BNF for Children 2011-2012

114 2.7.3 Cardiopulmonary resuscitation BNFC 2011–20122 Cardiovascular systemPregnancy may reduce placental perfusion and candelay second stage of labour; manufacturers adviseuse only if benefit outweighs riskBreast-feeding present in milk but unlikely to beharmful as poor oral bioavailabilitySide-effects nausea, vomiting, dry mouth, anorexia,hypersalivation; arrhythmias, palpitation, tachycardia,syncope, angina, hypertension (risk of cerebralhaemorrhage), cold extremities, pallor; dyspnoea,pulmonary oedema (on excessive dosage or extremesensitivity); anxiety, tremor, restlessness, headache,insomnia, confusion, weakness, dizziness, hallucinations,psychosis; hyperglycaemia; difficulty in micturition,urinary retention; metabolic acidosis; hypokalaemia;mydriasis, angle-closure glaucoma; tissuenecrosis at injection site and of extremities, liver andkidneys, sweatingIndication and doseAcute hypotension. By continuous intravenous infusionNeonate initially 100 nanograms/kg/minuteadjusted according to response; higher doses up to1.5 micrograms/kg/minute have been used inacute hypotensionChild 1 month–18 years initially 100 nanograms/kg/minute adjusted according to response; higherdoses up to 1.5 micrograms/kg/minute have beenused in acute hypotensionAnaphylaxis section 3.4.3Cardiopulmonary arrest section 2.7.3Administration for continuous intravenous infusion,dilute with Glucose 5% or Sodium Chloride 0.9% andgive through a central venous catheter. Incompatiblewith bicarbonate and alkaline solutions.Neonatal intensive care, dilute 3 mg/kg body-weightto a final volume of 50 mL with infusion fluid; anintravenous infusion rate of 0.1 mL/hour provides adose of 100 nanograms/kg/minuteNote These infusions are usually made up with adrenaline 1in 1000 (1 mg/mL) solution; this concentration of adrenalineis not licensed for intravenous administrationPreparationsSection 3.4.32.7.3 CardiopulmonaryresuscitationThe algorithms for cardiopulmonary resuscitation (seeinside back cover) reflect the recommendations of theResuscitation Council (UK); they cover paediatric basiclife support, paediatric advanced life support, and newbornlife support. The guidelines are available atwww.resus.org.uk.Paediatric advanced life support Cardiopulmonary(cardiac) arrest in children is rare and frequently representsthe terminal event of progressive shock or respiratoryfailure.During cardiopulmonary arrest in children withoutintravenous access, the intraosseous route is chosenbecause it provides rapid and effective response; ifcirculatory access cannot be gained, the endotrachealtube can be used. When the endotracheal route is usedten times the intravenous dose should be used; the drugshould be injected quickly down a narrow bore suctioncatheter beyond the tracheal end of the tube and thenflushed in with 1 or 2 mL of sodium chloride 0.9%. Theendotracheal route is useful for lipid-soluble drugs,including lidocaine, adrenaline, atropine, and naloxone.Drugs that are not lipid-soluble (e.g. sodium bicarbonateand calcium chloride) should not be administered bythis route because they will injure the airways.For the management of acute anaphylaxis see section3.4.3.2.8 Anticoagulants andprotamine2.8.1 Parenteral anticoagulants2.8.2 Oral anticoagulants2.8.3 Protamine sulphateAlthough thrombotic episodes are uncommon in childhood,anticoagulants may be required in children withcongenital heart disease; in children undergoing haemodialysis;for preventing thrombosis in children requiringchemotherapy and following surgery; and for systemicvenous thromboembolism secondary to inheritedthrombophilias, systemic lupus erythematosus, orindwelling central venous catheters.2.8.1 Parenteral anticoagulantsHeparinHeparin initiates anticoagulation rapidly but has a shortduration of action. It is now often referred to as beingstandard or unfractionated heparin to distinguish itfrom the low molecular weight heparins (see p. 116),which have a longer duration of action. For children athigh risk of bleeding, unfractionated heparin is moresuitable than low molecular weight heparin because itseffect can be terminated rapidly by stopping the infusion.Heparins are used in both the treatment and prophylaxisof thromboembolic disease, mainly to prevent furtherclotting rather than to lyse existing clots—surgery or athrombolytic drug may be necessary if a thrombusobstructs major vessels.Treatment For the initial treatment of thromboticepisodes unfractionated heparin is given as an intravenousloading dose, followed by continuous intravenousinfusion (using an infusion pump) or by intermittentsubcutaneous injection; the use of intermittentintravenous injection is no longer recommended. Alternatively,a low molecular weight heparin may be givenfor initial treatment. If an oral anticoagulant (usuallywarfarin, section 2.8.2) is also required, it may be startedat the same time as the heparin (the heparin needs to becontinued for at least 5 days and until the INR has beenin the therapeutic range for 2 consecutive days). Labora-