Cardiac arrest

Cardiopulmonary resuscitation

Overview

The algorithms for cardiopulmonary resuscitation (Life support algorithm (see inside back cover)) reflect the recommendations of the Resuscitation Council (UK); they cover paediatric basic life support, paediatric advanced life support, and newborn life support. The guidelines are available atwww.resus.org.uk.

Paediatric advanced life support

Cardiopulmonary (cardiac) arrest in children is rare and frequently represents the terminal event of progressive shock or respiratory failure.

During cardiopulmonary arrest in children without intravenous access, the intraosseous route is chosen because it provides rapid and effective response; if circulatory access cannot be gained, the endotracheal tube can be used. When the endotracheal route is used ten times the intravenous dose should be used; the drug should be injected quickly down a narrow bore suction catheter beyond the tracheal end of the tube and thenflushed in with1^or2mL of sodium chloride0^.9%. The endotracheal route is useful for lipid-soluble drugs, including lidocaine hydrochloride p.70^, adrenaline/epinephrine below, atropine sulfate p.764^{, and} naloxone hydrochloride p.796. Drugs that are not lipid-soluble (e.g. sodium bicarbonate p.544and calcium chloride p.553^{) shouldnot}be administered by this route because they will injure the airways.

For the management of acute anaphylaxis, see allergic emergencies under Antihistamines, allergen immunotherapy and allergic emergencies p.162^..

SYMPATHOMIMETICS

›

VASOCONSTRICTOR

Adrenaline/epinephrine

lDRUG ACTIONActs on both alpha and beta receptors and increases both heart rate and contractility (beta₁effects); it can cause peripheral vasodilation (a beta₂effect) or vasoconstriction (an alpha effect).

lINDICATIONS AND DOSE Acute hypotension

▶BY CONTINUOUS INTRAVENOUS INFUSION

▶Neonate:Initially100nanograms/kg/minute, adjusted according to response, higher doses up to

1^.5micrograms/kg/minute have been used in acute hypotension.

▶Child:Initially100nanograms/kg/minute, adjusted according to response, higher doses up to 1^.5micrograms/kg/minute have been used in acute hypotension

Croup (when not effectively controlled with corticosteroid treatment)

▶BY INHALATION OF NEBULISED SOLUTION

▶Child 1 month–11 years:400micrograms/kg (max. per dose5mg), dose to be repeated after30^{minutes if} necessary

PHARMACOKINETICS

The effects of nebulised adrenaline for the treatment of croup lasts for2–3^hours.

Emergency treatment of acute anaphylaxis (under expert supervision)|Angioedema (if laryngeal oedema is present) (under expert supervision)

▶BY INTRAMUSCULAR INJECTION

▶Child 1 month–5 years:150micrograms, doses may be repeated several times if necessary at5^minute intervals according to blood pressure, pulse, and respiratory function, suitable syringe to be used for measuring small volume; injected preferably into the anterolateral aspect of the middle third of the thigh

▶Child 6–11 years:300micrograms, doses may be repeated several times if necessary at5^minute intervals according to blood pressure, pulse, and respiratory function, to be injected preferably into the anterolateral aspect of the middle third of the thigh

▶Child 12–17 years:500micrograms, to be injected preferably into the anterolateral aspect of the middle third of the thigh, doses may be repeated several times if necessary at5minute intervals according to blood pressure, pulse, and respiratory function, 300micrograms (0^.3mL) to be administered if child small or prepubertal

Acute anaphylaxis when there is doubt as to the adequacy of the circulation (specialist use only)|Angioedema (if laryngeal oedema is present) (specialist use only)

▶BY SLOW INTRAVENOUS INJECTION

▶Child:1microgram/kg (max. per dose50micrograms), using dilute1ⁱⁿ10 000adrenaline injection, dose to be repeated according to response, if multiple doses required, adrenaline should be given as a slow intravenous infusion stopping when a response has been obtained

