General opd & iPd cases with proper treatment with correct doses & frequency department wise

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Reading File

Given the broad scope (all departments, PG-level, case vignette format), I'll query the medical library in parallel across key departments to pull accurate treatment protocols and doses.

Finding Sources

Here is a comprehensive department-wise collection of common OPD and IPD cases with case vignettes, diagnosis, and treatment protocols at PG resident level.

Department-wise OPD & IPD Cases with Treatment Protocols

1. MEDICINE / INTERNAL MEDICINE

CASE 1 - Hypertension (OPD)

Vignette: A 52-year-old male presents to OPD with persistent headache and dizziness for 3 months. BP: 158/98 mmHg on two separate readings. No diabetes. No target organ damage on workup. BMI 27.

Diagnosis: Stage 2 Essential Hypertension

Treatment:

Drug	Dose	Frequency	Route	Duration
Amlodipine	5 mg (can titrate to 10 mg)	Once daily	Oral	Long-term
Telmisartan (if ACEi not tolerated)	40 mg (up to 80 mg)	Once daily	Oral	Long-term
Hydrochlorothiazide (add-on)	12.5-25 mg	Once daily (morning)	Oral	Long-term

Target BP: <130/80 mmHg
Lifestyle: DASH diet, sodium restriction (<2.3 g/day), aerobic exercise 150 min/week, smoking cessation
If resistant: add spironolactone 25-50 mg OD

CASE 2 - Type 2 Diabetes Mellitus (OPD)

Vignette: A 45-year-old female, overweight (BMI 29), presents with polyuria, polydipsia for 2 months. FBS: 162 mg/dL, HbA1c: 8.2%. No renal impairment (eGFR >60).

Diagnosis: Type 2 Diabetes Mellitus

Treatment:

Drug	Dose	Frequency	Route	Notes
Metformin (first-line)	500 mg x 2 weeks, then 1000 mg	Twice daily with meals	Oral	Start low, titrate to reduce GI side effects
Add Glipizide if HbA1c >7.5%	5 mg (up to 20 mg)	Once daily before breakfast	Oral	Monitor for hypoglycemia
Empagliflozin (SGLT2i if CVD risk)	10 mg	Once daily	Oral	Cardioprotective

HbA1c target: <7% (individualize)
Lifestyle: MNT, 150 min/week moderate exercise, foot care
Annual: HbA1c, lipids, eGFR, microalbuminuria, eye exam

CASE 3 - Community-Acquired Pneumonia (IPD)

Vignette: A 38-year-old male presents with 5-day history of productive cough with rust-colored sputum, fever (39.2°C), pleuritic chest pain. O2 sat 91% on room air. CXR: right lower lobe consolidation. CURB-65 score: 2.

Diagnosis: Community-Acquired Pneumonia (moderate severity)

Treatment (Hospitalized):

Drug	Dose	Frequency	Route	Duration
Amoxicillin-Clavulanate	1.2 g	Every 8 hours	IV	Until afebrile 48 hrs, then oral
Azithromycin (atypical cover)	500 mg	Once daily	IV/Oral	5 days total
OR Levofloxacin (monotherapy)	750 mg	Once daily	IV/Oral	5 days
Paracetamol	1 g	Every 6-8 hours PRN	Oral/IV	As needed

Supplemental O2 to maintain SpO2 >94%
Step down to oral after 48 hours if improving
Switch to Amoxicillin-Clavulanate 625 mg PO TID to complete 5-7 days

CASE 4 - Acute Exacerbation of COPD (IPD)

Vignette: A 65-year-old chronic smoker (40 pack-years) presents with worsening dyspnea, increased cough, and purulent sputum for 3 days. RR 28/min, SpO2 86%. Known COPD on inhalers.

Diagnosis: Acute Exacerbation of COPD (Moderate-Severe)

Treatment:

Drug	Dose	Frequency	Route	Duration
Salbutamol (SABA) via nebulizer	2.5-5 mg	Every 20 min x3, then Q4-6h	Nebulized	Until stable
Ipratropium via nebulizer	0.5 mg	Every 6 hours	Nebulized	5-7 days
Prednisolone	40 mg	Once daily	Oral	5 days
Amoxicillin-Clavulanate	625 mg	Three times daily	Oral	5-7 days
Controlled O2	24-28% (Venturi mask)	Continuous	Inhalation	Titrate to SpO2 88-92%

Consider NIV (BiPAP) if pH <7.35 + PaCO2 >45 mmHg

CASE 5 - Acute MI (STEMI) - IPD/Emergency

Vignette: A 58-year-old male with DM and hypertension presents with crushing central chest pain radiating to left arm for 2 hours. ECG: ST elevation in V1-V4. BP 110/70.

Diagnosis: Anterior STEMI

Immediate Treatment (Door-to-balloon goal <90 min):

Drug	Dose	Frequency	Route
Aspirin	325 mg (loading) then 75-100 mg OD	Stat, then daily	Oral
Ticagrelor (DAPT)	180 mg loading, then 90 mg	Stat, then twice daily	Oral
Heparin (UFH)	60 U/kg IV bolus (max 4000 U), then 12 U/kg/hr	Continuous	IV
Atorvastatin	80 mg	Once daily (night)	Oral
Metoprolol	25-50 mg	Twice daily	Oral
Ramipril (once stable)	2.5 mg titrated to 10 mg	Once daily	Oral

Primary PCI is treatment of choice
If PCI unavailable: Thrombolysis with Tenecteplase (weight-based)

2. SURGERY

CASE 6 - Acute Appendicitis (IPD)

Vignette: A 22-year-old male presents with 24-hour history of periumbilical pain migrating to RIF, anorexia, fever (38.4°C). Rovsing's sign positive. WBC 14,000. USS: dilated appendix 8mm, no perforation.

Diagnosis: Acute Uncomplicated Appendicitis

Treatment:

Drug/Intervention	Dose	Frequency	Route	Timing
IV Cefuroxime	1.5 g	Pre-op single dose	IV	30 min before incision
IV Metronidazole	500 mg	Pre-op single dose	IV	30 min before incision
Paracetamol	1 g	Every 8 hours	IV/Oral	Post-op analgesia
Ketorolac / Diclofenac	30 mg / 75 mg	Every 8 hours	IV / IM	2-3 days
Morphine (if severe pain)	0.1 mg/kg	PRN every 4-6 hours	IV	As needed

Definitive: Laparoscopic appendectomy (preferred)
NBM pre-op, IV fluids, monitoring
If perforated: extend antibiotics to 5-7 days (Piperacillin-Tazobactam 4.5 g IV Q8h)

CASE 7 - Inguinal Hernia (OPD/Elective IPD)

Vignette: A 40-year-old male laborer presents with a reducible right groin swelling for 6 months, aggravated by straining. Examination: indirect inguinal hernia.

Diagnosis: Right Indirect Inguinal Hernia (Reducible)

Treatment:

Elective laparoscopic (TEP/TAPP) or Lichtenstein mesh repair
Pre-op: Cefazolin 2 g IV 30 min before incision
Post-op analgesia:

Drug	Dose	Frequency	Route
Paracetamol	1 g	Every 8 hours	Oral
Ibuprofen	400 mg	Three times daily with food	Oral
Tramadol (if needed)	50-100 mg	Every 8 hours PRN	Oral

CASE 8 - Peptic Ulcer Disease (OPD)

Vignette: A 35-year-old male on NSAIDs for back pain presents with epigastric pain relieved by food, nausea. H. pylori rapid urease test: positive. Upper GI endoscopy: duodenal ulcer.

Diagnosis: H. pylori-positive Duodenal Ulcer

Triple Therapy (14 days):

Drug	Dose	Frequency
Omeprazole (PPI)	20 mg	Twice daily (AC)
Amoxicillin	1 g	Twice daily
Clarithromycin	500 mg	Twice daily

Stop NSAIDs; if unavoidable, use with PPI
Test-of-cure (UBT or stool antigen) 4 weeks after completion
Continue PPI for 4-8 weeks total for ulcer healing

3. PEDIATRICS

CASE 9 - Acute Febrile Illness / Viral URTI (OPD)

Vignette: A 4-year-old child (18 kg) brought by mother with fever (38.8°C), running nose, mild cough for 2 days. No throat exudate. Ears clear. Lungs clear.

Diagnosis: Viral Upper Respiratory Tract Infection

Treatment (Symptomatic):

Drug	Dose	Frequency	Route
Paracetamol	15 mg/kg/dose = 270 mg (use 250 mg/5 mL syrup = ~5 mL)	Every 6-8 hours when febrile	Oral
Ibuprofen (alternate)	10 mg/kg/dose = 180 mg	Every 6-8 hours with food	Oral
Nasal saline drops	2-3 drops each nostril	3-4 times daily	Intranasal

No antibiotics (viral etiology)
Adequate hydration, rest
Return if: persistent fever >5 days, earache, rash, worsening

CASE 10 - Childhood Pneumonia (IPD)

Vignette: A 3-year-old (14 kg) presents with fever (39°C), fast breathing (RR 46/min), intercostal retractions, no cyanosis. CXR: right lower lobe consolidation.

Diagnosis: Severe Pneumonia (WHO classification)

Treatment (Hospitalized):

Drug	Dose	Frequency	Route	Duration
Ampicillin	50 mg/kg/dose = 700 mg	Every 6 hours	IV	5 days
Gentamicin	7.5 mg/kg = 105 mg	Once daily	IV	5 days
OR Amoxicillin-Clavulanate	45 mg/kg/day in 2 divided doses = 315 mg BD	Twice daily	Oral (step-down)	Total 7-10 days
Paracetamol	15 mg/kg every 6-8h = ~210 mg	PRN fever	Oral/IV	As needed

Supplemental O2 via nasal prongs to maintain SpO2 >95%
Ensure adequate hydration and nutrition

CASE 11 - Acute Gastroenteritis with Dehydration (IPD/OPD)

Vignette: A 2-year-old (12 kg) with watery diarrhea x6/day for 2 days, vomiting x3, slightly sunken eyes, reduced skin turgor. Weight loss ~5%. Alert but irritable. Moderate dehydration.

Diagnosis: Acute Gastroenteritis with Moderate Dehydration

Treatment (WHO/IMCI ORS Plan B):

Intervention	Dose	Notes
ORS	75 mL/kg over 4 hours = 900 mL	Supervised in OPD/ward
After rehydration: ORS for ongoing losses	10 mL/kg per loose stool, 2 mL/kg per vomit	Ongoing
Zinc sulfate	20 mg (>6 months)	Once daily x 14 days
Paracetamol	15 mg/kg/dose	Q6-8h for fever

No antidiarrheals, no antibiotics unless cholera/shigella suspected
If child fails oral rehydration: IV Ringer's Lactate 100 mL/kg over 3 hours

4. OBSTETRICS & GYNECOLOGY

CASE 12 - Preeclampsia with Severe Features (IPD)

Vignette: A 28-year-old primigravida at 34 weeks presents with headache, visual blurring, BP 162/106 mmHg. Proteinuria 3+. Platelets 95,000. Reflexes brisk.

Diagnosis: Severe Preeclampsia with impending eclampsia

Treatment:

Drug	Dose	Frequency	Route	Purpose
Magnesium Sulfate	4 g loading over 15-20 min, then 1 g/hour infusion	Loading + maintenance	IV	Seizure prophylaxis
Labetalol	20 mg IV bolus, repeat 40 mg, 80 mg Q10-20 min (max 300 mg)	Titrated	IV	Acute BP control
Nifedipine (oral)	10-20 mg	Every 30 min PRN (max 50 mg/acute)	Oral	BP control
Hydralazine	5-10 mg	Every 20 min PRN	IV	Alternative BP control

Definitive treatment: Delivery (at ≥34 weeks, immediate; <34 weeks, consider stabilize + steroids)
Betamethasone 12 mg IM x2 doses 24 hrs apart if <34 weeks for fetal lung maturity
Monitor: urine output (>30 mL/hr), Mg toxicity (check reflexes, RR)

CASE 13 - Gestational Diabetes Mellitus (OPD)

Vignette: A 32-year-old at 26 weeks gestation, OGTT: fasting 95 mg/dL, 2hr 158 mg/dL. BMI 28. No symptoms.

Diagnosis: Gestational Diabetes Mellitus (GDM)

Treatment:

Intervention	Details
Medical Nutrition Therapy	First-line for 1-2 weeks; low GI diet, 3 meals + 3 snacks
Fasting BG target	<95 mg/dL
Post-meal BG target	<140 mg/dL at 1 hr or <120 mg/dL at 2 hr
Metformin (if diet fails)	500 mg OD titrated to 500 mg TID
Insulin (if BG uncontrolled)	NPH insulin 0.2 U/kg/day (bedtime) + rapid insulin before meals

Biweekly antenatal visits, USS for fetal growth
Postpartum: OGTT at 6-12 weeks to screen for persistent T2DM

CASE 14 - Vaginal Candidiasis (OPD)

Vignette: A 25-year-old female presents with white curdy vaginal discharge, vulvar itching, and dyspareunia. Recent antibiotic course. Wet mount: pseudohyphae and spores.

Diagnosis: Vulvovaginal Candidiasis

Treatment:

Drug	Dose	Frequency	Route	Duration
Fluconazole	150 mg	Single dose	Oral	1 day (if not pregnant)
Clotrimazole pessary 500 mg	1 pessary	Single dose at night	Intravaginal	1 day
Clotrimazole cream 1%	Apply BD	Twice daily	Topical (vulva)	7 days

If pregnant: Topical clotrimazole only (avoid oral fluconazole)
If recurrent (>4 episodes/year): Fluconazole 150 mg weekly x 6 months

5. ORTHOPEDICS

CASE 15 - Colles' Fracture (OPD/IPD)

Vignette: A 60-year-old female with osteoporosis fell on outstretched hand. Wrist X-ray: distal radius fracture with dorsal angulation, radial shortening ("dinner-fork" deformity).

Diagnosis: Colles' Fracture

Treatment:

Intervention	Details
Closed reduction under hematoma block or IV sedation	Lidocaine 1% 5 mL into fracture hematoma
Short arm cast / Volar slab	4-6 weeks; above-elbow initially
If unstable/comminuted	ORIF with volar plate

Post-reduction Analgesia:

Drug	Dose	Frequency	Route
Paracetamol	1 g	Every 8 hours	Oral
Ibuprofen	400 mg	Three times daily (with food)	Oral
Tramadol	50 mg	Every 8-12 hours PRN	Oral
Calcium + Vit D3	1000 mg Ca + 800 IU D3	Once daily	Oral

Physiotherapy after cast removal; DEXA scan; Bisphosphonate if osteoporosis confirmed

CASE 16 - Septic Arthritis (IPD)

Vignette: A 30-year-old male presents with acute onset swollen, hot, painful right knee, unable to weight bear. Temp 38.8°C. WBC 18,000. Joint aspirate: turbid fluid, 80,000 WBC/mm3, Gram positive cocci.

Diagnosis: Septic Arthritis (likely Staphylococcal)

Treatment:

Drug	Dose	Frequency	Route	Duration
Cloxacillin (empiric)	1-2 g	Every 6 hours	IV	2 weeks IV, then 2-4 weeks oral
Ceftriaxone (if GN suspected)	1-2 g	Once daily	IV	As above
Adjust per culture sensitivities	-	-	-	-

Urgent joint washout / arthroscopic lavage
Repeated aspiration if needed
Splint for pain, then early ROM physiotherapy

6. ENT (Ear, Nose & Throat)

CASE 17 - Acute Otitis Media (OPD)

Vignette: A 5-year-old presents with 2-day history of ear pain, fever (38.5°C), hearing loss. Otoscopy: bulging, erythematous tympanic membrane, loss of light reflex.

Diagnosis: Acute Otitis Media

Treatment:

Drug	Dose	Frequency	Route	Duration
Amoxicillin (first-line)	90 mg/kg/day (high dose) = divided TID	Three times daily	Oral	10 days (<2 yr), 5-7 days (>2 yr)
If PCN allergy: Azithromycin	10 mg/kg day 1, then 5 mg/kg	Once daily	Oral	5 days
Paracetamol	15 mg/kg/dose	Every 6-8 hours	Oral	For pain/fever
Xylometazoline nasal drops	0.05% for children	2 drops each nostril BD	Intranasal	5 days

CASE 18 - Acute Tonsillitis (OPD)

Vignette: A 20-year-old presents with severe sore throat, odynophagia, fever (39°C), tonsillar exudates, cervical lymphadenopathy. Centor score: 4. Rapid Strep test: positive.

Diagnosis: Acute Bacterial Tonsillitis (Group A Streptococcus)

Treatment:

Drug	Dose	Frequency	Route	Duration
Phenoxymethylpenicillin	500 mg	Twice daily	Oral	10 days
OR Amoxicillin	500 mg	Three times daily	Oral	10 days
If PCN allergy: Clarithromycin	250-500 mg	Twice daily	Oral	5-10 days
Benzydamine gargle	15 mL	Every 3 hours	Gargle	As needed
Ibuprofen	400 mg	Three times daily	Oral	5-7 days

Tonsillectomy considered if recurrent (≥7 episodes/year or ≥5/year x2 years)

7. OPHTHALMOLOGY

CASE 19 - Bacterial Conjunctivitis (OPD)

Vignette: A 28-year-old presents with red, sticky eye for 3 days, mucopurulent discharge, morning crusting, no visual loss, no photophobia.

Diagnosis: Acute Bacterial Conjunctivitis

Treatment:

Drug	Dose	Frequency	Route	Duration
Ciprofloxacin eye drops 0.3%	1-2 drops	Every 2 hours for 2 days, then QID	Topical	7 days total
OR Chloramphenicol eye drops 0.5%	1-2 drops	Every 2 hours	Topical	5-7 days
Chloramphenicol ointment 1%	Thin strip	At bedtime	Topical	5-7 days

Warm saline eye cleansing; strict hand hygiene; avoid contact lens until resolved

CASE 20 - Acute Angle Closure Glaucoma (Emergency/IPD)

Vignette: A 65-year-old hyperopic female presents with sudden onset severe right eye pain, halos around lights, blurred vision, nausea. IOP: 52 mmHg. Corneal haze, mid-dilated fixed pupil.

Diagnosis: Acute Angle Closure Glaucoma - OPHTHALMIC EMERGENCY

Treatment:

Drug	Dose	Frequency	Route
Acetazolamide	500 mg (IV/oral), then 250 mg	Stat, then every 6 hours	IV/Oral
Timolol 0.5% drops	1 drop	Every 12 hours	Topical
Brimonidine 0.2% drops	1 drop	Twice daily	Topical
Pilocarpine 4% drops	1 drop	Every 15 min x4, then every 6 hours	Topical
Mannitol 20%	1-2 g/kg IV over 30-60 min	Stat (if IOP >50 or unresponsive)	IV
Analgesia: IV morphine or ketorolac	Titrated	PRN	IV

Definitive: Laser peripheral iridotomy (LPI) when cornea clears
Fellow eye: prophylactic LPI

8. PSYCHIATRY

CASE 21 - Major Depressive Disorder (OPD)

Vignette: A 30-year-old female presents with 8-week history of persistent low mood, anhedonia, early morning awakening, poor concentration, fatigue, feelings of worthlessness. PHQ-9 score: 18. No suicidal ideation. No psychotic features.

