.
9. MIMSOnline. St Leonards, NSW: UBM Medica; 2012. Accessed: 27/06/2013.

SODIUM NITROPRUSSIDE
Vasodilator
Preparations
INJ 50mg

IV preparation and compatibilities
Dilute to 0.05 to 0.25mg/mL and infuse via syringe
pump. Protect from light.

Dose
IV INF: Initially 0.5microgram/kg/minute,
increased according to response to maximum of
6microgram/kg/minute.

Notes
Use with caution in renal and hepatic impairment.
Continuous blood pressure monitoring is
essential. If used over several days, monitor blood
cyanide level (max serum level 80microgram/L).
Monitor blood pH.

17/11/2009
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol
sotalol.doc

SOTALOL

DESCRIPTION AND INDICATION FOR USE

Sotalol is a non-selective B-adrenergic receptor blocker without intrinsic sympathomimetic
activity, membrane stabilizing activity or cardioselectivity. It causes a decrease in heart rate and a
limited reduction in the force of contraction of the heart. There is a reduction in cardiac work and in
myocardial oxygen demand. Sotalol also possesses Class III antiarrhythmic activity. Its major
effects are prolongation of the atrial, ventricular and accessory pathway effective refractory periods.

It is used in treatment and prevention of supraventricular and ventricular arrhythmias.

DOSE

IV: 0.5 to 1.5mg/kg 6 hourly
ORAL: 1 to 2mg/kg 8 hourly

RECONSTITUTION/DILUTION

Ampoule = 80mg in 8mL (10mg/mL) NOT WARD STOCK

IV: The required dose of Sotalol should be added to an appropriate volume of Sodium Chloride
0.9% or Dextrose 5% to produce a concentration of not greater than 2mg/mL.
Withdraw 1mL of 10mg/mL solution and add to 4mL of Normal Saline in a 5mL syringe
= 10mg in 5mL = 2mg/mL
Discard excess volume to obtain required dose or withdraw dose using another syringe.

ROUTE & METHOD OF ADMINISTRATION

IV: TO BE GIVEN BY MEDICAL STAFF ONLY.
Give over at least 10 minutes.

Not for IM injection.

SIDE EFFECTS

GI tract upset Hypotension
Drowsiness Bradycardia
Dyspnoea, bronchospasm Skin irritation
Ventricular tachyarrhythmias

CONTRAINDICATIONS

Bronchospasm
Right ventricular failure secondary to pulmonary hypertension
Sinus bradycardia
Second & third degree A-V block
Shock (cardiogenic and hypovolaemic)

17/11/2009
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol
sotalol.doc

INCOMPATIBILITIES

No information available

ADMINISTER ALONE OR CONTACT PHARMACY IF FURTHER
INFORMATION IS REQUIRED.

DRUG INTERACTIONS

Verapamil, synergistic adverse effects on atrioventricular conduction.
Amiodarone, used with Sotalol may cause bradycardia, severe hypotension and sinus arrest.

NURSING RESPONSIBILITIES

Cardio/respiratory monitor
Monitor blood pressure

Spironolactone

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Neonatal Protocol

Description and indication for use
Spironolactone is a potassium sparing diuretic that antagonises aldosterone receptors in the distal
convoluting tubules to increase sodium and water excretion whilst sparing potassium excretion. It
may be used in the treatment of fluid overload associated with hyperaldosteronism, including
congestive heart failure and chronic lung disease and can be used in combination with other
diuretics.

Preparations
Oral suspension Spironolactone 5mg/mL (RWH)

Dose
Oral: 1 to 3 mg/kg/day in 1 to 2 divided doses

Route and Method of Administration
Oral: Give with feeds to reduce GI upset and enhance absorption

Side Effects
x Hyperkalaemia, hyponatraemia, hypochloraemia
x Gastrointestinal disturbance (e.g. nausea, vomiting, diarrhoea)
x Lethargy (uncommon)
x Renal impairment (uncommon)

Contraindications
x Hyperkalaemia
x Acute renal insufficiency or severe renal impairment (increased risk of hyperkalaemia)
x Adrenal insufficiency
x Caution in infants with hepatic impairment

Drug Interactions

Potassium supplements Increased risk of hyperkalaemia
ACE inhibitors (e.g. captopril) Increased risk of hyperkalaemia
Trimethoprim Increased risk of hyperkalaemia
Ibuprofen, indomethacin NSAIDs may antagonise the diuretic effects of spironolactone
and may increase the risk of hyperkalaemia by reducing renal
function.

Nursing Responsibilities
x Monitor electrolytes especially potassium
x Monitor fluid balance

Spironolactone

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Neonatal Protocol

References
1. Spironolactone. In: Lexicomp Online® , Pediatric & Neonatal Lexi-Drugs® , Hudson, Ohio: Lexi-Comp,
Inc.[Accessed 01/03/2018]
2. Paediatric Formulary Committee. BNF for Children (online) London: BMJ Group, Pharmaceutical Press,
and RCPCH Publications <http://www.medicinescomplete.com> [Accessed on 01/03/2018]
3. Zenk KE, Sills JH, Koeppel RM. Neonatal Medications & Nutrition: A Comprehensive Guide. 3
rd
Ed. Santa
Rosa, California: NICU Ink; 2003.
4. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
5. Australian Medicines Handbook 2016 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2015
January. Available from: http://amhonline.amh.net.au/
6. AMH Children’s Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2018
January. Available from: https://childrens.amh.net.au/

SUCROSE
Analgesic
Preparations
MIXT 33% (RWH)

Dose
Analgesia for minor painful procedures including venepuncture
and heel pricks
Babies who are Nil By Mouth:
Up to 0.2mL per procedure

Babies on Enteral Feeds:
CW <1500g Up to 0.5mL per procedure
CW ≥ 1500g Up to 1mL per procedure

Maximum daily dose
CW <1500g 2.5mL
CW ≥1500g 5mL

Administer dose slowly to front of tongue. Administer 25 to 50% of
procedural dose 2mins prior to painful procedure. Continue every
2mins until procedure is over or maximum procedural dose has
been reached.

