The majority of paediatric and neonatal units in the UK used traditional weight-based methods for IV infusions and only 40% of responding units had established SCI. This local implementation of SCI resulted in a wide variation of presentations and concentrations and thus there is no true 'standardisation'. Further research should be conducted on harmonising these SCI across neonatal and paediatric care to facilitate adoption across all units.

Plasma-Lyte is a balanced, crystalloid intravenous fluid which has been shown to avoid the hyperchloremic metabolic acidosis associated with 0.9% sodium chloride. Data on physical, pH and chemical compatibility with other medicines are essential. Methods: The compatibility of adrenaline, dobutamine, dopamine, furosemide, midazolam, morphine and milrinone with Plasma-Lyte 148 (PLA) and Plasma-Lyte 148 with 5% glucose (PLA-G) was investigated. Control solutions were 0.9% sodium chloride and 5% glucose. Chemical stability was defined as < 5% concentration change with high-performance liquid chromatography (HPLC). Physical compatibility was assessed by checking for colour changes and precipitate formation. The pH of the admixtures was considered acceptable if between 5 and 9 at all time points. Six repeats were carried out for HPLC, 2 for physical compatibility checks and pH measurements, with all admixtures being tested at 0, 2 and 24 h after mixing. Results: All combinations were found to be chemically stable at 0, 2 and 24 h apart from furosemide with PLA-G at 24 h and midazolam with PLA or PLA-G at both 2 and 24 h. Only midazolam was physically incompatible when mixed with both Plasma-Lyte solutions. The pH remained stable in all admixtures, although not all pH values recorded were within the range of 5-9. Conclusion: All drugs excluding furosemide and midazolam were shown to be chemically, physically and pH stable at the tested concentrations when diluted with PLA and PLA-G.

Summary Background Plasma‐Lyte 148® is a balanced, crystalloid intravenous (IV) fluid which is both calcium‐free and isotonic. It prevents the hyperchloremic metabolic acidosis and iatrogenic hyponatremia seen with use of 0.9% sodium chloride and hypotonic solutions, respectively. However, data on compatibility with commonly used drugs are lacking. Aims To investigate the stability of Plasma‐Lyte 148® and Plasma‐Lyte 148® + 5% Glucose with eight commonly used therapeutic agents when compared with 5% glucose and 0.9% sodium chloride as diluents. We aimed to provide vital data which may facilitate the introduction of what appears to be a safer and more economic fluid. Methods Plasma‐Lyte 148® and Plasma‐Lyte 148® + 5% Glucose were mixed with morphine, midazolam, fentanyl, ketamine, clonidine, aminophylline, salbutamol, and furosemide at set concentrations. Comparisons were made to 0.9% sodium chloride and 5% glucose fluid controls. Six repeats of each IV fluid and drug admixture were analyzed through high‐performance liquid chromatography at three time points: 0, 2, and 24 hours. A concentration change of <5% was defined as chemically stable. Physical stability was assessed by observation of precipitate formation or color change. pH changes were measured using a Fisherbrand Hydrus 300 pH meter. Results Relative to starting concentration, all drugs except midazolam were stable to ±3%. All examined therapeutic agents were chemically stable at 2 and 24 hours relative to control solutions. No precipitate formed in any of the samples. All Plasma‐Lyte 148® and Plasma‐Lyte 148® + 5% Glucose drug admixtures remained in a safe, peripheral administration pH range of 5‐9 and were closer to the pH of blood than standard fluid‐drug admixtures. Conclusion Morphine, fentanyl, ketamine, salbutamol, aminophylline, and clonidine are stable for 24 hours when mixed with Plasma‐Lyte 148® and Plasma‐Lyte 148®+5% Glucose for administration at concentrations equivalent to those found at a typical Y‐site with maintenance fluid. Furosemide is stable at lower concentrations than those seen at a Y‐site, but midazolam displayed instability.

Aims In 2008, the BNF for children changed their target range from 5-10 mg/l to 10-15 mg/l secondary to recommendations from the Special Advisory Committee on Antimicrobial Resistance. The dosing regimen of 15 mg/kg eight hourly did not change. The aim was to establish whether levels were therapeutic according to the dosing in the BNFc. Methods A drug chart and case note audit was performed on infants and children started on vancomycin in a tertiary paediatric hospital between January and June 2010. Patients were excluded if less than 35 weeks postmenstrual age or had renal disease.Results 36 infants and children with 43 different episodes, with a median age 2 years 9 months (range 11 days to 15 years) were included (fi gure 1). 44% received vancomycin for presumed line sepsis, 26% for sepsis, 14% for cardiorespiratory infections, 9% for neurosurgical infections and 7% for wound infections. 23% had positive microbiology. 95% (41/43) of episodes had one or more levels performed. First vancomycin levels showed, 76% were sub therapeutic group.bmj.com on June 7, 2015 -Published by http://adc.bmj.com/ Downloaded from