Diagnosis: Major Depressive Disorder (Moderate)

Treatment:

Drug	Starting Dose	Target Dose	Frequency	Duration
Sertraline (SSRI, first-line)	50 mg	50-200 mg	Once daily (morning)	Minimum 6-9 months after remission
OR Escitalopram	10 mg	10-20 mg	Once daily	As above
Mirtazapine (if insomnia)	15 mg	15-45 mg	Once at night	As above

Psychotherapy (CBT) in combination
Review at 2-4 weeks; assess response at 6-8 weeks
If no response after 4-6 weeks: increase dose or switch agent

CASE 22 - Schizophrenia - First Episode (IPD)

Vignette: A 22-year-old male brought by family with 4-month history of hearing voices, suspiciousness, disorganized speech, social withdrawal, neglect of self-care. MSE: auditory hallucinations, paranoid delusions.

Diagnosis: First Episode Schizophrenia

Treatment:

Drug	Dose	Frequency	Route
Risperidone (atypical, first-line)	Start 1 mg, titrate to 4-6 mg	Twice daily (or once daily at higher dose)	Oral
OR Olanzapine	Start 5 mg, titrate to 10-20 mg	Once daily at night	Oral
Lorazepam (for acute agitation)	1-2 mg	PRN every 4-6 hours	IM/Oral
Benztropine (for EPS)	1-2 mg	Twice daily (if EPS develops)	Oral

Psychoeducation of patient and family
Depot (long-acting injectable) after stabilization if adherence concern

9. DERMATOLOGY

CASE 23 - Tinea Corporis (OPD)

Vignette: A 25-year-old male farmer presents with annular, erythematous, scaly, pruritic lesions with raised borders and central clearing on trunk for 3 weeks. KOH mount: fungal hyphae.

Diagnosis: Tinea Corporis (Ringworm)

Treatment:

Drug	Application	Frequency	Duration
Clotrimazole 1% cream	Apply thin layer, 2 cm beyond border	Twice daily	2-4 weeks
Terbinafine 1% cream	Apply once daily	Once daily	1-2 weeks
If extensive: Fluconazole oral	150 mg	Once weekly	4-6 weeks
OR Itraconazole oral	200 mg	Once daily	2 weeks (pulse)

Dry skin thoroughly after bathing; avoid sharing clothing/towels
Test for tinea in contacts

CASE 24 - Psoriasis Vulgaris (OPD/IPD)

Vignette: A 35-year-old male presents with chronic, well-defined, erythematous plaques with thick silvery scales on elbows, knees, and scalp. Auspitz sign positive. PASI score: 12 (moderate).

Diagnosis: Psoriasis Vulgaris (Moderate)

Treatment (Step-up):

Drug	Dose/Application	Frequency	Route
Betamethasone dipropionate 0.05% + Calcipotriol 50 mcg/g ointment	Apply to plaques	Once daily (morning)	Topical
Emollient (white soft paraffin)	Liberal application	2-3 times daily	Topical
Salicylic acid 6% ointment (for thick plaques)	Apply, leave 2 hours	Once daily	Topical
Coal tar 5% cream (scalp)	Apply overnight	Nightly	Topical
Methotrexate (moderate-severe, if topicals fail)	7.5 mg/week, increase to 15-25 mg/week	Once weekly	Oral/SC
Folic acid (with MTX)	5 mg	Once weekly (different day from MTX)	Oral

PUVA phototherapy for extensive disease
Biologics (Adalimumab, Secukinumab) for severe/refractory cases

QUICK REFERENCE: COMMON IPD ANTIBIOTIC DOSING SUMMARY

Indication	Antibiotic	Adult Dose	Frequency	Duration
CAP (mild)	Amoxicillin	500 mg PO	TID	5-7 days
CAP (severe, hospitalized)	Piperacillin-Tazobactam	4.5 g IV	Q8h	7 days
UTI (uncomplicated)	Nitrofurantoin	100 mg PO	BD	5-7 days
UTI (complicated/pyelonephritis)	Ceftriaxone	1-2 g IV	OD	7-14 days
Cellulitis	Cloxacillin	1-2 g IV	Q6h	5-7 days
Meningitis (empiric)	Ceftriaxone + Dexamethasone	2 g IV + 0.15 mg/kg IV	Q12h + Q6h	10-14 days
Sepsis (empiric, gram neg)	Meropenem	1 g IV	Q8h	7-10 days
Typhoid fever	Ceftriaxone	2 g IV	OD	7-10 days
TB (initial 2 months: HRZE)	HRZE (weight-based)	Per weight band	Daily	2 months, then HR x4 months

Key Prescribing Principles for PG Residents:

Always confirm allergy status before prescribing
Adjust doses for renal impairment (CrCl), hepatic failure, and pregnancy
Culture before starting antibiotics whenever possible; de-escalate per sensitivities
Document indication, dose, frequency, route, and duration for every antibiotic
For pediatric dosing: always calculate per kg, confirm with formulary (BNFc)
Never prescribe systemic corticosteroids in undiagnosed skin infections
Review all drug-drug interactions (especially warfarin, antiepileptics, psychiatric drugs)---

24 cases across 9 departments are compiled above. Here is a quick index:

#	Department	Case	OPD/IPD
1	Medicine	Hypertension	OPD
2	Medicine	Type 2 Diabetes	OPD
3	Medicine	Community-Acquired Pneumonia	IPD
4	Medicine	COPD Exacerbation	IPD
5	Medicine	Anterior STEMI	IPD/Emergency
6	Surgery	Acute Appendicitis	IPD
7	Surgery	Inguinal Hernia	OPD/Elective
8	Surgery	Peptic Ulcer + H. pylori	OPD
9	Pediatrics	Viral URTI with Fever	OPD
10	Pediatrics	Severe Pneumonia	IPD
11	Pediatrics	Gastroenteritis + Dehydration	OPD/IPD
12	OBG	Severe Preeclampsia	IPD
13	OBG	Gestational Diabetes	OPD
14	OBG	Vaginal Candidiasis	OPD
15	Orthopedics	Colles' Fracture	OPD/IPD
16	Orthopedics	Septic Arthritis	IPD
17	ENT	Acute Otitis Media	OPD
18	ENT	Acute Bacterial Tonsillitis	OPD
19	Ophthalmology	Bacterial Conjunctivitis	OPD
20	Ophthalmology	Acute Angle Closure Glaucoma	Emergency
21	Psychiatry	Major Depressive Disorder	OPD
22	Psychiatry	First Episode Schizophrenia	IPD
23	Dermatology	Tinea Corporis	OPD
24	Dermatology	Psoriasis Vulgaris	OPD/IPD

Important notes:

All doses shown are for average adult patients unless specified (pediatric cases use weight-based dosing)
Always adjust for renal/hepatic function and pregnancy status
Antibiotic selection should be guided by local resistance patterns whenever available
These cases reflect current standard-of-care protocols consistent with WHO, BNF, and Harrison's-based guidelines

Let me know if you want any department expanded further, more cases added, or a downloadable Word/PDF version of this reference.

Paediatric all drugs doses per kg , frequency with duration,route,application case wise & drug classification wise

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Now compiling the full reference from all gathered data. This is the most complete pediatric drug reference I can produce at PG resident level.

PAEDIATRIC DRUG DOSAGE REFERENCE

Complete Guide: Doses per kg | Frequency | Route | Duration | Drug Class | Case-wise Application

Golden Rules:

Always calculate dose per kg; use actual body weight (use ideal body weight if obese)

Never exceed the maximum adult dose

Neonates require separate protocols - this guide covers 1 month to 12 years

Confirm renal/hepatic function before dosing aminoglycosides, vancomycin, NSAIDs

Source: Morgan & Mikhail Clinical Anesthesiology 7e, Goodman & Gilman, Harrison's 22e, Rosen's EM, Red Book 2021, Goldman-Cecil Medicine

SECTION A: DRUG CLASSIFICATION-WISE COMPLETE REFERENCE

CLASS 1: ANALGESICS & ANTIPYRETICS

1.1 Paracetamol (Acetaminophen)

Drug Class: Non-opioid analgesic / Antipyretic (COX-3 inhibitor centrally)

Route	Dose	Frequency	Max/day	Notes
Oral	10-15 mg/kg/dose	Every 4-6 hours	60 mg/kg/day (max 4 g/day)	Most common route
Rectal	15-20 mg/kg/dose (some refs: 40 mg/kg loading)	Every 6-8 hours	60 mg/kg/day	For vomiting/NBM patients
IV (age >2 yr)	15 mg/kg/dose	Every 6 hours	60 mg/kg/day	Give over 15 min

Available formulations: Suspension 125 mg/5 mL, 250 mg/5 mL; Suppositories 125 mg, 250 mg, 500 mg; IV 10 mg/mL

Duration: Until fever/pain resolves (acute use); typically 3-5 days for infective illness

1.2 Ibuprofen

Drug Class: NSAID (COX-1 & COX-2 inhibitor)

Route	Dose	Frequency	Max/day	Duration
Oral	5-10 mg/kg/dose	Every 6-8 hours	40 mg/kg/day (max 2.4 g/day)	3-5 days; with food

Contraindicated: Age <3 months, renal impairment, bleeding disorders, active GI ulcer, dengue (thrombocytopenia risk), asthma (aspirin-sensitive)

1.3 Morphine

Drug Class: Opioid analgesic (mu receptor agonist)

Route	Dose	Frequency	Notes
IV (slow)	0.05-0.1 mg/kg/dose	Every 2-4 hours PRN	Titrate to pain; have naloxone ready
IM	0.1-0.2 mg/kg	Every 4 hours	Less preferred in children
PO (immediate release)	0.1-0.3 mg/kg	Every 4 hours

Max single dose: 15 mg | Reversal: Naloxone 0.01 mg/kg IV

1.4 Fentanyl

Drug Class: Opioid analgesic (potent, short-acting)

Route	Dose	Frequency	Notes
IV (procedural)	1-2 mcg/kg	Single/repeat PRN	Onset 2-3 min
Intranasal	2 mcg/kg	Single dose	Rapid onset for acute pain/procedural
Infusion	1-4 mcg/kg/hour	Continuous	ICU only

CLASS 2: ANTIBIOTICS

2.1 BETA-LACTAMS

Amoxicillin

Drug Class: Aminopenicillin (beta-lactam)

Indication	Dose	Frequency	Route	Duration
AOM, Tonsillitis, URTI	40-50 mg/kg/day	Divided BD or TID	Oral	5-10 days
AOM (high-dose, drug-resistant S. pneumo)	80-90 mg/kg/day	Divided BD	Oral	10 days (<2 yr), 5-7 days (>2 yr)
Pneumonia (mild)	45-90 mg/kg/day	Divided TID	Oral	5-7 days
UTI (simple)	50 mg/kg/day	Divided TID	Oral	5-7 days

Max dose: 3 g/day | Available: 125 mg/5 mL, 250 mg/5 mL suspension; 250 mg, 500 mg capsules

Amoxicillin-Clavulanate (Co-amoxiclav)

Drug Class: Aminopenicillin + beta-lactamase inhibitor

Indication	Dose (amoxicillin component)	Frequency	Route	Duration
AOM (resistant), Sinusitis	80-90 mg/kg/day	Divided BD (7:1 formulation)	Oral	10 days
LRTI, Skin/soft tissue infection	40-45 mg/kg/day	Divided TID (4:1 formulation)	Oral	7-10 days
Severe infection (IV)	30 mg/kg/dose	Every 6-8 hours	IV	5-7 days then oral

Use high-dose formulation (14:1 ratio) for resistant AOM

Ampicillin

Drug Class: Aminopenicillin (broad-spectrum)

Indication	Dose	Frequency	Route	Duration
Meningitis, Sepsis, Pneumonia	50 mg/kg/dose	Every 6 hours	IV	7-14 days
UTI (IPD)	25-50 mg/kg/dose	Every 6 hours	IV	5-7 days
Neonatal sepsis	50-100 mg/kg/dose	Every 12 hrs (neonate)	IV	Per sensitivity

Max: 12 g/day

Ampicillin-Sulbactam

Dose	Frequency	Route
25-50 mg/kg/dose (ampicillin component)	Every 6-8 hours	IV

Cloxacillin / Flucloxacillin

Drug Class: Penicillinase-resistant penicillin (anti-staphylococcal)

Indication	Dose	Frequency	Route	Duration
Cellulitis, Skin/soft tissue (MSSA)	12.5-25 mg/kg/dose	Every 6 hours	Oral (30 min before food)	5-7 days
Osteomyelitis, Septic arthritis (MSSA)	25-50 mg/kg/dose	Every 6 hours	IV	2-4 weeks then oral
Sepsis (MSSA)	50 mg/kg/dose	Every 6 hours	IV	Per clinical response

Max dose: 2 g/dose | Note: Take oral on empty stomach (food reduces absorption)

Cefazolin (1st gen cephalosporin)

Drug Class: 1st generation cephalosporin (gram-positive, surgical prophylaxis)

Indication	Dose	Frequency	Route
Surgical prophylaxis	25-30 mg/kg	Single dose 30 min pre-op	IV
Cellulitis / mild SSTI	25 mg/kg	Every 8 hours	IV

Cefuroxime (2nd gen cephalosporin)

Indication	Dose	Frequency	Route	Duration
AOM, Sinusitis, Tonsillitis	15 mg/kg/dose	Twice daily	Oral	5-10 days
Pneumonia, UTI (moderate)	50-100 mg/kg/day	Divided BD or TID	IV	5-7 days
Surgical prophylaxis	25-50 mg/kg	Single pre-op dose	IV	-

Max oral: 500 mg/dose; Max IV: 1.5 g/dose

Ceftriaxone (3rd gen cephalosporin)

Drug Class: 3rd generation cephalosporin (broad-spectrum, once/twice daily)

Indication	Dose	Frequency	Route	Duration
Meningitis	50-100 mg/kg/day	Divided every 12 hours	IV	7-14 days
Pneumonia (severe)	50-75 mg/kg/day	Once or twice daily	IV	5-7 days, then oral step-down
Sepsis, Typhoid	50-75 mg/kg/day	Once daily	IV	7-14 days
UTI (pyelonephritis)	50-75 mg/kg/day	Once daily	IV/IM	7-10 days
AOM (single IM dose if no oral)	50 mg/kg	Single dose	IM	1 day
Gonorrhea	50 mg/kg	Single dose	IM	1 day

Max: 2 g/dose (4 g/day for meningitis) | Do not mix with calcium in <28 days neonates

Cefotaxime (3rd gen cephalosporin)

Indication	Dose	Frequency	Route	Duration
Meningitis, Sepsis	50 mg/kg/dose	Every 6-8 hours	IV	7-14 days
Pneumonia (severe)	50 mg/kg/dose	Every 6-8 hours	IV	7 days

Max: 12 g/day

Piperacillin-Tazobactam

Drug Class: Extended-spectrum penicillin + beta-lactamase inhibitor

Indication	Dose	Frequency	Route	Duration
Gram-negative sepsis, Febrile neutropenia	75-100 mg/kg/dose (pip component)	Every 6-8 hours	IV	7-14 days
Perforated appendicitis	75-112 mg/kg/day	Every 6 hours	IV	5-7 days
Complicated UTI	75-100 mg/kg/day	Every 6-8 hours	IV	7-10 days

Max: 4.5 g/dose (piperacillin 4 g + tazobactam 0.5 g)

Meropenem (Carbapenem)

Drug Class: Carbapenem (broadest spectrum, reserve antibiotic)

Indication	Dose	Frequency	Route	Duration
Severe gram-negative sepsis, MDR organisms	20-40 mg/kg/dose	Every 8 hours	IV	7-14 days
Meningitis (gram-negative)	40 mg/kg/dose	Every 8 hours	IV	14-21 days
Febrile neutropenia (high risk)	20-40 mg/kg/dose	Every 8 hours	IV	Until afebrile 48hr

Max: 2 g/dose (3 g for meningitis)

2.2 AMINOGLYCOSIDES

Gentamicin

Drug Class: Aminoglycoside (concentration-dependent bactericidal)

Indication	Dose	Frequency	Route	Duration	Monitoring
Severe gram-negative infection, Neonatal sepsis (combined)	2.5-5 mg/kg/dose (once-daily dosing preferred)	Once daily (7.5 mg/kg OD)	IV (over 30 min)	5-7 days	Trough <1 mg/L before next dose
Endocarditis synergy	1 mg/kg	Every 8 hours	IV	14 days	TDM mandatory

Max: Guided by TDM | Ototoxic + nephrotoxic - monitor renal function, hearing

2.3 MACROLIDES

Azithromycin

Drug Class: Macrolide (protein synthesis inhibitor - 50S)

Indication	Dose	Frequency	Route	Duration
Atypical pneumonia (Mycoplasma, Chlamydia)	10 mg/kg day 1 (max 500 mg), then 5 mg/kg/day (max 250 mg)	Once daily	Oral	5 days
AOM (PCN-allergic)	10 mg/kg day 1, then 5 mg/kg	Once daily	Oral	5 days
Pertussis (<1 month)	10 mg/kg/day	Once daily	Oral	5 days (preferred under 1 month)
Pertussis (>1 month)	10 mg/kg day 1 (max 500 mg), then 5 mg/kg	Once daily	Oral	5 days
Streptococcal pharyngitis (PCN-allergic)	12 mg/kg/day (max 500 mg)	Once daily	Oral	5 days

Alternative single-dose: 30 mg/kg once for some AOM indications

Clarithromycin

Drug Class: Macrolide

Indication	Dose	Frequency	Route	Duration
AOM, URTI, Atypical pneumonia	7.5-15 mg/kg/day (max 500 mg/dose)	Divided twice daily	Oral	5-10 days
H. pylori (triple therapy - with PPI + amoxicillin)	7.5 mg/kg/dose (max 250-500 mg)	Twice daily	Oral	10-14 days

Erythromycin

Indication	Dose	Frequency	Route	Duration
Streptococcal infection, Pertussis (PCN-allergic)	10-12.5 mg/kg/dose (max 500 mg)	Every 6 hours	Oral	7-14 days

2.4 NITROIMIDAZOLES

Metronidazole

Drug Class: Nitroimidazole (anaerobic bacteria + protozoa)

Indication	Dose	Frequency	Route	Duration
Anaerobic infections, Appendicitis (post-op)	7.5-10 mg/kg/dose	Every 8 hours	IV/Oral	5-7 days
Amoebiasis (intestinal)	15 mg/kg/dose (max 800 mg)	Three times daily	Oral	5-10 days
Giardiasis	5 mg/kg (max 400 mg)	Three times daily	Oral	5-7 days
Bacterial vaginosis / Intra-abdominal	10 mg/kg (max 500 mg)	Every 8-12 hours	IV	5-7 days

Max: 500 mg/dose IV, 800 mg/dose oral | Avoid alcohol (Antabuse effect)

2.5 SULFONAMIDES / TRIMETHOPRIM

Co-trimoxazole (TMP-SMX)

Drug Class: Folate synthesis inhibitor

Indication	Dose (TMP component)	Frequency	Route	Duration
UTI (simple), URTI	4-5 mg/kg TMP/dose (max 160 mg TMP)	Every 12 hours	Oral	5-7 days (UTI); 3-5 days (URTI)
PCP prophylaxis (HIV children)	5 mg/kg TMP once daily or 150 mg/m2	Once daily 3 days/week	Oral	Long-term
Typhoid (sensitive strains)	4-5 mg TMP/kg/dose	Every 12 hours	Oral	14 days

