Dear colleagues,

I was wondering what your practice is regarding preparation of drugs for intravenous administration in the NICU? Are your units employing an individualized approach, whereby each drug is prepared for each infant in the prescribed dose and thus administered, or a 'standard concentration' approach, whereby a drug solution is prepared in a fixed concentration and the volume to be administered is calculated from that concentration?

In our unit we employ the latter approach, as can be observed in the attached figure.

The doctor prescribes a weight-based dose, the pharmacist prepares a standard concentration solution in sufficient volume to account for dose and tubing, and the nurse calculates the volume that would provide the precise prescribed dose and sets the syringe pump to deliver that dose.

I am interested to know of other units working this way, as well as other approaches. Please share for everyone's benefit!

Thanks for posting, important question!

We also have standard solutions with a standard concentrations. Prescriptions are added to the infusion pumps as dose/kg/time unit (usually hour). Compared to the old days, when infusors were set to ml/hour, this works with less dosing errors.

Interesting.

So the infusion pump gets the weight from the medical record automatically? If yes, then this removes another step of "manual" calculation, which surely contributes to less dosing errors. However, you still need to factor in the weight when the nurse connects the syringe to the pump and prepares to deliver the dose. If the drug solution is in mg/mL and the dose is given as a dosing rate (mg/kg*hour), then when dividing the dosing rate by the concentration you get mL/kg*hour, which is a weight-adjusted delivery rate. Is the weight factored in automatically by the pump, i.e., the pump calculates the final delivery rate in mL/hour?

I will check the details with the nurses when back in the NICU in one week but principally it works like this:

• Pumps are programmed, all infusions are listed with their concentrations

• Weight is added manually, as a max infused volume per 24h

• Dose is set at e.g. mg/kg/h

• The infused volume is checked and recorded every 8h or any time a dose is adjusted

We prescribe a dose as mg/kg/day combined with doseweight of the baby and frequency of the medication/day.

Pharmacy prepares from standard concentration.

Nurse administers unique dose to the baby.

3 hours ago, Petri Mansvelt said:

We prescribe a dose as mg/kg/day combined with doseweight of the baby and frequency of the medication/day.

Pharmacy prepares from standard concentration.

Nurse administers unique dose to the baby.

Thanks. So if I understand correctly, your process is similar to the one depicted in the figure in the original post? Pharmacy prepares a standard concentration for all infants, from which the exact dose is calculated and administered based on specific weight-based dosage?

On 3/3/2026 at 11:26 AM, Petri Mansvelt said:

We prescribe a dose as mg/kg/day combined with doseweight of the baby and frequency of the medication/day.

Pharmacy prepares from standard concentration.

Nurse administers unique dose to the baby.

Do you use pumps that are pre-programmed, with infusion with standardised concentrations? Or is the prescribed dose communicated as a volume/time that is set in the pump?

On 2/28/2026 at 8:00 AM, Stefan Johansson said:

I will check the details with the nurses when back in the NICU in one week but principally it works like this:

• Pumps are programmed, all infusions are listed with their concentrations

• Weight is added manually, as a max infused volume per 24h

• Dose is set at e.g. mg/kg/h

• The infused volume is checked and recorded every 8h or any time a dose is adjusted

I went into the details around this and the work flow above is the one the nurses use. There are a few steps before an infusion can get started but the pre-programmed medicines (with pre-recorded concentrations) can indeed reduce dosing errors. Naturally, the preparation of the infusions (dilutions, although we have written protocols for all) can still be a weak link...

Good evening!

Thanks for this important issue.

I learned during my time in Sweden how important standard concentrations for the reduction of medical errors are.

We have a working group in Germany of pharmacists, neonatologists and nurses and our proposal of standard concentrations for the 60 most important drugs at the NICU has just been submitted.

At our ward we changed from weight based concentrations to standard drug concentrations after the introduction of an PDMS at the NICU. We just finished all the pump instructions to make the dosage work. We have to enter the weights manually into the pumps.

But only by using dosage and no longer ml/h increases the patient safety especially in high action situations.

Greetings from Germany

Dirk

Hi everyone! Great talk. I was wondering if you could share the standard concentrations you're using. I'm having a hard time standardizing them, especially for very small preemies due to the high volumes involved. It's a great project! Thanks for any info or experience you can share

@juan carlos vidal there's plenty of our standard concentrations 😀 and a some special drugs have variants (to adapt to patients volume load), like dobutamin which have three different standards (500, 1000 and 2000 microg/mL). Anyway, you can find all drugs used in NICUs in Stockholm in our "eped" formulary, it is all in Swedish but you can easily find all medicines by generic names and an AI 🤖 can help translate the PDFs with dilution instructions.

Hope this helps!

We have published our recommended standard concentrations in a position statement last year. While the majority of the statement is in Hebrew, the recommendations are in English and are attached below. The full text can be found here and can be translated using AI/Google Translate as needed (or you can ask me for any clarifications).

I also played a bit with Gemini recently and created this "NICU Smart Infusion Tool" (also attached, should work offline from any browser, just download and open in browser - free to use and share). This tool takes as input a medication from a predetermined list of drugs administered continuously in the NICU, infant weight and dosage OR delivery rate, and calculates the pump rate, delivered dose and total volume of fluid per day as output for each of the standard concentrations. These calculations complement the recommendation for using standard concentrations and should help the clinician choose the most appropriate concentration for any individual patient.

It should be noted that the various concentrations were originally meant for different weight categories, but with accumulated experience we have found that for e.g. Fentanyl, using the 2.5 mcg/mL for very small babies may actually load them with excess fluids, so in practice we use 5 or 10 mcg/mL (using the tool as a decision supporting system). So while all of the recommendations are evidence-based, some are pending revision, but can still be used at the discretion of the clinician.

For other common drugs administered as intermittent infusion, we use the following concentrations:

1. Ampicillin: 25 mg/mL or 50 mg/mL (when higher doses are needed, e.g., for meningitis, or for very large babies).

2. Caffeine: 5 mg/mL or 10 mg/mL (when a loading dose is required)

3. Fluconazole: 2 mg/mL or 1 mg/mL (for very small babies)

4. Darbepoetin: 40 mcg/mL

And in general, even for rarely administered drugs with no established standard concentration, we try to prepare them in a concentration that will be easy to calculate, easy to dilute down to and produce a volume that will be easy to administer (i.e., not too small).

NICU Smart Infusion Tool.html

9 hours ago, Stefan Johansson said:

@juan carlos vidal ...Anyway, you can find all drugs used in NICUs in Stockholm in our "eped" formulary...

Forgot the link 😬 comes here!

https://eped.se/backup/eped/lists/13285307916697158430.html

muchas gracias a todos