EMERADE^®150 MICROGRAMS

Acute anaphylaxis (for self-administration)

▶BY INTRAMUSCULAR INJECTION

▶Child (body-weight up to 15 kg):150micrograms, then 150micrograms after5–15minutes as required

▶Child (body-weight 15–30 kg):150micrograms, then 150micrograms after5–15minutes as required, on the basis of a dose of10micrograms/kg,300^micrograms may be more appropriate for some children EMERADE^®300 MICROGRAMS

Acute anaphylaxis (for self-administration)

▶BY INTRAMUSCULAR INJECTION

▶Child (body-weight 30 kg and above):300micrograms, then300micrograms after5–15minutes as required EMERADE^®500 MICROGRAMS

Acute anaphylaxis (for self-administration for patients at risk of severe anaphylaxis)

▶BY INTRAMUSCULAR INJECTION

▶Child 12–17 years:500micrograms, then500^micrograms after5–15minutes as required

EPIPEN^®AUTO-INJECTOR 0.3MG Acute anaphylaxis (for self-administration)

▶BY INTRAMUSCULAR INJECTION

▶Child (body-weight 30 kg and above):300micrograms, then300micrograms after5–15minutes as required EPIPEN^®JR AUTO-INJECTOR 0.15MG

Acute anaphylaxis (for self-administration)

▶BY INTRAMUSCULAR INJECTION

▶Child (body-weight up to 15 kg):150micrograms, then 150micrograms after5–15minutes as required

▶Child (body-weight 15–30 kg):150micrograms, then 150micrograms after5–15minutes as required, on the basis of a dose of10micrograms/kg,300^micrograms may be more appropriate for some children

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JEXT^®150 MICROGRAMS

Acute anaphylaxis (for self-administration)

▶BY INTRAMUSCULAR INJECTION

▶Child (body-weight up to 15 kg):150micrograms, then 150micrograms after5–15minutes as required

▶Child (body-weight 15–30 kg):150micrograms, then 150micrograms after5–15minutes as required, on the basis of a dose of10micrograms/kg,300^micrograms may be more appropriate for some children JEXT^®300 MICROGRAMS

Acute anaphylaxis (for self-administration)

▶BY INTRAMUSCULAR INJECTION

▶Child (body-weight 30 kg and above):300micrograms, then300micrograms after5–15minutes as required lUNLICENSED USE

▶With intramuscular use for acute anaphylaxisAuto-injectors delivering150-microgram dose of adrenaline may not be licensed for use in children with body-weight under15^kg.

▶With intravenous use for acute hypotensionAdrenaline1ⁱⁿ 1000⁽1mg/mL) solution is not licensed for intravenous administration.

IMPORTANT SAFETY INFORMATION SAFE PRACTICE

Intravenous route should be used withextreme careby specialists only.

lCAUTIONSArrhythmias

.

cerebrovascular disease

.

cor pulmonale

.

diabetes mellitus

.

hypercalcaemia

.

hyperreflexia

.

hypertension

.

hyperthyroidism

.

hypokalaemia

.

ischaemic heart disease

.

obstructive cardiomyopathy

.

occlusive vascular disease

.

organic brain damage

.

phaeochromocytoma

.

prostate disorders

.

psychoneurosis

.

severe angina

.

susceptibility to angle-closure glaucoma

CAUTIONS, FURTHER INFORMATION

Cautions listed are only for non-life-threatening situations.

lINTERACTIONS→Appendix1(sympathomimetics) Severe anaphylaxis in patients taking beta-blockers may not respond to adrenaline—consider bronchodilator therapy. Furthermore, adrenaline can cause severe hypertension and bradycardia in those taking non-cardioselective beta-blockers.

lSIDE-EFFECTSAngina

.

angle-closure glaucoma

.

anorexia

.

anxiety

.

arrhythmias

.

cold extremities

.

confusion

.

difficulty in micturition

.

