PedsConLive Staff

A 1-month-old boy (weight, 5 kg) was prescribed clonidine (5 mg [1 mg/kg/dose] PO q8h) for neonatal abstinence syndrome. His parents filled this prescription at a local pharmacy. After taking a few doses of the medication, the boy became extremely lethargic. He was seen at the clinic and was found to be hypotensive and was admitted to a nearby hospital.

What is the problem here?



Click here for the answer and discussion.

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After several 5 mg doses of clonidine, this 5 kg boy became extremely lethargic and hypotensive. What went wrong?

Top 10 Common Medication Errors-Drug #9: Clonidine

A gastrostomy tube–dependent 5-year-old girl who weighed 20 kg presented with a 2-day history of fever and lethargy. Urine and blood samples were obtained for culture at that time. The patient was sent home without medication because the clinician thought that the patient might have a viral respiratory infection.

Two days later, the urine culture turned positive for 

sensitive to only ciprofloxacin. The clinician thus called in a prescription to a local pharmacy for ciprofloxacin suspension (200 mg via G-tube bid [10 mg/kg/dose]). After the patient received 2 doses of the medication, the parents noticed that the G-tube was clogged off.

What’s the problem here?

Please click here for the answer and discussion.

A prescription was called into the local pharmacy for ciprofloxacin suspension (200 mg via G-tube bid [10 mg/kg/dose]). After the patient received 2 doses of the medication, the parents noticed that the G-tube was clogged off. What’s the problem here?

Top 10 Common Medication Errors -- Drug #7 -- Ciprofloxacin

A 5-year-old boy (20 kg) with sickle cell disease presented with a 2-day history of increasingly severe back pain. A detailed workup showed no signs of infection. The patient’s parents did not want their son to take narcotics for the pain. Thus, the boy was given a prescription for ketorolac -- 10 mg PO every 6 hours x 5 days [0.5 mg/kg dose]).

Ketorolac is a good option for relieving pain in patients with sickle cell disease, but there can be a problem with how this agent is prescribed for children.

Common Medication Errors: Drug #6: Ketorolac

 In this series, I focus on 10 errors commonly seen in the pediatric outpatient setting.

A 22-day-old neonate (gestational age, 37 weeks; weight, 4 kg) with otitis media was seen by his pediatrician. On presentation, he was febrile and looked jaundice. His bilirubin level was slightly above the upper limit of normal.

The clinician prescribed 200 mg of ceftriaxone (50 mg/kg) IM x 1 for the otitis media. The 1-g ceftriaxone vial was mixed with 2.1 mL of 1% lidocaine to a final concentration of 350 mg/mL. The dose was drawn up and administered accordingly.


 Ceftriaxone is a third-generation intravenous cephalosporin that is often used in the pediatric population for an array of infections ranging from pneumonia to otitis media. This antibiotic has the advantage of once-daily dosing, and it can be given intravenously or intramuscularly. This is especially beneficial in the outpatient setting: a single dose of ceftriaxone administered intramuscularly can be given to a pediatric patient who presents with a first episode of uncomplicated otitis media. 
  

The problem, however, is that ceftriaxone should be generally avoided in neonates, especially those whose bilirubin level is elevated because ceftriaxone can displace bilirubin from its binding site.

 The free bilirubin can cross the blood-brain barrier and cause kernicterus, which can be deadly. 
  

Another example of medication that should be avoided in neonates is oral ibuprofen. Medications that contain a high amount of sodium benzoate should also be avoided because benzoate can displace bilirubin from its binding site. High levels of benzoic acid (≥ 99 mg/kg/d) may also lead to gasping syndrome in neonates.

Another problem in this case is that sterile water for injection (SWI) rather than 1% lidocaine should be used to reconstitute the ceftriaxone vial in patients younger than 3 months. Potential mistakes can occur in which too much lidocaine is erroneously given to young patients, leading to toxicity.
 
 References
 1. Kaushal R, Goldmann D, Keohane C, et al. Adverse drug events in pediatric outpatients. 

Top 10 common medication errors-and how to avoid them: Drug #1: acetaminophen.

 Top 10 common medication errors-and how to avoid them: Drug #2: insulin.

 Oct 18, 2012. 
 4. Taketomo CK, Hodding JH, Kraus DM. 

18th ed. Hudson, Ohio: Lexi-Comp; 2011.
 
  

Ceftriaxone is used to treat an array of infections and can be given once daily IV or IM. However, it should generally be avoided in neonates, especially those with high bilirubin levels. This case demonstrates how problems can -- and do -- occur with this agent.

Author | PedsConLive Staff

Articles

Top 10 Common Medication Errors-Drug #9: Clonidine

Top 10 Common Medication Errors -- Drug #7 -- Ciprofloxacin

Common Medication Errors: Drug #6: Ketorolac

Top 10 Common Medication Errors-Drug #3: Ceftriaxone