Prescribing on the Neonatal Unit

NICU Junior Doctors Induction

February 2010
Why discuss prescribing?
 Why discuss prescribing?

Potential for serious error is huge

Examples that we can learn from
– Indomethacin: 10x overdose prescribed
– Morphine and dopamine prescriptions written with
doses the wrong way round
– Morphine infusion prescribed as g not mg (x1000),
– Furosemide prescribed as 1ml/kg not 1mg/kg (given
from 10mg/ml injection, a 10x overdose)
– Gentamicin dosing interval errors leading to high drug
levels
 The 10 Commandments

1. Always prescribe legibly in black indelible ink or by using

approved sticker
2. Always use the 24 hour clock for prescribing and avoid
1200 and 2400
3. Doses prescribed using only agreed abbreviations:
• g (grams)
• mg (milligrams)
• micrograms (written in full)
• nanograms (written in full)
• units (written in full)
4. Write dose expressed as per kg if relevant
 The 10 Commandments

5. Carry forward original starting date when re-writing charts

6. Take care with unusual dosage interval, especially
gentamicin. Always check when last dose was given.
7. Always re-write prescription when dose, route or timing
altered
8. Always use a calculator
9. Always refer to the drug information file, neonatal guidelines,
code of practice
10. Don’t be rushed – take your time and check your calculation
 Where to go for help

Use the pink folder as first choice

Contains
- drug monographs and dosing
summaries
- IV guide including the “Alaris” pump
information for drugs given by infusion
- additional information
e.g. 12.5% & 25% glucose
sodium chloride infusions
PN checking procedure
Intubation drug dose banding

Children’s BNF – most doses should conform to those in the Children’s BNF
Pharmacist - available for advice (daytime) & on-call (out-of-hours)
 Drug Charts on NICU

Types of chart:
– White chart (Neonatal drug chart)
– Yellow infusion chart
– Green PRIDE chart (For TTOs)
– Blood Product Infusion Chart
– Vaccination chart
– Intubation chart
 Neonatal Prescribing Questions

1. Convert 0.086 mg into micrograms

……….micrograms

2. Convert 294 micrograms in to mg

………..mg

3. The dose of indomethacin is 100micrograms/kg.

What is the does for a baby weighing 0.9kg?

………..micrograms
 Neonatal Prescribing Answers

1. Convert 0.086 mg into micrograms

86 micrograms

2. Convert 294 micrograms in to mg

0.294 mg

3. The dose of indomethacin is 100micrograms/kg.

What is the does for a baby weighing 0.9kg?

90 micrograms
 Neonatal Prescribing Questions

The dose/route of benzylpenicillin for sepsis/meningitis

• <7 days 50mg/kg IV twice daily

• 7-28 days 50mg/kg IV three times daily
• >28 days 50mg/kg IV four times daily

“Review dose/frequency in renal impairment”

4. Write a prescription of benzylpenicillin for a 2 day old baby you

have just admitted from postnatal ward with respiratory distress
with birth weight of 1.35kg, admitted weight 1.2kg
 Neonatal Prescribing Answers

4. Write a prescription of benzylpenicillin for a 2 day old baby you

have just admitted from postnatal ward with respiratory distress
with birth weight of 1.35kg, admitted weight 1.2kg

Open the drug chart: inside left hand side – Regular Prescriptions

Use the birth weight as current weight lower

 Stopping a Prescription

Antibiotic prescriptions should be reviewed daily

Chase cultures promptly

Positive blood culture results are telephoned through to

NICU by the microbiology team.

Give as short a course as possible based on clinical need

 Stopping a Prescription

When there is a plan to stop antibiotics a line should be drawn

after the last dose.

If the antibiotic course is complete - Cross off the prescription

sign & date
 Stopping a Prescription

Antibiotics should NEVER be stopped

without checking the medical notes,
especially in ward babies.

A change to antibiotic therapy including stopping medication,

MUST be documented in the medical notes.

Certain antibiotics (e.g. meropenem) should only be used on

microbiology advice.
 Rewriting Drug Charts

When rewriting a chart ALWAYS

Check the regular, prn and variable dose prescriptions

Check when the last dose of antibiotic was given
Document the START date (when the first dose of
antibiotic was given)
 Gentamicin

Why is Gentamicin prescribing particularly important?

 Gentamicin

There are more errors made with

Gentamicin than any other drug

Great care must be taken when prescribing gentamicin

There is a separate gentamicin prescription area on the drug chart
High gentamicin levels are associated with ototoxicity and nephrotoxicity
 Gentamicin

Prescribing checklist:
1) Check last prescription – incl. old charts
• when was last dose given

2) Check patient’s current weight

Dose required = 4mg/kg

 Gentamicin

Prescribing checklist:
1) Check last prescription – incl. old charts
• when was last dose given

2) Check patient’s current weight

Dose required = 4mg/kg

Always round down to the nearest 0.5mg

For example:
3.12kg baby = 4 x 3.12mg = 12.48mg
round down = 12mg
 Gentamicin

Prescribing checklist:

3) Check dose frequency

In <32/40 prescribe every 36 hours
 Gentamicin

Prescribing checklist:

3) Check dose frequency

≥32/40 prescribe every 24 hours
 Gentamicin

Prescribing checklist:
4) Ensure that all dates are completed
Take care over month ends
DO NOT prescribe for midday and midnight
 Gentamicin

For 36hourly dosing

If the starting dose is pm, cross through the first box
then prescribe the subsequent doses.

