BNF for Children 2011-2012

84 2.3.2 Drugs for arrhythmias BNFC 2011–20122 Cardiovascular systemLidocaine can be used in cardiopulmonary resuscitationin children with ventricular fibrillation or pulselessventricular tachycardia unresponsive to d.c. shock,but only if amiodarone is not available. Doses may needto be reduced in children with persistently poor cardiacoutput and hepatic or renal failure (see under lidocaine,below).Verapamil (section 2.6.2) can cause severe haemodynamiccompromise (refractory hypotension and cardiacarrest) when used for the acute treatment of arrhythmiasin neonates and infants; it is contra-indicated inchildren under 1 year. It is also contra-indicated in thosewith congestive heart failure, syndromes associatedwith accessory conducting pathways (e.g. Wolff-Parkinson-Whitesyndrome) and in most receiving concomitantbeta-blockers. It can be useful in older children withsupraventricular tachycardia.ADENOSINECautions monitor ECG and have resuscitation facilitiesavailable; atrial fibrillation or flutter with accessorypathway (conduction down anomalous pathwaymay increase); first degree AV block; bundle branchblock; left main coronary artery stenosis; uncorrectedhypovolaemia; stenotic valvular heart disease; left toright shunt; pericarditis; pericardial effusion; autonomicdysfunction; stenotic carotid artery diseasewith cerebrovascular insufficiency; recent myocardialinfarction; heart failure; heart transplant (see dose);interactions: Appendix 1 (adenosine)Contra-indications second- or third-degree AV blockand sick sinus syndrome (unless pacemaker fitted);long QT syndrome; severe hypotension; decompensatedheart failure; asthmaPregnancy large doses may produce fetal toxicity;manufacturer advises use only if essentialBreast-feeding no information available—unlikely tobe present in milk owing to short half-lifeSide-effects nausea; arrhythmia (discontinue if asystoleor severe bradycardia occur), sinus pause, AVblock, flushing, angina (discontinue), dizziness; dyspnoea;headache; less commonly metallic taste, palpitation,hyperventilation, weakness, blurred vision,sweating; very rarely transient worsening of intracranialhypertension, bronchospasm, injection-site reactions;also reported vomiting, syncope, hypotension(discontinue if severe), cardiac arrest, respiratoryfailure (discontinue), and convulsionsLicensed use not licensed for use in childrenIndication and doseArrhythmias (see also section 2.3.1), diagnosisof arrhythmias. By rapid intravenous injectionNeonates 150 micrograms/kg; if necessary repeatinjection every 1–2 minutes increasing dose by 50–100 micrograms/kg until tachycardia terminatedor max. single dose of 300 micrograms/kg givenChild 1 month–1 year 150 micrograms/kg; ifnecessary repeat injection every 1–2 minutesincreasing the dose by 50–100 micrograms/kguntil tachycardia terminated or max. single dose of500 micrograms/kg givenChild 1–12 years 100 micrograms/kg; ifnecessary repeat injection every 1–2 minutesincreasing dose by 50–100 micrograms/kg untiltachycardia terminated or max. single dose of500 micrograms/kg (max. 12 mg) givenChild 12–18 years initially 3 mg; if necessaryfollowed by 6 mg after 1–2 minutes, and then by12 mg after a further 1–2 minutesNote In some children over 12 years 3-mg dose ineffective(e.g. if a small peripheral vein is used for administration)and higher initial dose sometimes used; however,those with heart transplant are very sensitive tothe effects of adenosine, and should not receive higherinitial doses. In children receiving dipyridamole reducedose to a quarter of usual dose of adenosineAdministration by rapid intravenous injection over 2seconds into central or large peripheral vein followedby rapid Sodium Chloride 0.9% flush; Injection solutionmay be diluted with Sodium Chloride 0.9% ifrequiredAdenocor c (Sanofi-Aventis) AInjection, adenosine 3 mg/mL in physiological saline,net price 2-mL vial = £4.45 (hosp. only)Note Intravenous infusion of adenosine (Adenoscan c ,Sanofi-Aventis) may be used in conjunction with radionuclidemyocardial perfusion imaging in patients who cannotexercise adequately or for whom exercise is inappropriate—consult product literatureAMIODARONE HYDROCHLORIDECautions liver-function and thyroid-function testsrequired before treatment and then every 6 months(see notes above for tests of thyroid function); hypokalaemia(measure serum-potassium concentrationbefore treatment); pulmonary function tests and chestx-ray required before treatment; heart failure; severebradycardia and conduction disturbances in excessivedosage; intravenous use may cause moderate andtransient fall in blood pressure (circulatory collapseprecipitated by rapid administration or overdosage) orsevere hepato-cellular toxicity (monitor transaminasesclosely); ECG monitoring and resuscitationfacilities must be available during intravenous use;acute porphyria (section 9.8.2); avoid benzyl alcoholcontaining injections in neonates (see Excipients,p. 2); interactions: Appendix 1 (amiodarone)Contra-indications except in cardiac arrest: sinusbradycardia, sino-atrial heart block; unless pacemakerfitted avoid in severe conduction disturbances orsinus node disease; thyroid dysfunction; iodine sensitivity;avoid intravenous use in severe respiratoryfailure, circulatory collapse, or severe arterial hypotension;avoid bolus injection in congestive heartfailure or cardiomyopathy; avoid rapid loading aftercardiac surgeryPregnancy possible risk of neonatal goitre; use only ifno alternativeBreast-feeding avoid; significant amount present inmilk—risk of neonatal hypothyroidism from release ofiodineSide-effects nausea, vomiting, taste disturbances,raised serum transaminases (may require dosereduction or withdrawal if accompanied by acute liverdisorders), jaundice; bradycardia (see Cautions);pulmonary toxicity (including pneumonitis and fibrosis);tremor, sleep disorders; hypothyroidism, hyperthyroidism;reversible corneal microdeposits (sometimeswith night glare); phototoxicity, persistent slategreyskin discoloration (see also notes above); lesscommonly onset or worsening of arrhythmia, conductiondisturbances (see Cautions), peripheral