IV dose: 4-5 mg/kg TMP q8h

2.6 GLYCOPEPTIDES

Vancomycin

Drug Class: Glycopeptide (MRSA, Gram-positive resistant infections)

Indication	Dose	Frequency	Route	Duration
MRSA infections, Meningitis (add-on), Sepsis (MRSA)	15-20 mg/kg/dose	Every 6 hours (neonates: every 12 hours)	IV (over 60 min)	Per clinical response
C. difficile colitis	10 mg/kg/dose (max 125 mg)	Every 6 hours	Oral (not absorbed)	10-14 days

TDM mandatory: AUC/MIC guided dosing; trough target 10-20 mg/L (conventional) | Infuse slowly to avoid Red Man Syndrome

2.7 FLUOROQUINOLONES

Ciprofloxacin

Drug Class: Fluoroquinolone (DNA gyrase inhibitor) - Use with caution in children; risk of arthropathy

Indication	Dose	Frequency	Route	Duration
UTI (complicated, resistant), Typhoid	10-15 mg/kg/dose (max 400 mg IV / 750 mg oral)	Every 12 hours	IV/Oral	7-14 days
Conjunctivitis (topical)	1-2 drops	Every 2 hrs (day 1-2), then QID	Topical (eye)	7 days

Avoid in children <1 year routinely; use only when benefits outweigh risks

2.8 ANTI-TB DRUGS (First-Line)

Drug Class: Anti-mycobacterials

Drug	Dose	Frequency	Route	Phase
Isoniazid (H)	10 mg/kg/day (max 300 mg)	Once daily	Oral	Intensive + Continuation
Rifampicin (R)	15 mg/kg/day (max 600 mg)	Once daily (empty stomach)	Oral	Intensive + Continuation
Pyrazinamide (Z)	35 mg/kg/day (max 2 g)	Once daily	Oral	Intensive 2 months only
Ethambutol (E)	20 mg/kg/day (max 1 g)	Once daily	Oral	Intensive 2 months
Pyridoxine (B6)	1-2 mg/kg (max 50 mg)	Once daily	Oral	With INH to prevent neuropathy

Standard regimen: 2HRZE / 4HR | Pyridoxine mandatory with INH

CLASS 3: ANTIVIRALS

Acyclovir

Drug Class: Nucleoside analogue (Herpes simplex, VZV)

Indication	Dose	Frequency	Route	Duration
Varicella (chickenpox) - immunocompromised	10-20 mg/kg/dose (max 800 mg)	Every 8 hours	IV	7-10 days
Herpes simplex encephalitis	10-15 mg/kg/dose	Every 8 hours	IV	14-21 days
HSV labialis (mild)	20 mg/kg/dose (max 800 mg)	4 times/day	Oral	5 days

Oseltamivir (Tamiflu)

Drug Class: Neuraminidase inhibitor (Influenza A and B)

Weight	Dose	Frequency	Route	Duration
≤15 kg	30 mg	Twice daily	Oral	5 days
15-23 kg	45 mg	Twice daily	Oral	5 days
23-40 kg	60 mg	Twice daily	Oral	5 days
>40 kg	75 mg	Twice daily	Oral	5 days

Start within 48 hours of symptom onset for best effect

CLASS 4: ANTIFUNGALS

Fluconazole

Drug Class: Triazole antifungal (ergosterol synthesis inhibitor)

Indication	Dose	Frequency	Route	Duration
Oral / Oropharyngeal candidiasis (thrush)	3-6 mg/kg/day (max 400 mg)	Once daily	Oral	7-14 days
Invasive candidiasis (candidemia)	6-12 mg/kg/day (max 800 mg loading, then 400 mg)	Once daily	IV/Oral	14 days after last +ve blood culture
Cryptococcal meningitis (HIV)	6-12 mg/kg/day	Once daily	IV/Oral	6-8 weeks (induction + consolidation)

Nystatin

Drug Class: Polyene antifungal (topical)

Indication	Dose	Frequency	Route	Duration
Oral thrush (neonates/infants)	100,000 units (1 mL) each side of mouth	4 times daily	Oral (swish and swallow)	7-14 days
Oral thrush (older children)	500,000 units (5 mL)	4 times daily	Oral	7-14 days

Griseofulvin

Drug Class: Antifungal (tinea capitis - ringworm of scalp)

Indication	Dose	Frequency	Route	Duration
Tinea capitis	15-20 mg/kg/day (microsize, max 1 g)	Once daily with fatty meal	Oral	6-8 weeks

CLASS 5: ANTIPARASITICS / ANTIHELMINTHICS

Mebendazole

Drug Class: Benzimidazole (intestinal worms)

Indication	Dose	Frequency	Route	Duration
Ascariasis, Hookworm, Trichuriasis	100 mg (age >2 yr; dose NOT weight-based)	Twice daily	Oral	3 days
Single-dose option (Ascaris only)	500 mg	Single dose	Oral	1 day
Enterobiasis (threadworm)	100 mg	Single dose; repeat after 2 weeks	Oral	2 doses

Albendazole

Drug Class: Benzimidazole (broad-spectrum anthelmintic)

Indication	Dose	Frequency	Route	Duration
Ascariasis, Hookworm	400 mg (>2 yr, single dose; NOT weight-based)	Single dose	Oral	1 day
Neurocysticercosis	15 mg/kg/day (max 800 mg)	Divided twice daily	Oral	8-28 days (with steroids)
Giardiasis	400 mg	Once daily	Oral	5 days

Chloroquine

Drug Class: 4-aminoquinoline (antimalarial)

Indication	Dose	Frequency	Route	Duration
Uncomplicated malaria (P. vivax, P. ovale)	Day 1+2: 10 mg/kg; Day 3: 5 mg/kg (max 600 mg base)	Once daily	Oral	3 days

Artesunate + Amodiaquine / Artemether-Lumefantrine

Drug Class: Artemisinin combination therapy (ACT) - first-line for P. falciparum

Weight	Artemether-Lumefantrine dose	Frequency	Duration
5-14 kg	1 tablet (20/120 mg)	BD	3 days
15-24 kg	2 tablets	BD	3 days
25-34 kg	3 tablets	BD	3 days
>34 kg	4 tablets (adult dose)	BD	3 days

Artesunate IV (Severe Malaria - IPD)

Dose	Frequency	Route	Duration
2.4 mg/kg IV at 0, 12, 24 hrs, then daily	At 0h, 12h, 24h, then once daily	IV	Until able to take oral ACT

CLASS 6: ANTI-EPILEPTICS / ANTICONVULSANTS

Diazepam (Emergency Seizure)

Drug Class: Benzodiazepine (GABA-A agonist)

Route	Dose	Repeat	Max
IV (slow push)	0.1-0.3 mg/kg	After 5-10 min if seizure continues	10 mg total
Rectal (if no IV access)	0.5 mg/kg	Once	10 mg
Intranasal / Buccal	0.3-0.5 mg/kg	Once	10 mg

Administration rate: IV no faster than 1 mg/min | Watch for respiratory depression

Lorazepam (Preferred for Status Epilepticus)

Drug Class: Benzodiazepine (longer duration than diazepam)

Route	Dose	Repeat	Max
IV	0.05-0.1 mg/kg	After 5-10 min	4 mg
IM	0.1 mg/kg	Once	4 mg

Phenobarbitone (Phenobarbital)

Drug Class: Barbiturate (GABA enhancer - first-line neonatal seizures, maintenance)

Indication	Dose	Frequency	Route	Notes
Status epilepticus (loading)	15-20 mg/kg IV	Single loading dose	IV (over 20-30 min)	May repeat 5-10 mg/kg after 20 min
Maintenance (epilepsy)	3-5 mg/kg/day	Once daily (or divided BD)	Oral/IV	Long-term; therapeutic level 15-40 mcg/mL
Neonatal seizures (loading)	20 mg/kg	Single dose	IV	Then 3-5 mg/kg/day maintenance

Phenytoin / Fosphenytoin

Drug Class: Sodium channel blocker

Indication	Dose	Rate	Route	Notes
Status epilepticus (2nd line)	15-20 mg/kg (phenytoin equivalent for fosphenytoin)	No faster than 1 mg/kg/min phenytoin (3 mg/kg/min fosphenytoin)	IV	Monitor ECG and BP
Maintenance	4-8 mg/kg/day	Divided BD/TID	Oral	Therapeutic level 10-20 mcg/mL

Fosphenytoin preferred IV (less cardiac toxicity, can give IM)

Sodium Valproate

Drug Class: Multiple mechanisms (GABA, sodium channel)

Indication	Dose	Frequency	Route	Notes
Epilepsy maintenance (absence, generalized)	20-40 mg/kg/day	Divided BD or TID	Oral	Titrate slowly; avoid in girls <18 yr if possible (teratogenic)
Status epilepticus (IV loading)	20-40 mg/kg	Single loading dose over 5 min	IV	Then 1-2 mg/kg/hr infusion

Levetiracetam

Drug Class: SV2A modulator (newer antiepileptic, safe profile)

Indication	Dose	Frequency	Route	Notes
Focal/generalized epilepsy, Status epilepticus	20-60 mg/kg/day; IV loading: 20-60 mg/kg	Divided twice daily (oral); single loading (IV)	Oral / IV	Minimal drug interactions; first-line in many protocols

Carbamazepine

Drug Class: Sodium channel blocker (focal seizures, trigeminal neuralgia)

Dose	Frequency	Route	Notes
Start 5-10 mg/kg/day; increase to 10-20 mg/kg/day	Divided TID	Oral	Therapeutic level 4-12 mcg/mL; autoinduser

CLASS 7: RESPIRATORY DRUGS

Salbutamol (Albuterol)

Drug Class: Short-acting beta-2 agonist (SABA) - Bronchodilator

Indication	Dose	Frequency	Route	Notes
Acute asthma / wheeze	2.5 mg (<20 kg) or 5 mg (>20 kg) in 2-3 mL saline	Every 20 min x3 (severe), then Q4h	Nebulized	First-line bronchodilator
Acute severe asthma (IV)	5 mcg/kg/min initially; titrate	Continuous infusion	IV	ICU setting
Maintenance (inhaler)	100-200 mcg (1-2 puffs)	Every 4-6 hours PRN	MDI + spacer	Reliever inhaler
Hyperkalaemia (emergency)	4 mcg/kg IV (or 2.5-5 mg nebulized)	Single dose	IV / Nebulized	Lowers K+ rapidly

Ipratropium Bromide

Drug Class: Short-acting muscarinic antagonist (SAMA)

Indication	Dose	Frequency	Route	Notes
Acute severe asthma (add-on to salbutamol)	250 mcg (<5 yr) / 500 mcg (>5 yr)	Every 20 min x3, then Q4-6h	Nebulized	Combined with salbutamol for first 1 hour

Budesonide / Beclometasone (Inhaled Corticosteroid - ICS)

Drug Class: Inhaled corticosteroid (controller medication)

Drug	Dose	Frequency	Route	Notes
Budesonide (mild persistent asthma)	200-400 mcg/day	Once or twice daily	MDI + spacer / DPI	Preventer - must not stop abruptly
Budesonide nebulization (croup)	2 mg (single dose or BD x2 doses)	Once/twice	Nebulized	Acute croup
Beclometasone	100-400 mcg/day	Divided BD	MDI	Alternative ICS

Dexamethasone

Drug Class: Corticosteroid (high potency, long-acting)

Indication	Dose	Frequency	Route	Duration
Croup (laryngotracheobronchitis)	0.15-0.6 mg/kg (max 10 mg)	Single dose	Oral/IM/IV	1 dose (often sufficient)
Meningitis (adjunct)	0.15 mg/kg/dose	Every 6 hours	IV	4 days (with ceftriaxone)
Cerebral oedema (raised ICP)	0.5 mg/kg loading, then 0.25 mg/kg/dose	Every 6 hours	IV	Short course
Asthma exacerbation	0.6 mg/kg/day (max 16 mg)	Once or twice daily	Oral/IV	3-5 days
Antiemetic (peri-operative)	0.1-0.5 mg/kg (max 10 mg)	Single dose	IV	-

Prednisolone

Drug Class: Corticosteroid (oral)

Indication	Dose	Frequency	Route	Duration
Asthma exacerbation	1-2 mg/kg/day (max 40 mg)	Once daily (morning)	Oral	3-5 days
Croup (mild-moderate)	1 mg/kg (max 20 mg)	Single dose	Oral	1-3 days
Nephrotic syndrome (initial)	60 mg/m2/day or 2 mg/kg/day (max 60 mg)	Daily x 4-6 weeks, then alternate day	Oral	12-week course
Severe allergic reaction (after epinephrine)	1-2 mg/kg	Single or once daily	Oral	3-5 days

Montelukast (Singulair)

Drug Class: Leukotriene receptor antagonist (LTRA) - Controller

Age	Dose	Frequency	Route
6 months - 5 years	4 mg (granules/chewable)	Once daily (evening)	Oral
6-14 years	5 mg (chewable)	Once daily (evening)	Oral
>15 years	10 mg (tablet)	Once daily (evening)	Oral

Aminophylline

Drug Class: Methylxanthine (bronchodilator - 3rd line)

Indication	Dose	Route	Notes
Status asthmaticus (loading)	5-6 mg/kg over 20 min	IV	Only if not on theophylline; monitor cardiac
Maintenance infusion	0.5-0.9 mg/kg/hour	IV infusion	Therapeutic level 10-20 mg/L

CLASS 8: CARDIOVASCULAR DRUGS

Adenosine

Drug Class: Purine nucleoside (SVT conversion)

Dose	Route	Notes
0.1 mg/kg rapid IV bolus; repeat with 0.2 mg/kg; max 12 mg	IV (rapid push into large vein, flush immediately)	T1/2 = 10 sec; have crash cart ready

Amiodarone

Drug Class: Class III antiarrhythmic

Indication	Dose	Route	Notes
VF/Pulseless VT (after 2nd shock)	5 mg/kg	IV rapid bolus	Max 300 mg
SVT/VT (stable, second-line)	5 mg/kg over 20-60 min	IV slow infusion	Repeat 5 mg/kg; max 20 mg/kg/day

Epinephrine (Adrenaline)

Drug Class: Sympathomimetic (alpha + beta agonist)

Indication	Dose	Route	Frequency
Cardiac arrest (IV/IO)	0.01 mg/kg (0.1 mL/kg of 1:10,000)	IV/IO	Every 3-5 min
Cardiac arrest (ET tube)	0.1 mg/kg (0.1 mL/kg of 1:1,000)	Endotracheal	Single attempt
Anaphylaxis (IM, preferred)	0.01 mg/kg (max 0.5 mg) = 0.01 mL/kg of 1:1,000	IM (anterolateral thigh)	Repeat after 5-15 min if needed
Croup (severe, racemic)	0.05 mL/kg of 2.25% in 3 mL saline	Nebulized	Observe 2-4 hrs post-dose

Dopamine

Drug Class: Catecholamine (inotrope/vasopressor) - ICU

Dose range	Effect	Route
2-5 mcg/kg/min	Renal / splanchnic vasodilation ("renal dose")	IV infusion
5-10 mcg/kg/min	Positive inotropy (beta-1)	IV infusion
>10 mcg/kg/min	Vasoconstriction (alpha-1)	IV infusion

Furosemide

Drug Class: Loop diuretic

Indication	Dose	Frequency	Route	Notes
Fluid overload, Heart failure, Pulmonary oedema	0.5-1 mg/kg/dose (max 40-80 mg)	Every 6-12 hours	IV/Oral	Monitor electrolytes; K+ supplementation
Hypertensive emergency	1 mg/kg IV	Stat	IV

CLASS 9: GASTROINTESTINAL DRUGS

Ondansetron (Antiemetic)

Drug Class: 5-HT3 receptor antagonist

Route	Dose	Frequency	Max/day	Notes
IV	0.1-0.15 mg/kg (max 4 mg)	Every 8 hours	3 doses	Give over 15 min
Oral (wafer/tablet)	0.1-0.15 mg/kg	Every 8 hours	3 doses	ODT wafer very useful in vomiting

Domperidone

Drug Class: D2 dopamine antagonist (prokinetic/antiemetic)

Dose	Frequency	Route	Notes
0.25-0.5 mg/kg/dose (max 10 mg)	Three times daily (before meals)	Oral	Caution: avoid in cardiac patients (QT prolongation)

Omeprazole (PPI)

Drug Class: Proton pump inhibitor

Indication	Dose	Frequency	Route	Duration
GERD, Peptic ulcer	0.5-1 mg/kg/day (max 20 mg)	Once daily (morning, AC)	Oral	4-8 weeks
H. pylori eradication (triple therapy)	1 mg/kg/day (max 20 mg)	Twice daily	Oral	14 days

Ranitidine / Famotidine (H2-blocker)

Drug	Dose	Frequency	Route
Ranitidine	2-4 mg/kg/dose (max 150 mg)	Twice daily	Oral
Famotidine IV	0.15 mg/kg	Every 12 hours	IV

ORS (Oral Rehydration Solution)

Drug Class: Electrolyte replacement (WHO Low-Osmolarity ORS)

Dehydration Grade	Volume / Plan	Administration
Mild (<5%) - Plan A	10 mL/kg per loose stool + 2 mL/kg per vomit	At home; continue feeding
Moderate (5-10%) - Plan B	75 mL/kg over 4 hours	Supervised in OPD/ward
Severe (>10%) - Plan C	IV Ringer's Lactate: 100 mL/kg over 3 hours	IPD; IV fluids first

Zinc Sulfate

Age	Dose	Frequency	Route	Duration
<6 months	10 mg/day	Once daily	Oral	14 days
>6 months	20 mg/day	Once daily	Oral	14 days

Adjunct to ORS in all acute diarrhea; reduces severity, duration, and recurrence

CLASS 10: FLUIDS & ELECTROLYTES

Drug	Indication	Dose	Route	Notes
Sodium Bicarbonate	Metabolic acidosis, Cardiac arrest	1 mEq/kg	IV (slow)	4.2% solution for neonates; dilute to 0.5 mEq/mL for children
Calcium Gluconate 10%	Hypocalcaemia, Hyperkalaemia	0.5-1 mL/kg (= 5-10 mg/kg elemental Ca)	IV (slow over 10 min)	Monitor ECG; extravasation causes tissue necrosis
Calcium Chloride 10%	Cardiac arrest, Severe hypocalcaemia	0.1-0.2 mL/kg (= 10-20 mg/kg)	IV	3x more elemental Ca than gluconate; central line preferred
Potassium Chloride	Hypokalaemia	0.5-1 mEq/kg over 2-4 hours	IV (slow infusion)	Max rate: 0.3-0.5 mEq/kg/hr; NEVER IV bolus
20% Mannitol	Raised ICP, Cerebral oedema	0.5-1 g/kg	IV over 20-30 min	Repeat Q4-6h; monitor osmolality
Glucose (Dextrose)	Hypoglycaemia	0.5-1 g/kg (= 2-4 mL/kg of 25% dextrose)	IV bolus	Check BG 15 min after

CLASS 11: VACCINES (Immunization Schedule Summary)

Age	Vaccine	Route	Dose
Birth	BCG, OPV0, Hep B (birth dose)	ID (BCG), Oral, IM	0.05 mL BCG; 0.5 mL HepB
6 weeks	OPV1, Penta1 (DTwP-HepB-Hib), PCV1, RV1	Oral, IM, Oral	Per schedule
10 weeks	OPV2, Penta2, PCV2, RV2	Oral, IM, Oral
14 weeks	OPV3, Penta3, PCV3, IPV	Oral, IM, IM
9 months	Measles-Rubella (MR1)	SC	0.5 mL
16-24 months	MR2, OPV booster, DPT booster	SC/Oral/IM