dizziness

.

dry mouth

.

dyspnoea

.

headache

.

hyperglycaemia

.

hypersalivation

.

hypertension (risk of cerebral haemorrhage)

.

hypokalaemia

.

insomnia

.

metabolic acidosis

.

mydriasis

.

myocardial infarction

.

nausea

.

pallor

.

palpitation

.

psychosis

.

pulmonary oedema (on excessive dosage or extreme sensitivity)

.

restlessness

.

sweating

.

tachycardia

.

tissue necrosis at injection site

.

tissue necrosis of bowel

.

tissue necrosis of extremities

.

tissue necrosis of kidneys

.

tissue necrosis of liver

.

tremor

.

urinary retention

.

vomiting

.

weakness lPREGNANCYMay reduce placental perfusion and cause

tachycardia, cardiac irregularities, and extrasystoles in fetus. Can delay second stage of labour. Manufacturers advise use only if benefit outweighs risk.

lBREAST FEEDINGPresent in milk but unlikely to be harmful as poor oral bioavailability.

lRENAL IMPAIRMENTManufacturers advise use with caution in severe impairment.

lMONITORING REQUIREMENTSMonitor blood pressure and ECG.

lDIRECTIONS FOR ADMINISTRATION

▶With intravenous use for acute hypotensionForcontinuous intravenous infusion, dilute with Glucose5% or Sodium

Chloride0^.9% and give through a central venous catheter.

Incompatible with bicarbonate and alkaline solutions.

Neonatal intensive care, dilute3mg/kg body-weight to a final volume of50mL with infusionfluid; an intravenous infusion rate of0^.1mL/hour provides a dose of 100nanograms/kg/minute; infuse through a central venous catheter. Incompatible with bicarbonate and alkaline solutions. These infusions are usually made up with adrenaline1ⁱⁿ1000⁽1mg/mL) solution.

▶When used by inhalationFor nebulisation in croup, adrenaline1ⁱⁿ1000solution may be diluted with sterile sodium chloride0^.9% solution.

lPRESCRIBING AND DISPENSING INFORMATIONIt is important, in acute anaphylaxis where intramuscular injection might still succeed, time should not be wasted seeking intravenous access.

Great vigilance is needed to ensure that thecorrect strengthof adrenaline injection is used; anaphylactic shock kits need to make avery clear distinctionbetween the1ⁱⁿ 10 000strength and the1ⁱⁿ1000^strength.

Patients with severe allergy should be instructed in the self-administration of adrenaline by intramuscular injection.

Packs for self-administration need to beclearly labelled with instructionson how to administer adrenaline (intramuscularly, preferably at the midpoint of the outer thigh, through light clothing if necessary) so that in the case of rapid collapse someone else is able to give it. It is important to ensure individuals at risk and their carers understand that:

.two injection devices should be carried at all times to treat symptoms until medical assistance is available; if, after thefirst injection, the individual does not start to feel better, the second injection should be given5^to 15minutes after thefirst;

.an ambulance should be called after every administration, even if symptoms improve;

.the individual should lie down with their legs raised (unless they have breathing difficulties, in which case they should sit up) and should not be left alone.

Adrenaline for administration by intramuscular injection is available in‘auto-injectors’(e.g.Emerade^®,EpiPen^®, or Jext^®), pre-assembled syringesfitted with a needle suitable for very rapid administration (if necessary by a bystander or a healthcare provider if it is the only preparation available); injection technique is device specific.

To ensure patients receive the auto-injector device that they have been trained to use, prescribers should specify the brand to be dispensed.

lPATIENT AND CARER ADVICE

Individuals at considerable risk of anaphylaxis need to carry (or have available) adrenaline at all times and the patient, or their carers, need to beinstructed in advance when and how to inject it.

JEXT^®300 MICROGRAMS1^.1mL of the solution remains in the auto-injector device after use.

