Original version Date: 15/04/2019

Alert
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1 microgram = 1000 nanograms.
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Indication
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For temporary maintenance of ductus arteriosus patency until corrective or palliative surgery can be performed in neonates with ductal-dependent congenital heart defects.
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Action
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Relaxes the ductus arteriosus in early postnatal life and supports its patency.
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Drug Type
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Prostaglandin E1 or PGE1
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Trade Name
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Prostin VR.
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Presentation
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Ampoules (sterile solution) 500 microgram/mL 1 mL
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Dosage / Interval
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Starting Dose
Dose: 10 nanogram/kg/minute (range: 5 to 50 nanogram/kg/minute).
For known congenital heart disease patients and prior to ductal closure: Start at 10 nanogram/kg/min.
If there is no clinical or echocardiographic response to the maximum dose of 50 nanogram/kg/min, then consult a paediatric cardiologist. Very rarely they may suggest a very short trial of up to 100 nanogram/kg/min.
Maintenance Dose
3-20 nanogram/kg/minute. Aim is to be on the lowest dose that safely maintains ductal patency.
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Maximum dose
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Higher doses ≥50 nanogram/kg/minute may be needed to resuscitate infants with poor perfusion and oxygenation (‘grey baby’) and with ductal closure in suspected duct-dependent congenital heart disease.
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Route
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Continuous IV infusion.
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Preparation/Dilution
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LOW concentration continuous IV infusion [use if attempting to avoid ventilation and keep ductus open]
Infusion strength
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Prescribed amount
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1 mL/hour = 10 nanogram/kg/minute
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30 microgram/kg alprostadil (Prostin VR, PGE1) and make up to 50 mL
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First dilution: Draw up 1 mL (500 microgram) of alprostadil and add 9 mL of sodium chloride 0.9% or glucose 5% to make a final volume of 10 mL with a concentration of 50 microgram/mL.
Second dilution: From this, draw up 0.6 mL/kg (30 microgram/kg) and dilute to 50 mL with sodium chloride 0.9% or glucose 5%. Infuse at rate of 1 mL/h = 10 nanogram/kg/minute.
HIGH concentration continuous IV infusion [consider if ductus closed and/or mechanically ventilated]
Infusion strength
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Prescribed amount
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1 mL/hour = 50 nanogram/kg/minute
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150 microgram/kg alprostadil (Prostin VR, PGE1) and make up to 50 mL
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First dilution: Draw up 1 mL (500 microgram of alprostadil) and add 9 mL of sodium chloride 0.9% or glucose 5% to make a final volume of 10 mL with a concentration of 50 microgram/mL.
Second dilution: From this, draw up 3 mL/kg (150 microgram/kg) and dilute to 50 mL with sodium chloride 0.9% or glucose 5%. Infusing at rate of 1 mL/h = 50 nanogram/kg/minute.
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Administration
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Continuous intravenous infusion. Ensure reliable intravenous access as short half-life.
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Monitoring
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Continuous pulse oximetry, heart rate, ECG and blood pressure monitoring.
Assess urine output and peripheral perfusion frequently.
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Contraindications
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Precautions
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Ensure adequate cardiorespiratory monitoring and cardiorespiratory resuscitation equipment available for immediate use if necessary.
Apnoea is frequent. Commencement of alprostadil ≤ 20 nanogram/kg/min and low maintenance dose reduces apnoea incidence.
Titrate to infant’s response (increased oxygenation, echo findings and side effects) - Aim is to be on the lowest dose that safely maintains the ductal patency.
Hyperosmolar – infuse at concentrations < 20 microgram/mL.
Neonates with total anomalous pulmonary venous return below the diaphragm – may precipitate pulmonary oedema because of increased pulmonary blood flow.
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Drug Interactions
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Concomitant administration with heparin may result in an increased risk of bleeding.
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Adverse Reactions
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Apnoea is frequent. Commencement of alprostadil ≤ 20 nanogram/kg/min and low maintenance dose reduces apnea incidence. Methylxanthines (caffeine or aminophylline) may be used to prevent or treat apnoea. [4]
May lower blood pressure by relaxing the vascular smooth muscle causing vasodilatation and can elevate body temperature.
Other reported effects include abdominal distension, bradycardia, enterocolitis, vomiting and skin rash. [5]
With prolonged use, skeletal changes [10] and hypertrophic pyloric stenosis [11, 12] have been reported.
Extravasation may cause tissue necrosis.
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Compatibility
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Fluids: Glucose 5%, sodium chloride 0.9%.
Y-site: Amino acid solutions, ampicillin; cefazolin; cefotaxime; chlorothiazide; dobutamine; dopamine; fentanyl; gentamicin; methylprednisolone; nitroprusside; potassium chloride; tobramycin, vancomycin; vecuronium.
Syringe: Caffeine; dobutamine; dopamine; adrenaline (epinephrine); fentanyl; midazolam; morphine.
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Incompatibility
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Y-site: Levofloxacin
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Stability
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Diluted solution stable for up to 24 hours.
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Storage
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Ampoule: Store at 2 to 8°C. Do not freeze.
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Special Comments
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Do not use if cloudy (crystallised).
Undiluted solution (500 microgram/mL) is hyperosmolar. Dilute before administration to a concentration of 20 microgram/mL or less.
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Evidence summary
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Efficacy:
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