Objective Syringe drivers are the principle method of giving small-volume continuous infusions of important drugs to patients. Many of these drugs are critical for the maintenance of normal physiology. Anecdotal evidence abounds of severe patient instability on movement of syringe drivers during infusion. We aimed to define the variation in drug delivery seen in three syringe drivers, with changes in relative height between the syringe driver and the end of the giving set. Design Three syringe drivers (Alaris CC [Becton Dickinson], Perfusor Space [B Braun], and Synamed μSP6000 [Arcomed]) were analyzed for reliability of flow at 0.5, 1, 2, and 5 mL/h. Setting and subjects This is an in vitro investigation. Interventions A small air bubble was introduced into the giving set, and the progression of this was documented before and after a vertical movement of the syringe driver by 25 or 50 cm upward or downward relative to the delivery port. Measurements and Main Results For all pumps, delivery was interrupted on movement of the pumps downward, and a bolus was given with movement of the pump upward. Delivery halted at lower pump speeds for longer than higher pump speeds. The maximum delivery interruption was 11.8 minutes. Boluses given on moving the pump up were calculated as the equivalent number of minutes needed to deliver the bolus volume at steady state. The maximum bolus given was equivalent to 15.8 minutes of delivery. We were unable to eliminate the effects seen by very slow, steady movement of the pumps up or down. Static height differences made no difference to delivery. Conclusions Syringe drivers should not be moved vertically in relation to the patient. Critical drug delivery is interrupted for up to 12 minutes with relative downward movements, and significant boluses of drugs are given with relative upward movements. As far as possible, elimination of relative height movements is advised, and extreme caution is necessary if any movements are unavoidable.

AimsCrystalloid fluid boluses are a mainstay of treatment in unwell children, with the traditional fluid of choice being 0.9% saline (NS). However, the use of NS has been associated with an increase in plasma chloride levels and acidosis, leading to kidney injury and other detrimental clinical effects. Plasma-Lyte 148 (PLA) is a balanced, physiological, crystalloid intravenous fluid, which is both calcium-free and isotonic. Its use in place of NS for fluid resuscitation may circumvent hyperchloraemic metabolic acidosis. In May 2015 our hospital altered its standard resuscitation fluid from NS to PLA. We aimed to compare the effect of fluid boluses of NS to those of PLA in children.MethodsAll patients admitted in the 18 month periods before and after the change from NS to PLA, and receiving a fluid bolus in the first 24 hours of admission, were included. Post-surgical patients and those who had undergone haemofiltration were excluded. Arterial blood gas and creatinine values for up to 5 days after bolus fluid administration were examined. Patients were stratified according to the total resuscitation volume (ml/kg), then split into categories determined by the balance of PLA vs. NS.The primary outcome was plasma chloride. Secondary outcomes included blood pH and percentage change in creatinine. Clinical outcomes were length of ventilation and length of PICU stay.Results126 patients were included in the analysis. Patients receiving NS boluses tended to have a higher maximum chloride, higher average chloride, lower pH and higher percentage creatinine increase than those given PLA. Subgroup analysis showed a statistically significant difference in average serum chloride for the 61–90 ml/kg group {PLA 105.59±1.29 vs NS 111.29±2.1 mmol/L; difference: −6.21 [95% confidence interval (CI)−9.55,–2.87]}. Patients who received PLA tended to have a higher pH than those receiving NS. A statistically significant difference was seen in the 10–30 ml/kg group [PLA 7.42±0.49 vs NS 7.33±0.65; difference: 0.0913 (95% CI: −0.18 to −0.02)].Significant differences were not seen in the clinical outcomes of length of stay or ventilationConclusionPLA as a resuscitation fluid is significantly associated with a more physiological plasma chloride and pH across several resuscitation fluid volume categories, when compared to NS. The trends in the other fluid volume categories are in line with these findings, but are not statistically significant. There was also a trend towards patients receiving PLA having a lower percentage rise in creatinine than those who received saline. These results were consistent over all weight and age categories.

