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Electronic letters published:
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Optimal Pediatric Emergency Drug Dosing: Volume-Based Dosing
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Young S. Choi, MD Womack Army Medical Center
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young.choi2{at}amedd.army.mil Young S. Choi
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TO THE EDITOR: Wheeler et al. (1) address the occurrence of medication errors during pediatric emergency treatment. In their simulated model, participants were required to calculate the correct dose of intramuscular epinephrine for a 5-year-old with peanut anaphylaxis. They concluded that patient safety might be improved by expressing epinephrine drug concentrations exclusively as mass concentration rather than ratio. While the dose of emergency medications is standardized in adults, pediatric dosages are weight based. Once the milligram amount of a medication is determined, the correct volume must then be calculated. A volume-based protocol would eliminate the extra step of conversion and furthermore, might eliminate calculations altogether. The Broselow Pediatric Emergency Tape uses a child’s length to estimate weight and automatically calculate not only the milligram amount but also the correct volume for two common intravascular resuscitative medications, epinephrine and atropine. For instance, a 13 kg child’s dose of intravenous epinephrine (1:10,000 dilution) is 0.13 mg which is delivered as 1.3 mL. Unfortunately, the Broselow Pediatric Emergency Tape does not pre- calculate the volume for other medications. A complete volume-based emergency protocol is the optimal method for delivery of resuscitative medications. Automated computerized “code” sheets can easily be developed for at risk patients. At Womack Army Medical Center, all pediatric patients have a weight based computerized “code” sheet posted at the bedside listing the specific volume for all the common emergency medications. No calculations are required. For outpatients, a pediatric emergency protocol that does not require calculations remains optimal. The Color Coding Kids Hospital System is a commercially available example. While such a hospital-wide system may be a drastic change, it certainly is feasible to have some type of system in place for at least the most common emergencies (2). For example, for treatment of anaphylaxis, the recommended dose is 0.01 mg/kg of epinephrine (1:1,000 dilution or 1 mg/mL concentration) to a max of 0.3 mg intramuscularly or subcutaneously (3). Therefore, any child 30 kg or more would receive 0.3 mL. For those patients weighing less than 30 kg, a pre- calculated volume could be ascribed to various weights. Even if pre- calculated volume-based dosing is not used, the volume-based calculation can be posted to eliminate one additional calculation, i.e., the emergency dose would be 0.01 mL/kg rather than 0.01 mg/kg. References 1. Wheeler DH, Carter JJ, Murray LJ, Degnan BA, Dunling CP, Salvador R, et al. The effect of drug concentration expression on epinephrine dosing errors. Ann Intern Med. 2008;148:11-14. [PMID: 18166759] 2. Shah AN, Frush K, Luo X, Wears RL. Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events. Arch Pediatr Adolesc Med. 2003;157:229-36. [PMID: 12622671] 3. Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol 2005;115:S483-523. [PMID: 15753926] Conflict of Interest:The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or Department of Defense. |
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