SECTION B: CASE-WISE APPLICATION

CASE 1: Febrile Seizure (IPD) - Child 2 years, 12 kg

Scenario: 2-year-old (12 kg), first febrile seizure, lasted 3 minutes, now post-ictal, temp 39.5°C

Drug	Dose Calculation	Route	Notes
Diazepam IV (if still seizing)	0.3 mg/kg = 3.6 mg	IV slow	If no IV: rectal 0.5 mg/kg = 6 mg
Paracetamol	15 mg/kg = 180 mg (120 mg/5 mL syrup = 7.5 mL)	Oral / Rectal	Q6h
Ibuprofen (alt antipyretic)	10 mg/kg = 120 mg	Oral	Q8h with food

Duration of anticonvulsant: Single dose only (febrile seizure); no maintenance AED unless complex FS

CASE 2: Status Epilepticus (IPD) - Child 5 years, 18 kg

Step-wise Management:

Step	Drug	Dose	Route	Timing
Step 1 (0-5 min)	Lorazepam IV	0.1 mg/kg = 1.8 mg	IV	Stat
Step 2 (if persists >10 min)	Phenobarbitone IV	20 mg/kg = 360 mg over 30 min	IV
Step 3 (if persists >20 min)	Phenytoin IV	20 mg/kg = 360 mg (no faster than 1 mg/kg/min)	IV with ECG
Step 4 (refractory)	Midazolam infusion	0.05-0.5 mg/kg/hr	IV	ICU

CASE 3: Community-Acquired Pneumonia (IPD) - Child 3 years, 14 kg

Severe Pneumonia (WHO - fast breathing + retractions):

Drug	Dose Calculation	Frequency	Route	Duration
Ampicillin	50 mg/kg = 700 mg	Every 6 hours	IV	5 days
Gentamicin (OD dosing)	7.5 mg/kg = 105 mg	Once daily	IV	5 days
Paracetamol	15 mg/kg = 210 mg	Every 6-8 hours	Oral	PRN
Salbutamol (if wheeze)	2.5 mg in 2.5 mL saline	Every 4-6 hours	Nebulized	Until wheezing resolves
Step-down (oral)	Amoxicillin 90 mg/kg/day = 630 mg/day = 315 mg TID	TID	Oral	Complete 7-10 days total

CASE 4: Acute Gastroenteritis with Dehydration (OPD) - Child 18 months, 10 kg

Moderate dehydration (Plan B):

Intervention	Dose Calculation	Route	Duration
ORS	75 mL/kg = 750 mL over 4 hours	Oral (sips)	4 hours supervised
Zinc sulfate	20 mg/day (age >6 months)	Oral	14 days
Ondansetron (if vomiting)	0.15 mg/kg = 1.5 mg	Oral/IV	Q8h; max 3 doses
Paracetamol (if febrile)	15 mg/kg = 150 mg	Oral	Q6-8h

If cholera: Azithromycin 20 mg/kg single dose oral

CASE 5: Acute Asthma Attack (IPD) - Child 6 years, 20 kg

Moderate-Severe Asthma Exacerbation:

Drug	Dose Calculation	Frequency	Route	Duration
Salbutamol	5 mg (>20 kg) in 2.5 mL saline	Every 20 min x3, then Q4h	Nebulized	Until improving
Ipratropium	500 mcg	Every 20 min x3, then Q6h	Nebulized (combined)	First 1-2 hours
Prednisolone	2 mg/kg = 40 mg (max 40 mg)	Once daily (morning)	Oral	3-5 days
O2	To maintain SpO2 >94%	Continuous	Via face mask	Until stable
Salbutamol inhaler (discharge)	2 puffs (200 mcg)	Every 4-6 hours PRN	MDI + spacer	As needed
Budesonide (preventer on discharge)	200 mcg	Twice daily	MDI + spacer	Long-term

CASE 6: Bacterial Meningitis (IPD) - Child 4 years, 16 kg

Drug	Dose Calculation	Frequency	Route	Duration
Ceftriaxone	50 mg/kg = 800 mg	Every 12 hours (1.6 g/day)	IV	10-14 days
Dexamethasone	0.15 mg/kg = 2.4 mg	Every 6 hours	IV	4 days (start with or before antibiotics)
Paracetamol	15 mg/kg = 240 mg	Every 6-8 hours	IV/Oral	PRN fever
Mannitol 20% (if raised ICP)	0.5 g/kg = 8 g = 40 mL of 20%	Over 20-30 min	IV	Q4-6h as needed

CASE 7: Dengue Fever with Warning Signs (IPD) - Child 8 years, 25 kg

Drug	Dose Calculation	Frequency	Route	Notes
Paracetamol	15 mg/kg = 375 mg	Every 6 hours	Oral	Do NOT give ibuprofen or aspirin
IV Ringer's Lactate	5-7 mL/kg/hour initially	Adjust by clinical response	IV	Monitor haematocrit, platelet, BP
If platelet <10,000 with bleeding: Platelet concentrate	10-20 mL/kg	Stat	IV	Single-donor pooled platelets

CASE 8: Neonatal Sepsis (IPD) - Neonate 3 kg (term)

Drug	Dose Calculation	Frequency	Route	Duration
Ampicillin	50 mg/kg = 150 mg	Every 12 hours (first week)	IV	10-14 days
Gentamicin	5 mg/kg = 15 mg	Every 36-48 hours (neonate <34 wks) or every 24-36 hours (term)	IV (over 30 min)	5-7 days; adjust by TDM
If MRSA suspected: Vancomycin	15 mg/kg = 45 mg	Every 12 hours	IV	Per culture

CASE 9: UTI (OPD/IPD) - Child 5 years, 18 kg, Female

Uncomplicated Cystitis (OPD):

Drug	Dose	Frequency	Route	Duration
Nitrofurantoin	1-2 mg/kg = 25-35 mg (max 100 mg)	Four times daily	Oral	5-7 days
OR Co-trimoxazole	4 mg/kg TMP = 72 mg TMP	Twice daily	Oral	5-7 days

Pyelonephritis/Febrile UTI (IPD):

Drug	Dose	Frequency	Route	Duration
Ceftriaxone	50 mg/kg = 900 mg	Once daily	IV/IM	3-5 days IV, then oral 7-14 days total
Step-down: Amoxicillin-clavulanate	45 mg/kg/day = 405 mg/day = 200 mg BD	Twice daily	Oral	Complete 10-14 days total

CASE 10: Acute Otitis Media (OPD) - Child 2 years, 12 kg

Drug	Dose Calculation	Frequency	Route	Duration
Amoxicillin (high-dose)	90 mg/kg/day = 1080 mg/day = 540 mg BD	Twice daily	Oral	10 days
Paracetamol	15 mg/kg = 180 mg	Every 6-8 hours	Oral	For pain/fever
If PCN allergic: Azithromycin	10 mg/kg day 1 = 120 mg; then 5 mg/kg days 2-5 = 60 mg	Once daily	Oral	5 days

CASE 11: Typhoid Fever (IPD) - Child 7 years, 22 kg

Drug	Dose Calculation	Frequency	Route	Duration
Ceftriaxone	75 mg/kg = 1650 mg (max 2 g)	Once daily	IV	7-10 days
Step-down: Azithromycin (if sensitive)	10 mg/kg = 220 mg (max 500 mg)	Once daily	Oral	7 days
Paracetamol	15 mg/kg = 330 mg	Every 6 hours	Oral	PRN fever

CASE 12: Severe Malnutrition (SAM) with Infection (IPD) - Child 2 years, 7 kg

Drug	Dose Calculation	Frequency	Route	Duration
Ampicillin	50 mg/kg = 350 mg	Every 6 hours	IV	5 days
Gentamicin	7.5 mg/kg = 52.5 mg	Once daily	IV	5 days
Vitamin A (if deficient)	200,000 IU (>12 months)	Day 1, 2, 14	Oral	3 doses
Folic acid	5 mg Day 1, then 1 mg/day	Once daily	Oral	2-4 weeks
F-75 Therapeutic milk	100 mL/kg/day	Every 2 hours = 12 feeds	Oral	Phase 1 (Stabilization)
F-100 / RUTF	150-220 mL/kg/day	Every 3-4 hours	Oral	Phase 2 (Rehabilitation)

QUICK PAEDIATRIC DOSE REFERENCE CARD

Drug	Oral Dose	IV Dose	Max single	Frequency
Paracetamol	15 mg/kg	15 mg/kg	1 g	Q6h
Ibuprofen	5-10 mg/kg	-	400 mg	Q6-8h
Amoxicillin	45-90 mg/kg/day	-	1 g/dose	BD-TID
Ampicillin	-	50 mg/kg	2 g	Q6h
Ceftriaxone	-	50-100 mg/kg/day	2-4 g/day	OD-BD
Cefotaxime	-	50 mg/kg	2 g	Q6-8h
Gentamicin	-	7.5 mg/kg	-	OD (TDM)
Vancomycin	-	15-20 mg/kg	-	Q6h (TDM)
Azithromycin	10 mg/kg D1, 5 mg/kg D2-5	-	500 mg	OD
Metronidazole	7.5-10 mg/kg	7.5-10 mg/kg	500 mg	Q8h
Diazepam	-	0.1-0.3 mg/kg	10 mg	PRN Q10 min
Phenobarbitone	3-5 mg/kg/day	15-20 mg/kg (load)	-	OD maint.
Phenytoin	4-8 mg/kg/day	15-20 mg/kg (load)	-	BD-TID
Salbutamol (neb)	-	-	5 mg	Q20min x3
Prednisolone	1-2 mg/kg/day	-	40-60 mg	OD
Dexamethasone	0.6 mg/kg	0.15 mg/kg Q6h	10 mg	Varies
Ondansetron	0.15 mg/kg	0.15 mg/kg	8 mg	Q8h
Furosemide	1-2 mg/kg	0.5-1 mg/kg	80 mg	BD-QID
Adrenaline (anaphylaxis)	-	0.01 mg/kg IM	0.5 mg	Q5-15min
Atropine	-	0.02 mg/kg	1 mg	PRN
Adenosine (SVT)	-	0.1 mg/kg rapid IV	12 mg	Q2min x2
Mannitol 20%	-	0.5-1 g/kg	-	Q4-6h

Critical Reminders for Paediatric Prescribing:

Always double-check dose AND weight - a 10x error is the most common paediatric medication error
Never exceed adult maximum dose regardless of weight
Neonates are not small infants - separate protocols apply (different half-lives, protein binding, renal clearance)
Aminoglycosides (Gentamicin, Amikacin): TDM is mandatory - check trough before 3rd dose
Vancomycin: Infuse over minimum 60 minutes (Red Man Syndrome); TDM guided
Avoid in children: Aspirin (Reye's syndrome), Chloramphenicol (grey baby), Tetracyclines (<8 yr - teeth), Quinolones (joints - unless benefits outweigh risk), Codeine (<12 yr - CYP2D6 variability)
Antipyretics in dengue: Paracetamol ONLY - ibuprofen/aspirin worsen bleeding
Steroid taper: Not needed for courses <14 days; taper if >3 weeks use

Sources: Morgan & Mikhail Clinical Anesthesiology 7e (Table 42-3); Harrison's 22e; Rosen's Emergency Medicine; Goodman & Gilman's Pharmacology; Goldman-Cecil Medicine; Red Book 2021 (AAP); WHO IMCI Guidelines---

Here's a summary of what's covered:

What's Included

Section A - Drug Classification-wise (11 Classes):

Class	Drugs Covered
1. Analgesics/Antipyretics	Paracetamol (oral/rectal/IV), Ibuprofen, Morphine, Fentanyl
2. Antibiotics	Amoxicillin, Co-amoxiclav, Ampicillin, Cloxacillin, Cefazolin, Cefuroxime, Ceftriaxone, Cefotaxime, Pip-Tazobactam, Meropenem, Gentamicin, Azithromycin, Clarithromycin, Metronidazole, Co-trimoxazole, Vancomycin, Ciprofloxacin, Anti-TB (HRZE)
3. Antivirals	Acyclovir, Oseltamivir
4. Antifungals	Fluconazole, Nystatin, Griseofulvin
5. Antiparasitics	Mebendazole, Albendazole, Chloroquine, Artemether-lumefantrine
6. Anticonvulsants	Diazepam, Lorazepam, Phenobarbitone, Phenytoin, Valproate, Levetiracetam, Carbamazepine
7. Respiratory	Salbutamol, Ipratropium, Budesonide, Dexamethasone, Prednisolone, Montelukast, Aminophylline
8. Cardiovascular	Adenosine, Amiodarone, Epinephrine, Dopamine, Furosemide
9. GI Drugs	Ondansetron, Domperidone, Omeprazole, ORS, Zinc
10. Fluids/Electrolytes	NaHCO3, Calcium, Potassium, Mannitol, Dextrose
11. Vaccines	Immunization schedule overview

Section B - 12 Clinical Case Applications with actual dose calculations per kg

Let me know if you'd like this as a downloadable Word or PDF document, or if you need any specific drug/condition expanded further.

Add neonatal (<1 month) drug dosing specific protocols

Reading File

Finding Sources

The library's neonatal-specific entries are sparse for this level of detail. I'm drawing on the textbook data retrieved plus robust evidence-based neonatal pharmacology (NNF guidelines, BNFc, Neofax/Lexicomp Neonatal, WHO Essential Medicines for Neonates) to compile this full protocol.

NEONATAL DRUG DOSING PROTOCOLS

Age < 1 Month (Neonates) - Complete Reference

PG/Resident Level | Dose per kg | Gestational Age-Adjusted | Route | Frequency | Duration

⚠️ CRITICAL NEONATAL PRESCRIBING RULES

ALWAYS specify: Gestational Age (GA), Postnatal Age (PNA), Corrected Gestational Age (CGA), and Weight

Dosing interval is determined by GA + PNA (not weight alone) - immature renal/hepatic clearance

Preterm ≠ Term neonate - separate dosing intervals for <28 wks, 28-32 wks, 32-36 wks, ≥37 wks

TDM mandatory for: Gentamicin, Amikacin, Vancomycin, Phenobarbitone, Phenytoin, Digoxin

Volume of distribution is larger in neonates (higher total body water - affects loading doses)

Protein binding is reduced - higher free drug fractions (albumin low; bilirubin competition)

Renal clearance matures by ~34 weeks CGA - dosing intervals lengthen before this

Never give: Aspirin, Tetracyclines, Chloramphenicol (grey baby syndrome), Ceftriaxone (displaces bilirubin/calcium precipitation), Sulfonamides (kernicterus risk)

Dilute ALL IV drugs appropriately - neonates are extremely sensitive to concentration errors

Double-check every decimal point - 10x errors are the leading cause of neonatal drug fatalities

SECTION 1: NEONATAL ANTIBIOTICS

KEY PRINCIPLE: Dosing Interval by Gestational + Postnatal Age

GA (weeks)	Postnatal Age	Aminoglycoside Interval	Ampicillin / Penicillin Interval
<28 wks	0-28 days	Every 48 hours	Every 12 hours
28-34 wks	0-7 days	Every 36-48 hours	Every 12 hours
28-34 wks	8-28 days	Every 24-36 hours	Every 8 hours
≥35 wks	0-7 days	Every 36 hours	Every 8 hours
≥35 wks	>7 days	Every 24 hours	Every 6 hours

1.1 Ampicillin

Drug Class: Aminopenicillin | Indication: Early-onset sepsis (GBS, Listeria, E. coli), Meningitis

GA + PNA	Dose	Interval	Route	Duration
All GA, 0-7 days	50 mg/kg/dose (meningitis: 100 mg/kg/dose)	Every 12 hours	IV (over 30 min)	10-14 days (sepsis); 14-21 days (meningitis)
All GA, 8-28 days	50 mg/kg/dose (meningitis: 100 mg/kg/dose)	Every 8 hours	IV	As above
Preterm <34 wks, 0-7 days	50 mg/kg/dose	Every 12 hours	IV

Max single dose: 2 g | Combine with Gentamicin for early-onset sepsis synergy

1.2 Gentamicin (Once-Daily / Extended-Interval Dosing)

Drug Class: Aminoglycoside | Indication: Gram-negative sepsis, EOS synergy with ampicillin

GA (weeks)	Dose	Interval	Route	TDM
<29 weeks GA	5 mg/kg/dose	Every 48 hours	IV (over 30 min)	Trough <1 mg/L before next dose
29-35 weeks GA	4-5 mg/kg/dose	Every 36 hours	IV	Trough <1 mg/L
≥36 weeks GA, 0-7 days	4-5 mg/kg/dose	Every 36 hours	IV	Trough <1 mg/L
≥36 weeks GA, >7 days	4-5 mg/kg/dose	Every 24 hours	IV	Trough <1 mg/L

TDM target: Trough <1 mg/L (draw 30 min before 3rd dose); Peak 5-10 mg/L Duration: 5-7 days (sepsis); 14-21 days (gram-negative meningitis - avoid; use cefotaxime instead) Monitor: Renal function (creatinine, urea), urine output; hold if oliguria

Note: Ceftriaxone is CONTRAINDICATED in neonates <28 days (precipitates with calcium - fatal); use Cefotaxime instead

1.3 Cefotaxime (NOT Ceftriaxone in Neonates)

Drug Class: 3rd generation cephalosporin | Indication: Gram-negative meningitis, sepsis, Ceftriaxone-contraindicated situations

GA + PNA	Dose	Interval	Route	Duration
<34 wks, 0-7 days	50 mg/kg/dose	Every 12 hours	IV	Per indication
<34 wks, >7 days	50 mg/kg/dose	Every 8 hours	IV
≥34 wks, 0-7 days	50 mg/kg/dose	Every 12 hours	IV
≥34 wks, >7 days	50 mg/kg/dose	Every 8 hours	IV
Meningitis (all ages)	50-75 mg/kg/dose	Every 6-8 hours	IV	14-21 days

Max: 12 g/day | Preferred over Ceftriaxone in neonates

1.4 Vancomycin

Drug Class: Glycopeptide | Indication: MRSA / CoNS sepsis (LOS), Resistant Gram-positive meningitis

GA	PNA	Dose	Interval	Route
<29 weeks	0-14 days	15-20 mg/kg/dose	Every 24 hours	IV (over 60 min)
<29 weeks	>14 days	15-20 mg/kg/dose	Every 18-24 hours	IV
29-35 weeks	0-14 days	15-20 mg/kg/dose	Every 18-24 hours	IV
29-35 weeks	>14 days	15-20 mg/kg/dose	Every 12-18 hours	IV
≥36 weeks	0-7 days	15-20 mg/kg/dose	Every 12-18 hours	IV
≥36 weeks	>7 days	15-20 mg/kg/dose	Every 8-12 hours	IV

TDM target (AUC-guided): AUC/MIC 400-600; trough (conventional) 10-15 mg/L Trough drawn 30 min before 4th dose; peak 1 hour post-infusion Red Man Syndrome: Prevented by infusing over ≥60 minutes; pretreat with diphenhydramine if needed

1.5 Penicillin G (Benzylpenicillin)

Drug Class: Natural penicillin | Indication: GBS sepsis, Syphilis, Listeria (with gentamicin)

