BNF for Children 2011-2012

BNFC 2011–2012 15.1.7 Antagonists for central and respiratory depression 647Breast-feeding section 10.2.1Side-effects section 10.2.1Indication and doseReversal of non-depolarising muscle block. By intravenous injection over 1 minuteNeonate 50 micrograms/kg, after or with glycopyrroniumor atropine; a further dose of 25 micrograms/kgmay be requiredChild 1 month–12 years 50 micrograms/kg(max. 2.5 mg) after or with glycopyrronium oratropine; a further dose of 25 micrograms/kg maybe requiredChild 12–18 years 50 micrograms/kg (max.2.5 mg) after or with glycopyrronium or atropine; afurther dose of 25 micrograms/kg (max. 2.5 mg)may be requiredMyasthenia gravis section 10.2.1Administration for intravenous injection, give undilutedor dilute with Glucose 5% or Sodium Chloride0.9%Neostigmine (Non-proprietary) AInjection, neostigmine metilsulfate 2.5 mg/mL, netprice 1-mL amp = 58pWith glycopyrroniumGlycopyrronium-Neostigmine (Non-proprietary) AInjection, neostigmine metilsulfate 2.5 mg, glycopyrroniumbromide 500 micrograms/mL, net price 1-mL amp = 91pDoseReversal of non-depolarising neuromuscular blockade. By intravenous injection over 10–30 secondsChild 1 month–18 years 0.02 mL/kg (or 0.2 mL/kg of a1 in 10 dilution), dose may be repeated if required (totalmax. 2 mL)Administration for intravenous injection, may be diluted withSodium Chloride 0.9%Other drugs for reversal ofneuromuscular blockadeSugammadex is a modified gamma cyclodextrin thatcan be used for rapid reversal of neuromuscular blockadeinduced by rocuronium (section 15.1.5). In practice,sugammadex is used mainly for rapid reversal of neuromuscularblockade in an emergency.SUGAMMADEXCautions recurrence of neuromuscular blockade—monitor respiratory function until fully recovered;recovery may be delayed in cardiovascular disease;pre-existing coagulation disorders or use of anticoagulants(unrelated to surgery); wait 24 hours beforere-administering rocuronium; interactions: Appendix1 (sugammadex)Renal impairment avoid if estimated glomerular filtrationrate less then 30 mL/minute/1.73 m 2Pregnancy use with caution—no information availableSide-effects taste disturbances; less commonly allergicreactions; bronchospasm also reportedIndication and doseRoutine reversal of neuromuscular blockadeinduced by rocuronium. By intravenous injectionChild 2–18 years 2 mg/kg (consult product literature)Administration for intravenous injection dose may bediluted to a concentration of 10 mg/mL with SodiumChloride 0.9%Bridion c (Schering-Plough) TAInjection, sugammadex (as sodium salt) 100 mg/mL,net price 2-mL amp = £59.64, 5-mL amp = £149.10Electrolytes Na + 0.42 mmol/mL15.1.7 Antagonists for centraland respiratorydepressionImportantThe drugs in this section should be used by experiencedpersonnel only.Respiratory depression is a major concern with opioidanalgesics and it may be treated by artificial ventilationor be reversed by an opioid antagonist. Naloxone givenintravenously immediately reverses opioid-inducedrespiratory depression but the dose may have to berepeated because of its short duration of action. Intramuscularinjection of naloxone produces a more gradualand prolonged effect but absorption may be erratic.Care is required in children requiring pain relief becausenaloxone also antagonises the analgesic effect ofopioids.Neonates Naloxone is used in newborn infants toreverse respiratory depression and sedation resultingfrom the use of opioids by the mother, usually for painduring labour. In neonates the effects of opioids maypersist for up to 48 hours and in such cases naloxone isoften given by intramuscular injection for its prolongedeffect. In severe respiratory depression after birth,breathing should first be established (using artificialmeans if necessary) and naloxone administered only ifuse of opioids by the mother is thought to cause therespiratory depression; the infant should be monitoredclosely and further doses of naloxone administered asnecessary.Flumazenil is a benzodiazepine antagonist for thereversal of the central sedative effects of benzodiazepinesafter anaesthetic and similar procedures. Flumazenilhas a shorter half-life and duration of action thandiazepam and midazolam, so children may becomeresedated.FLUMAZENILCautions short-acting (repeat doses may be necessary—benzodiazepineeffects may persist for at least24 hours); benzodiazepine dependence (may precipitatewithdrawal symptoms); prolonged benzodiazepinetherapy for epilepsy (risk of convulsions); historyof panic disorders (risk of recurrence); ensure neuromuscularblockade cleared before giving; avoid rapidinjection in high-risk or anxious children and following15 Anaesthesia