Notes
Administration is nurse initiated, but must be prescribed by a doctor.
Prescribe maximum procedural and maximum daily doses.
See policy 9W-04-2-138 for full guidance on use of sucrose.

SULPHADIAZINE
Antibiotic
Preparations
INJ (SAS) 1g/4mL
TAB 500mg
MIXT 100mg/mL (RWH)

IV preparation and compatibilities
Compatible with NaCl 0.9%.
May be diluted.
Give slowly via infusion pump.

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

Treatment of congenital toxoplasmosis
IV: 50mg/kg/dose 6hrly
ORAL: 50mg/kg/dose 12hrly

Notes
Used in combination with pyrimethamine to treat
toxoplasmosis.
May increase phenytoin levels. Consider dose reduction and
increasing dosage interval in renal impairment. Can increase
the risk of kernicterus.

RWH Neonatal Intensive and Special Care Nurseries
Drug Protocol – Curosurf.doc
CUROSURF
®
(Poractant alfa)

DESCRIPTION AND INDICATION FOR USE
Curosurf® is an exogenous pulmonary surfactant made by purification of the lipids extracted
from minced porcine lungs consisting of 99% polar lipids (mainly phospholipids) and 1%
hydrophobic low molecular weight proteins (surfactant associated proteins SP-B and SP-C).
Curosurf® is a white to creamy white suspension, suspended in 0.9% sodium chloride solution
and is sterile and non-pyrogenic.
It is used to treat ventilated very premature infants who are either at high risk of respiratory
distress syndrome (RDS) or are suffering from RDS.
Surfactant is a “wetting agent” that lowers surface tension at an air/liquid interface.
Mature human lungs excrete surfactant from type 2 pneumocytes. It facilitates lung expansion
and also maintains lung volume during expiration. Very premature neonates do not synthesise
surfactant very well and so they have difficulty expanding their lungs at birth and their lungs
collapse easily during expiration (RDS). Exogenous surfactants are used to decrease surface
tension on the surface of the immature lung, thereby improving gaseous exchange and reducing
tissue damage. Exogenous surfactants are occasionally used to treat neonates with other
serious lung conditions but only on the advice of a senior neonatologist.

CRITERIA FOR USE
Prophylactic use of Curosurf®: intubated and ventilated babies 30 weeks gestation or less,
as soon as possible after intubation (preferably within 15 minutes).
Babies should not be intubated solely to administer surfactant.
Rescue treatment using Curosurf®: ventilated infants with RDS, who require more than 40%
oxygen to maintain their oxygen saturation between 88% and 92%.

Discuss with the Consultant the need for surfactant when the infant does not meet the criteria, but
may be thought to benefit from surfactant on admission and/or subsequently (e.g. infants greater
than 30 weeks gestation, Meconium Aspiration Syndrome).

DOSE
E.T.T. (intra-tracheal) 100 mg/kg (1.25ml/kg) bolus
4, 11

Dose can be repeated once (prophylactic & rescue) after an interval of about 12 hours.
Please do not access a second or third vial unless the volume required from that vial
would be ≥ 0.25mL (20mg)
If a third dose is considered necessary – a senior neonatologist must be consulted.

PREPARATION
Curosurf® is available in vial sizes 120mg in 1.5mL and 240mg in 3mL.
- Before use, slowly warm vial of Curosurf® to room temperature. Artificial warming methods
should not be used. (i.e. remove from fridge & foam packaging and place vial on bench)
- Must not be diluted or have any additives.
- Gently turn vial upside-down in order to obtain a uniform suspension. DO NOT SHAKE.
- Vials can be labelled and stored for 24 hours (as per RWH multi-dose vial policy
5
)
- Do not access or re-warm vial more than twice.

RWH Neonatal Intensive and Special Care Nurseries
Drug Protocol – Curosurf.doc

ROUTE AND METHOD OF ADMINISTRATION
TO BE ADMINISTERED VIA ENDOTRACHEAL TUBE ONLY
Curosurf® is administered as a bolus, via the endotracheal tube, using a syringe containing the
appropriate dose of Curosurf®, attached to a shortened, 5 French end-hole catheter
6
. (Refer to
RWH policy 9W-04-2-121 for more details of administration procedure)
The clinician administering Curosurf® must be experienced in neonatal intensive care, including
endotracheal intubation, mechanical ventilation and cardiorespiratory and oxygen monitoring
6
.

SIDE EFFECTS
The administration of Curosurf® can rapidly affect oxygenation and lung compliance.
Transient adverse effects that may be seen with the administration of Curosurf® include:
- bradycardia
- hypotension
- endotracheal tube blockage
- oxygen desaturation & bradycardia
Severe adverse effects may include:
- pneumothorax

CONTRAINDICATIONS
None known

DRUG INTERACTIONS
There are no known interactions with any other drugs.

