Perioperative Care Newborns/Infants — Medication Review and Conversion — Clinical Pathway: ICU and Inpatient

Newborn/Infant Perioperative Care Clinical Pathway — N/IICU

Medication Review and Conversion

General Recommendations

  • Pre-op: Enteral medications do not need to be converted to IV formulations unless the enteral dose volumes exceed 10 mL AND would need to be given within 1 hour of OR time. If the total enteral medication volume exceeds 10 mL and the dose times cannot be moved due to clinical condition, please contact frontline ordering clinician/attending physician to assist with medication prioritization or conversion to IV formulation (if one is available).
  • Post-op: Consider conversion to IV medications if patient to remain NPO (only when IV formulation available and recommended by chart below).
Medication Type Recommendations
Cardiac
  • Propranolol
    • Administer enterally pre-op and post-op
    • Do not convert to IV
    • Discuss with EP if unable to tolerate
  • Sildenafil
    • Discuss continuation post-op; consider changing to nitric oxide if prolonged NPO course
  • Digoxin
    • Convert to IV formulation, if necessary, post-op
  • Bosentan
    • Consider continuation if prolonged NPO
Anti-epileptic
  • Agent with IV formulation
    • Phenobarbital
    • Levetiracetam
    • Phenytoin
  • Continue enteral agent if conversion is not possible
    • Topiramate
    • Vigabatrin
    • Carbamazepine
Opioid/Sedative
  • Patient on chronic opioid/benzodiazepine enteral doses
    • Post-op, convert to intermittent IV doses
    • If a prolonged NPO period or significant post-op pain anticipated, please convert to continuous infusions
    • Conversion approach
Anti-reflux Medications
  • Famotidine/Ranitidine
    • Convert to IV formulation
  • Omeprazole
    • Convert to pantoprazole
    • If PPI discontinued abruptly, patient is at risk for rebound hypergastrinemia
Electrolyte Replacements
  • Add to IVF as necessary when NPO
    • Calcium, heparin, potassium not to be added to OR fluids but can be added to post-op fluids when indicated
Diuretics
  • Furosemide, Bumetanide, Chlorothiazide
    • Convert to IV formulation, if NPO post-op
  • Spironolactone
    • No IV formulation, discuss holding if NPO post-op
Thyroid Medications
  • Levothyroxine
    • Convert to IV formulation, if prolonged NPO status post-op
Steroid Replacement
  • Preoperative Providers
    • Order stress dose hydrocortisone 100 mg/m2/dose IV x 1
    • Send to OR with patient to be given by anesthesia. If patient to have bedside procedure, please send to unit.
  • Anesthesia Providers
    • Administer steroid dose during procedure
    • Postoperatively, discuss necessity of continuing stress dose steroids or if patient can return to maintenance dose, where indicated.
Enoxaparin
  • Discontinue 24 hours before surgery
  • Daily discussion on when to restart post-op

 

Opioid Conversion: Enteral Agent to Continuous Intravenous Infusion/Intermittent Injection

  Convert Medications Instructions
Enteral Agent to Continuous Intravenous Infusion
  • Morphine PO to Morphine IV
  • Example: Morphine 1.2 mg GT q4h 2 kg patient
  • Calculating Total Daily Enteral Dose:
    Morphine 1.2 mg x 6 doses per day = 7.2 mg total morphine per day
  • Calculating Infusion:
    total daily enteral dose (mg) ÷ (conversion factor) 3 ÷ 24 hrs ÷ weight in kg 7.2 mg ÷ 3 ÷ 24 hours ÷ 2 kg = Morphine infusion 0.05 mg/kg/hr
  • Morphine PO to Hydromorphone IV
  • Contact team clinical pharmacist
  • Methadone to:
    • Morphine IV
      • or
    • Fentanyl IV
      • or
      Hydromorphone IV
Enteral Agent to Intermittent IV Dosing
  • Morphine PO to Morphine IV
  • 3:1 PO:IV conversion
  • Example: Morphine 3 mg NG q4h = Morphine 1 mg IV q4h

 

Benzodiazepine Conversion: Enteral Agent to Continuous Intravenous Infusion/Intermittent Injection

  Convert Medications Instructions
Enteral Agent to Continuous Intravenous Infusion
  • Midazolam PO to Midazolam IV
  • Example: Midazolam 1.2 mg GT q4h in patient who is 3 kg
  • Calculating Total Daily Enteral Dose:
    Midazolam 1.2 mg x 6 doses per day = 7.2 mg total midazolam per day
  • Calculating Infusion:
    Total daily enteral dose (mg) ÷ (conversion factor) 3 ÷ 24 hrs ÷ weight in kg 7.2 mg ÷ 3 ÷ 24 hours ÷ 3 kg = Midazolam infusion 0.03 mg/kg/hr
  • Lorazepam PO to Midazolam IV
    (N/IICU does not use continuous lorazepam infusions)
  • Example: Lorazepam 0.4 mg GT q4h in patient who is 5 kg
  • Calculating Total Daily Enteral Dose:
    Lorazepam 0.4 mg x 6 doses per day = 2.4 mg total lorazepam per day
  • Calculating Infusion:
    Total daily enteral dose (mg) ÷ (conversion factor) 0.3 ÷ 24 hrs ÷ weight in kg 2.4 mg ÷ 0.3 ÷ 24 hours ÷ 5 kg = Midazolam infusion 0.07 mg/kg/hr
Enteral Agent to Intermittent IV Dosing
  • Midazolam PO to Midazolam IV
  • Conversion: 3:1 PO:IV
  • Example: Midazolam 3 mg NG q4h = Midazolam 1 mg IV q4h
  • Lorazepam PO to Lorazepam IV
  • Conversion: PO:IV 1:1
  • Example: Lorazepam 0.4 mg GT q4h = Lorazepam 0.4 mg IV q4h