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Standard Dose Development for Medications Commonly Used in the Neonatal Intensive Care Unit

Friday, October 19, 2012
Room R02-R05 (Morial Convention Center)
Christine Robinson, PharmD1, Anita Siu, PharmD1, Rachel Meyers, PharmD;BCPS1, Lisa Degnan, PharmD;BCPS1, Yitin Huang, PharmD2, Suzannah Cox, PharmD1, Christopher McPherson, PharmD3, Dawn Butler, PharmD4, Charla Miller, PharmD5, Katherine Pham, PharmD;BCPS6, Amy Potts, PharmD;BCPS7, Brian Winther, PharmD;BCPS8, Heather Monk9, Ben H. Lee, MD, MPH, MSCR10 and Jared Cash, PharmD11, (1)Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers The State University of New Jersey, Piscataway, NJ, (2)Tufts Medical Center, Boston, MA, (3)St. Louis Children's Hospital, St. Louis, MT, (4)Cincinnati Children's Hospital Medical Center, Cincinnati, OH, (5)Wolfson's Children's Hospital, Jacksonville, FL, (6)Children's National Medical Center, Washington, WA, (7)Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, (8)Primary Children's Medical Center, Salt Lake City, UT, (9)Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, (10)Neonatology, MidAtlantic Neonatology Associates, Morristown, NJ, (11)Pharmacy, Primary Children's Medical Center, Salt Lake City, UT

Case Report

: Background: A universal challenge in pediatric pharmacology is the mandatory use of weight and body surface area calculations for individualized drug-dosing; this is particularly true for neonatology where weight differences as small as 50 grams can result in significantly different dosing regimens. Unfortunately, such calculations are error prone and a significant source of medication error in this population. Furthermore, pediatric medication references and e-prescribing systems often require detailed calculations such as 0.1 mg per kilogram and the practically infinite number of pediatric weights creates an equally large number of potential final doses. “Standard doses”, “dose banding”, or “rounding tolerance” are terms used to describe the limitation of doses to a smaller subset to simplify medication processes without altering clinically desired effects. To our knowledge, however, the use of such standardized doses has not been described in the neonatal population.

Objective: The goal of this project is to establish standardized, rounded doses of medications for neonates in the neonatal intensive care unit (NICU) through a multi-institutional peer-reviewed process.

Methods:  Pediatric faculty and pediatric pharmacy residents from the Ernest Mario School of Pharmacy (Piscataway, NJ) conducted a systematic review of rounded, weight-based medication information for neonatal patients from September 2010 to April 2011. After initial review, an expanded workgroup of expert pediatric pharmacy clinicians from academic institutions throughout the United States were invited to conduct a final review. The workgroup identified 74 commonly prescribed medications in the NICU for the first phase of the review. Recommended standardized doses were established for discrete weight categories at workgroup consensus web-meetings conducted from June 2011 to December 2011. Workgroup recommendations were cross-referenced with published neonatal pharmacology resources (Neofax®, Lexi-Comp Pediatric Dosage Handbook®, primary literature, national guidelines). 

Results/Discussion: Standardized dosing was determined for each of the 74 reviewed medications. Three drug categories were utilized: oral medication (4), intermittent intravenous medication (64), and other modes of administration (e.g. intratracheal or intramuscular administration) (6).  Seventeen weight categories of increasing ranges in 10 gram increments were used, from 50 grams for the lowest weights (e.g. 350-400 grams) to 850 grams for the highest weights (e.g. 3650-4500g).  Most doses were rounded within 15% of the calculated dose: one less than 5%, none between 5-10%, 61 from 10-15%, and 12 between 15-20%.  Final recommendations for each drug were determined through workgroup peer-review. Consensus was obtained when references provided insufficient information on medication information. 

Conclusion:  Standardized, rounded doses of medications commonly used in the NICU were feasibly established by a multi-institutional peer review process. All standardized doses varied less than 20%, with the majority differing less than 15%, from calculated doses.