NURSING RESPONSIBILITIES
9

Before administering Curosurf®:
- Ensure proper placement and patency of the endo-tracheal tube
- Suction ETT as necessary
- Cardio-respiratory monitoring and pulse oximeter must be insitu (as a minimum requirement)
Following administration of Curosurf®:
- Observe for chest movement to ensure that surfactant has reached the lungs.
- Adjust oxygen requirements as needed.
- Adjust ventilator requirements according to blood gases and medical orders
- Do not suction ETT for at least 1 hour after administration unless clinically unavoidable

RELIGIOUS CONSIDERATIONS
Jews
Learned Jewish rabbis who have been consulted, say that Curosurf® can be administered to
Jewish infants for the following reasons: 1) it is life saving. 2) it is inhaled and not ingested.
Their conclusion was that surfactant use is clearly permitted according to the strict Jewish
Halachah
1
.
Muslims
The essence of Islamic Laws is for the protection of individual life, religion, mind, property and
family. Therefore in difficult circumstances the rules are: 1) take the lesser of two evils, 2) “but if
one is compelled by necessity, neither craving nor transgressing – there is on him no sin, for
indeed God is Clement and Merciful”. Holy Quran – 16:117
Muslims are allowed to consume medications which contain pig by-products (e.g. insulin) if it is
a life saving necessity. Pork derivatives are prohibited when taken by mouth or in diet but not if
they are used for indications other than food or diet e.g. intratracheal instillation
2,3
.

RWH Neonatal Intensive and Special Care Nurseries
Drug Protocol – Curosurf.doc
COMPATIBILITY INFORMATION

Not applicable

References:
1. The Position of Jewish Halacha towards Curosurf (a porcine derived surfactant) A summary
document, Rabbi Mordechai Halperin M.D. 19
th
Dec., 2004
2. Use of Animal Surfactant: should we seek consent? R.Adappa, R.Benson, S.Oddie, J.Wylie,
Archives of Disease in Childhood, 2003;88:F-a351
3. Use of Animal Surfactant: a religious perspective, Murat Yurdakok, letter to the editor,
Archives of Disease in Childhood 2003;88:351
4. Multicentre randomised trial comparing high & low dose surfactant regimens for the
treatment of RDS (the Curosurf trial) Halliday et al. Archives of Disease in Childhood,
1993;69: 276-280
5. Guidelines for use of multi-access vials, RWH pharmacy, K.McMillan, C.Morley, 2003.
6. Surfactant Administration RWH Policy& Procedure Manual 9W-04-2-121
7. MIMS online, December 2005
8. Neonatal Formulary 11
th
ed. Northern Neonatal Network, BMJ Books, 2000

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.

RWH Neonatal Intensive and Special Care Nurseries
Suxamethonium IV Protocol – Jan 2011

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 relaxation 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 0.06mL/kg/dose) repeated when required.

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

IV: No dilution necessary

ROUTE AND METHOD OF ADMINISTRATION
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-
adrenergic blockers, phenytoin
May enhance or prolong the effects of 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

RWH Neonatal Intensive and Special Care Nurseries
Suxamethonium IV Protocol – Jan 2011

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 potassium
2

COMPATIBILITY INFORMATION
3,4
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%, sodium chloride 0.9% Alkaline solutions
Drugs Amikacin, isoprenaline, morphine sulphate,
noradrenaline
Phenobarbitone, sodium
bicarbonate
Y-Site Heparin sodium, hydrocortisone sodium succinate,
potassium chloride (≤40mmol/L)

References:

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

RWH Neonatal Intensive and Special Care Nurseries
Teicoplanin IV Protocol

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 (3.14ml Water for Injection).

NB: Overage included in vial and 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.
Withdraw the contents of the vial slowly into a syringe. Concentration of reconstituted
solution = 133mg/mL.
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 Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of teicoplanin.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration’ 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same
as in syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x 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 10mL syringe and infuse at the same
infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Teicoplanin IV Protocol

SIDE EFFECTS
x Nephrotoxicity
x Ototoxicity
x Thrombophlebitis
x Leucopoenia
x Thrombocytopoenia
x Alterations of liver function
x Adverse effects seem to occur less frequently with teicoplanin compared with
vancomycin, however, there is less clinical experience with teicoplanin as opposed to
vancomycin

CONTRAINDICATIONS
x Not indicated for minor infections
x CAUTION in patients with renal impairment
x 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
x Ensure patency of IV line
x Infuse slowly to avoid flushing of the skin, which may be associated with rapid infusion
x Visually inspect IV tubing for particulate matter/discolouration
x Observe urine output
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 4%, Hartmann's, Sodium
Chloride 0.9%, Sodium Chloride 0.18%
Aminoglycosides, ciprofloxacin
Drugs No information No information
Y-Site No information No information
References:
1. Australian Injectable Drugs Handbook, 2nd Ed., The Society of Hospital Pharmacists of Australia, 1999
2. Neonatal Formulary 10th Ed, The Northern Neonatal Network. 1998
3. Targocid monograph, MIMS Online, Australia, 2003.
4. Paediatric Pharmacopoeia, 13th Ed, Royal Children’s Hospital, Melbourne.
5. Personal Communication, Aventis Pharma Pty Ltd, Australia (Manufacturer), June 2003.
6. Handbook on Injectable Drugs, 11th Ed, Trissel 2001.

RWH Neonatal Intensive and Special Care Nurseries

Thiopentone

DESCRIPTION AND INDICATION FOR USE
Thiopentone is a sulphur analogue of pentobarbitone sodium. It is an ultra-short acting
depressant of the CNS, inducing hypnosis and anaesthesia. Occasionally thiopentone is used
for the control of seizure activity when anti-convulsant therapy has been unsuccessful.

