Bleomycin Injection - Preparation & Administration in a 29 kg Child

Important note: This guide covers both oncology (IV/IM/SC) and interventional/sclerotherapy (intralesional) use, as the indication determines the dose and route. Verify the indication before proceeding.

1. Dose Calculation for a 29 kg Child

A. Intralesional Sclerotherapy (Vascular Malformations - most common pediatric use)

• Children >1 year: single-session dose capped at 15 units (international units, IU)
• Children <1 year: cap at 1 mg/kg per injection
• Cumulative lifetime dose must not exceed 300,000 IU (300 units); track carefully at each session

B. Oncology Use (Hodgkin lymphoma, testicular carcinoma - per COG protocol)

• Standard dose: 0.25-0.5 units/kg (10-20 units/m²) IV/IM/SC weekly or twice weekly
• Pediatric dosing is protocol-driven (Children's Oncology Group); always follow the specific COG protocol

2. Reconstitution and Preparation

Bleomycin is a hazardous/cytotoxic drug - must be prepared in pharmacy under a biological safety cabinet. Wear impermeable gloves + eye protection.

Standard Reconstitution

For Sclerotherapy (intralesional use)

• Pharmacy prepares pre-filled syringe (2 business days notice required)
• Reconstitute in pharmacy sterile suite only
• Alternative foam preparation for large lesions: 15 mg bleomycin in 7.5 mL saline + 7.5 mL 25% human serum albumin + 30 mL room air (total 45 mL foam)
• Transport using cytotoxic medication precautions

For IV/IM/SC (oncology)

• Reconstitute with 1-5 mL NaCl 0.9% or D5W
• For IV infusion: further dilute in 50-100 mL NaCl 0.9%
• Infuse IV over 10-30 minutes minimum

3. Administration

Intralesional Route (Sclerotherapy)

• Administered by an interventional radiologist or paediatric surgeon with vascular anomaly experience
• Always under imaging guidance (ultrasound or fluoroscopy)
• Inject directly into the lesion (lymphatic malformation, venous malformation)
• Prescribe and document dose in the medical record before administration

IV/IM/SC Route (Oncology)

• IV: slow push or infusion over 10-30 min
• IM/SC: inject into large muscle or subcutaneous tissue
• Test dose (for lymphoma): 1-2 units IM/IV before first full dose, wait 1-2 hours to observe for anaphylactoid reaction (especially important in lymphoma patients)

4. Renal Dose Adjustment

5. Monitoring and Safety

Pre-procedure

• Review cumulative lifetime bleomycin dose (limit: 300,000 IU total lifetime)
• Baseline pulmonary function (spirometry) if oncology use
• Renal function (serum creatinine)
• Confirm indication, lesion location (extra caution near airway, orbit, tongue, axillae, genitalia, digits)

Peri-procedure

• Monitor oxygen saturation
• Watch for anaphylactoid reaction (fever, chills, hypotension) - particularly with first dose in oncology
• Keep resuscitation equipment available

Post-procedure (Sclerotherapy)

• Monitor for post-injection swelling (critical if near airway)
• Reassess lesion at 4-week follow-up
• Next session not before 6-8 weeks

Key Toxicities

6. For 29 kg Child - Practical Summary

• SCHN Drug Protocol 2024-113 v1.1 - Percutaneous Bleomycin for Sclerotherapy, Sydney Children's Hospital Network (March 2025)
• Pediatric IR Handbook - Medication Doses - Boston Children's Hospital IR
• PrescriberPoint Bleomycin 2026 - Pediatric pharmacokinetics and renal dosing
• MedCrave - Bleomycin for Vascular Anomalies - Foam preparation protocol

Clinical reminder: For oncology indications, always follow the specific COG or institutional chemotherapy protocol. For sclerotherapy, this must be performed by a trained interventional radiologist or paediatric surgeon with vascular anomaly expertise. Always verify cumulative dose history before each session.