Indication	Dose	Interval	Route	Duration
GBS sepsis	50,000 units/kg/dose	Every 12h (0-7 days); Every 8h (>7 days)	IV	10-14 days
GBS meningitis	100,000-150,000 units/kg/dose	Every 8 hours	IV	14-21 days
Congenital syphilis (early, <2 yr)	50,000 units/kg/dose	Every 12h (0-7 days); Every 8h (>7 days)	IV	10 days
Congenital syphilis (neurosyphilis)	50,000-100,000 units/kg/dose	Every 12h	IV	10-14 days

1.6 Metronidazole

Drug Class: Nitroimidazole | Indication: NEC, Anaerobic infections, Clostridium

GA	PNA	Dose	Interval	Route	Duration
<28 wks	Any	7.5 mg/kg/dose	Every 48 hours	IV (over 30 min)	5-7 days
28-34 wks	0-14 days	7.5 mg/kg/dose	Every 24 hours	IV
28-34 wks	>14 days	7.5 mg/kg/dose	Every 12 hours	IV
≥35 wks	Any	7.5 mg/kg/dose	Every 8-12 hours	IV / Oral	5-7 days

1.7 Acyclovir

Drug Class: Antiviral | Indication: Neonatal HSV (herpes simplex - high mortality if untreated)

Indication	Dose	Interval	Route	Duration
HSV - Skin/Eye/Mouth (SEM)	20 mg/kg/dose	Every 8 hours	IV	14 days
HSV - Disseminated / CNS	20 mg/kg/dose	Every 8 hours	IV	21 days
Suppressive therapy (post-acute)	300 mg/m²/dose (or ~30 mg/kg/day)	Three times daily	Oral (Acyclovir suspension)	6 months

Monitor: Renal function; ensure adequate hydration to prevent crystalluria; adjust in renal impairment

1.8 Azithromycin (Pertussis / Chlamydial conjunctivitis)

Indication	Dose	Interval	Route	Duration
Pertussis prophylaxis/treatment (<1 month)	10 mg/kg/day	Once daily	Oral	5 days
Chlamydial conjunctivitis / pneumonia	20 mg/kg/day	Once daily	Oral	3 days

Preferred agent for pertussis in neonates (erythromycin - risk of IHPS; co-trimoxazole - risk of kernicterus)

1.9 Fluconazole (Antifungal prophylaxis / Treatment)

Indication	GA	Dose	Interval	Route	Duration
Invasive candidiasis treatment	Any	12 mg/kg loading, then 6-12 mg/kg/day	Every 72h (<28 wks); Every 48h (28-34 wks); Every 24h (>34 wks)	IV/Oral	21 days min
Prophylaxis (VLBW <1000 g)	<28 wks	3-6 mg/kg	Every 72h (first 2 wks), then every 48h	IV/Oral	6 weeks

SECTION 2: NEONATAL NEUROLOGY

2.1 Neonatal Seizures - Step-Wise Management

Step 1: Phenobarbitone (FIRST-LINE)

Drug Class: Barbiturate | Indication: All causes of neonatal seizures (first-line)

Indication	Dose	Rate	Route	Notes
Loading dose	20 mg/kg	Over 10-20 min	IV	If seizures continue after 20 min: additional 10 mg/kg x2 (max total 40 mg/kg)
Maintenance dose	3-5 mg/kg/day	-	IV/Oral	Start 12-24 hrs after loading; divided q12h or once daily

TDM target: 15-40 mcg/mL (therapeutic) | Draw trough before 3rd maintenance dose Side effects: Respiratory depression, sedation, hypotension Duration: Typically discontinue at 3 months if seizure-free (EEG normal)

Step 2: Phenytoin / Fosphenytoin (SECOND-LINE)

Indication	Dose	Rate	Route	Notes
Loading (if phenobarbitone failed)	15-20 mg/kg PE (fosphenytoin equivalents)	No faster than 0.5-1 mg/kg/min	IV	Monitor ECG, BP continuously
Maintenance	4-8 mg/kg/day	Divided BD-TID	IV/Oral	Therapeutic: 10-20 mcg/mL

Fosphenytoin strongly preferred (can be given IM; less cardiac toxicity) Contraindicated: Phenytoin in preterm neonates routinely (propylene glycol vehicle toxicity)

Step 3: Midazolam (Refractory Seizures)

Dose	Route	Notes
0.05-0.15 mg/kg IV bolus, then 0.06-0.4 mg/kg/hour infusion	IV	NICU only; continuous EEG monitoring mandatory
0.1-0.2 mg/kg buccal	Buccal mucosa	If no IV access

Step 4: Levetiracetam (Emerging First/Second-Line)

Dose	Interval	Route	Notes
40-60 mg/kg loading, then 20-30 mg/kg/day maintenance	Loading: single; Maintenance: divided BD	IV/Oral	Excellent safety profile; no sedation; gaining acceptance as first-line

Step 5: Pyridoxine (Vitamin B6) - Pyridoxine-Dependent Epilepsy

Dose	Route	Notes
100 mg IV (diagnostic/therapeutic trial) - may repeat	IV bolus (give with seizure monitoring/EEG)	Life-saving in pyridoxine-dependent seizures; if response: 15-30 mg/kg/day oral maintenance

2.2 Hypoxic Ischaemic Encephalopathy (HIE) - Therapeutic Hypothermia

Intervention	Protocol	Duration	Notes
Therapeutic Hypothermia (whole-body or selective head cooling)	Target core temp 33-34°C	72 hours	For HIE Grade 2-3 (moderate-severe); start within 6 hours of birth
Phenobarbitone (prophylactic/therapeutic)	20 mg/kg loading	As above	Standard for seizure control in HIE
Morphine analgesia during cooling	0.05-0.1 mg/kg/dose; or 0.01-0.02 mg/kg/hr infusion	PRN / continuous	Comfort care; avoid hypotension
Dextrose infusion	Maintain BG 4-7 mmol/L (72-126 mg/dL)	During cooling	Avoid hypoglycaemia (worsens outcome)

SECTION 3: NEONATAL RESPIRATORY

3.1 Surfactant Replacement Therapy

Indication: Respiratory Distress Syndrome (RDS) in premature neonates (<34 weeks)

Drug	Dose	Route	Notes
Poractant alfa (Curosurf)	100-200 mg/kg (= 1.25-2.5 mL/kg)	Intratracheal (via ET tube)	Rescue: 200 mg/kg; Prophylactic: 100-200 mg/kg; Can repeat 100 mg/kg after 6-12 hrs x2 doses
Beractant (Survanta)	100 mg/kg (= 4 mL/kg)	Intratracheal	Can repeat every 6h up to 4 doses in 48 hrs
Calfactant (Infasurf)	105 mg/kg (= 3 mL/kg)	Intratracheal

Administer: Position neonate; instill via catheter through ET tube in 2-4 aliquots; ventilate between Response: Rapid improvement in FiO2 requirements within 30-60 minutes Less invasive surfactant administration (LISA/MIST): Thin catheter into trachea while on CPAP; preferred in many centres

3.2 Caffeine Citrate (Apnoea of Prematurity)

Drug Class: Methylxanthine | Indication: Apnoea of prematurity; post-extubation support; BPD prevention

Dose	Interval	Route	Duration
Loading: 20 mg/kg caffeine citrate (= 10 mg/kg caffeine base)	Single loading dose	IV (over 30 min) / Oral	-
Maintenance: 5-10 mg/kg/day caffeine citrate (= 2.5-5 mg/kg caffeine base)	Once daily	IV / Oral	Until 34-36 weeks CGA; may continue to discharge if apnoea-free 5-7 days before 34 wks

Therapeutic level: 5-25 mcg/mL (caffeine base); TDM if toxicity suspected Side effects: Tachycardia, jitteriness, feeding intolerance Evidence: Reduces apnoea, facilitates extubation, reduces BPD, improves neurodevelopment (CAP trial)

3.3 Aminophylline (Alternative to Caffeine if unavailable)

Dose	Interval	Route	TDM
Loading: 5-6 mg/kg	Single dose over 20-30 min	IV	Therapeutic 6-11 mcg/mL (theophylline)
Maintenance: 1-3 mg/kg/dose	Every 8-12 hours (term); Every 12-24 hours (preterm)	IV / Oral	TDM mandatory

Caffeine preferred (safer, once-daily, wider therapeutic index)

3.4 Dexamethasone (Post-natal - BPD Prevention/Treatment)

Drug Class: Corticosteroid | Indication: Ventilator-dependent BPD; post-extubation stridor; PPHN adjunct

Indication	Protocol	Route	Notes
BPD - DART protocol (low-dose)	0.075 mg/kg/dose BD x3 days; 0.05 mg/kg/dose BD x3 days; 0.025 mg/kg/dose BD x2 days; 0.01 mg/kg/dose BD x2 days	IV / Oral	Total course 10 days; ONLY in ventilated infants >7 days; avoid in first 7 days of life
Post-extubation subglottic oedema	0.25 mg/kg/dose Q6-8h x3-4 doses	IV	Start 4-6 hrs before extubation attempt

Concerns: High-dose dexamethasone (0.5 mg/kg/day) associated with neurodevelopmental impairment - AVOID; use DART or lower protocols only

3.5 Indomethacin (Prophylactic / Therapeutic PDA)

Drug Class: Non-selective COX inhibitor | Indication: Hemodynamically significant PDA; IVH prophylaxis in VLBW

Indication	Dose	Interval	Route	Notes
PDA treatment	0.2 mg/kg/dose x3 doses	Every 12 hours	IV (slow over 20-30 min)	Age-adjusted: <48h PNA = 0.1 mg/kg; 2-7 days = 0.2 mg/kg; >7 days = 0.25 mg/kg
IVH prophylaxis	0.1 mg/kg/dose	Every 24 hours x3 doses	IV	Start within 6-12 hrs of birth in <28 weeks VLBW

Contraindications: Creatinine >1.8 mg/dL, oliguria (<1 mL/kg/hr), bleeding, NEC, thrombocytopenia <50,000, ductal-dependent cardiac lesion Monitor: Urine output, creatinine, Na+, BUN, platelet count

3.6 Ibuprofen (PDA - alternative to Indomethacin)

Dose	Interval	Route	Notes
10 mg/kg Day 1, then 5 mg/kg/day Days 2-3	Once daily x3 doses	IV / Oral	Less renal side effects than indomethacin; oral ibuprofen equally effective

3.7 Sildenafil (Persistent Pulmonary Hypertension - PPHN)

Drug Class: PDE-5 inhibitor (pulmonary vasodilator)

Dose	Interval	Route	Notes
0.5-1 mg/kg/dose	Every 6-8 hours	Oral	WHO recommends low-dose (0.5 mg/kg q6h); IV available but evidence limited in neonates

Adjunct to iNO (inhaled Nitric Oxide): iNO at 20 ppm for PPHN if available Monitor: BP closely; avoid in hypotension

SECTION 4: NEONATAL CARDIOVASCULAR

4.1 Epinephrine (Adrenaline) - Resuscitation / NAS

Indication	Dose	Route	Notes
Neonatal resuscitation (HR <60 despite PPV + chest compressions)	0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000)	IV/IO preferred	May repeat every 3-5 min
ET tube (if no IV)	0.05-0.1 mg/kg (0.5-1 mL/kg of 1:10,000)	Endotracheal	Less reliable absorption
Septic shock (vasopressor)	0.05-0.5 mcg/kg/min	IV infusion	Titrate to MAP >35-40 mmHg

4.2 Dopamine (Vasopressor - Septic Shock)

Dose	Effect	Route	Notes
2-5 mcg/kg/min	Renal / splanchnic	IV infusion	Limited evidence for renal dose in neonates
5-10 mcg/kg/min	Cardiac inotropy (beta-1)	IV infusion	First-line vasopressor for neonatal septic shock in many centres
>10 mcg/kg/min	Vasoconstriction (alpha-1)	IV infusion	Combine with dobutamine if myocardial dysfunction

4.3 Dobutamine (Myocardial Dysfunction)

Dose	Route	Notes
5-20 mcg/kg/min	IV infusion	For poor myocardial function / cardiogenic shock; inotropy without vasoconstriction

4.4 Digoxin (SVT / Heart Failure in term neonates)

Drug Class: Cardiac glycoside | Indication: SVT, Atrial flutter, CCF with dilated cardiomyopathy

GA	Digitalising Dose (TDD)	Maintenance	Interval	Route
Preterm (<36 wks)	20 mcg/kg TDD (give ½ TDD stat; ¼ TDD at 8h; ¼ TDD at 16h)	5 mcg/kg/day	Divided BD	IV/Oral
Term (≥36 wks)	30 mcg/kg TDD	7.5-10 mcg/kg/day	Divided BD	IV/Oral

Therapeutic level: 0.8-2 ng/mL | TDM draw 6-8 hrs post-dose Toxicity signs: Vomiting, bradycardia, heart block - ECG monitoring mandatory Reduce dose in renal impairment; hypokalaemia potentiates toxicity

4.5 Prostaglandin E1 (Alprostadil) - Duct-Dependent CHD

Drug Class: Prostaglandin | Indication: Cyanotic CHD with duct-dependent pulmonary circulation (e.g., TGA, pulmonary atresia, critical PS, HLHS)

Starting dose	Effective maintenance	Route	Monitoring
0.05-0.1 mcg/kg/min	0.01-0.05 mcg/kg/min (titrate down to lowest effective dose)	IV continuous infusion	Apnoea (20%), fever, hypotension, flushing; intubation at bedside

Start IMMEDIATELY when duct-dependent CHD suspected (do not wait for echo) Side effects: Apnoea (have intubation ready), fever, hypotension, inhibition of platelet aggregation

4.6 Furosemide

Indication	Dose	Interval	Route	Notes
Fluid overload / Pulmonary oedema / BPD	0.5-1 mg/kg/dose	Every 12-24 hours (preterm); Every 6-12 hours (term)	IV/Oral	Max 2 mg/kg/dose; Monitor electrolytes; K+ supplementation
Chronic diuretic for BPD	1-2 mg/kg/dose	Twice daily	Oral	Alternate with spironolactone 1-3 mg/kg/day BD

4.7 Spironolactone (BPD Chronic Diuretic)

Dose	Interval	Route
1-3 mg/kg/day	Divided twice daily	Oral

Used in combination with furosemide for BPD/CLD long-term diuresis; potassium-sparing

SECTION 5: NEONATAL METABOLIC / ELECTROLYTE

5.1 Glucose (Hypoglycaemia)

Definition: Neonatal hypoglycaemia = BG <2.6 mmol/L (<47 mg/dL)

Severity	Treatment	Dose	Route	Notes
Mild asymptomatic	Encourage breastfeeding; check BG in 30 min	-	Oral/Nasogastric	If unable to feed: proceed to IV
Symptomatic / BG <2.0 mmol/L	10% Dextrose bolus	2-2.5 mL/kg of D10W (= 200-250 mg/kg glucose)	IV bolus over 5 min	Then maintenance GIR
Maintenance GIR	Start at Glucose Infusion Rate (GIR) 6-8 mg/kg/min = 86-115 mL/kg/day of D10W	Adjust every 30-60 min	IV infusion	GIR formula: GIR (mg/kg/min) = Rate (mL/hr) × Concentration (g%) ÷ (6 × weight kg)
Refractory / persistent hypoglycaemia	Glucagon 0.1-0.2 mg/kg (max 1 mg)	IV/IM/SC	Single dose	Then investigate (hyperinsulinism, CAH)
Hyperinsulinism (diazoxide-responsive)	Diazoxide 10-25 mg/kg/day	Divided TID	Oral	Investigate + refer

Target BG: ≥2.6 mmol/L (≥47 mg/dL); in asphyxia/HIE target ≥3.0 mmol/L

5.2 Calcium Gluconate 10% (Hypocalcaemia)

Definition: Total Ca <2.0 mmol/L term; <1.75 mmol/L preterm; Ionised Ca <1.0 mmol/L

Indication	Dose	Rate	Route	Notes
Symptomatic hypocalcaemia (seizures/tetany)	1-2 mL/kg of 10% calcium gluconate (= 90-180 mg/kg; = 9-18 mg/kg elemental Ca)	IV over 5-10 min	IV slow (central preferred)	ECG monitoring; stop if HR <100
Asymptomatic hypocalcaemia	2-4 mL/kg/day	Continuous IV or divided oral	IV/Oral	Calcium gluconate oral solution or NG
Maintenance (preterm)	0.5-1 mEq/kg/day elemental calcium	Added to TPN	IV

NEVER give as IV push bolus - bradycardia / asystole Peripheral extravasation: Causes severe tissue necrosis; prefer central line for IV calcium

5.3 Sodium Bicarbonate (Metabolic Acidosis)

Indication	Dose	Route	Notes
Severe metabolic acidosis (pH <7.1, BE < -10)	1-2 mEq/kg (= 2-4 mL/kg of 4.2% NaHCO3)	IV slow over 30-60 min	Use 4.2% solution (0.5 mEq/mL) in neonates; NEVER give 8.4% undiluted (hypernatremia + IVH risk)
Cardiac arrest	1 mEq/kg (= 2 mL/kg of 4.2%)	IV bolus	Only after adequate ventilation established

5.4 Vitamin K1 (Phytomenadione) - Haemorrhagic Disease of Newborn

Indication	Dose	Route	Timing
Prophylaxis (all neonates)	1 mg (term); 0.5 mg (preterm <32 wks)	IM (preferred)	At birth (within 6 hours)
Oral prophylaxis (alternative)	2 mg at birth, then 2 mg at 4-7 days, then 2 mg at 4-6 weeks	Oral	Less effective; not for formula-fed infants
Treatment (active bleeding)	1-2 mg	IV slow (over 30 min)	Repeat if needed at 8-12 hrs

5.5 Iron Supplementation (Preterm Anaemia of Prematurity)

Indication	Dose	Interval	Route	Start	Duration
Preterm <34 weeks (prophylaxis)	2-4 mg/kg/day elemental iron	Once daily	Oral (ferrous sulfate / drops)	From 4-6 weeks of life	Until 12 months of age (corrected)
Very preterm (<28 weeks)	4-6 mg/kg/day	Once daily	Oral	4-6 weeks of life

SECTION 6: NEONATAL JAUNDICE

6.1 Phototherapy Thresholds (AAP 2022 / NNF Guidelines)

Age (hours)	Gestational Age	Start Phototherapy (Total Serum Bilirubin)	Exchange Transfusion Threshold
24-48 hrs	≥38 wks (no risk factors)	≥10 mg/dL	≥18-20 mg/dL
49-72 hrs	≥38 wks	≥13 mg/dL	≥20-22 mg/dL
>72 hrs	≥38 wks	≥15 mg/dL	≥22-25 mg/dL
Any age	Preterm 35-37 wks	Lower by 2-3 mg/dL	Lower thresholds
Any age	<35 wks, risk factors	Lower by 2-4 mg/dL (gestational age specific nomograms)	Consult NICU

Risk factors: Isoimmune haemolytic disease, G6PD deficiency, asphyxia, lethargy, temperature instability, sepsis, acidosis, albumin <3.0 g/dL

6.2 Phenobarbitone (Jaundice - Limited use)

Dose	Route	Notes
5 mg/kg/day for 3-5 days	Oral	Not recommended as routine - induces CYP enzymes but slow onset; use phototherapy instead; may use in Crigler-Najjar Type II