DOSE
Therapy to be initiated only by or following discussion with consultant neonatologist

Anticonvulsant
Loading Dose
IV:4mg/kg/dose

Maintenance Dose
IV INFUSION: 2mg/kg/hr

RECONSTITUTION/D ILUTION
IV: Reconstitute 500mg vial with 20mL of Water for Injection = 25mg/mL

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 24hours 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
Drowsiness, 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,
spironolactone

May increase risk of hypotension

RWH Neonatal Intensive and Special Care Nurseries

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
3

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

Compatible Incompatible
Fluids Glucose 5%, Sodium Chloride 0.9% Glucose 10%, intralipid, PN

Drugs Aminophylline, hydrocortisone,
phenobarbitone, potassium chloride

Adrenaline, amikacin, 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:
1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed, 2005. Pharmacy Department, The Royal Women's Hospital, Carlton
3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia, 1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network 2003
5. Paediatric Pharmacopoeia 13
th
Ed, Pharmacy Department, The Royal Children’s Hospital, Parkville
3052
6. King et al. Guide to Parenteral Admixtures 2002
7. Trissel L. Handbook on Injectable Drugs 11
th
Ed.
8. Manual of Neonatal Care 4
th
Ed., Cloherty J and Stark A. Joint Program in Neonatology, Boston 1998
9. Guidelines for Administration of Intravenous Medications to paediatric Patients 5
th
Ed. 1996 ASHSP
10. Paediatric Injectable Guidelines, 2
nd
Ed , 2000, Pharmacy Department, RCH
11. Paediatric Dosage handbook 6
th
Edition 199-2000, Taketomo, Hodding and Kraus

Thyroxine

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 7 Jan 2016
Review Date: January 2019
Page 1 of 2

Neonatal Protocol
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 the 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
x 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.
x Excessive bone loss may develop in infants treated with excessive doses.

Contraindications
x Cardiovascular disorders; risk of arrhythmias
x 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.

Thyroxine

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 7 Jan 2016
Review Date: January 2019
Page 2 of 2

Neonatal Protocol
Nursing Responsibilities
x Monitor thyroid function. Aim to maintain serum thyroxine in the upper half of the normal range
and serum TSH level in the normal range.
x Monitor heart rate, blood pressure and for clinical signs of hypo- and hyperthyroidism.

References
1. Australian Medicines Handbook 2015 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2015
January. Available from: http://amhonline.amh.net.au/
2. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013.
3. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015.
4. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
5. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.

RWH Neonatal Intensive and Special Care Nurseries
Ticarcillin-clavulanate IV Protocol

TICARCILLIN/POTASSIUM CLAVULANATE
(TIMENTIN
?
)
DESCRIPTION AND INDICATION FOR USE
Timentin
®
is an antibacterial combination of the semisynthetic penicillin antibiotic, ticarcillin sodium and
the B-lactamase inhibitor, potassium clavulanate (the potassium salt of clavulanic acid).
Ticarcillin, like other penicillins, has a bactericidal effect on susceptible bacteria during active
multiplication. The addition of clavulanic acid extends the antibactericidal spectrum of ticarcillin.
DOSE
Use only following discussion with neonatologist and/or in consultation with clinical
microbiologist

Dose is expressed as ticarcillin: IV: 75mg/kg/dose
Interval
CA <37 weeks 12hrly
CA ≥37 weeks 8hrly

RECONSTITUTION/DILUTION
Vial = 3g Ticarcillin - 100mg Potassium Clavulanate

IV: Reconstitute vial with 13mL of Water for Injection = 3g in 15mL = 200mg/mL
(Powder volume per 3g-100mg vial = 2mL)

Withdraw 2mL of 200mg/mL solution from vial and add to 18mL of Sodium Chloride 0.9% or Glucose 5%
in a 20mL syringe = 400mg in 20mL = 20mg/mL. Withdraw required dose and discard remaining
solution.

If fluid restriction applies - a more concentrated solution may be considered, but concentration must
not exceed 100mg/mL.

ROUTE AND METHOD OF ADMINISTRAT ION
Not for IM use
IV infusion: Give slowly over 30 minutes via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded syringe
containing exact dose of Ticarcillin-Clavulanic acid

6 steps to
infuse safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration’ matches concentration shown on pump then press ‘OK’
x For concentration of 100mg/mL, hit ‘Modify’ to ‘select concentration’ of syringe
o Enter 100mg then press ‘OK’
o Enter 1mL then press ‘OK’ and check concentration is correct
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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in syringe
then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x 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 10mL syringe and infuse at the same infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Ticarcillin-clavulanate IV Protocol

SIDE EFFECTS
x Irritability
x Seizures
x GI tract disturbances, severe colitis
x Hypernatraemia, leukopenia, neutropenia
x Thrombophlebitis
x Abnormalities of hepatic and renal function tests

CONTRAINDICATIONS
x Caution in patients with cardiac disease
x Hypersensitivity to penicillin antibiotics

NURSING RESPONSIBILITIES
x Observe injection site carefully
x Monitor sodium levels
x Record volume of drug on fluid chart - large volume drug.
COMPATIBILITY INFORMATION

