1. Sucrose in Neonates: Sources of Sweet Errors Pooja Shah, PharmD, BCPPS Clinical Assistant Professor Ernest Mario School of Pharmacy Rutgers University Clinical Pediatric Pharmacist, General Pediatric and Neonatal Intensive Care Hackensack University Medical Center Hackensack, NJ

2. Ernest Mario School of Pharmacy Disclosures I do not have any conflicts of interest to disclose.

3. Ernest Mario School of Pharmacy Objective Pharmacist –Explain strategies to avoid errors with procedural pain medications in neonatal patients focusing on the administration of sucrose Technician –List an indication and potential side effect of sucrose use in the pediatric population

4. Ernest Mario School of Pharmacy Meet Baby Boy Mickey Baby Boy Mickey, an ex-26 + 3 day newborn was admitted to the NICU for prematurity, respiratory distress and possible sepsis Nurse administers 0.5 mL of sucrose 2 minutes prior to peripheral line placement per procedural pain policy: Unsuccessful attempt Another dose of sucrose is administered prior to second attempt: Successful line placement

5. Ernest Mario School of Pharmacy Few Hours Later…. Pneumothorax is discovered and chest tube placement is planned: 3 doses of sucrose administered prior to and throughout procedure Patient has various other procedures performed and receives an additional 7 doses of sucrose throughout the day…. Sources of error associated with sucrose?

6. Ernest Mario School of Pharmacy Sucrose in Procedural Pain Recommended for analgesia to infants during mild to moderately painful procedures Not to be swallowed but absorbed via oral mucosa Additive analgesic effect has been noted when used in conjunction with pacifier Mechanism not clear elucidated –Opioid-mediated –Dopamine –Acetylcholine Available in 24% sucrose solution Dosing varies from 0.1 to 1 mL AAP Committee on Fetus and Newborn Prevention and Management of Procedural Pain in the Neonate: An Update. Pediatrics. 2016;137(2):e20154271. Holsti L, Grunau RE. Pediatrics. 2010;125(5):1042-1047.

7. Ernest Mario School of Pharmacy Sources of Medication Errors: Formulation & Administration Cups- 15 mL Made to dip pacifier into the cup Should only be used once – bacterial growth Difficult to gauge dose during administration Oral Syringes – 0.5 mL, 1 mL, 2 mL Dosing is measured in drops Differs between products 1 drop ranges 40 – 60 microliters 1 mL = 12.5 to 20 drops Can be reused within the same procedure

8. Ernest Mario School of Pharmacy Sources of Error: Repeated Dosing Repeated dosing of sucrose is recommended during longer procedures ~ 15 painful procedures/day in preterm, critically ill infants Limited studies with frequent dosing and long-term safety –>10 doses/day in patients <31 weeks’ gestational age are more likely to have neurodevelopment impairment –Hyperglycemia only reported in one patient in the literature Lack of awareness of how many doses administered in clinical practice by all healthcare professionals Lack of knowledge on appropriate use and administration AAP Committee on Fetus and Newborn Prevention and Management of Procedural Pain in the Neonate: An Update. Pediatrics. 2016;137(2):e20154271. Holsti L, Grunau RE. Pediatrics. 2010;125(5):1042-1047.

9. Ernest Mario School of Pharmacy Recommendations for Error Prevention Institutional Guidelines and Protocols Recommend dosing based on weight or age Maximum doses/day Incorporate non- pharmacologic therapies and escalating to pharmacologic alternatives Treat and Track Sucrose as a Medication Order placed in the medication administration record with specific dose Documented administration of each dose Stored in an automated dispensing cabinet Education Causes of error Administration of appropriate dose Products that can be reused versus single use Procedures that are appropriate for sucrose AAP Committee on Fetus and Newborn Prevention and Management of Procedural Pain in the Neonate: An Update. Pediatrics. 2016;137(2):e20154271.

10. Ernest Mario School of Pharmacy Sample Policy and Sucrose Orders 27 – 31 weeks gestation - 24% Sucrose 0.2 mL (4 drops) 32 – 36 weeks - 24% Sucrose 0.5 mL (10 drops) ≥ 37 weeks - 24% Sucrose 1 mL (20 drops)

11. Ernest Mario School of Pharmacy Sample Policy: Procedure

12. Ernest Mario School of Pharmacy Pharmacist Question Which of the following is not an appropriate error prevention strategy with regards to the administration of sucrose in neonates for procedural pain management? A.Recommend an alternative, more potent pain medication to prevent and treat procedural pain rather than sucrose B.Develop a guideline highlighting selected uses of sucrose for administration of procedural pain in neonates C.Store sucrose in the automated dispensing cabinets that requires an order for dispensing D.Educate nurses on how to estimate the number of milliliters of sucrose to administer the desired amount when using the oral syringe formulations

13. Ernest Mario School of Pharmacy Technician Question Which of the following is TRUE regarding sucrose: A.It can be used in infants for pain relief B.Excessive use could cause elevated blood sugars C.Sucrose has been an association with multiple medication errors D.All of the above