JEXT^®150 MICROGRAMS1^.25mL of the solution remains in the auto-injector device after use.

EPIPEN^®JR AUTO-INJECTOR 0.15MG1^.7mL of the solution remains in the auto-injector device after use.

EPIPEN^®AUTO-INJECTOR 0.3MG1^.7mL of the solution remains in the auto-injector device after use.

EMERADE^®300 MICROGRAMS0^.2mL of the solution remains in the auto-injector device after use.

EMERADE^®500 MICROGRAMSNo solution remains in the auto-injector device after use.

EMERADE^®150 MICROGRAMS0^.35mL of the solution remains in the auto-injector device after use.

Medicines for Children leaflet: Adrenaline auto-injector for anaphylaxiswww.medicinesforchildren.org.uk/

adrenaline-for-anapylaxis

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lEXCEPTIONS TO LEGAL CATEGORYPOM restriction does not apply to the intramuscular administration of up to 1mg of adrenaline injection1ⁱⁿ1000⁽1mg/mL) for the emergency treatment of anaphylaxis.

lMEDICINAL FORMS

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: solution for injection

Solution for injection EXCIPIENTS:May contain Sulfites

▶Adrenaline/epinephrine (Non-proprietary) Adrenaline 100 microgram per 1 mlAdrenaline (base) 100micrograms/1ml (1in10,000) dilute solution for injection ampoules|10ampoule^P £60.09

Adrenaline (base)1mg/10ml (1in10,000) dilute solution for injection pre-filled syringes|1pre-filled disposable injection^P £6.87 Adrenaline (base)1mg/10ml (1in10,000) dilute solution for injection Minijet pre-filled syringes|1pre-filled disposable injection^P

£6.99

Adrenaline (as Adrenaline acid tartrate) 100 microgram per 1 mlAdrenaline (base)1mg/10ml (1in10,000) dilute solution for injection ampoules|1ampoule^P £43.53|10ampoule^P

£69.65

Adrenaline (base)500micrograms/5ml (1in10,000) dilute solution for injection ampoules|10ampoule^P £64.02

Adrenaline 1 mg per 1 mlAdrenaline (base) for anaphylaxis 1mg/1ml (1in1,000) solution for injection pre-filled syringes|1 pre-filled disposable injection^P£10.40

Adrenaline (base)1mg/1ml (1in1,000) solution for injection Minijet pre-filled syringes21gauge|1pre-filled disposable injection^P

£15.00

Adrenaline (base)1mg/1ml (1in1,000) solution for injection pre-filled syringes|1pre-filled disposable injection^P £10.40–£30.00 Adrenaline (base)1mg/1ml (1in1,000) solution for injection Minijet pre-filled syringes25gauge|1pre-filled disposable injection^P

£13.90

Adrenaline (as Adrenaline acid tartrate) 1 mg per 1 mlAdrenaline (base)5mg/5ml (1in1,000) solution for injection ampoules| 10ampoule^P£73.66

Adrenaline (base)500micrograms/0.5ml (1in1,000) solution for injection ampoules|10ampoule^P £58.08–£58.41DT price =

£58.25

Adrenaline (base)1mg/1ml (1in1,000) solution for injection ampoules

|10ampoule^P£5.82DT price = £5.81

▶Emerade(Imed Systems Ltd)

Adrenaline 1 mg per 1 mlEmerade300micrograms/0.3ml (1in 1,000) solution for injection auto-injectors|1pre-filled disposable injection^P£26.94DT price = £26.45

Adrenaline (as Adrenaline acid tartrate) 1 mg per 1 mlEmerade 150micrograms/0.15ml (1in1,000) solution for injection auto-injectors|1pre-filled disposable injection^P £26.94 Emerade500micrograms/0.5ml (1in1,000) solution for injection auto-injectors|1pre-filled disposable injection^P £28.74

▶EpiPen(Meda Pharmaceuticals Ltd) Adrenaline 500 microgram per 1 mlEpiPen Jr.