AimFor several drugs available as licensed liquids, multiple concentrations exist. Four different propranolol concentrations are available: 1 mg/mL, 2 mg/mL, 8 mg/mL and 10 mg/mL.1Existence of multiple concentrations increases the chance of dosing errors. The Neonatal and Paediatric Pharmacists Group (NPPG) and the Royal College of Paediatrics and Child Health (RCPCH) recommend standard concentrations for some unlicensed liquid medicines2, but no such recommendation exists for drugs available as licensed products. The British National Formulary for Children (BNFC) advocates that propranolol 1 mg/mL be used to manage infantile haemangioma, but no recommendation is made for other indications.1This study aimed to characterise the use of the various propranolol liquid concentrations and determine how closely the recommendation to use 1 mg/mL for haemangioma is followed.MethodA Survey Monkey®questionnaire was created and distributed to NPPG members by email, remaining open for two weeks. Respondents were asked whether the recommendation to use 1 mg/mL for haemangioma is followed in their centres. Where this recommendation was not followed, respondents indicated the alternative concentration used. Use of alternative concentrations for other indications was also probed, plus the rationale for the use of more than one concentration. Centre name was requested to identify duplicate responses, with the plan to subsequently present the data in an anonymised form. Ethical approval was not required.Results64 responses were received. Three centres provided duplicate responses; in two of these cases the answers given matched, but in one the answers conflicted. Where the duplicates matched, data was included in the analysis only once for each centre. Where the response conflicted, it was excluded from analysis. Responses from 60 centres were analysed: 57 from the United Kingdom (UK) and 3 from elsewhere. 31 (52%) of centres use 1 mg/mL for treatment of infantile haemangioma, reflecting BNFC recommendations. For those not following the recommendation, 9 used only a 2 mg/mL concentration and 17 used only 10 mg/mL. Two centres used different concentrations according to the dose prescribed; none reported using 8 mg/mL and one non-UK centre reported use of 20 mg/mL. 26 (43%) centres reported using more than one concentration of propranolol liquid. One cited reason included trying to follow both the BNFC recommendation to use 1 mg/mL for haemangioma whilst also trying to meet regional cardiac centre requests to use 10 mg/mL. Deviating from the recommended 1 mg/mL for haemangioma due to patients being unable to tolerate large dose volumes was raised, as was excipient load in some 1 mg/mL products. Respondents expressed a desire to standardise to a single concentration, though the recommendation to use 1 mg/mL for haemangioma was highlighted as a barrier. Treatment of both adults and children within individual institutions was also considered a complicating factor.ConclusionsThe recommendation to use 1 mg/mL when treating haemangioma is not followed in just under 50% of centres. Over 40% of centres reported having more than one concentration of propranolol in use. There is a desire to adopt a single standardised concentration for all indications, although there are a number of potential barriers. Further work is needed to establish the best approach for standardisation.ReferencesPropranolol. Joint Formulary Committee. British National Formulary for Children (Online). London: BMJ Group and Pharmaceutical Press. Available from: http://www.medicinescomplete.com [Accessed June 2022].Using Standardised Concentrations of Liquid Medicines in Children. Neonatal and Paediatric Pharmacists Group and Royal College of Paediatrics and Child Health. Available from http://nppg.org.uk/standardised-strengths-of-liquid-medicines-for-children/ [Accessed June 2022].

AimIn 2018, the Neonatal and Paediatric Pharmacists Group (NPPG) and Royal College of Paediatrics and Child Health (RCPCH) published a Position Statement recommending use of standard concentrations for 20 unlicensed medicines. The current version of this document contains recommendations for 12 of the original 20; the remainder having been removed due to introduction of licensed products.1 This project aimed to assess the extent to which the current list has been adopted nationally, and to identify any barriers to its implementation.MethodA survey was developed using Microsoft Forms before email circulation to all NPPG members, asking them to share the survey with non-member colleagues who had been involved with local discussions and/or implementation of the recommendations. The survey was open for two weeks.Participants were asked if they were aware of the recommendations. Those who answered ‘no’ were asked no further questions; those answering ‘yes’ were asked to indicate if each of the 12 recommended concentrations was in use locally, and whether or not this was as a result of the publication. If a conscious decision had been taken not to adopt the concentration for a particular drug, respondents were asked to indicate if this was in favour of an alternative concentration, a non-liquid formulation or because the drug is not used locally. Multiple options could be selected for each drug.Respondents were then asked to detail any difficulties experienced in adopting the recommended concentration for particular drugs, or the list as a whole; and to suggest ideas which would support implementation if the list were to be extended in future.Results108 responses were received. 73 respondents (67.6%) were aware of the publication and provided feedback for the 12 recommended concentrations. Responses for a selected 4 of the 12 medicines were as follows:Spironolactone: 88.3% were using the recommended concentration; of those 24.4% reported adding it to a local formulary as a result of the list; 11.6% were unsure when it was added.Phenobarbital: 86.7% were using the recommended concentration; of those 19.3% reported adding it to a local formulary as a result of the list; 8.4% were unsure when it was added.Chloral Hydrate: 94.4% were using the recommended concentration; of those 11.1% reported adding it to a local formulary as a result of the list; 13.6% were unsure when it was added.Sodium Chloride: 72.8% were using the recommended concentration; of those 11.1% reported adding it to a local formulary as a result of the list; 11.1% were unsure when it was added.Common reasons given for not adopting a recommended concentration were a licensed product existing of a different concentration, or a different strength being more suitable for administration.Suggestions to aid implementation of future recommendations included ensuring dissemination to community-based practitioners, and providing clearer detail on the rationale behind choice of a concentration.ConclusionThe NPPG/RCPCH position statement has helped drive standardisation to some extent, though work is needed to understand how best to support practitioners implementing these and any future recommendations.ReferenceNeonatal and Paediatric Pharmacists Group and Royal College of Paediatrics and Child Health, UK. Using Standardised Concentrations of Unlicensed Liquid Medicines in Children. April 2020. Available at: https://nppg.org.uk/wp-content/uploads/2020/04/NPPG-Position-Statement-18-01-V5-April-2020.pdf