IMPORTANT: Contact pharmacy for drugs not appearing in the table below.
Uncommon drugs have simply been omitted and may be incompatible.
Compatible Incompatible
Fluids Glucose 5%, Sodium Chloride 0.9% Intralipid, PN
Drugs No information Aminoglycosides (gentamicin, amikacin,
tobramycin), sodium bicarbonate,
vancomycin
Y-Site Fluconazole, heparin, insulin(neutral),
morphine, pethidine

References:
1. Neofax 16
th
Ed. 2003 A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Neonatal Pharmacopoeia 2
nd
Ed, Pharmacy Department, The Royal Women's Hospital, Carlton
3053
3. Australian Injectable Drugs Handbook, 2
nd
Ed., The Society of Hospital Pharmacists of Australia,
1999
4. Neonatal Formulary 4
th
Ed, The Northern Neonatal Network 2003
5. Paediatric Pharmacopoeia 13
th
Ed, Pharmacy Department, The Royal Children’s Hospital,
Parkville 3052
6. King et al. Guide to Parenteral Admixtures 2002
7. Trissel L. Handbook on Injectable Drugs 11
th
Ed.

RWH Neonatal Intensive and Special Care Nurseries
Tobramycin IV Protocol

TOBRAMYCIN

DESCRIPTION AND INDICATION FOR USE
Tobramycin is an aminoglycoside antibiotic obtained from cultures of Streptomyces tenebrarius.
Tobramycin is bactericidal in activity, and in common with all other aminoglycosides, is primarily active
against aerobic Gram-negative bacilli. Tobramycin is considered more active than most other
aminoglycosides against Pseudomonas aeruginosa.
Tobramycin is indicated in the treatment of serious infections caused by susceptible micro-organisms.
DOSE
Use only following discussion with neonatologist and/or in consultation with clinical
microbiologist
IV, IM: 5mg/kg/dose

Interval
Current weight <1200g and post natal age:
≤7 days 48hrly
8 to 30 days 36hrly
> 30 days 24hrly

Current weight ≥1200g and post natal age:
≤ 7 days 36hrly
> 7 days 24hrly
RECONSTITUTION/DILUTION
Vial = 80mg in 2mL (40mg/mL)

IV: Withdraw 1mL of 40mg/mL solution and add to 19mL of Sodium Chloride 0.9% in a 20mL
syringe = 40mg in 20mL = 2mg/mL

IM: No dilution necessary. If dilution is required to measure dose, take 0.5mL of 40mg/mL
solution and add to 1.5mL of Sodium Chloride 0.9% in a 5mL syringe = 20mg in 2mL =
10mg/mL.

ROUTE AND METHOD OF ADMINISTRATION
IV infusion: Give slowly over 30 minutes via syringe pump using Guardrails
Prime Line Use Minimum Volume Extension tubing (Volume = 1mL) prime line with preloaded
syringe containing exact dose of tobramycin.

6 steps to
infuse
safely
using
Guardrails
1. Select the correct medicine to be infused
2. Check syringe concentration’ 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:
x Press ‘confirm’ if it is the right syringe OR
x Press ‘Type’ to choose the right syringe brand then press ‘Confirm’
6. Infuse dose: To start infusion over 30 minutes:
x Hit ‘?’ key and choose ‘SET VTBI OVER TIME’ then press ‘OK’
x Enter actual volume in syringe then press ‘OK’
x Enter time to infuse over. Check volume and amount shown is the same as in
syringe then press ‘OK’.
x Press ‘OK’ to choose ‘STOP’ infusion when finished
x 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 10mL syringe and infuse at the same
infusion rate.

RWH Neonatal Intensive and Special Care Nurseries
Tobramycin IV Protocol

SIDE EFFECTS
x Ototoxicity
x Nephrotoxicity
x Increased serum bilirubin
x Electrolyte disturbances

CONTRAINDICATIONS
x CAUTION in patients with impaired renal function. Increased dosage interval may be
required.

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

NURSING RESPONSIBILITIES
x Monitor urine output
x Serum levels to be taken on the 3rd dose
x Pre-dose (trough) level taken immediately prior to dose
x Therapeutic level: Trough < 2mg/L
COMPATIBILITY INFORMATION

IMPORTANT: Contact 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 chloride
0.9%
Intralipid, PN
Drugs Calcium gluconate, clindamycin, frusemide,
metronidazole, ranitidine, verapamil
Amphotericin, flucloxacillin, heparin,
imipenem/cilastatin
1
, indomethacin,
magnesium salts
Generally, penicillins and cephalosporins are
considered incompatible with aminoglycoside
antibiotics
Y-Site Aciclovir, amiodarone, ciprofloxacin,
dopamine
1
, fluconazole, insulin (neutral),
metronidazole
1
, midazolam, morphine

References:
1. Young T, Mangum B. (2008) Neofax: A Manual of Drugs Used in Neonatal Care.(21ed). Montvale: Thomson Reuters
2. Neonatal Pharmacopoeia (2
nd
ed).(2005) Carlton: Pharmacy department, The Royal Women's Hospital
3. Australian Injectable Drugs Handbook, 4
th
Ed.(2008), Collingwood: The Society of Hospital Pharmacists of Australia,
4. The Northern Neonatal Network (2007) Neonatal Formulary 5
th
Ed, Oxford: Blackwell Publishing
5. King et al. (2002) Guide to Parenteral Admixtures, Napa: King Guide Publications Inc
6. Trissel L. (2009) Handbook on Injectable Drugs.15
th
Ed. Bethesda: ASHP

17/11/2009
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol
tolazol.doc

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 the 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 4mL (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 METHOD 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.
Infusion: 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 arryhthmias
Reversible impairment of renal function, oliguria

CONTRAINDICATIONS

Use with CAUTION in patients with mitral stenosis

17/11/2009
RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol
tolazol.doc

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 RESPONSIBILITIES

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.