150micrograms/0.3ml (1in2,000) solution for injection auto-injectors

|1pre-filled disposable injection^P £26.45|2pre-filled disposable injection^P£52.90

Adrenaline 1 mg per 1 mlEpiPen300micrograms/0.3ml (1in1,000) solution for injection auto-injectors|1pre-filled disposable injection^P£26.45DT price = £26.45|2pre-filled disposable injection^P£52.90

▶Jext(ALK-Abello Ltd)

Adrenaline 1 mg per 1 mlJext300micrograms/0.3ml (1in1,000) solution for injection auto-injectors|1pre-filled disposable injection^P£23.99DT price = £26.45

Adrenaline (as Adrenaline acid tartrate) 1 mg per 1 mlJext 150micrograms/0.15ml (1in1,000) solution for injection auto-injectors|1pre-filled disposable injection^P £23.99

8 Oedema

Diuretics

Overview

Diuretics are used for a variety of conditions in children including pulmonary oedema (caused by conditions such as respiratory distress syndrome and bronchopulmonary dysplasia), congestive heart failure, and hypertension.

Hypertension in children is often resistant to therapy and may require the use of several drugs in combination.

Maintenance offluid and electrolyte balance can be difficult in children on diuretics, particularly neonates whose renal function may be immature.

Loop diureticsare used for pulmonary oedema, congestive heart failure, and in renal disease.

Thiazidesare used less commonly than loop diuretics but are often used in combination with loop diuretics or spironolactone p.117in the management of pulmonary oedema and, in lower doses, for hypertension associated with cardiac disease.

Aminophylline p.158^infusionhas been used with intravenous furosemide p.132^{to relieve}fluid overload in critically ill children.

Heart failure

Heart failure is less common in children than in adults; it can occur as a result of congenital heart disease (e.g. septal defects), dilated cardiomyopathy, myocarditis, or cardiac surgery. Drug treatment of heart failure due to left ventricular systolic dysfunction is covered below; optimal management of heart failure with preserved left ventricular function has not been established.

Acute heart failurecan occur after cardiac surgery or as a complication in severe acute infections with or without myocarditis. Therapy consists of volume loading, vasodilator or inotropic drugs.

Chronic heart failureis initially treated with aloop diuretic, usually furosemide supplemented with spironolactone, amiloride hydrochloride p.133^{, or} potassium chloride p.561^.

If diuresis with furosemide is insufficient, the addition of metolazone p.134^{or a}thiazide diureticcan be considered.

With metolazone the resulting diuresis can be profound and care is needed to avoid potentially dangerous electrolyte disturbance.

If diuretics are insufficient an ACE inhibitor, titrated to the maximum tolerated dose, can be used.ACE inhibitorsare used for the treatment of all grades of heart failure in adults and can also be useful for children with heart failure.

Addition of digoxin p.75can be considered in children who remain symptomatic despite treatment with a diuretic and an ACE inhibitor.

Some beta-blockers improve outcome in adults with heart failure, but data on beta-blockers in children are limited.

Carvedilol p.116has vasodilatory properties and therefore (like ACE inhibitors) also lowers afterload.

In children receiving specialist cardiology care, the phosphodiesterase type-3inhibitor enoximone p.118^is sometimes used by mouth for its inotropic and vasodilator effects. Spironolactone is usually used as a potassium-sparing drug with a loop diuretic; in adults low doses of spironolactone are effective in the treatment of heart failure.

Careful monitoring of serum potassium is necessary if spironolactone is used in combination with an ACE inhibitor.

Thiazides and related diuretics

Thiazides and related compounds are moderately potent diuretics; they inhibit sodium reabsorption at the beginning of the distal convoluted tubule. They are usually

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administered early in the day so that the diuresis does not interfere with sleep.

In the management ofhypertensiona low dose of a thiazide produces a maximal or near-maximal blood pressure lowering effect, with very little biochemical disturbance.