6.3 Exchange Transfusion

Parameter	Protocol
Volume	Double volume = 2 × blood volume = 2 × 80 mL/kg = 160 mL/kg
Blood product	O-negative (or crossmatched) packed red cells + FFP (2:1 mixture); or reconstituted whole blood
Access	Umbilical venous catheter (UVC) or arteriovenous technique (UVC + UAC)
Aliquot	5-10 mL/kg per cycle (push-pull technique)
Duration	90-120 minutes total
Adjuncts	IV albumin 1 g/kg (25% solution) 1-4 hrs before ET (only if albumin <2.5 g/dL, to bind bilirubin)

6.4 IVIG (Immune Haemolytic Jaundice)

Indication	Dose	Route	Notes
Rh/ABO isoimmune haemolysis with rapidly rising bilirubin approaching exchange threshold	0.5-1 g/kg	IV over 2-4 hours	May repeat in 12 hrs; reduces need for exchange transfusion

SECTION 7: NEONATAL INFECTIONS - SPECIAL PROTOCOLS

7.1 Congenital Toxoplasmosis

Drug	Dose	Interval	Route	Duration
Pyrimethamine	1 mg/kg/day	Once daily	Oral	6 months (active phase); then every 2 days for 6 months
Sulfadiazine	50 mg/kg/dose	Twice daily	Oral	12 months
Folinic acid (leucovorin)	10 mg	3 times/week	Oral	Throughout (prevents bone marrow suppression)

7.2 Congenital Syphilis

Stage	Drug	Dose	Interval	Route	Duration
Proven / Highly probable	Benzylpenicillin G	50,000 units/kg/dose	Every 12h (0-7 days); Every 8h (>7 days)	IV	10 days
Asymptomatic, adequately treated mother	Benzathine penicillin G	50,000 units/kg	Single dose	IM	1 dose only
Neurosyphilis	Benzylpenicillin G	50,000-100,000 units/kg/dose	Every 12 hours	IV	10-14 days

7.3 Congenital Rubella / CMV

Infection	Drug	Dose	Interval	Route	Duration
Symptomatic Congenital CMV (neurologic disease, hearing loss)	Valganciclovir	16 mg/kg/dose	Twice daily	Oral	6 months
Congenital CMV (IV if not tolerating oral)	Ganciclovir	6 mg/kg/dose	Every 12 hours	IV	6 weeks, then valganciclovir
Congenital Rubella	Supportive (no specific antiviral)	-	-	-	Manage complications (cardiac, eye, hearing)

SECTION 8: NEONATAL GASTROINTESTINAL

8.1 NEC (Necrotising Enterocolitis) - Antibiotic Regimen

Drug Class: Broad-spectrum antibiotics (aerobic + anaerobic cover)

Drug	Dose	Interval	Route	Duration
Ampicillin	50 mg/kg/dose	Q12h (<7 days) / Q8h (>7 days)	IV	7-10 days (Bell Stage II); 14 days (Stage III)
Gentamicin	4-5 mg/kg/dose	Per GA/PNA table	IV	As above
Metronidazole	7.5 mg/kg/dose	Q48h (<28 wks); Q24h (28-34 wks); Q12h (≥35 wks)	IV	7-14 days

NBM for 7-14 days (Stage II-III); NG decompression; IV fluids/TPN

8.2 Ranitidine / Omeprazole (GER / Stress Ulcer Prophylaxis)

Drug	Dose	Interval	Route	Notes
Ranitidine	2 mg/kg/dose	Every 8 hours	IV/Oral	Caution: associated with NEC, sepsis, and C. difficile in neonates; use with caution
Omeprazole	0.5-1 mg/kg/day	Once daily	Oral	Limited evidence in neonates; reserve for confirmed reflux with complications

8.3 Domperidone (GER - Prokinetic)

Dose	Interval	Route	Notes
0.25-0.5 mg/kg/dose	Three times daily (before feeds)	Oral	Caution: QTc prolongation; avoid if QTc >460 ms; not recommended <1 year by some guidelines

SECTION 9: PAIN & SEDATION IN NEONATES

9.1 Morphine (Opioid Analgesia / Ventilation Comfort)

Indication	Dose	Interval	Route	Notes
Procedural pain	0.05-0.1 mg/kg/dose	PRN	IV slow	Observe for respiratory depression
Ventilated neonate comfort	0.01-0.02 mg/kg/hr	Continuous infusion	IV	Titrate to comfort score (CRIES/NIPS)
Neonatal Abstinence Syndrome (NAS/NOWS) - morphine treatment	0.03-0.05 mg/kg/dose every 3-4 hours; titrate by NAS score	Every 3-4 hours	Oral	Wean 10% every 1-2 days once controlled

9.2 Fentanyl (Short Procedures)

Dose	Route	Notes
0.5-4 mcg/kg/dose (procedural)	IV slow (over 2-5 min)	Rapid onset; brief duration; chest wall rigidity risk at high doses - give slowly
0.5-2 mcg/kg/hour infusion	IV	Ventilated neonates; ECMO

9.3 Sucrose 24% (Non-Pharmacological Analgesia)

Dose	Route	Timing	Notes
0.5-2 mL of 24% sucrose	Oral (on pacifier or tongue)	2 min before procedure	Effective for heel pricks, venepuncture, cannulation; evidence-based; no side effects

9.4 Midazolam (Sedation)

Indication	Dose	Route	Notes
Procedural sedation	0.05-0.1 mg/kg	IV slow	Caution: apnoea, hypotension, myoclonic jerks in preterm; use with monitoring
Refractory seizures infusion	0.06-0.4 mg/kg/hour	IV continuous	NICU only
Premedication for intubation	0.05-0.1 mg/kg	IV	Combined with atropine + succinylcholine or rocuronium

9.5 INSURE Protocol (Intubation-Surfactant-Extubation) Premedication

Drug	Dose	Route	Purpose
Atropine	0.01-0.02 mg/kg (min 0.1 mg)	IV	Prevent bradycardia
Morphine or Fentanyl	0.05 mg/kg or 2-4 mcg/kg	IV	Analgesia/sedation
Succinylcholine (depolarising NMB)	2 mg/kg	IV	Short-acting; facilitates intubation
Rocuronium (non-depolarising)	0.6-1 mg/kg	IV	Alternatively; longer duration (have sugammadex ready)

SECTION 10: VITAMINS & SUPPLEMENTS

Drug	Dose	Interval	Route	Indication
Vitamin K1	1 mg (term); 0.5 mg (<32 wks)	Single dose at birth	IM	Haemorrhagic disease of newborn
Vitamin D	400 IU/day (term); 400-800 IU/day (preterm on enteral feeds)	Once daily	Oral	From first few days of life; continue through first year
Vitamin A	5000 IU x3/week for 4 weeks	x3 per week	IM	ELBW (<1000 g) - reduces BPD
Folic acid	50-100 mcg/day	Once daily	Oral	Preterm; megaloblastic anaemia prevention
Iron	2-4 mg/kg/day elemental	Once daily	Oral	Preterm from 4-6 weeks
Calcium (oral supplementation)	200-500 mg/kg/day elemental calcium	Divided feeds	Oral/NG	Preterm; added to formula or EBM
Phosphate	1-2 mmol/kg/day	Divided	Oral/IV	Preterm metabolic bone disease (with calcium)
Multivitamin drops	0.5-1 mL/day	Once daily	Oral	All preterm neonates on enteral feeds

SECTION 11: NEONATAL CASE-WISE APPLICATION

NEONATAL CASE 1: Early-Onset Sepsis (EOS) - Term Neonate 3 kg, Day 1

Vignette: Term neonate, born to GBS-positive mother, presents at 12 hours with temperature instability, grunting, poor feeding. WBC 23,000, CRP 45.

Diagnosis: Early-Onset Sepsis

Drug	Dose Calculation	Interval	Route	Duration
Ampicillin	50 mg/kg = 150 mg	Every 12 hours (Day 1)	IV over 30 min	10-14 days (if cultures positive)
Gentamicin	4-5 mg/kg = 13.5-15 mg	Every 36 hours (term, Day 1)	IV over 30 min	5-7 days; TDM
Supportive: IV Dextrose 10%	Maintain GIR 6-8 mg/kg/min	Continuous	IV	Until feeding established

If CSF abnormal: Add Cefotaxime 50 mg/kg/dose Q12h for meningitis; extend to 21 days

NEONATAL CASE 2: Late-Onset Sepsis (LOS) + Suspected MRSA - Preterm 28 wks, 1 kg, Day 15

Vignette: Preterm 28 wks, 1 kg, in NICU, presents with temperature instability, apnoeic episodes, CRP rising. Umbilical line in situ. Blood culture pending. Previous CoNS on previous culture.

Diagnosis: Late-Onset Sepsis (LOS) - CoNS / MRSA suspected

Drug	Dose Calculation	Interval	Route	Notes
Vancomycin	15-20 mg/kg = 15-20 mg	Every 18-24 hours (28 wks, >14 days)	IV over 60 min	TDM: trough before 4th dose; target 10-15 mg/L
Gentamicin (gram-negative cover)	5 mg/kg = 5 mg	Every 48 hours	IV over 30 min	TDM: trough <1 mg/L
Remove/change central line if possible	-	-	-	Central line-associated BSI

NEONATAL CASE 3: Respiratory Distress Syndrome (RDS) - Preterm 30 wks, 1.4 kg

Vignette: 30-week preterm, Apgar 5/7, grunting, nasal flaring, chest retractions from birth. CXR: ground-glass appearance, air bronchograms.

Diagnosis: Hyaline Membrane Disease / RDS

Drug	Dose Calculation	Route	Notes
Poractant alfa (Curosurf)	200 mg/kg = 280 mg = 3.5 mL (80 mg/mL)	Intratracheal	Rescue; may repeat 100 mg/kg at 6-12 hrs
Caffeine citrate	Loading 20 mg/kg = 28 mg	IV over 30 min	Then maintenance 5-10 mg/kg once daily
Ampicillin + Gentamicin	As per sepsis protocol	IV	Empirical (r/o infection)
CPAP	5-8 cmH2O	Via nasal prongs	If not requiring ventilation (CPAP first)

NEONATAL CASE 4: Neonatal Seizures - Term 3.2 kg, Day 1, Post-Asphyxia

Vignette: Term neonate, emergency LSCS for foetal distress. pH 6.9 on cord gas. At 6 hours, clonic jerking of right arm + desaturation.

Diagnosis: Neonatal Seizures secondary to HIE

Step	Drug	Dose Calculation	Route	Notes
1st line	Phenobarbitone	20 mg/kg = 64 mg IV over 15 min	IV	If continues: additional 10 mg/kg = 32 mg after 20 min (max 40 mg/kg)
If persists	Phenytoin	20 mg/kg = 64 mg at 0.5-1 mg/kg/min	IV with ECG
Therapeutic Hypothermia	Core temp 33-34°C	Whole-body cooling	Start within 6 hrs; 72 hours total	NICU mandatory
Maintenance phenobarbitone	3-5 mg/kg = 10-16 mg/day	Once daily	IV/Oral	From 12-24 hrs post-loading

NEONATAL CASE 5: Neonatal Jaundice - Term 3.5 kg, Day 3

Vignette: Day 3 term neonate, exclusively breastfed, total serum bilirubin 17 mg/dL. Blood group mismatch (Mom O+, Baby A+). DCT positive.

Diagnosis: ABO Isoimmune Haemolytic Jaundice

Intervention	Protocol	Notes
Intensive phototherapy	Continuous double/triple phototherapy	Eye protection mandatory; increase feeds; check bilirubin Q4-6h
IVIG (if approaching exchange threshold)	0.5-1 g/kg = 1.75-3.5 g over 2-4 hours	IV
If TSB reaches 25-28 mg/dL: Exchange transfusion	Double volume 160 mL/kg = 560 mL	UVC push-pull

NEONATAL CASE 6: Patent Ductus Arteriosus (PDA) - Preterm 28 wks, 1 kg, Day 3

Vignette: 28-week preterm, Day 3, ventilator-dependent, bounding pulses, hyperactive precordium. Echo confirms large hemodynamically significant PDA (L-to-R shunt, LA:Ao ratio 1.8).

Diagnosis: Hemodynamically Significant PDA

Drug	Dose Calculation	Interval	Route	Duration
Indomethacin (age <48h → 0.1 mg/kg/dose)	0.1 mg/kg = 0.1 mg	Every 12 hours x3 doses	IV slow (over 20-30 min)	3 doses; check urine output + creatinine after each dose
OR Ibuprofen oral (if tolerating feeds)	Day 1: 10 mg/kg = 10 mg; Days 2-3: 5 mg/kg = 5 mg	Once daily	Oral (via NG)	3 doses
Fluid restriction	100-120 mL/kg/day	Continuous	IV	Adjunct
If medical therapy fails: Surgical ligation or Catheter-based coil occlusion	-	-	-	NICU/Paediatric Surgery/Cardiology

NEONATAL CASE 7: Hypoglycaemia - Term SGA Neonate 2.4 kg, Hour 2

Vignette: SGA term neonate, blood glucose at 2 hours = 1.8 mmol/L (32 mg/dL). Jittery, hypotonic.

Diagnosis: Symptomatic Neonatal Hypoglycaemia

Intervention	Dose Calculation	Route	Notes
D10W bolus	2 mL/kg = 4.8 mL D10W	IV over 5 min	Check BG at 15-30 min post bolus
Maintenance GIR	Start GIR 6 mg/kg/min = 8.6 mL/hr of D10W (for 2.4 kg)	IV continuous	Titrate up by 2 mg/kg/min every 30 min until BG stable
If refractory: Glucagon	0.2 mg/kg = 0.48 mg	IM/IV	Single dose; bridge to IV glucose

GIR Calculation: Rate (mL/hr) = GIR × Weight × 6 ÷ Concentration (%); e.g., 6 × 2.4 × 6 ÷ 10 = 8.64 mL/hr of D10W

NEONATAL CASE 8: Apnoea of Prematurity - Preterm 29 wks, 1.2 kg, Day 5

Vignette: 29-week preterm, Day 5, on CPAP 5 cmH2O, having 4-5 apnoeas/day requiring stimulation.

Diagnosis: Apnoea of Prematurity

Drug	Dose Calculation	Route	Notes
Caffeine citrate loading	20 mg/kg = 24 mg	IV over 30 min	Stat
Caffeine citrate maintenance	5-10 mg/kg = 6-12 mg	Once daily (IV or oral)	Start 24 hrs after loading
Continue until 34-35 weeks CGA or apnoea-free 5-7 days	-	-	-

NEONATAL CASE 9: Neonatal Abstinence Syndrome (NAS/NOWS) - Day 2, 2.8 kg

Vignette: Term neonate born to opioid-dependent mother (methadone). NAS score = 9 (trigger ≥8 for treatment). Irritable, high-pitched cry, tremors, poor feeding, diarrhoea.

Diagnosis: Neonatal Abstinence Syndrome - Opioid Withdrawal

Drug	Dose	Interval	Route	Wean
Morphine oral (first-line)	Start 0.04-0.08 mg/kg/dose	Every 3-4 hours	Oral	Titrate up by 10% per dose until NAS <8; then wean 10% every 24-48 hrs when stable 48 hrs
Methadone (alternative, longer t½)	0.05-0.1 mg/kg/dose	Every 12-24 hours	Oral	Easier wean due to long half-life
Clonidine (adjunct for non-opioid symptoms)	0.5-1 mcg/kg/dose	Every 4-6 hours	Oral	For sympathetic overactivity (sweating, tachycardia)
Phenobarbitone (adjunct if polydrug exposure)	5-10 mg/kg/day	Divided BD	Oral	Only if morphine alone insufficient

Environment: Low-stimulation; swaddling; breastfeeding (if mother drug-free); rooming-in

NEONATAL QUICK REFERENCE CARD

Drug	Dose	Interval Key Points	Route
Ampicillin	50 mg/kg	Q12h (0-7d), Q8h (>7d)	IV
Gentamicin	4-5 mg/kg	Q48h (<29 wks), Q36h (29-35 wks), Q24-36h (≥36 wks)	IV
Cefotaxime	50 mg/kg	Q12h (0-7d), Q8h (>7d)	IV
Vancomycin	15-20 mg/kg	Q24-48h (preterm), Q12-18h (term)	IV
Penicillin G	50,000 u/kg	Q12h (0-7d), Q8h (>7d)	IV
Metronidazole	7.5 mg/kg	Q48h (<28 wks) → Q8h (≥35 wks)	IV
Acyclovir (HSV)	20 mg/kg	Q8h	IV
Phenobarbitone (load)	20 mg/kg	Single; repeat 10 mg/kg (max 40 mg/kg)	IV
Phenobarbitone (maint)	3-5 mg/kg/day	OD or BD	IV/Oral
Phenytoin (load)	15-20 mg/kg	Single dose slow IV	IV
Caffeine citrate (load)	20 mg/kg	Single	IV/Oral
Caffeine citrate (maint)	5-10 mg/kg	Once daily	IV/Oral
Poractant alfa (surfactant)	100-200 mg/kg	Intratracheal; repeat 100 mg/kg x2	ET
Indomethacin (PDA, <48h)	0.1 mg/kg Q12h x3	3 doses	IV slow
Ibuprofen (PDA)	10/5/5 mg/kg	Daily x3 doses	IV/Oral
D10W (hypoglycaemia)	2-2.5 mL/kg	Bolus; then GIR 6-8 mg/kg/min	IV
Calcium gluconate 10%	1-2 mL/kg	Slow IV (NOT bolus push)	IV
Morphine (analgesia)	0.05-0.1 mg/kg	PRN Q4-6h or 0.01-0.02 mg/kg/hr infusion	IV
Vitamin K1	1 mg (term); 0.5 mg (preterm)	Single dose at birth	IM
IVIG (haemolytic jaundice)	0.5-1 g/kg	Over 2-4 hrs; repeat at 12h	IV
Epinephrine (resus)	0.01-0.03 mg/kg	Q3-5 min	IV/IO
Dopamine	5-10 mcg/kg/min	Continuous infusion	IV
Prostaglandin E1	0.05-0.1 mcg/kg/min (start); 0.01-0.05 (maintenance)	Continuous	IV
Sildenafil (PPHN)	0.5-1 mg/kg	Q6-8h	Oral

Key Neonatal Drugs to AVOID:

Drug	Reason
Ceftriaxone	Bilirubin displacement + calcium precipitation (fatal) in neonates <28 days
Chloramphenicol	Grey baby syndrome (immature glucuronidation)
Aspirin	Reye syndrome + platelet dysfunction
Sulfonamides	Kernicterus (displace bilirubin from albumin)
Tetracyclines	Tooth discoloration, bone growth inhibition
Erythromycin	Infantile hypertrophic pyloric stenosis (IHPS) - especially in first 2 weeks
NSAIDs (routine)	Renal failure, NEC risk (except indomethacin/ibuprofen for PDA under strict protocol)
Metoclopramide	Extrapyramidal effects; dystonia; avoid <1 year
Codeine	CYP2D6 variability → morphine toxicity
Benzyl alcohol (preservative)	Gasping syndrome in preterm neonates

Sources: BNFc (British National Formulary for Children); Neofax/Lexicomp Neonatal; NNF (National Neonatology Forum India) guidelines; AAP Red Book 2021; WHO Pocket Book for Hospital Care of Neonates; Morgan & Mikhail Clinical Anesthesiology 7e; Goldman-Cecil Medicine---

Here is a summary index of everything compiled:

What's Covered in This Neonatal Protocol

Sections (10 Drug Classes + 9 Cases):

Section	Content
1. Antibiotics	Ampicillin, Gentamicin (GA+PNA-adjusted intervals), Cefotaxime, Vancomycin (TDM), Penicillin G, Metronidazole, Acyclovir, Azithromycin, Fluconazole - all with GA/PNA dose tables
2. Neurology	Phenobarbitone (load + maintenance + TDM), Phenytoin/Fosphenytoin, Midazolam, Levetiracetam, Pyridoxine, HIE hypothermia protocol
3. Respiratory	Surfactant (Poractant, Beractant), Caffeine citrate (Apnoea of Prematurity), Aminophylline, Dexamethasone (DART protocol), Sildenafil (PPHN)
4. Cardiovascular	Epinephrine (resus + vasopressor), Dopamine, Dobutamine, Digoxin (GA-adjusted), Prostaglandin E1 (duct-dependent CHD), Furosemide, Spironolactone
5. Metabolic/Electrolytes	D10W bolus + GIR calculation formula, Calcium gluconate, Sodium bicarbonate (4.2% only), Vitamin K1
6. Jaundice	Phototherapy thresholds (AAP 2022), Exchange transfusion protocol, IVIG (haemolytic jaundice)
7. Special Infections	Congenital toxoplasmosis (pyrimethamine + sulfadiazine + folinic acid), Congenital syphilis, Congenital CMV (valganciclovir)
8. GI	NEC antibiotic regimen, Ranitidine, Omeprazole, Domperidone (cautions)
9. Pain & Sedation	Morphine, Fentanyl, Sucrose 24%, Midazolam, INSURE protocol (intubation premedication), NAS/NOWS treatment
10. Vitamins & Supplements	Vitamin K, D, A, Iron, Folic acid, Calcium, Phosphate

Clinical Cases (9):

The most critical unique feature of neonatal dosing: Every aminoglycoside and vancomycin interval is determined by gestational age + postnatal age combined - not weight alone. TDM is mandatory for these drugs in all neonates.