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Tromethamine - THAM.doc

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 is 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

mL of 0.3M solution = weight (kg) x Base deficit (mmol/L) x 1.1
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 not be used for more than 24 hours.
4
1mmol = 3.3mL of 0.3M solution

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
x Apnoea, respiratory depession
x Hypoglycaemia
x Hypokalaemia
x Alkalosis
x Transient hypocalcaemia
x Venospasm and thrombosis
x Extravasation may cause tissue necrosis

RWH Neonatal Intensive and Special Care Nurseries
IV Drug Protocol - Tromethamine - THAM.doc

CONTRAINDICATIONS
x Renal failure
x Anuria
x Chronic respiratory acidosis

NURSING RESPONSIBILITIES
x Observe IV site closely for signs of extravasation
x Monitor and record urine output
x Cardio-respiratory monitor
x Monitor blood glucose levels for hypoglycaemia

COMPATIBILITY INFORMATION
3

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

Notes:

References:

1. Cockington RA, Vonwiller JB; Acute emergencies in the Newborn, Med J of Aust Vol 24, p900 1977.
2. Rehder H, Heiming E; Fatal complications of THAM administration in the newborn, Arch Dis Childhood Vol 1, 49,
p76 1974
3. 1974-1999 Micromedex, Inc Volume 99 Expiration date: 31/3/99
4. THAM solution, Product Information, Abbott 1998
5. Blench HL, et al; TRIS buffer (THAM): An appraisal of it’s physiological effect and clinical usefulness. N Eng J Med
274, p782-6, 1966.
6. Roberton NRC; Apnoea after THAM administration in the newborn, Arch Dis Chilhood Vol 45, p206-213, 1970.

Valganciclovir
(NISC Protocol)

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Effective Date: 4 Aug 2016
Review Date: Aug 2019
Page 1 of 2

Description and indication for use
Valganciclovir is an L-valine ester prodrug of ganciclovir that is rapidly converted to ganciclovir
after oral admismistration.
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:
x CNS involvement: microcephaly, suggestive radiological abnormalities on cranial
imaging
x CSF for CMV PCR is not a routine investigation. However, a positive result is indicative
of CNS involvement
x Chorioretinitis
x Sensorineural hearing loss
x Severe organ disease – bone marrow suppression, colitis, pneumonitis, hepatitis.

Preparations
Oral solution 50 mg/mL (100mL)

Dose
Use only following discussion with consultant neonatologist and/or in consultation with clinical
infectious diseases team.

Oral: 16 mg/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
x Anaemia
x Neutropenia
x Thrombocytopenia
x Renal impairment
x Hepatotoxicity
x GI upset
x Gonadal toxicity
x Twice weekly FBE, U&Es, and LFTs during the first 4 weeks, then every 2-4 weeks once stable

Valganciclovir
(NISC Protocol)

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Effective Date: 4 Aug 2016
Review Date: Aug 2019
Page 2 of 2

Contraindications
x Caution in patients with renal impairment

Drug Interactions
Zidovudine Increased risk of profound myelosupression, if
possible avoid during concomitant therapy.

Nursing Responsibilities
x Give with feeds
x 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
x 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
x Use soap and water immediately to wash any accidental contact with skin, if eye contact rinse
immediately with water
x Return any unused valganciclovir oral solution to pharmacy for disposal

References

1. MIMSOnline. Accessed: 13/10/2016
2. Ainsworth SB, editor. Neonatal Formulary: Drug use in Pregnancy and the First Year of Life. 7
th
Ed.
Chichester, West Sussex: John Wiley & Sons, Ltd; 2015
3. Australian Medicines Handbook 2016 (online). Available from: http://amhonline.amh.net.au/
4. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013.
5. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.

Vancomycin

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Effective Date: 2 Feb 2015
Review Date: February 2018
Page 1 of 3

Neonatal Protocol
Description and indication for use
Vancomycin is a glycopeptide antibiotic derived from Niocardia orientalis organism (formerly
Streptomyces orientales). It is bactericidal against many 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 8hrly

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 1mL of 50mg/mL solution from the vial and add to 9mL of sodium chloride 0.9% or
glucose 5% in a 10mL syringe = 50mg in 10mL = 5mg/mL.
Discard excess volume to obtain required dose or withdraw required dose using another syringe.

Route and Method of Administration

NOT TO 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
x Ototoxicity, nephrotoxicity.
x Thrombophlebitis

Vancomycin

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Review Date: February 2018
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Neonatal Protocol
x Rapid bolus administration may cause hypotension, tachycardia, and rarely, cardiac arrest.
x Transient neutropenia, rarely thrombocytopenia.
x Skin flushing or rash (red man syndrome) is associated with rapid bolus injection.
x Hypersensitivity (chills, fever, rash).

Contraindications
x Vancomycin is not indicated for the treatment of minor infections.
x CAUTION in patients with renal impairment.
x Concurrent use of other ototoxic/nephrotoxic medicines, unless clearly indicated and closely
monitored.