Higher doses cause more marked changes in plasma potassium, sodium, uric acid, glucose, and lipids, with little advantage in blood pressure control. Thiazides also have a role in chronic heart failure.

Bendroflumethiazide p.102is licensed for use in children;

chlorothiazide p.103is also used.

Chlortalidone p.134, a thiazide-related compound, has a longer duration of action than the thiazides and may be given on alternate days in younger children.

Metolazone is particularly effective when combined with a loop diuretic (even in renal failure) and is most effective when given30–60minutes before furosemide profound diuresis can occur and the child should therefore be monitored carefully.

Loop diuretics

Loop diuretics inhibit reabsorption of sodium, potassium, and chloride from the ascending limb of the loop of Henlé in the renal tubule and are powerful diuretics.

Furosemide and bumetanide p.132are similar in activity;

they produce dose-related diuresis. Furosemide is used extensively in children. It can be used for pulmonary oedema (e.g. in respiratory distress syndrome and

bronchopulmonary dysplasia), congestive heart failure, and in renal disease.

Potassium-sparing diuretics and aldosterone antagonists

Spironolactone is the most commonly used potassium sparing diuretic in children; it is an aldosterone antagonist and enhances potassium retention and sodium excretion in the distal tubule. Spironolactone is combined with other diuretics to reduce urinary potassium loss. It is also used in nephrotic syndrome, the long-term management of Bartter’s syndrome, and high doses can help to control ascites in babies with chronic neonatal hepatitis. The clinical value of spironolactone in the management of pulmonary oedema in preterm neonates with chronic lung disease is uncertain.

Potassium canrenoate p.117given intravenously, is an alternative aldosterone antagonist that may be useful if a potassium-sparing diuretic is required and the child is unable to take oral medication. It is metabolised to canrenone, which is also a metabolite of spironolactone.

Amiloride hydrochloride on its own is a weak diuretic. It causes retention of potassium and is therefore given with thiazide or loop diuretics as an alternative to giving potassium supplements.

A potassium-sparing diuretic such as spironolactone or amiloride hydrochloride may also be used in the management of amphotericin-induced hypokalaemia.

Potassium supplements mustnotbe given with sparing diuretics. Administration of a potassium-sparing diuretic to a child receiving an ACE inhibitor or an angiotensin-II receptor antagonist can also cause severe hyperkalaemia.

Potassium-sparing diuretics with other diuretics Although it is preferable to prescribe diuretics separately in children, the use offixed combinations may be justified in older children if compliance is a problem. (Some preparations may not be licensed for use in children— consult product literature).

Other diuretics

Mannitol p.133is used to treat cerebral oedema, raised intraocular pressure, peripheral oedema, and acites.

The carbonic anhydrase inhibitor acetazolamide p.638^{is a} weak diuretic although it is little used for its diuretic effect.

Acetazolamide and eye drops of dorzolamide p.639^and brinzolamide p.639inhibit the formation of aqueous humour and are used in glaucoma. Acetazolamide is also used in the treatment of epilepsy, and raised intracranial pressure.

Diuretics with potassium

Diuretics and potassium supplements should be prescribed separately.

DIURETICS

›

LOOP DIURETICS

Loop diuretics

f

lDRUG ACTIONLoop diuretics inhibit reabsorption from the ascending limb of the loop of Henlé in the renal tubule and are powerful diuretics.

lCONTRA-INDICATIONSAnuria

.

renal failure due to nephrotoxic or hepatotoxic drugs

.

severe hypokalaemia

.

severe hyponatraemia

lCAUTIONSCan cause acute urinary retention in children with obstruction of urinary outflow

.

can exacerbate diabetes (but hyperglycaemia less likely than with thiazides)

.

can excacerbate gout

.

comatose and precomatose states associated with liver cirrhosis

.

hypotension should be corrected before initiation of treatment

.

hypovolaemia should be corrected before initiation of treatment

CAUTIONS, FURTHER INFORMATION

▶Potassium lossHypokalaemia can occur with both thiazide and loop diuretics. The risk of hypokalaemia depends on the duration of action as well as the potency and is thus greater with thiazides than with an equipotent dose of a loop diuretic.

