March 2012

Standard Concentrations for Continuous Infusions

And Improving Opioid Safety in

Critically Ill ChildrenRoxane Carr PharmD, BCPS, FCSHP

Supervisor, Clinical Pharmacy Critical Care Program&

Tracie Northway, RN, MSN, CNCCP(C)Project Manager, Strategic Implementation, BC Children’s & Sunny Hill

&Kris Thibault RN, BScN

Quality & Safety Leader Critical Care Program

*Note: Patient weight range of 2 -157 kg

Pediatric Critical Care

•Delivery of “high risk” continuous infusion medications occurs commonly–Opioids–Benzodiazepines–Vasopressors/inotropes

Rule of Six Mixing:

•6 X pt weight (kg) = X mg•Put X mg into 100 mL of fluids(6 mg/kg/100 ml IV fluid)

•1 ml/hr delivers 1 mcg/kg/minute

•Concentration different for each patient but rate the same

Practice makes perfect?

Order reads: Norepinephrine at 0.1 mcg/kg/min

What you need to know…–J.M. weighs 26 kg –Norepinephrine comes as 1 mg/ml–Mix 0.6 mg/kg in 100 ml of D5W–1 ml/hr delivers 0.1 mcg/kg/minute

How much drug do you need to make the infusion?What is your final concentration?

Practice makes perfect?

Now calculate it based on a 50 mL volume.

Do the math:• 0.6 mg/kg x 26 kg = 15.6 mg•15.6 mg / Norepinephrine 1 mg/mL = 15.6 mL•D5W 100 mL. Remove 15.6 mL and add norepinephrine. Final concentration is 15.6 mg/100mL = 0.156 mg/mL

Standard Concentration

Order reads: Norepinephrine at 0.1 mcg/kg/minWhat you need to know…

J.M. weighs 26 kg

Norepinephrine standard concentrations:•Neonatal: 25 mcg/mL•Child: 50 mcg/mL•> 30 kg or fluid restricted: 200 mcg/mL

Which one do you select?

Selection Guidelines

Standard Concentrations

Mixing recipe:

•50 mcg/mL

•To make 50 mL of 50 mcg/mL

•Draw up 2.5mL of 1 mg/mL norepinephrine

•Add to 47.5 mL D5W

Standard Concentrations

Programming pump

•Calculate infusion rate:Rate (mL/hr) = dosage (mcg/kg/min) X 60 min/hr X pt wt (kg)

Concentration (mcg/mL)

1.561.872.182.502.813.126.249.36

12.4815.60

26

DOSE(mcg/kg/

min)0.050.060.070.080.090.100.200.300.400.50

Standard Concentrations

Program pump

•Enter patient weight

•Select drug and concentration from drug library in pump

(or scan barcode)

•Enter dosage (mcg/kg/min)

•Pump calculates infusion rate

•Confirm using equation

•Advantages:– Set rate for dose–Minimized fluid volume issues

•Disadvantages:–Different mixing–Errors in calculation –At time exceeded recommended safe concentrations for infusion–Not always rule of “6”

ComparisonWeight Based Concentration Standard Concentrations

•Advantages:–Standardized approach–Concentration always same–Decrease calculation & compounding errors

•Disadvantages:–Visual rate to dose identification difficult– Wrong concentration pick

Timeline

2006 – Dopamine vial shortage Switch to premade standard conc 2007 – Standard concentrations: epinephrine & milrinone - Smart pumps- Standard concentrations for all IV medications determined - Drug library created

Timeline

2008 - Standard concentrations: morphine & midazolam-Secured storage

2010 - Barcoding capabilities

2011/12 – Ongoing review of standards (number and concentrations)

Implementation strategies

• Collaborative effort between PICU and pharmacy

• Communication & interprofessional education for emergency, PICU & surgical suites

• Clinical support• Prompts & reminders• Responsive to feedback

Opioids

•Standard concentrations–Morphine (pre-mixed by pharmacy)–Hydromorphone–Fentanyl

•Bolus from continuous infusion syringe via pumps

•Education

Results

Results

Results

Summary

•Multipronged approach to improve safety•Standard concentrations decrease mixing errors•Smart pumps decrease pump programming errors•Bar coding decrease pump programming errors and drug selection errors

Summary - Opioids

•Multiple small changes to system over 1-2 yrs•Addressed variety of aspects

– Mixing– Administration– Monitoring

•Sustainable: – With each change review & reinforce previous

practice changes

Successful large sustained practice change