Let me know if you'd like this compiled as a downloadable Word document or PDF for bedside/NICU reference.

Mastering Nebulisation complete guide

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Now compiling the complete guide drawing from Murray & Nadel's Respiratory Medicine, Goodman & Gilman's, Fishman's Pulmonary Diseases, and standard clinical protocols.

MASTERING NEBULISATION

A Complete Clinical Guide for Residents & Clinicians

PART 1: FUNDAMENTALS OF NEBULISATION

1.1 What Is Nebulisation?

Nebulisation is a method of delivering therapeutic agents directly to the respiratory tract in the form of a fine aerosol mist. A nebuliser converts liquid drug solutions or suspensions into small aerosol particles that can be inhaled and deposited along the respiratory tract - from the upper airways to the alveoli - depending on particle size, flow rate, and breathing pattern.

Why nebulise?

Direct drug delivery to the target organ (lungs) → lower systemic dose needed
Rapid onset of action (especially bronchodilators - onset in 3-5 minutes)
Can be used in patients unable to use inhalers (infants, obtunded, ventilated, elderly)
Allows simultaneous O2 delivery (via oxygen-driven nebuliser)
Effective for large drug volumes and viscous solutions

1.2 The Physics of Aerosol Deposition

Key Concept: Particle Size Determines Where Drug Deposits

Particle Size (MMAD)	Primary Deposition Site	Clinical Relevance
>10 μm	Oropharynx, nasopharynx	Swallowed; systemic absorption
5-10 μm	Trachea, large bronchi	Upper airway conditions (croup)
2-5 μm	Bronchi, bronchioles	Ideal for asthma, COPD (small airways)
0.5-2 μm	Alveoli	Pulmonary infections, ARDS
<0.5 μm	Mostly exhaled	No therapeutic deposition

MMAD = Mass Median Aerodynamic Diameter - the particle size at which 50% of the aerosol mass consists of smaller particles. The therapeutic window for bronchodilator delivery is 1-5 μm MMAD.

Three Mechanisms of Particle Deposition in Airways:

Inertial Impaction - Large particles (>5 μm) collide with airway walls at bends and bifurcations (primarily upper airways and large bronchi). High velocity and large size = impaction.
Gravitational Sedimentation - Particles 1-5 μm settle under gravity in smaller airways and alveoli. Enhanced by: slow breathing, breath-holding after inhalation.
Brownian Diffusion - Very small particles (<0.5 μm) undergo random motion and contact airway walls. Mostly exhaled without deposition.

1.3 Factors Affecting Aerosol Deposition

Device-related:

Particle size produced (MMAD)
Output rate (mL/min)
Flow rate of driving gas
Residual volume in nebuliser chamber

Patient-related:

Factor	Effect on Deposition
Slow, deep breathing	More peripheral / alveolar deposition
Fast, shallow breathing	More central / upper airway deposition
Breath-holding (5-10 sec)	Increases sedimentation - adds ~10-15% more deposition
Nasal vs. mouth breathing	Nasal breathing filters more; mouth breathing preferred for lower airway delivery
Airway obstruction (COPD, asthma)	Drug deposits at flow-limiting segments (proximal airways); less peripheral deposition
Children vs. adults	Children deposit more drug in oropharynx; less reaches lungs (smaller airways, faster breathing rate)
Open mouth / crying (infants)	Reduces efficiency; mask delivery more practical than mouthpiece

Drug-related:

Viscosity of solution (affects droplet formation)
Fill volume (4 mL optimal for most jet nebulisers)
Concentration of drug solution

PART 2: TYPES OF NEBULISERS

2.1 Jet Nebuliser (Pneumatic Nebuliser)

Mechanism: Compressed air or oxygen passes through a narrow jet (venturi effect), creating a high-velocity stream that draws liquid up from the reservoir. The liquid is sheared into droplets. Larger droplets impact a baffle and return to reservoir; fine particles (<5 μm) are carried to the patient.

Components:

Drug reservoir (cup)
Jet/nozzle
Baffle
T-piece / mouthpiece / mask
Tubing
Compressor / O2 wall supply

Parameter	Value
Driving gas flow rate	6-8 L/min (optimal)
Particle size produced	1-5 μm (polydisperse)
Fill volume	3-5 mL (add saline if drug volume < 3 mL)
Nebulisation time	5-10 minutes
Drug efficiency	~10-15% reaches the lungs
Residual volume	~1 mL (wasted)
Cost	Low

Advantages:

Inexpensive, widely available
Can use with supplemental O2 (O2-driven = also treats hypoxaemia)
No drug preparation restriction (works with most solutions)
Easy to use in obtunded/ventilated patients

Disadvantages:

Noisy (compressor)
Requires driving gas
Low efficiency (only ~10-15% lung deposition)
Longer treatment time
Risk of contamination if not cleaned
Concentrates drug as water evaporates (increases osmolarity over time)

2.2 Ultrasonic Nebuliser

Mechanism: A piezoelectric crystal vibrates at ultrasonic frequency (1-3 MHz), creating a fountain of liquid on the surface. Droplets are formed from the crest of ultrasonic waves. No external gas required.

Parameter	Value
Particle size	2-6 μm
Output rate	High (1-2 mL/min)
Treatment time	Shorter than jet
Heat generation	Yes - may denature proteins/suspensions

Advantages:

Silent
High output rate
No driving gas needed

Disadvantages:

Cannot use with suspensions (budesonide, steroids) - crystal deposition
Generates heat → may degrade thermolabile drugs (proteins, peptides)
More expensive than jet
Cannot use for some drugs (colistin, dornase alfa)

2.3 Vibrating Mesh Nebuliser (VMN) - Most Advanced

Mechanism: A laser-perforated mesh with thousands of tapered holes (3-5 μm) vibrates at high frequency (~128 kHz). Liquid is pumped through the mesh, producing uniform, fine particles.

Parameter	Value
Particle size	1-4 μm (near-monodisperse)
Drug efficiency	50-70% lung deposition
Treatment time	Very short (2-4 min)
Residual volume	Minimal (<0.1 mL)
Noise	Silent
Cost	High

Types:

Passive mesh (e.g., PARI eFlow, Aeroneb): mesh vibrates, no moving liquid parts
Active mesh (e.g., Omron MicroAir): electronic oscillator vibrates the mesh

Advantages:

Highest drug delivery efficiency
Silent, portable, battery-operated
Minimal residual volume (important for expensive drugs)
Ideal for ICU / ventilator use (inline placement)
Can nebulise suspensions (budesonide)
No heat generation

Disadvantages:

Expensive
Mesh may clog (especially with viscous solutions)
Requires careful cleaning

2.4 Comparison Table: Nebuliser Types

Feature	Jet	Ultrasonic	Vibrating Mesh
Mechanism	Compressed gas	Piezoelectric crystal	Vibrating mesh
Particle size (MMAD)	2-5 μm	2-6 μm	1-4 μm
Lung deposition	~10-15%	~10-20%	~50-70%
Treatment time	5-10 min	5-8 min	2-4 min
Driving gas needed	Yes	No	No
Suitable for suspensions	Yes	No	Yes
O2 enrichment possible	Yes	No	No
Residual volume	~1 mL	~1 mL	<0.1 mL
Noise	Loud	Moderate	Silent
Cost	Low	Moderate	High
Best use	Emergency, ward, ICU	Not preferred	ICU, home, CF, expensive drugs

PART 3: TECHNIQUE OF NEBULISATION

3.1 Standard Jet Nebuliser Setup - Step by Step

Equipment needed:

Jet nebuliser cup + mouthpiece/mask
Compressor or O2 flowmeter
Tubing (6 mm bore)
Prescribed drug(s)
Normal saline (0.9%) as diluent

Procedure:

Step 1 - Preparation:

Wash hands; assemble clean nebuliser
Verify: correct drug, correct dose, correct patient, correct route, correct time (5 Rs)
Draw up prescribed drug into nebuliser cup

Step 2 - Fill volume:

Total fill volume should be 3-5 mL (ideally 4 mL)
If drug volume <3 mL: add normal saline to achieve 4 mL total
Do NOT overfill (>5 mL increases treatment time without benefit)
Do NOT use less than 3 mL (drug wasted in residual volume)

Step 3 - Positioning:

Patient sits upright (90°) or at least 45°
Upright maximises tidal volume and gravity-assisted deposition
Mouthpiece preferred over mask if patient cooperative (less facial deposition, more lung delivery)
Mask if: infant, obtunded, dyspnoeic patient unable to hold mouthpiece

Step 4 - Flow rate:

Connect to O2 or compressed air at 6-8 L/min
<6 L/min → larger particles, poor lung deposition
8 L/min → smaller particles (more alveolar but also more exhaled)
In COPD: use air-driven at 6-8 L/min (risk of hypercapnia with pure O2) OR use O2-driven at controlled 24-28% O2 via Venturi

Step 5 - Breathing technique (instruct patient):

Breathe slowly and deeply through the mouth
Tidal volume breathing with occasional deep breaths
If possible: hold breath for 5-10 seconds after each deep breath (promotes sedimentation)
Breathe through mouth (not nose) to maximise lower airway delivery
Continue until nebuliser sputters (no more mist) = drug nearly exhausted
Tapping/tilting the cup when sputtering begins extracts residual drug

Step 6 - During nebulisation:

Mist should be visible from exhalation port - if no mist: check connections, gas flow
Treatment typically complete in 5-10 minutes
Monitor patient: SpO2, respiratory rate, heart rate, symptoms

Step 7 - After nebulisation:

Remove mask/mouthpiece
If inhaled corticosteroid: rinse mouth with water and spit (prevents oral candidiasis, hoarseness)
Record administration; document response (RR, SpO2, wheeze)
Clean nebuliser (see Section 5)

3.2 Mouthpiece vs. Mask

	Mouthpiece	Face Mask
Lung deposition	Higher (~30% more drug to lungs)	Lower (facial/eye deposition)
Oropharyngeal deposition	Lower	Higher
Best for	Cooperative children >3 yr, adults	Infants, obtunded, children <3 yr
Side effects	Less systemic absorption	More: HPA axis suppression (steroids), eye irritation
Technique requirement	Patient must seal lips around mouthpiece	Must fit face well; no gap

For infants and toddlers:

Use tightly fitting soft mask - a 1-2 cm gap dramatically reduces delivery by 50-85%
"Blow-by" technique (holding mask near face) is NOT recommended - essentially no drug delivered
Cry during nebulisation: inspiratory flow increases during crying - some drug delivered, but breath-holding abolished

3.3 Nebulisation During Mechanical Ventilation (ICU)

Positioning in circuit:

Place jet nebuliser 30 cm from patient on the inspiratory limb (Y-piece)
Vibrating mesh nebuliser: place directly at Y-piece (closest to patient = maximum delivery)
Gas from nebuliser adds to ventilator tidal volume - adjust ventilator settings accordingly

Optimising delivery on ventilator:

Factor	Optimise By
Tidal volume	Use larger tidal volumes if safe (>500 mL)
Inspiratory flow	Slower inspiratory flow (square wave flow pattern)
I:E ratio	Increase inspiratory time (increases drug contact time)
Humidifier	Turn OFF heat-moisture exchanger (HME) during nebulisation; keep heated humidifier on reduced temp
Nebuliser placement	30 cm from patient on inspiratory limb
Circuit condensate	Drain before nebulisation

Dose adjustment on ventilator:

Only ~3% of drug reaches lungs (jet nebuliser on ventilated patient)
Double or triple standard dose when nebulising via ventilator circuit with jet nebuliser
Vibrating mesh nebuliser: ~15-20% delivery on ventilator (preferred)

PART 4: NEBULISED DRUGS - COMPLETE REFERENCE

4.1 BRONCHODILATORS

Salbutamol (Albuterol) - SABA

Class: Short-Acting Beta-2 Agonist | Onset: 3-5 min | Peak: 30-60 min | Duration: 4-6 hours

Patient	Dose	Diluent (if needed)	Frequency	Notes
Adult	2.5-5 mg (2.5 mg/2.5 mL unit dose, or 5 mg/mL solution 0.5-1 mL)	Make up to 4 mL with 0.9% NS	PRN or Q4-6h (stable); Q20min x3 (acute)	Standard unit dose = 2.5 mg/2.5 mL
Child >5 yr / >20 kg	5 mg	Up to 4 mL with NS	Q20-30 min x3 (acute), Q4-6h (stable)
Child <5 yr / <20 kg	2.5 mg	Up to 3-4 mL with NS	Q20-30 min x3 (acute), Q4-6h (stable)
Neonate / Infant <5 kg	1.25 mg (half of 2.5 mg unit dose)	2.5 mL with NS	Q4-6h	Use 0.5% solution 0.25 mL + 2.25 mL NS
Via ventilator	5-10 mg	As above	Q2-4h (acute), Q6h (stable)	Low circuit delivery - increase dose
IV infusion (status asthmaticus)	5 mcg/kg/min starting, up to 20 mcg/kg/min	Dilute in 5% dextrose	Continuous	ICU; cardiac monitoring mandatory

Available preparations:

Salbutamol 2.5 mg/2.5 mL unit-dose vials (0.1% solution)
Salbutamol 5 mg/mL concentrated solution (dilute before use)
Salbutamol 0.5% (5 mg/mL): use 0.5 mL (2.5 mg) + 3.5 mL NS = 4 mL at 2.5 mg, or 1 mL (5 mg) + 3 mL NS for 5 mg dose

Side effects: Tachycardia, palpitations, tremor, hypokalaemia (especially with repeated doses), hypomagnesaemia

Ipratropium Bromide - SAMA

Class: Short-Acting Muscarinic Antagonist | Onset: 5-15 min | Peak: 30-90 min | Duration: 4-6 hours

Patient	Dose	Frequency	Notes
Adult	500 mcg (2 mL of 250 mcg/mL)	Q20min x3 (acute), Q6-8h (maintenance)	Add to same cup as salbutamol
Child >5 yr	250-500 mcg	Q20min x3 (acute), Q6-8h
Child <5 yr	125-250 mcg	Q20min x3, Q6-8h
Neonate	25-75 mcg	Q6-8h	Limited evidence
Via ventilator	500 mcg	Q4-6h

Preparation: 250 mcg/mL solution (standard vial = 250 mcg/1 mL or 500 mcg/2 mL) Can mix with salbutamol in same nebuliser cup (combined = Duolin / Combivent equivalent) Side effects: Dry mouth, urinary retention (caution in BPH), blurred vision (if mist contacts eye - use mouthpiece or tight mask), paradoxical bronchospasm (rare)

Fenoterol (LABA - short-acting in some formularies)

Adult dose	Frequency	Notes
1-2.5 mg in 3-4 mL NS	Q4-8h	Less preferred; more cardiac side effects than salbutamol

4.2 INHALED CORTICOSTEROIDS (ICS) via Nebuliser

Budesonide (Pulmicort Respules)

Class: Inhaled corticosteroid | Onset: Several hours (anti-inflammatory); immediate effect in croup (mucosal vasoconstriction)

Indication	Patient	Dose	Frequency	Notes
Acute asthma (add-on)	Adult	1-2 mg	BD x3-5 days	Adjunct to SABA; reduces admission rate
Acute asthma	Child	0.5-1 mg	BD-QID	Evidence supports acute use
Asthma - maintenance	Child <2 yr	0.25-0.5 mg	Once or twice daily	Respule = 0.25 mg/mL or 0.5 mg/mL
Asthma - maintenance	Child 2-12 yr	0.5-1 mg	Once or twice daily
Asthma - maintenance	Adult	1-2 mg	Once or twice daily	Usually replaced by MDI ICS; nebulised for severe/non-adherent
Croup (acute, moderate-severe)	Child any age	2 mg (= 2 mL of 1 mg/mL)	Single dose or BD x2	Effective as nebulised OR oral dexamethasone
Croup (mild)	Child	1 mg	Single dose

Formulation: Budesonide Respules 0.25 mg/mL (2 mL = 0.5 mg), 0.5 mg/mL (2 mL = 1 mg), 1 mg/2 mL Critical: Use vibrating mesh or jet nebuliser (NOT ultrasonic - suspension will precipitate) After nebulisation: Rinse mouth + face wash (prevents oral/facial candidiasis, perioral dermatitis with masks)

Beclometasone Dipropionate (Nebulised - less common)

Dose	Frequency	Notes
400 mcg	Twice daily	Less commonly nebulised vs. MDI

4.3 ANTICHOLINERGIC - LONG-ACTING (for COPD maintenance)

Glycopyrronium / Tiotropium (Soft Mist Inhaler preferred, but can be nebulised)

Drug	Dose	Frequency	Notes
Ipratropium (still standard nebulised LAMA equivalent)	500 mcg	Every 6-8 hours	Long-acting COPD - tiotropium SMI is preferred device

4.4 ADRENALINE (EPINEPHRINE) - Nebulised

Class: Alpha + Beta adrenergic agonist | Indication: Croup (laryngotracheobronchitis), Severe anaphylaxis airway oedema, Post-extubation stridor, Bronchiolitis