Hypokalaemia is particularly dangerous in children being treated with cardiac glycosides. In hepatic failure hypokalaemia caused by diuretics can precipitate encephalopathy.

The use of potassium-sparing diuretics avoids the need to take potassium supplements.

▶Urinary retentionLoop diuretics can cause acute urinary retention in children with obstruction of urinary outflow, therefore adequate urinary output should be established before initiating treatment.

lINTERACTIONS→Appendix1(diuretics).

lSIDE-EFFECTS

▶Very rareHyperuricaemia

▶Frequency not knownAcute urinary retention

.

blood disorders

.

bone-marrow depression

.

deafness (usually with high doses and rapid intravenous administration, and in renal impairment)

.

electrolyte disturbances

.

hepatic encephalopathy

.

hyperglycaemia (less common than with thiazides)

.

hypersensitivity reactions

.

hypochloraemia

.

hypokalaemia

.

hypomagnesaemia

.

hyponatraemia

.

increased calcium excretion (nephrocalcinosis and nephrolithiasis reported with long-term use of furosemide in preterm infants)

.

leucopenia

.

metabolic alkalosis

.

mild gastro-intestinal disturbances

.

pancreatitis

.

photosensitivity

.

postural hypotension

.

rash

.

temporary increase in serum-cholesterol and triglyceride concentration

.

thrombocytopenia

.

tinnitus (usually with high doses and rapid intravenous administration, and in renal impairment)

.

visual disturbances

lHEPATIC IMPAIRMENTHypokalaemia induced by loop diuretics may precipitate hepatic encephalopathy and coma—potassium-sparing diuretics can be used to prevent this.

lRENAL IMPAIRMENTHigh doses of loop diuretics may occasionally be needed in renal impairment. High doses or

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rapid intravenous administration can cause tinnitus and deafness.

lMONITORING REQUIREMENTS Monitor electrolytes during treatment.

eiii^F131 i

Bumetanide

lINDICATIONS AND DOSE

Oedema in heart failure, renal disease, and hepatic disease|Pulmonary oedema

▶BY MOUTH

▶Child 1 month–11 years:15–50micrograms/kg1–4^times a day (max. per dose2mg); maximum5^{mg per day}

▶Child 12–17 years:Initially1mg, dose to be taken in the morning, then1^{mg after}6–8hours if required Oedema in heart failure, renal disease, and hepatic disease (severe cases)|Pulmonary oedema (severe cases)

▶BY MOUTH

▶Child 12–17 years:Initially5mg daily, increased in steps of5^{mg every}12–24hours, adjusted according to response

lUNLICENSED USENot licensed for use in children under 12^years.

lSIDE-EFFECTSBreast pain

.

gynaecomastia

.

musculoskeletal pain (associated with high doses in renal failure)

lPREGNANCYBumetanide should not be used to treat gestational hypertension because of the maternal hypovolaemia associated with this condition.

lBREAST FEEDINGNo information available. May inhibit lactation.

lMEDICINAL FORMS

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: oral suspension

Tablet

▶Bumetanide (Non-proprietary)

Bumetanide 1 mgBumetanide1mg tablets|28tablet^P£3.00 DT price = £1.18

Bumetanide 5 mgBumetanide5mg tablets|28tablet^P£7.00 DT price = £6.98

Oral solution

▶Bumetanide (Non-proprietary)

Bumetanide 200 microgram per 1 mlBumetanide1mg/5ml oral solution sugar free sugar-free|150ml^P£168.00DT price =

£168.00

eiii^F131 i

Furosemide

(Frusemide)

lINDICATIONS AND DOSE

Oedema in heart failure, renal disease, and hepatic disease|Pulmonary oedema

▶BY MOUTH

▶Neonate:0^.5–2mg/kg every12–24hours, alternatively 0^.5–2mg/kg every24hours, if corrected gestational age under31^weeks.

