BNF for Children 2011-2012

110 2.6.4 Peripheral vasodilators and related drugs BNFC 2011–20122 Cardiovascular systemUniver c (Cephalon) ACapsules, m/r, verapamil hydrochloride 120 mg(yellow/dark blue), net price 28-cap pack = £4.86;180 mg (yellow), 56-cap pack = £11.38; 240 mg (yellow/darkblue), 28-cap pack = £7.67. Label: 25Excipients include propylene glycol (see Excipients, p. 2)DoseGive once dailyVerapress MR c (Dexcel) ATablets, m/r, pale green, f/c, verapamil hydrochloride240 mg, net price 28-tab pack = £6.04. Label: 25DoseGive 1–2 times dailyNote Also available as Cordilox c MRVertab c SR 240 (Chiesi) ATablets, m/r, pale green, f/c, scored, verapamilhydrochloride 240 mg, net price 28-tab pack = £5.45.Label: 25DoseGive 1–2 times daily2.6.3 Other antianginal drugsClassification not used in BNF for Children.2.6.4 Peripheral vasodilatorsand related drugsRaynaud’s syndrome consists of recurrent, long-lasting,and episodic vasospasm of the fingers and toes oftenassociated with exposure to cold. Management includesavoidance of exposure to cold and stopping smoking (ifappropriate). More severe symptoms may require vasodilatortreatment, which is most often successful inprimary Raynaud’s syndrome. Nifedipine and diltiazem(section 2.6.2) are useful for reducing the frequencyand severity of vasospastic attacks. In verysevere cases, where digital infarction is likely, intravenousinfusion of the prostacyclin analogue iloprostmay be helpful.Vasodilator therapy is not established as being effectivefor chilblains (section 13.13).ILOPROSTCautions see section 2.5.1.2Contra-indications see section 2.5.1.2Hepatic impairment dose may need to be halved inliver cirrhosisSide-effects see section 2.5.1.2Licensed use not licensed for use in childrenIndication and doseRaynaud’s syndrome see notes above. By intravenous infusionChild 12–18 years initially 30 nanograms/kg/hour, increased gradually to 60–120 nanograms/kg/hour given over 6 hours daily for 3–5 daysPulmonary hypertension section 2.5.1.2Administration for intravenous infusion, dilute to aconcentration of 200 nanograms/mL with Glucose5% or Sodium Chloride 0.9%; alternatively, may bediluted to a concentration of 2 micrograms/mL andgiven via syringe driverIloprost (Non-proprietary)Concentrate for infusion, iloprost (as trometamol)100 micrograms/mLFor dilution and use as an intravenous infusionNote available on a named patient basis from Bayer Scheringin 0.5 mL and 1 mL ampoules2.7 Sympathomimetics2.7.1 Inotropic sympathomimetics2.7.2 Vasoconstrictor sympathomimetics2.7.3 Cardiopulmonary resuscitationThe properties of sympathomimetics vary according towhether they act on alpha or on beta adrenergic receptors.Response to sympathomimetics can also varyconsiderably in children, particularly neonates. It isimportant to titrate the dose to the desired effect andto monitor the child closely.2.7.1 InotropicsympathomimeticsThe cardiac stimulants dobutamine and dopamine acton beta 1 receptors in cardiac muscle and increase contractilitywith little effect on rate.Dopamine has a variable, unpredictable, and dosedependent impact on vascular tone. Low dose infusion(2 micrograms/kg/minute) normally causes vasodilatation,but there is little evidence that this is clinicallybeneficial; moderate doses increase myocardial contractilityand cardiac output in older children, but in neonatesmoderate doses may cause a reduction in cardiacoutput. High doses cause vasoconstriction and increasevascular resistance, and should therefore be used withcaution following cardiac surgery, or where there is coexistingneonatal pulmonary hypertension.In neonates the response to inotropic sympathomimeticsvaries considerably, particularly in thoseborn prematurely; careful dose titration and monitoringare necessary.Isoprenaline injection is available from ‘special-order’manufacturers or specialist importing companies, seep. 809.Shock Shock is a medical emergency associated with ahigh mortality. The underlying causes of shock such ashaemorrhage, sepsis or myocardial insufficiency shouldbe corrected. Additional treatment is dependent on thetype of shock.Septic shock is associated with severe hypovolaemia(due to vasodilation and capillary leak) which should becorrected with crystalloids or colloids (section 9.2.2). Ifhypotension persists despite volume replacement,dopamine should be started. For shock refractory totreatment with dopamine, if cardiac output is high andperipheral vascular resistance is low (warm shock),noradrenaline (norepinephrine) (section 2.7.2) shouldbe added or if cardiac output is low and peripheral