Transcript Prescribing for Paediatrics

Prescribing in Paediatrics
How to do it well!
Rowena MCArtney and Liz Webb
Senior Information Pharmacists,
Cardiff & Vale NHS Trust.
David Tuthill,
Consultant Paediatrician,
Children's Hospital for Wales.
Mistakes happen but how do we learn
and improve our performance?
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• How risky are healthcare systems as a
cause of mortality? e.g. compared to
cancer, MIs etc
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Top 5
6-10
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21-50
51-100
Background
 There are eight steps to prescribing.
 624 million prescriptions in NHS….. error
prone
 Single largest group of errors by doctors
 Second largest payout in children
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Potential for significant harm
Paediatric errors
• Intrathecal vincristine
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• How many paediatric admissions are
complicated by a medication error?
Children are more at
Risk-Why?
• 5% of paediatric admissions are
complicated by medication error
– Subsequent resulting harm in 2 - 7%
• Weight, pharmacokinetics, physiology and
autonomy
• All Wales guidance exists on prescribing
practice to reduce potential errors
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All Wales Standard Drug chart
GMC report
Dec 2009
RM
Prescribing in paediatrics
• Is prescribing for children any
different than adults?
• What do we need to consider in
prescribing for children?
• What are the common problems in
prescribing for children?
Factors to consider in
prescribing for children
• Size factors
– Age
– Weight; excessively fat or thin?
– Surface area
• Dose : Choose correct dose for
age, weight and disease
• Dose interval : Fit into child's
waking day if possible
Common sources of error in
prescribing for children
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Most products are designed for adults
Miscalculations
10 fold and 100 fold overdoses
mg/Kg dose versus mg/Kg/day
Confusion between doses in mg and in ml
Confusion between units
– milligrams/ micrograms/ nanograms)
Help is at hand - BNFc
• National BNFc should be used
• gives safe advisable doses taking into
account:
• age
• prematurity
• weight
• surface area
• Disease state
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Use the latest version;
App available
How to use BNFc:
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Look at appropriate drug section
Any contraindications?
Any allergies?
What's the indication?
Check dose against weight
Frequency?
Prescribe clearly
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use block capitals
sign and date
bleep number
Example
• You admit a 10 year old weighing 30Kg with
meningitis. Prescribe ceftriaxone.
• BNFc 2012-13 - pg 274
– Select appropriate indication-infections due
to gram –ve organisms.
– Check weight-under 50kg
– Give 80mg/Kg/day dose (for severe infection
and meningitis): 30 x 80= 2400mg dose daily
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Correct dose = 2.4g daily
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Note - slow infusion due to the high dose.
Summary Of C&V NHS
Trust Prescribing
Standards - 1
• Minimum acceptable patient identity details
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Name
Address
DOB
Unit number
• Weight (accurate in kg)
• Allergies no/ yes-what to? Reaction?
Summary Of C&V NHS
Trust Prescribing
Standards - 2
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Indelible black pen (Not fountain or felt-tip pen)
NO abbreviations
Approved names
Sign and date at time of writing
Bleep number
Sign and date any changes made
Crossing off drugs (through prescribing
section AND through administration boxes)
Summary Of C&V NHS
Trust Prescribing
Standards - 3
• Label multiple charts e.g. 1 of 2
• Care with units mg / μgm / ng can be misread
- write in full: micrograms and nanograms
• Avoid decimal points! e.g..5mg should be written
up as 500micrograms
• Don’t use mls use the dose in mg
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UNITS must be written out in full
What’s the
error?
Use your common sense
940mg?? Weight 7.5 kg!
Things to avoid
Missing route
Missing
bleep no
Do not write
dose in ml
Do not
amend
frequency
like this
No
strength
and dose
in ml
All Wales Chart- What’s
missing?
Important –
do not
forget to
complete
Details as per
addressograph
Sign and
date when
changing
dose or
route
Cross off at
front and
end of the
prescription
That’s better !
Sign and
date
crossing off
Include strength but
don’t prescribe in
ml
Now to put it into practice!
• Use Calculators or your mobile
• Please write your name on the drug chart ,
year of graduation and any Paediatric
postgraduate qualifications
• Please ask if you are unclear regarding any
question. They are not meant to trick you!
• Answers will be given out once the sheets
have been collected! (you will be given
feedback later)
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Thank you for taking part. Hope this has been helpful to you!
