alprostadil

Alprostadil 5 mcg/ml solution

Dose: 0.05 to 0.10 mcg/kg/min IV
(may increase to 0.4 mcg/kg/min see comments)
Reduce dose when patency achieved to 0.002 to 0.05 mcg/kg/min.

Frequency: Continuous infusion

Comments: Alprostadil is a prostaglandin used to maintain blood flow through the ductus arteriosus when this structure is essential for maintaining either pulmonary or systemic circulation. The use of prostaglandins have allowed for stabilization of infants and the prevention of tissue hypoxia and acidosis which can adversely effect myocardial function and pulmonary vascular resistance. Surgery can then be carried out under less emergent conditions with improved survival. Further comments on alprostadil. The following table lists congenital heart lesions potentially responsive to alprostadil:
DUCTUS DEPENDENT PULMONARY BLOOD FLOW

1. Severe tetralogy of Fallot

2. Critical pulmonary stenosis/pulmonary atresia

3. Tricuspid atresia

DUCTUS DEPENDENT SYSTEMIC BLOOD FLOW

1. Aortic arch interruption

2. Juxtaductal coarctation of the aorta

3. Hypoplastic left heart syndrome

TRICUSPID VALVE ANOMALIES

1. Tricuspid insufficiency

2. Ebstein's anomaly

TRANSPOSITION OF THE GREAT ARTERIES

1. Without restricted pulmonary blood flow

Toxicity: Approximately 18% of infants may exhibit cardiovascular side effects, the most common of which are cutaneous vasodilatation and edema. Although much less common, arrhythmias and hypotension may also occur. Respiratory depression and apnea can be seen in as many as 12% of infants, especially in those weighing less than 2 kg. This is dose-related and is not typically seen with infusions < 0.05 mcg/kg/min. The relationship between the use of alprostadil and infection remains controversial. Other side effects which may occur include: temperature elevation, seizure-like activity, irritability, muscle twitching or jitteriness, lethargy, hypoglycemia, hypocalcemia, hyperbilirubinemia, diarrhea, and thrombocytopenia. The majority of the above problems are minor compared to the clinical situation of the infant's need for treatment. See adverse reactions associated with alprostadil.

	Preparation: Caution: New Method of Infusing alprostadil! If there is time, alprostadil can be ordered from the pharmacy for use with our NICU programable pumps. The pharmacy will send up a 5 mcg/ml (500 mcg/100 ml at SJMMC or 250 mcg/50 ml at SLH) concentration of alprostadil. The infusion rate programed from the pump can be double checked using the drip sheet calculator (must have microsoft excel installed). For transports and in an emergency, Alprostadil (Prostin VR Pediatric) is available in the Omnicel in a 500 mcg/ml vial. Dilute 500 mcg (1 ml) of alprostadil in 100 ml of D₅W to prepare a 5 mcg/ml solution. The solution is stable for 24 hours after mixing.
	Compatibility: Alprostadil is compatible with TPN (2% solution), though no information is available about the filter. It is also compatible with D5W, D10W, D15W, D20W, dobutamine, dopamine, epinephrine, fentanyl, midazolam, and morphine. The information is based on an upcoming paper "Chemical and physical stability of alprostadil with total parenteral nutrition, and selected intravenous medications" by Mark MacKay BS RPh, David Mann BS RPh, William Rusho BS RPh, MS, John Sweeley BS, and Ralph A. Lugo Pharm D.
	Alprostadil Code Sheet

The following table was prepared using a 5 mcg/ml concentration of alprostadil. To deliver the medication at 0.05 mcg/kg/min, the alprostadil should be infused at the ml/hr listed in the column under 0.05 mcg/kg/min corresponding to the infant's weight. To infuse the alprostadil at 0.01 mcg/kg/min, use the 0.01 mcg/kg/min column and infuse the alprostadil at the ml/hr listed for the infants weight.
Weight	0.05 mcg/kg/min	0.01 mcg/kg/min	Weight	0.05 mcg/kg/min	0.01 mcg/kg/min
1000	0.60 ml/hr	0.12 ml/hr	3250	1.95 ml/hr	0.39 ml/hr
1250	0.75 ml/hr	0.15 ml/hr	3500	2.10 ml/hr	0.42 ml/hr
1500	0.90 ml/hr	0.18 ml/hr	3750	2.25 ml/hr	0.45 ml/hr
1750	1.05 ml/hr	0.21 ml/hr	4000	2.40 ml/hr	0.48 ml/hr
2000	1.20 ml/hr	0.24 ml/hr	4250	2.55 ml/hr	0.51 ml/hr
2250	1.35 ml/hr	0.27 ml/hr	4500	2.70 ml/hr	0.54 ml/hr
2500	1.50 ml/hr	0.30 ml/hr	4750	2.85 ml/hr	0.57 ml/hr
2750	1.65 ml/hr	0.33 ml/hr	5000	3.00 ml/hr	0.60 ml/hr
3000	1.80 ml/hr	0.36 ml/hr	5250	3.15 ml/hr	0.63 ml/hr

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