Drug Interactions

Aminoglycoside antibiotics
(gentamicin, amikacin)
Increased risk of nephrotoxicity and 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
x Ensure trough blood level is taken immediately before 4th dose
Therapeutic range: 10 to 15mg/L
x Ensure patency of IV. Do not inject IM as vancomycin can cause necrosis
x Infuse slowly to avoid rash, hypotension and thrombophlebitis, which may be associated with
rapid infusion
x Visually inspect IV tubing for particulate matter/discoloration
x 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 Aciclovir, adrenaline, alprostadil, amikacin,
calcium gluconate, ciprofloxacin, clindamycin,
dexamethasone, digoxin, dobutamine,
dopamine, erythromycin, fentanyl, fluconazole,
insulin, magnesium sulphate, meropenem,
metronidazole, midazolam, morphine,
noradrenaline, potassium, pyridoxine,
ranitidine, sodium bicarbonate, zidovudine, IVN
starter, IVN maintenance, lipid emulsion 17%

Amphotericin B liposomal, cephazolin,
cefotaxime, ceftriaxone, frusemide,
ganciclovir, heparin, indomethacin,
piperacillin-tazobactam

Vancomycin

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Effective Date: 2 Feb 2015
Review Date: February 2018
Page 3 of 3

Neonatal Protocol
References
1. Neofax 16
th
Ed. 2010. A Manual of Drugs Used in Neonatal Care, Young T, Mangum O.
2. Burridge N (Ed) 2013. Australian Injectable Drugs Handbook, 6th Ed., Melbourne: The Society of
Hospital Pharmacists of Australia.
3. Neonatal Formulary: Drug use in pregnancy and the first year of life, 5th Ed, Massachusetts: Blackwell
Publishing Inc, 2007.
4. BNF for children, London: BMJ Publishing Group Ltd, 2012-2013.
5. Trissell LA, 2014, Handbook on Injectable drugs, 15th Ed, Bethesda, American Society of Health-System
Pharmacists
6. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013

Vecuronium

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Please remember to read our disclaimer.

Effective Date: 29 Sept 2016
Review Date: Sept 2019
Page 1 of 3

Neonatal Protocol
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 oxygenation and minimisation of fluctuations in cerebral blood
flow.

Preparations
Injection 10mg (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: neostigmine 50 micrograms/kg with atropine 20 micrograms/kg.

Reconstitution/Dilution
IV: Reconstitute 10 mg vial with 5mL of Water for Injection = 2 mg/mL. Withdraw 5mL of the
reconstituted solution and add to 5mL of sodium chloride 0.9% or glucose 5% in a 10mL
syringe = 1 mg/mL.

IV Infusion: After reconstitution, dilute required dose to 50 mL with a compatible fluid

CONCENTRATION HOW TO DILUTE DOSE EQUIVALENT
Vecuronium
SINGLE
3mg/kg to 50mL 1mL/hr = 1microgram/kg/min
Vecuronium
DOUBLE
6mg/kg to 50mL 1mL/hr = 2microgram/kg/min

Route and Method of Administration
IV bolus: Administer over 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’.

Vecuronium

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Effective Date: 29 Sept 2016
Review Date: Sept 2019
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Neonatal Protocol
Side Effects

x Fluid retention due to immobility
x Dry eyes
x Heart rate or blood pressure may decrease when used with opioids

Contraindications

x Non-ventilated patients
x Ventilated babies with no analgesia and/or sedation
x CAUTION in patients with encephalopathy; muscle relaxation may make neurological
assessment difficult and mask seizures
x CAUTION in patients with anuria and/or worsening fluid retention (renal failure)
x CAUTION in significant hepatic impairment

Drug Interactions

Aminoglycosides (gentamicin, amikacin,
tobramycin)
May enhance the action of vecuronium
Corticosteroids (dexamethasone,
hydrocortisone)
May reduce effectiveness of vecuronium
Frusemide May alter effectiveness of vecuronium
Magnesium Sulphate May potentiate the action of vecuronium
Phenytoin May alter effectiveness of vecuronium
Vancomycin May enhance the action of vecuronium

Nursing Responsibilities

x Monitor hourly heart rate, blood pressure and oxygenation saturation during muscle relaxation
x Ensure adequate analgesia and/or sedation
x Remain by the bedside until effects of IV bolus vecuronium are complete or at all times during
the administration of continuous IV infusion
x Ensure use of lubricating eye drops 4-6 hourly to avoid corneal drying
x Monitor for renal or hepatic impairment; dosage reduction may be necessary
x Consider need for bladder catheterisation if urine output decreases
x Monitor for movement
x Protect vecuronium syringe from light. Cover syringe with foil.

Vecuronium

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Effective Date: 29 Sept 2016
Review Date: Sept 2019
Page 3 of 3

Neonatal Protocol
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 Glucose 10%*
Adrenaline, calcium gluconate,
dobutamine, dopamine, fluconazole,
heparin, insulin, metronidazole,
magnesium sulphate, midazolam,
milrinone, morphine sulphate,
noradrenaline, ranitidine, sodium
bicarbonate, zidovudine
Aciclovir, amphotericin b liposomal,
cefotaxime, diazepam, furosemide
(frusemide), ganciclovir, piperacillin-
tazobactam, phenytoin
*Note: there is no compatibility information available with glucose 10%