Ensure that am and pm times are the right way round

Use the 24 hour clock !
Drugs with variable doses, such as gentamicin, need to be prescribed
BOTH
on the regular section of the chart
AND
in the appropriate box on the gentamicin section
 Gentamicin

5) Levels
If renal function normal – take levels on the 3rd dose and give the dose
 Gentamicin

Desired levels

TROUGH – (taken immediately pre-dose) <2mg/L

In the presence of severe, confirmed infection, discuss the
senior staff and consider aiming for 1-2mg/L.

PEAK – 5-10mg/L
In presence of severe infection,including pseudomonas, discuss
with senior staff and consider aiming for 7-10mg/L.
 Gentamicin

Levels

Antibiotic levels should be chased and documented

Any changes to doses should be documented and signed
Vancomycin levels are also written here on the drug chart
 Neonatal Prescribing Question

5. Write a prescription for gentamicin for a 2 day old baby, born at 35

weeks gestation, that you admit from the postnatal ward at 00.30
with respiratory distress with weight of 1.85kg
 Neonatal Prescribing Answer

5. Write a prescription for gentamicin for a 2 day old baby, born at 35

weeks gestation, that you admit from the postnatal ward at 00.30
with respiratory distress with weight of 1.85kg

Remember to write Drug and time on the “Regular Prescription” side

of the chart
 Neonatal Prescribing Question

6. Write a prescription for gentamicin for a baby, born at 26 weeks

gestation, now 30 days of age that develops NEC at 15.00 with
weight of 0.9 kg
 Neonatal Prescribing Answer

6. Write a prescription for gentamicin for a baby, born at 26 weeks

gestation, now 30 days of age that develops NEC at 15.00 with
weight of 0.9 kg
Intravenous Drug Infusions and Fluids

7.5 ml/hr
 Intravenous Drug Infusions and Fluids

• Drug infusion monographs

– Live in the pink files
• Calculations
– Always take your time
– Calculate out the rate – is it correct?

• Potassium Chloride
– Dose as per IV monograph and summary table
• MAXIMUM peripheral conc. = 40mmol/L
• MAXIMUM central conc. = 80mmol/L
• MAXIMUM rate of infusion = 0.5mmol/kg/hr
 Neonatal Prescribing Question

7. Write a prescription for morphine for

a 1.5kg baby at
0-20micrograms/kg/hr
 Neonatal Prescribing Answer

7. Write a prescription of morphine for a ventilated 1.5kg baby at

0-20micrograms/kg/hr
 Neonatal Prescribing Question

8. Write a prescription of dopamine for a ventilated 3kg baby at

5-15 micrograms/kg/min
 Neonatal Prescribing Answer

8. Write a prescription of dopamine for a ventilated 3kg baby at

5-15 micrograms/kg/min
 Neonatal Prescribing Question

9. Write a prescription for maintenance fluids for a 5 day old 1.4 kg

baby with normal baseline electrolytes (receiving 120 ml/kg/day)
 Neonatal Prescribing Answer

9. Write a prescription for maintenance fluids for a 5 day old 1.4 kg

baby with normal baseline electrolytes (receiving 120 ml/kg/day)

10.4mmol
Prescribing drugs on the Neonatal Unit

Importance of accurate prescribing

10 commandments
Where to go for help
Prescribing
- Antibiotics incl gentamicin
-Stopping prescriptions
- iv fluids and infusions
Prescribing drugs on the Neonatal Unit

?
 Parenteral Nutrition Prescribing
D6 Neonatal Parenteral Nutrition (PN) Guideline
 Parenteral Nutrition Prescribing

Prescribing PN is the responsibility of the On Service Registrar

in consultation with the On Service (daytime) Consultant
 Parenteral Nutrition Prescribing

All staff should be aware that:

There are 4 sorts of PN available:

1. Starter PN – for preterm infants < 48 hours of age

• Routinely <28/40 OR <1kg
• Consider in <34 weeks
• Start as soon as central access available.

2. Standard Preterm PN – for preterm infants > 48 hours of age

• Infants <34 weeks

3. “Term” PN
• Babies born > 34 weeks gestation and > 2.5 kg

All 3 require central administration

4. Peripheral PN for short term only due to lower nutrition
 Parenteral Nutrition Information

All staff should be aware

that:
Nutritional information on
regimes at delivered
volumes is summarised in
Guideline D6, to be
included in daily patient
reviews
 Parenteral Nutrition Information

Guideline D6 contains
detailed information about
PN as well as summary
guidance on prescribing PN
Prescribing PN on the Neonatal Unit