Question 1
• Tinkywinky is a 3 year old child who
weighs 14kg
• She has scalded skin syndrome and
no IV access.
• Prescribe prn paracetamol and
regular oral morphine for her.
Question 2
• Milo is a 7 year old oncology patient
who weighs 24kg.
• He is immunocompromised and has
been admitted with chickenpox.
• Prescribe IV aciclovir for him for
7days.
• BSA for child 24kg is 0.9m2
Question 3
• Sara is a 10 year old surgical
patient who weighs 45kg.
• She has complicated appendicitis
with abscess formation.
• Prescribe piperacillin/tazobactam
for her for 7 days.
Question 4
• Bella is 20 days old and has been
admitted febrile and irritable,
probably septic; possibly meningitic.
• She weighs 3kg.
• Prescribe amoxicillin and cefotaxime
for her for 7 days.
Answers and 2 last
things!
Question 1
• Tinkywinky is a 3 year old child who weighs 14kg, She has scalded
skin syndrome and no IV access. Prescribe prn paracetamol and
regular oral morphine for her.
• Paracetamol
• pain; pyrexia with discomfort
• BNFC – 1-6years 120-250mg every 4-6hours (Max QDS)
– for this age choose mid range eg 180mg
• New MHRA dose - 2-4 years 180mg (7.5ml) QDS
• Common practice is 15mg/kg QDS = 210mg (in patient)
• severe pain dose in BNFc is now
stipulated only for post-op pain
New MHRA guidance on
paracetamol dosing – Nov11
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Infant paracetamol suspension (120mg in 5mL):
Question 2
• Milo is a 7 year old oncology patient who
weighs 24kg. He is immunocompromised
and has been admitted with chickenpox.
Prescribe IV aciclovir for him.
• BSA for child 24kg is 0.9m2
• Aciclovir for chickenpox and herpes zoster
- IV infusion
• 3 month-12 years – 250mg/m2 TDS
(doubled if immunocompromised)
• i.e. 500mg/m2 = 450mg TDS
Question 3
• Sara is a surgical patient who weighs 45kg.
She is 10 years old. She has ruptured
appendix with abscess. Prescribe
piperacillin/tazobactam for her.
• Answer – complicated appendicitis – age
2-12 years
• 112.5mg/kg every 8 hours (max 4.5g every
8 hours) for 5-14 days.
• 112.5 x 45 = 5062mg (5.062g)
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Correct dose is therefore 4.5g TDS
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Question 4
Bella is 20 days old and has been admitted with sepsis (signs of possible
meningitis). Prescribe amoxicillin and cefotaxime for her. She weighs 3kg.
• Amoxicillin for listerial meningitis, Group B
strep, enterococcal endocarditis
• neonate 7-21 days 50mg/kg every 8 hours
(doubled if meningitis is likely)
• correct answer is 300mg TDS
• Cefotaxime dose is 25mg/kg every 8 hours
for neonate 7-21 days, doubled in severe
infection and meningitis
50mg/kg every 8 hours = 150mg TDS
C&V Child Health Sepsis guidelines
Amoxicillin* and Cefotaxime
<7days
50mg/kg/dose BD
7-28 days
50mg/kg/dose TID
1 – 3 months 50mg/kg/dose QID
> 3 months
Ceftriaxone
80mg/kg ONCE DAILY IV infusion
Max 50mg/kg ONCE DAILY IM
*Dose of Amoxicillin may be increased if suspicion of
Listeria meningitis is high.
Anti-infective initiation/change
Indication:
Planned duration:
Temperature
oC
CRP
Microbiology advice
sought:
YES / NO
WCC
x 109/L
Urine culture 
Neutrophils
x 109/L
Stool
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Blood culture
Sputum
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Consultant review@ 48-72hrs: STOP / CONTINUE for………...days total
or alternative directions:
ANTI-INFECTIVE
(Approved name)
Route 
Specify time if required
Name of microbiologist:
Specimens sent: (tick box)
mg/L
Date 
days
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Wound swab
Other
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Site(s):
 (state):
Consultant
signature:
Date:
Special instructions
Prescriber’s signature
Bleep no.
Pharm
Supply
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Dose
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Sign
Discharges
• Plan 24 hours in advance if possible
• Get T T H done asap
• Ward pharmacist collects mid morning
• Include all regular medicines on the
discharge letter as a record for GP
• If no meds to be dispensed write “pts own”