▶Child 1 month–11 years:0^.5–2^mg/kg2–3times a day, alternatively0^.5–2mg/kg every24hours, if corrected gestational age of under31weeks, higher doses may be required in resistant oedema; maximum80mg per day;

maximum12mg/kg per day

▶Child 12–17 years:20–40mg daily; increased to 80–120mg daily, in resistant oedema

▶BY SLOW INTRAVENOUS INJECTION

▶Neonate:0^.5–1mg/kg every12–24hours, alternatively 0^.5–1mg/kg every24hours, if corrected gestational age under31^weeks.

▶Child 1 month–11 years:0^.5–1mg/kg every8hours (max.

per dose40^{mg every}8hours) as required; maximum 6mg/kg per day

▶Child 12–17 years:20–40^{mg every}8hours as required, higher doses may be required in resistant cases

▶BY CONTINUOUS INTRAVENOUS INFUSION

▶Child:0^.1–2^mg/kg/hour

Oedema in heart failure, renal disease, and hepatic disease following cardiac surgery|Pulmonary oedema following cardiac surgery

▶BY CONTINUOUS INTRAVENOUS INFUSION

▶Child:Initially100micrograms/kg/hour, dose to be doubled every2hours until urine output exceeds 1^mL/kg/hour

Oliguria

▶BY MOUTH

▶Child 12–17 years:Initially250mg daily, then increased in steps of250^{mg every}4–6hours (max. per dose2^g) if required

▶BY INTRAVENOUS INFUSION

▶Child 1 month–11 years:2–5mg/kg up to4times a day;

maximum1^{g per day}

▶Child 12–17 years:Initially250mg, dose to be administered over1hour, increased to500^mg, increased dose is given if satisfactory urine output not obtained; dose administered over2hours, then increased to1g, increased dose given if satisfactory response not obtained within subsequent hour; dose to be administered over4hours. If no response obtained dialysis probably required;, effective dose of up to1^g given at a maximum rate of4mg/minute can be repeated every24^hours

lCAUTIONSEffect may be prolonged in neonates (in neonates)

.

hepatorenal syndrome

.

hypoproteinaemia may reduce diuretic effect and increase risk of side-effects lSIDE-EFFECTSGout

.

intrahepatic cholestasis lPREGNANCYFurosemide should not be used to treat

gestational hypertension because of the maternal hypovolaemia associated with this condition.

lBREAST FEEDINGAmount too small to be harmful. May inhibit lactation.

lDIRECTIONS FOR ADMINISTRATION

▶With intravenous useForintravenous injection, give over 5–10minutes at a usual rate of100micrograms/kg/minute (not exceeding500micrograms/kg/minute), max.

4mg/minute; lower rate of infusion may be necessary in renal impairment. Forintravenous infusion, dilute with Sodium Chloride0^.9% to a concentration of1–2^mg/mL.

Glucose solutions unsuitable (infusion pH must be above 5^.5^).

▶With oral useFor administration bymouth, tablets can be crushed and mixed with water or injection solution diluted and given by mouth. Risk of ototoxicity may be reduced by giving high oral doses in2or more divided doses.

lPRESCRIBING AND DISPENSING INFORMATION

▶With oral useSome liquid preparations contain alcohol, caution especially in neonates.

lMEDICINAL FORMS

There can be variation in the licensing of different medicines containing the same drug. Forms available from special-order manufacturers include: oral suspension, oral solution Tablet

▶Furosemide (Non-proprietary)

Furosemide 20 mgFurosemide20mg tablets|28tablet^P

£1.02DT price = £0.73

Cardiovascularsystem

2

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