PALS meds

Pediatric Critical Care Columnist · Nov 7, 2005

We don't dilute our meds down. We use 1cc syringes to draw up accurate doses, give them rapid IV push then follow them with a good sized flush, at least 5cc per med if using peripheral access. For ETT doses they get a larger dose (of course) and a minimum 10cc flush. We don't use the Broselow tape or the rule of six; much evidence lately that neither are accurate enough. Nothing in our facility is premixed. Each of our code carts has a spiral bound book with weight-based charts, in 0.5kg increments, of doses for the most commonly used code drugs and recipes for infusions.

In the unit most of our patients have central access and they all have a customized code sheet with their accurate weight and all the calculations done. It's simply a matter of finding the drug you want and drawing it up. Our code sheets are done on the computer using a spreadsheet designed by our code committee and pharmacy; when a kid is admitted we automatically do a code sheet by entering their weight and age in the appropriate fields on the spreadsheet and printing the result. I like to tuck them into the back of the chart when I transfer a kid to the ward, just in case something goes wrong later, but the book on the cart is usually close enough.

ERERER · Nov 8, 2005

thanks for the info, really appreciate it. the ER where i am working now doesn't see many sick sick kids (no peds unit in the hospital), but the worst case scenerio is the ones that arrive by private car. and that occasionally happens (lost a 9 day old last week). not too many nurses here are comfortable with kids, so it helps to have some guidelines. hopefully we can get everything going. too bad they don't have a PALS for Dummies book!!

Pediatric Critical Care Columnist · Nov 8, 2005

It might be worthwhile to purchase a PALS algorithm poster to put in your resus room to guide you through a pediatric resus. It definitely would help you out to have the drug manual I mentioned. That way you could have close-enough dosing information right at hand. Peds resuses are very anxiety-provoking, even for those of us who do them all the time. Having readily-accessible guidelines makes it much less likely that things will get missed. Another thing you might want to institute is mock code. You can get your resusibaby out and do some dry runs using different scenarios so that everyone in the room feels like they could actually do it if they had to. Good luck.

outlierrn · Feb 20, 2006

In my ER we have a dedicated peds crash cart, each drawer is a different color and corresponds to a color on the Braslow tape. Within each drawer are the supplies that are right size for that pt. We have several cheat sheets, peds micro blood tubes, and sealed intubation and drug trays. Try and eliminate every step possible from the actual code, your brain just won't work right unless you get lots of practice,

Larry

Pedi-ER-RN, RN · Feb 21, 2006

Being at a Ped's facility, we do not use Braslow's tapes. We have a resuscitation book like mentioned above. I use this as my brain when I am the one responsible for meds during the code. The only problem I have now is mixing gtts, since the rule of 6's has been done away with. We have some computerized gtt program, but who has enough since to log onto a computer during a resuscitation? I plan to take this matter up with education or pharmacy and try to get it resolved. In our old resuscitation book, the rule of 6's was there for each wt (it told you everything to do). How are you guys mixing gtts (epi, etc..)??

Pediatric Critical Care Columnist · Feb 21, 2006

we use a method for our drips that i find to be quite simple and we can have an epi infusion running in about 2 minutes... we use syringe pumps to deliver all vasoactive meds, we find that other types of volumetric pumps typically use a pulse delivery system that causes nasty peaks and valleys in our bps. we mix all our drips based on a "standard" rate such that 1ml/hr will give us "xmg(mcg, or whatever the base dose will be)/kg/hr(min). we have some standard dose/concentrations for our most often used meds too. let's see if i can make this clear, because i can see your forehead wrinkling...

let's say we want to start epi on a post-arrest patient who weighs 16.8 kg. the usual dosage concentration for epi (and norepi) is 0.1 mcg/kg/min. we want the drip to start off at 0.05 mcg/kg/min. we calculate our recipe:

16.8 (kg) x 0.1 (concentration desired) x 50 (volume to be prepared) x 60 (minutes in an hour) = 5040 (mcg of drug needed) / 1000 (to obtain mg, the dosage of the drug in the bottle) = 5.04 mg since epi comes in a 1 ml = 1 mg formulation we then draw up 5.04 (or close enough) ml and mix it into a total volume of 50 ml d5w. running the pump at 1 ml per hour will then give us 0.1 mcg/ kg/ min of epi. to obtain our ordered dose of 0.05 mcg/kg/min we'd run the pump at 0.5 ml per hour.

there are several nice things about this method. it's the same for all patients. period. you (and anyone else walking by, or covering for a break) can see at a glance what your meds are running at. titration is a no-brainer. the pumps are all labeled with the name of the drug and the concentration formula, for example, our epi infusion would have a label stating " epinephrine 1 ml/hr = 0.1 mcg/kg/min".

the only time we depart from this recipe is for patients who are very big. then we will have to change the concentration of drug in the syringe to meet maximum concentrations allowed. an example of this would be milrinone. our standard concentration is 1 ml/hr = 0.5 mcg/kg/min, but for our bigger teenagers we have to mix it so that 1 ml/hr = 0.25mcg/kg/min because we can't get the desired concentration in the volume we have. milrinone comes as 1 ml = 1 mg. if the patient weighs 70 kg, with our standard concentraion we'd need 105 mg to be mixed in 50 ml of d5w... and i've never figured out how to get 105 into 50. but milrinone isn't a pals med... so i guess you didn't need to know that.

here's some more stuff you probaly don't need to know: our standard concentrations for other typical meds...

morphine = 1 ml/hr = 20 mcgs/kg/hr for non cardiac and either 50 or 100 mcg/kg/hr for fluid restricted patients

midazolam= 2 mcg/kg/min

norepinephrine = 0.1 mcg/kg/min

dopamine and dobutamine = 5 mcg/kg/min

vasopressin = 0.0003 mcg/kg/min

sodium nitroprusside and nitroglycerine = 1 mcg/kg/min

heparin = 10 units/kg/hr

insulin = 0.05 units/kg/hr

i hope this makes sense to you. it's a very easy system to learn and use. the harder part is knowing what the "usual" is.

Pedi-ER-RN, RN · Feb 22, 2006

Thanks, it makes perfect sense. I'm gonna jot this down and keep it with my PDA.

Pediatric Critical Care Columnist · Feb 22, 2006

No worries. Where I used to work we used standard concentrations in a diffferent way, like "dopamine 3200mcg/mL", which makes the math a LOT harder!! I don't know if I could even do it now. :eek: I'm thinking the drip would have to run at 1.4mL/hr to give a dose of 5 mcg/kg/min, but I'm really rusty... I like this method so much better.

JenACNPICU · Apr 4, 2006

We do not dilute any meds. We currently use the rules of 6's.

We have found that many reviews of the arrest cart (t/o the year) and doing Mock codes in the unit are very helpful to the staff. They really need the hands-on experiences esp with working with so many small amounts of ER drus on the little ones.

Sincerely,

Jennifer