Hello all! Working as an RN in the ER, occasionally I float to the PEDS ER and what makes me the most nervous is my dosages. I lexicomp and calculate every medication before I give it (as a prudent nurse should) but I'm still feel a bit uncomfortable with dosaging, most especially with IV infusions and narcotics.
1. Most of the kids come in for fevers, so it's either tylenol or motrin and I know tylenol is max 15mg/kg and motrin 10mg/kg. I'm wondering if for example I have a 10kg kid and motrin 160 mg is ordered would that be too much, or do under no circumstance exceed the dose limit?
2. I had a 2 year old admitted for bronchiolitis, MD ordered 40 mg solumedrol IV, as I understand for this medication (when I lexi-comped it) that the max is 20 mg in divided doses?????
3. I also had an 8 year old who received 1 percocet an hour prior to me giving her tylenol 360mg/codeine 36 mg. I questioned the order with both the MD, NP, and another RN which they said the dose was fine. Child was not lethargic, etc.. But still since I'm so used to giving narcotics to only adults, giving it in PEDS freaked me out a bit.
4. Lastly. Had a 6month old also admitted for bronchiolitis/RSV + and was received fluids. Are there any quick fluid calculations that I can do for peds so I can be sure I'm not overloading them???
Sorry if these questions seem a trivial. I like peds, but being a fairly new RN with limited peds training, I'd like to learn. Thanks!
Jan 3, '12
I won't answer each one individually but we use the Harriet Lane handbook for all peds dosing. It gives us specific instances where the general max dosing is exceeded. RE: solumedrol or prednisolone. When we calculate a dose and it is higher than the max dose, we question it with the MD. We even had a case where we "strongly" questioned a dose and asked for clarification. MD changed the dose. They explained their reasoning but we still did not feel comfortable with the dose so they changed it.
As for narcotics in kids, it depends why they are being given. We have some MDs that will go bonkers that narcotics were given to kids first without trying tylenol or motrin. All depends on the reason.
Try the Harriet Lane book, it is really a great tool for pedi.
Jan 3, '12
1. Motrin is 10 mg/kg and Tylenol is 10-15 mg/kg with a max of 75 mg/kg/day.
2. I am used to giving doses of Solu-Medrol much higher than 40 mg. By no means is 20 mg the max. 1g is the max I am used to for "high dose Solu-Medrol" which we use for autoimmune disorders and it's given in one daily dose. If you are giving what is considered to be "high dose" Solu-Medrol, it needs to be given over 2 hours with BPs done every 15-30 minutes. Admittedly, I am not familiar with the dosing for bronchiolitis because I am used to using it for autoimmune disorders.
3. Why was the child needing narcotics? I am assuming this child weighed 36 kg as codeine's dosing is 1:1 so that would be an appropriate tylenol and codeine dose. If, however, the child had received a percocet with 325 mg of Tylenol in it an hour before, she should not receive more tylenol because her q 4 hr tylenol dose as a 36 kg 8 year old would be 540 mg. It's unlikely that the small extra amount is going to do her any damage but, as a rule of thumb, we always tell people that 2 tylenol-containing medications cannot be given within 4 hours of each other. Why not just give her the straight codeine if she'd already gotten her tylenol in the percocet?
4. Maintenance fluids for children are as follows:
4 mL/kg/hr for the first 10 kg
2 mL/kg/hr for the next 10 kg
1 mL/kg/hr thereafter.
So maintenance for a 23 kg child would be 63 mL/hr. As far as fluid boluses go, usually 10-20 cc/kg. I believe the max in my facility is 40 mL/kg though usually that would be given as multiple boluses.
Jan 4, '12
No question about the safe dosing of medication to children can ever be considered trivial.
Stress-dose steroids should be given to any child exhibiting symptoms of serious illness at a dose of 1 mg/kg q6h. This is a recent change in practice supported by evidence that the stress of critical illness creates a relative and temporary adrenal insufficiency. As for administration of steroids for children with bronchiolitis, that practice should have fallen by the wayside. A number of studies have shown that they're not effective and may create more problems than they solve. You're unlikely to see children on chemotherapy which includes high-dose steroids such as prednisone 2-5 mg/kg/dose BID. That's a lot of prednisone but it's the dose that is required for adjunct chemo.
Having seen children with fulminant liver failure from acetaminophen overdose, I take the no-more-than-5-doses-in-24-hours rule very seriously. For many of our surgical patients we alternate acetaminophen and ibuprofen q6h so they are getting an analgesic q3h and the synergy is quite effective... as long as their renal function is good.
Jan 6, '12
Harriet Lane is a great resource as is The Teddy Bear book. I find it an easier read. It is strictly for IV meds whether they be pushes/intermittent infusions/continuous infusions and gives you the min and max dosing in a 24 hr period. (clarification: You have to know the weight in kg and actually do the calculation to figure out min and max, but great tool nonetheless).
Last edit by jnndub on Jan 6, '12
: Reason: clarification
Apr 19, '12
Wow you US guys do things differently! I'm a paeds nurse in the UK. We give paracetemol (tylenol) 15-20mg/kg max qds, ibuprofen (motrin) 5-10mg/kg max tds.
Apr 26, '12
i know this is late...... for the solumedrol the 40mg was probably a loading dose and the next doses will not be as high. At least that's how we do it for asthmatics at my hospital. At my hospital even though the safe dose of tylenol is 15mg/kg-20mg/kg MDs will only do 20mg/kg.
Oct 26, '13
If there is a dosage that looks off I always double check with the doc, sometimes they have rationale for their dose, other times it is a mistake. For the fluids the above poster is correct. I also check to make sure they are urinating at least 1ml/kg/hr over a number of hours. If they are eating and drinking and their IV is at a low rate (or non-existent) I don't worry about fluid overloading. (Unless of course there is underlying pathology such as kidney or cardiac issues). Respiratory babies do better when they are not dehydrated.