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Volumetric Dosing of EPINEPHrine for Neonates Could Lead to Dosing Errors

Hospitals that have a neonatal intensive care unit (NICU), or that otherwise care for neonates, may be using the current information from the American Academy of Pediatrics Neonatal Resuscitation Program (NRP) to guide emergency efforts. If so, it’s important to know that, in the organization’s Textbook of Neonatal Resuscitation, 7th edition (2016), page 189, the dosing of EPINEPHrine calls for “1:10,000 (0.1 mg/mL)” solutions to be used, but refers to dosing in terms of mL/kg. This is concerning because the recommended volumetric dosing might lead to dosing errors if the two commercially available EPINEPHrine concentrations (0.1 mg/mL and 1 mg/mL) are available. For example, although the 1 mg/10 mL (0.1 mg/mL) emergency syringe (formerly referred to as 1:10,000) is often used for neonates, a 1 mg/mL vial (available in 1 mL and 30 mL vials) is also available and may be used to prepare the 0.1 mg/mL solution by diluting 1 mg with 9 mL of normal saline in a 10 mL syringe. The 1 mg/mL vial is also available for making infusions or is used as a substitute during drug shortages of the 1 mg/10 mL (0.1 mg/mL) emergency syringes. It may be unclear to the person preparing a dose that the intended volumetric dosing refers only to the 1 mg/10 mL (0.1 mg/mL) solution. Another concern is that, since mL/kg is not a very familiar dosing method, it’s possible that mL/kg might sometimes be misread as mg/kg.

Dosing tables for use during codes can help ensure that no one is required to mathematically calculate doses during these stressful situations. Hospitals that have standard code sheets printed from their computer system can automatically calculate the dose and volume based on the patient’s weight and the drug concentration.

In addition, as of May 1, 2016, manufacturer labels for EPINEPHrine injection no longer use a ratio expression on container labels except for local anesthetics with EPINEPHrine. So clinicians won’t see on labels what the NRP has listed in its table (1:10,000). We wanted to bring this matter to your attention, especially since the label changes that eliminate the ratio expression have already begun to appear on the market. ISMP has repeatedly recommended against volumetric dosing since more than one concentration of a drug may exist or may be formulated extemporaneously. The textbook publishers have been notified of our concerns.