References

1. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 10
th
Ed.
Bethesda, Maryland: American Society of Health-System Pharmacists; 2013.
2. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013.
3. Burridge N, Collar N, Symons K, editors. Australian Injectable Drugs Handbook. 6
th
Ed. Melbourne: The
Society of Hospital Pharmacists of Australia; 2014.
4. Vecuronium. In: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility).
Greenwood Village, Colorado: Thomson Reuters (Healthcare). Accessed: 27/09/16
5. Vecuronium. In: Pediatrics and NeoFax. Trissel’s 2 Clinical Pharmaceutics Database. New Jersey:
Thomson Reuters (Healthcare). Accessed: 27/09/16
6. Ryan RSM, editor. BNF for children. London: BMJ Group; 2015.
7. Australian Medicines Handbook 2016 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2016
January. Available from: http://amhonline.amh.net.au/
8. Kemp CA, McDowell JM, editors. Paediatric Pharmacopeia. 13
th
Ed. Melbourne: Pharmacy Department,
Royal Children’s Hospital; 2002.
9. Paediatric Injectable Guidelines. 4
th
Ed. Melbourne: The Royal Children’s Hospital Pharmacy Department
2011.
10. Muscle Relaxation of Neonate on NISC guideline. Available at:
http://intranet.thewomens.loc/pgp/documents/Muscle%20Relaxation%20in%20Neonate%20in%20NISC.p
df . Access 29/09/16.

VITAMIN E (D-ALPHA TOCOPHERYL ACETATE)
Fat-soluble vitamin
Preparations
MIXT 15.6 units/0.1mL (d-alpha tocopheryl acetate)
MIXT Combination
Vitamin A = 2210units/mL
Vitamin E = 102units/mL

Dose
Chronic cholestasis
ORAL: 50units/kg/dose ONCE daily.
Increase in 50units/kg/DAY increments to 150 to
300units/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.
No longer used for supplementation at RWH
NISC.

VITAMIN A (RETINOL)
Fat-soluble vitamin
Preparations
MIXT Combination
Vitamin A =2210units/mL
Vitamin E =102units/mL

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

Notes
Adjust dose according to levels. Check
levels regularly in prolonged therapy.
1 unit vitamin A = 0.3microgram retinol.
No commercial preparation containing
Vitamin A alone is available.

Vitamin D3
(Cholecalciferol)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Reviewed by: Clinical pharmacists, Sue Jacobs, NISC Clinical educators
Authorised by: Carl Kuschel
Effective Date: 19 May 2014
Review Date: May 2017
Page 1 of 1

Description and indication for use
Vitamin D is a 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.
References
1. MIMS Online Prescribing Information for OsteVit-D
®
liquid.
2. Committee on Nutrition of Preterm Infant, European Society for Paediatric Gastroenterology, Hepatology
and Nutrition. Journal of Pediatric Gastroenterology and Nutrition 2009;50:1-9.
3. Munns C, Zacharin M, Rodda C, et al. Prevention and treatment of infant and childhood vitamin D
deficiency in Australia and New Zealand: a consensus statement. Medical Journal of Australia
2006;18(5):268-272.

Neonatal Protocol

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

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Effective Date:08/09/2015
Review Date: Sept 2018
Page 1 of 3

Neonatal Protocol
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.

Zidovudine

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Review Date: Sept 2018
Page 2 of 3

Neonatal Protocol
Route and Method of Administration
IV infusion: Administer infusions over 60 minutes through a syringe infusion pump (Guardrails) –
see ‘How to set up the Pump’.

Side Effects
x 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.
x Liver function tests should be monitored at 2 and 6 weeks
x Vomiting, diarrhoea
x Lactic acidosis

Contraindications
x Avoid in infants with very low neutrophil count (less than 0.75 x 10
9
/L) or low haemoglobin (less
than 75g/L).

Drug Interactions
Aciclovir 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 myelosuppresion, 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
x Observe for side effects
x If the infant vomits > 15 minutes after a dose, give the next dose at the next scheduled time.
x 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.

Zidovudine

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Neonatal Protocol
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, aciclovir,
amikacin, dobutamine, dopamine,
gentamicin, heparin, metronidazole,
morphine, piperacillin-tazobactam,
vancomycin

References
1. Phelps SJ, Hak EB, Crill CM, editors. Pediatric Injectable Drugs. The Teddy Bear Book. 10
th
Ed.
Bethesda, Maryland: American Society of Health-System Pharmacists; 2013.
2. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013
3. Burridge N, Collar N, Symons K, editors. Australian Injectable Drugs Handbook. 6
th
Ed. Melbourne: The
Society of Hospital Pharmacists of Australia; 2014.
4. Young T, Mangum B. Neofax 2010. 23
rd
Ed. New Jersey: Thomson Reuters; 2010.
5. Australian Medicines Handbook 2015 (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2015
January. Available from: http://amhonline.amh.net.au/
6. Ryan RSM, editor. BNF for children. London: BMJ Group; 2012.
7. Zidovudine: IV Index. Trissel’s 2 Clinical Pharmaceutics Database (Parenteral Compatibility). Greenwood
8. MIMSOnline. St Leonards, NSW: UBM Medica; 2015. Accessed: 10/08/15
9. BHIVA guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review)
http://www.bhiva.org/pregnancy-guidelines.aspx .[Accessed 22/07/2015]

Zinc
(Zinc Sulfate)

Note: The electronic version of this document is the version currently in use. Any printed version can not be assumed to be current.
Please remember to read our disclaimer.

Effective Date: 10 Feb 2017
Review Date: Feb 2020
Page 1 of 1

Neonatal Protocol

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
x Abdominal pain
x Diarrhoea
x Gastric irritation
x Irritability
x Lethargy
x Vomiting

Contraindications
x 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

References
1. BNF for children, London: BMJ Publishing Group Ltd, 2015-2016.
2. Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 20
th
Ed. Hudson, Ohio:
American Pharmacists Association. Lexicomp; 2013

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