BNF for Children 2011-2012

BNFC 2011–2012 2.14 Drugs affecting the ductus arteriosus 131concomitant use of nephrotoxic drugs; may inducehyponatraemia; inhibition of platelet aggregation(monitor for bleeding); interactions: Appendix 1(NSAIDs)Contra-indications untreated infection, bleeding(especially with active intracranial haemorrhage orgastro-intestinal bleeding); thrombocytopenia, coagulationdefects, necrotising enterocolitisHepatic impairment increased risk of gastro-intestinalbleeding and fluid retention; avoid in severeimpairmentRenal impairment use lowest effective dose andmonitor renal function; sodium and water retention;deterioration in renal function possibly leading torenal failure; avoid if possible in severe impairmentAnuria or oliguria If anuria or marked oliguria (urinaryoutput less than 0.6 mL/kg/hour), delay further doses untilrenal function returns to normalSide-effects haemorrhagic, renal, gastro-intestinal,metabolic, and coagulation disorders; pulmonaryhypertension, intracranial bleeding, fluid retention,and exacerbation of infectionIndication and doseSymptomatic ductus arteriosus. By intravenous infusion over 20–30 minutesNeonate initially 100–200 micrograms/kg as asingle dose followed by 2 doses of 100 micrograms/kgat 24-hour intervals; if residual patencypresent, give 100 micrograms/kg for a further 3doses at 24-hour intervalsNote Monitor carefully to ensure adequate urine output,see Anuria or Oliguria abovePain and inflammation in rheumatic diseasesection 10.1.1Administration for intravenous infusion, dilute eachvial with 1–2 mL Sodium Chloride 0.9% or Water forInjectionsIndometacin (Non-proprietary) AInjection, powder for reconstitution, indometacin (assodium trihydrate)Available from ‘special-order’ manufacturers or specialistimporting companies, see p. 809In the newborn with duct-dependent congenital heartdisease it is often necessary to maintain the patency ofthe ductus arteriosus whilst awaiting surgery.Alprostadil (prostaglandin E1) and dinoprostone (prostaglandinE2) are potent vasodilators that are effectivefor maintaining the patency of the ductus arteriosus.They are usually given by continuous intravenous infusion,but oral dosing of dinoprostone is still used in somecentres.During the infusion of a prostaglandin, the newbornrequires careful monitoring of heart rate, blood pressure,respiratory rate, and core body temperature. In theevent of complications such as apnoea, profound bradycardia,or severe hypotension, the infusion should betemporarily stopped and the complication dealt with;the infusion should be restarted at a lower dose. Recurrentor prolonged apnoea may require ventilatory supportin order for the prostaglandin infusion to continue.ALPROSTADILCautions see notes above; also history of haemorrhage;avoid in hyaline membrane disease; monitorarterial pressure, respiratory rate, heart rate, temperature,and venous blood pressure in arm and leg;facilities for intubation and ventilation must beimmediately available; interactions: Appendix 1(alprostadil)Side-effects apnoea (particularly in neonates under2 kg), flushing, bradycardia, hypotension, tachycardia,cardiac arrest, oedema, diarrhoea, fever, convulsions,disseminated intravascular coagulation, hypokalaemia;cortical proliferation of long bones; weakeningof the wall of the ductus arteriosus and pulmonaryartery may follow prolonged use; gastric-outletobstruction reportedIndication and doseMaintaining patency of the ductus arteriosus. By continuous intravenous infusionNeonate initially 5 nanograms/kg/minute,adjusted according to response in steps of 5 nanograms/kg/minute;max. 100 nanograms/kg/minute (but associated with increased side-effects)Note Alprostadil doses in BNFC may differ from those inproduct literatureAdministration dilute 150 micrograms/kg bodyweightto a final volume of 50 mL with Glucose 5% orSodium Chloride 0.9%; an intravenous infusion rate of0.1 mL/hour provides a dose of 5 nanograms/kg/minute. Undiluted solution must not come into contactwith the barrel of the plastic syringe; add therequired volume of alprostadil to a volume of infusionfluid in the syringe and then make up to final volumeProstin VR c (Pharmacia) AIntravenous solution, alprostadil 500 micrograms/mL in alcohol. For dilution and use as an infusion. Netprice 1–mL amp = £75.19 (hosp.only)2 Cardiovascular systemMaintenance of patencyDINOPROSTONECautions see notes above; also history of haemorrhage;avoid in hyaline membrane disease; monitorarterial oxygenation, heart rate, temperature, andblood pressure in arm and leg; facilities for intubationand ventilation must be immediately available; interactions:Appendix 1 (prostaglandins)Hepatic impairment manufacturer advises avoidRenal impairment manufacturer advises avoidSide-effects nausea, vomiting, diarrhoea; flushing,bradycardia, hypotension, cardiac arrest; respiratorydepression and apnoea, particularly with high dosesand in low birth-weight neonates, bronchospasm;pyrexia and raised white blood cell count, shivering;local reactions, erythema; if used for longer than 5days, gastric outlet obstruction; cortical hyperostosis(prolonged use)Licensed use not licensed for use in children