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Pediatric Emegency Room

Hello all!

So I am primarily an adult ED nurse but occasionally get floated to the peds ED. The thing that makes me the most nervous is of course medication in children, most especially

I had a child over the weekend who was 12.8kg with an order of ceftriaxone 750mg in 50ml over 30 minutes with a 0.9NS of 200ml/hr.

Our hopsital has uptodate.com which contains (lexicomp) so I did the calculation for ceftriaxone which is 50mg/kg so for this child it would be max of 640mg/dose but no more than 2G per dose per day, which was somewhat confusing.

Also as I understand fluid bolus calculation is 10-20ml/kg??? so 200ml/hr seemed appropriate.

Just wondering is it common to have dosages ordered that are slightly above recommended????

Also what is a great pediatric ED nursing or even physician reference.

Thanks in advance!

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology.

Kudos to you for looking it up. I understand where your confusion comes from. The maximum dose of 2gm is for the largest peds patient. Some of those teenagers are pretty large... bigger than a lot of adults. So when treating a peds patient who is on the large side you wouldn't ever want to go over what an adult would be given. An anecdote that I always think of when talking about those big kids was a 110 kg 16 year old who'd suffered a TBI and was eventually transferred to the peds floor. He arrested while sitting unobserved in his wheelchair. When the code team arrived the newly-fledged second year resident kept asking for "epi, 11 mg" based on the PALS dose of 0.1 mg/kg. The PICU nurse who was the code team nurse told him "you can have 10..." every time.

As for the ordered dose, when given for "serious" infections the usual dose is 50-75 mg/kg/dose and for meningitis the dose could go as high as 100 mg/kg for the initial dose (max 4gm) followed by 100 mg/kg/day in divided doses q12h. Does that help?

Thanks NotReady! so you mean the usual dose for ceftriaxone is 50-75mg/kg/dose? if so I feel better about the dosaging. I always look up my doses in peds, yes even with tylenol and motrin because floating between adult and peds can blur the lines sometimes and I just like being sure.

I even had a question of how fast antibiotics should go in per minute? But I guess that is not so big of a deal once the dosage and volume of fluids is safe???? am i right or????

But thanks for your reply!

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology.

Generally speaking ceftriaxone isn't prescribed for any of the garden-variety bugs. It's often given in the setting of sepsis as an initial antimicrobial while cultures are pending because of its broad spectrum and the fact it can be given IM. Rarely do we see it given as THE antimicrobial for duration of treatment for serious infection though.

Fluid boluses are usually 10 mL/kg x as many as needed to reach hemodynamic stability. If you're already up to 60 mL/kg then it might be time to consider norepinephrine as an adjunct to fluid. As long as you're not squeezing an empty tank, norepi is the best inotrope for shock in kids. Even kids with congenital heart conditions will typically tolerate a large volume of fluid.

There are a number of drugs that can be given IV direct over 3-5 minutes. They include morphine, midazolam, lorazepam, diazepam, ketamine, propofol, fentanyl, succinylcholine, rocuronium, vecuronium, pancuronium, ketorolac, hydrocortisone, dexamethasone, ondansetron, metoclopramide, cefazolin, ampicillin, meropenem, gentamicin, tobramycin, digoxin, atropine, diphenhydramine, dimenhydrinate, naloxone, flumazenil and vitamin K. Antibiotics such as cetotaxime, ceftriaxone, cefuroxime, imipenem, piperacillin (+/- tazobactam) and penicillin G can be ifused over 5-30 minutes. Others such as ciprofloxacin, levofloxacin, metronidazole, clindamycin, and vancomycin should run over at least 1 hour and amphotericin B over at least 2 hours. You probably won't be administering most of these to peds patients in the ER but you never know.

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