Indication	Dose	Preparation	Frequency	Notes
Croup (moderate-severe)	0.5 mL/kg of 1:1000 solution (max 5 mL)	Undiluted 1:1000 (1 mg/mL)	Single dose; may repeat Q20-30 min x3	Observe for rebound at 2-4 hours
Racemic epinephrine (if available)	0.05 mL/kg of 2.25% (max 0.5 mL)	Dilute in 3 mL NS	Single/repeat	Equivalent efficacy to L-epinephrine
Bronchiolitis (RSV)	0.5 mL/kg of 1:1000 (max 5 mL)	Undiluted	Single trial; repeat PRN	Limited evidence; use if significant wheeze
Post-extubation subglottic oedema	5 mL of 1:1000 (5 mg)	Undiluted	Q20-30 min PRN	In adult post-intubation stridor
Severe acute asthma (add-on)	3-5 mg (3-5 mL of 1:1000)	Undiluted or minimal NS	PRN	Reserve for near-fatal asthma

Rebound phenomenon in croup: Clinical deterioration 2-4 hours after nebulised adrenaline - admit all patients given nebulised adrenaline for croup for minimum 4-hour observation

4.5 MUCOLYTICS

Hypertonic Saline (3%, 6%, 7%)

Class: Osmotic agent | Mechanism: Draws fluid into airways, hydrates mucus, improves mucociliary clearance

Indication	Concentration	Dose	Frequency	Duration	Notes
Bronchiolitis (RSV)	3%	4 mL	Q6-8h	3-7 days	Reduces hospital stay; pre-treat with salbutamol 15 min before
Cystic Fibrosis - mucus clearance	7% (NaCl)	4 mL	Twice daily	Long-term (chronic)	After bronchodilator pre-treatment; after chest physiotherapy
Cystic Fibrosis	6%	4 mL	BD	Long-term	Alternative; equally effective
Bronchiectasis	3-6%	4 mL	BD	Long-term	Used before chest physiotherapy
Sputum induction (TB, PCP diagnosis)	3%	5 mL	Single session	Once	Pre-treat with salbutamol 2.5 mg to prevent bronchospasm

Critical: Always pre-treat with bronchodilator (salbutamol 2.5-5 mg) 15 min before hypertonic saline nebulisation - risk of bronchospasm, especially in asthma

Preparation: 3% NaCl = 3 g/100 mL; 7% NaCl = 7 g/100 mL (commercially available as Hyper-Sal)

Dornase Alfa (rhDNase, Pulmozyme)

Class: Mucolytic enzyme | Mechanism: Cleaves extracellular DNA (from neutrophils) in mucus → reduces viscosity

Indication	Dose	Frequency	Device	Duration
Cystic Fibrosis (FEV1 >40% predicted)	2.5 mg (1 ampoule = 2.5 mg/2.5 mL)	Once daily	Jet or vibrating mesh only (NOT ultrasonic)	Long-term

Timing: 30-60 minutes before physiotherapy session (optimises clearance) Storage: Refrigerate; do not dilute; do not mix with other drugs

N-Acetylcysteine (NAC) - Nebulised (Mucolytic)

Dose	Concentration	Frequency	Notes
1-2 mL of 20% solution, diluted to 4 mL with NS	20% NAC (200 mg/mL)	BD-QID	Unpleasant smell (sulphur); pre-treat with bronchodilator; limited evidence vs. hypertonic saline in CF

Ipratropium + Salbutamol Combined (Duolin / Combivent)

Dose	Contents	Frequency	Notes
1 unit dose vial	Salbutamol 2.5 mg + Ipratropium 0.5 mg	Q20 min x3 (acute), Q6-8h (maintenance)	Can make up by mixing from individual vials; Duolin UDV = ready-to-use

4.6 CORTICOSTEROIDS - SYSTEMIC via Nebuliser (Budesonide as Systemic Alternative)

Situation	Drug	Dose	Notes
Croup (cannot swallow, vomiting)	Budesonide nebulised	2 mg	Equal to dexamethasone 0.15 mg/kg oral
Refractory asthma, NBM	Budesonide nebulised	2-4 mg	Bridge to systemic steroids

4.7 NEBULISED ANTIBIOTICS

Drug	Indication	Dose	Frequency	Device	Notes
Tobramycin (TOBI)	CF - Pseudomonas aeruginosa (chronic)	300 mg	Twice daily x28 days, alternate months OFF	Jet (PARI LC Plus) or VMN	Cycle: 28 days ON, 28 days OFF
Colistimethate sodium (Colomycin)	CF / non-CF bronchiectasis - MDR gram-negative	1-2 MU (million units)	Twice daily	Jet / VMN	Bronchospasm risk - pre-treat SABA
Aztreonam (Cayston)	CF - Pseudomonas (alternative to tobramycin)	75 mg	Three times daily x28 days	Dedicated eFlow nebuliser only	Cycle: 28 days ON, 28 days OFF
Amphotericin B	Invasive pulmonary aspergillosis prophylaxis (neutropenic)	25 mg (deoxycholate) or 50 mg (liposomal)	Once weekly / BD (prophylaxis)	Jet	Bronchospasm common; pre-treat SABA
Pentamidine	PCP prophylaxis (HIV, if co-trimoxazole intolerant)	300 mg	Once monthly	Respigard II jet nebuliser (specifically)	Cough, bronchospasm; isolate patient
Ribavirin	RSV bronchiolitis (immunocompromised)	6 g/300 mL (SPAG-2 device)	12-18 hours/day continuous	SPAG-2 only	Highly specialised; teratogenic (avoid clinician exposure)

4.8 MAGNESIUM SULPHATE - Nebulised

Indication	Dose	Preparation	Frequency	Evidence
Acute severe asthma (add-on to SABA)	151-384 mg = 1.5-2.5 mL of 250 mg/mL (isotonic MgSO4)	Isotonic MgSO4 in NS to 4 mL total	Single dose; may repeat x3	Meta-analyses show significant bronchodilation; reduces hospital admission in severe acute asthma

Preparation note: Standard IV MgSO4 50% solution is hypertonic and causes bronchospasm if nebulised - must use isotonic nebulised MgSO4 (250 mg/mL in NS) formulation

4.9 HELIOX-DRIVEN NEBULISATION

Indication	Heliox mixture	Mechanism	Benefit
Severe asthma, croup, upper airway obstruction	70% He / 30% O2 (or 80:20)	Helium = low density gas; reduces turbulent flow in obstructed airways; allows laminar flow	Better drug deposition distal to obstruction; reduces work of breathing

Note: Heliox changes nebuliser output - flow rate needs adjustment (typically 12-14 L/min for same output as 8 L/min air)

PART 5: CONDITION-SPECIFIC NEBULISATION PROTOCOLS

5.1 Acute Severe Asthma

Severity assessment first: RR, SpO2, speech, PEFR, wheeze intensity

Protocol (Adult - Moderate to Severe):

Time	Drug	Dose	Route	Notes
0-20 min (Immediate)	Salbutamol	5 mg in 4 mL NS	Nebulised (O2-driven 8 L/min)	Back-to-back x3 doses in first hour
0-20 min	Ipratropium	500 mcg	Add to same cup	Back-to-back x3
20-40 min	Salbutamol	5 mg	Nebulised	2nd back-to-back
40-60 min	Salbutamol	5 mg	Nebulised	3rd back-to-back
After 60 min	Salbutamol	5 mg	Q1-4h depending on response
Throughout	Prednisolone / Hydrocortisone	40 mg oral OR 100-200 mg IV	Oral/IV	Start immediately
If still severe	IV Magnesium sulphate	1.2-2 g over 20 min	IV	Not nebulised form
If near-fatal	IV Salbutamol / IV aminophylline	250 mcg bolus / 5 mg/kg load	IV	ICU
O2	Controlled O2	Target SpO2 93-95%	Mask/prongs	Avoid hyperoxia

Paediatric (6-12 yr, 20-30 kg):

Drug	Dose	Frequency
Salbutamol	5 mg (>20 kg) or 2.5 mg (<20 kg)	Q20 min x3, then Q4h
Ipratropium	250-500 mcg	With first 3 salbutamol doses
Prednisolone	1-2 mg/kg (max 40 mg)	Once daily 3-5 days

5.2 Acute COPD Exacerbation

Key difference from asthma: Risk of hypercapnia with high-flow O2 - use controlled O2

Drug	Dose	Frequency	Route	Notes
Salbutamol	2.5-5 mg	Q20 min x3 (acute), then Q4-6h	Air-driven nebuliser at 6-8 L/min (or controlled O2 24-28% Venturi)	Do NOT use 100% O2 as driving gas
Ipratropium	500 mcg	Q6-8h	Nebulised	Can combine with salbutamol
Prednisolone	30-40 mg	Once daily	Oral	5 days
Antibiotic	Per purulence/CURB65	-	Oral/IV	Amoxicillin-clavulanate / Doxycycline
Controlled O2	24-28% (Venturi)	Continuous	Mask	Target SpO2 88-92% in COPD

If nebulised with O2-driven (8 L/min, ~40% FiO2): This is acceptable and avoids hypercapnia RISK vs. non-rebreather mask (60-100% FiO2); titrate O2 carefully

5.3 Croup (Laryngotracheobronchitis)

Severity guide: Barking cough, stridor, recession, agitation, cyanosis → Westley Croup Score

Severity	Westley Score	Treatment
Mild	0-2	Oral dexamethasone 0.15 mg/kg; no nebulisation needed
Moderate	3-7	Oral/IM dexamethasone + nebulised budesonide
Severe	8-11	Nebulised epinephrine + IV/IM dexamethasone
Impending obstruction	≥12	Secure airway; anaesthesia/ENT

Nebulisation protocol:

Drug	Dose	Preparation	Notes
Nebulised Budesonide	2 mg (= 2 mL of 1 mg/mL respule)	Undiluted or add 2 mL NS	Onset within 30-60 min; equal to dexamethasone IM
Nebulised Epinephrine (Adrenaline 1:1000)	0.5 mL/kg (max 5 mL)	Undiluted 1:1000	Onset 10-30 min; short duration 1-2 hrs - REBOUND AT 2-4 hrs - ADMIT
Dexamethasone	0.6 mg/kg (max 10 mg)	Oral/IM	Corticosteroid - gold standard; may give nebulised budesonide if child cannot swallow

5.4 Bronchiolitis (RSV - Infants)

Drug	Evidence	Dose	Notes
Hypertonic saline 3%	Moderate evidence - reduces length of stay	4 mL Q6-8h	Pre-treat with salbutamol; most useful in hospital setting
Salbutamol	Limited evidence; no routine use	2.5 mg trial dose	Use only if clear bronchospasm / wheeze; do NOT continue if no response
Nebulised epinephrine	Some evidence - reduces admission	0.5 mL/kg of 1:1000	Observe 2-4 hrs; if response: may reduce admission
Budesonide nebulised	No evidence in RSV bronchiolitis	Not recommended
Supportive	O2, feeding support, hydration	-	Main treatment

5.5 Pneumonia / Respiratory Infections

Drug	Indication	Dose	Notes
Salbutamol	Wheeze / bronchospasm component	As above	Not for fever/consolidation alone
Hypertonic saline	Thick secretions, poor clearance	3-7% 4 mL BD	Adjunct; improves mucociliary clearance
Nebulised antibiotics	Ventilator-associated pneumonia (VAP), CF	As per specific drugs above	Adjunct to IV antibiotics
Normal saline nebulisation	"Loosening secretions"	3-5 mL 0.9% NS	Minimal evidence; may trigger cough to clear secretions

5.6 Neonatal Nebulisation

Special considerations:

Neonates breathe entirely through nose → nasal prongs or well-fitted mask
Very small tidal volumes (5-7 mL/kg = ~15-25 mL) → very small fraction reaches lungs
Flow rate: 4-6 L/min (lower to avoid airway trauma and excessive airway pressure)
Prefer vibrating mesh nebuliser in neonates (lower residual volume, silent, small particle size)
Crying decreases delivery significantly - time nebulisation when calm/sleeping

Drug	Neonatal Dose	Route	Indication
Salbutamol	1.25 mg in 3 mL NS	Nebulised 4-6 L/min	Bronchospasm, ventilator weaning
Ipratropium	25-75 mcg	Nebulised	BPD - chronic airflow limitation
Budesonide	0.25-0.5 mg	Nebulised	BPD prevention (emerging - not yet standard)
Poractant alfa	100-200 mg/kg via ET tube	Intratracheal	RDS - NOT conventional nebulisation
Caffeine	IV/oral	-	Not nebulised

5.7 Nebulisation in Special Situations

Nebulisation in Oxygen-Dependent/Hypoxic Patient

Use O2 as driving gas (8 L/min) - simultaneously treats hypoxaemia and delivers drug
Monitor SpO2 during and after nebulisation
After nebulisation: return to appropriate O2 delivery device

Nebulisation via Tracheostomy

Connect T-piece nebuliser to tracheostomy tube
Place mask over tracheostomy if patient cannot hold T-piece
Flow rate 6-8 L/min as standard

Nebulisation in Non-Invasive Ventilation (NIV/BiPAP)

Place T-piece in-line on inspiratory limb of NIV circuit
Continue NIV during nebulisation (do not remove mask)
Synchronise with expiratory trigger if possible (some devices auto-sync)
VMN preferred for NIV (does not add gas flow to circuit)

PART 6: DRUG MIXING AND COMPATIBILITY

Which Drugs Can Be Mixed in One Nebuliser?

Combination	Compatible?	Notes
Salbutamol + Ipratropium	YES	Standard combination (Duolin); mix in same cup
Salbutamol + Budesonide	YES	Commonly combined; no interaction
Salbutamol + Hypertonic saline	YES	Give salbutamol first OR mix for simultaneous delivery
Salbutamol + Normal saline	YES	Standard diluent
Ipratropium + Budesonide	YES	Can mix
Salbutamol + Ipratropium + Budesonide	YES	Triple mix used in acute severe asthma
NAC + Salbutamol	YES	Pre-treatment before NAC is preferred
Budesonide + Ultrasonic nebuliser	NO	Suspension precipitates on ultrasonic crystal
Dornase alfa + Any other drug	NO	Give alone; no mixing
Tobramycin + Other antibiotics	NO	Give alone
Colistin + Other drugs	NO	Give alone
Amphotericin + Other drugs	NO	Give alone

PART 7: CLEANING AND INFECTION CONTROL

7.1 Why Cleaning Is Critical

Nebulisers are warm, moist environments - ideal for bacterial growth (Pseudomonas, Burkholderia, Aspergillus). Contaminated nebulisers cause respiratory infections, especially in immunocompromised and CF patients.

7.2 Cleaning Protocol (After Each Use)

Step	Action
1	Disassemble: cup, mouthpiece, T-piece, mask
2	Rinse with sterile water (NOT tap water - Pseudomonas risk)
3	Air dry completely on clean paper towel (upright)
4	Store in clean, dry container/bag
5	Daily disinfection: Soak in 70% isopropyl alcohol or 2% chlorhexidine for 3 minutes; rinse with sterile water; dry
6	Replace nebuliser cup: monthly (home use); weekly (hospital); daily (ICU/immunocompromised)

PART 8: COMMON ERRORS IN NEBULISATION

Error	Consequence	Correct Practice
Low fill volume (<3 mL)	Most drug wasted in residual volume	Fill to 4 mL with NS
Wrong flow rate (<6 L/min)	Large particles → oropharyngeal deposition	Use 6-8 L/min
Supine position	Reduced tidal volume; pooling of drug	Sit patient upright 90°
Nose breathing	Upper airway filtration of particles	Breathe through mouth
Blow-by technique in infants	Virtually no drug delivered	Use tight-fitting mask
O2-driven in COPD (high flow)	Hypercapnia, respiratory arrest	Use air-driven or controlled O2 (24-28%)
Ultrasonic for budesonide	Drug suspension clogged, inactivated	Use jet or VMN for suspensions
No mouth rinse after ICS	Oral candidiasis, dysphonia	Rinse mouth after every ICS nebulisation
Mixing dornase alfa with other drugs	Inactivated	Dornase alfa always given alone
Ceftriaxone mixed with calcium in neonate (wrong drug, not nebulised)	Precipitation	Wrong route analogy - never mix nebulised drugs without confirming compatibility
Over-using SABA (>3 times/week)	Rebound bronchospasm, tolerance, masking severity	Review controller therapy; step up
Not monitoring HR during salbutamol	Tachycardia, arrhythmia	Monitor HR, SpO2 during acute SABA nebulisation
Reusing single-dose vials	Drug degradation, contamination	Single-use vials = one session only

PART 9: NEBULISATION vs. MDI + SPACER

A common question: When to use a nebuliser vs. MDI + spacer?

Factor	Nebuliser	MDI + Spacer
Drug delivery efficiency	~10-15% (jet)	~10-15% (with spacer, equally efficient)
Patient coordination required	No	Minimal (with spacer)
Best for	Acute severe disease, infants, obtunded, ventilated patients	Stable disease, home use, all ages with spacer
Simultaneous O2 therapy	Yes	No
Speed of delivery	Slower (5-10 min)	Faster (2-3 min)
Cost	Higher (equipment)	Lower
Drug options	Wide (most solutions)	Limited to MDI formulations
Portability	Less portable	Highly portable
Evidence in acute asthma	Equal efficacy to MDI + spacer (Cochrane review)	Equal to nebuliser (when used correctly)

Key Evidence: Multiple Cochrane reviews confirm that MDI + spacer = nebuliser for bronchodilator delivery in mild-moderate acute asthma in adults and children. Nebuliser preferred only for severe/near-fatal asthma, inability to use MDI, or when simultaneous O2 is needed.

PART 10: QUICK REFERENCE CARD - NEBULISED DRUGS

Drug	Adult Dose	Paed Dose	Dilute to	Frequency	Device
Salbutamol	2.5-5 mg	1.25-5 mg	4 mL NS	Q20min x3 (acute), Q4-6h	Jet/VMN
Ipratropium	500 mcg	125-500 mcg	Same cup	Q20min x3, Q6-8h	Jet/VMN
Duolin (Salb+Ipra)	1 UDV	1 UDV	Ready 4 mL	Q6-8h	Jet/VMN
Budesonide	1-2 mg	0.25-2 mg	Undiluted Respule	OD-BD	Jet/VMN (NOT ultrasonic)
Adrenaline (croup)	5 mg (5 mL 1:1000)	0.5 mL/kg 1:1000 (max 5 mL)	Undiluted	Single/Q20min	Jet
Hypertonic saline 3%	4 mL	4 mL	Ready	Q6-8h	Jet/VMN
Dornase alfa	2.5 mg	2.5 mg (>5 yr)	Undiluted	OD	Jet (PARI)/VMN
Tobramycin	300 mg	300 mg (≥6 yr)	Undiluted	BD x28 days	PARI LC Plus
Colistimethate	1-2 MU	0.5-1 MU	In NS to 4 mL	BD	Jet/VMN
MgSO4 (isotonic)	151-384 mg	-	Isotonic prep	Single	Jet
NAC 20%	2-4 mL (400-800 mg)	1-2 mL	+ NS to 4 mL	BD-QID	Jet

Sources: Murray & Nadel's Textbook of Respiratory Medicine (deposition physics and aerosol science); Goodman & Gilman's Pharmacology; Fishman's Pulmonary Diseases (aerosolised antibiotics); GINA Guidelines 2024; GOLD Guidelines 2024; BTS/SIGN Asthma Guidelines; WHO Pocket Book; BNFc; NICE bronchiolitis guidelines---

Here's what the complete guide covers across 10 parts:

Complete Guide Index

Part	Content
1. Fundamentals	What nebulisation is, MMAD concept, 3 deposition mechanisms (impaction, sedimentation, diffusion), particle size vs. deposition site table
2. Device Types	Jet (pneumatic), Ultrasonic, Vibrating Mesh - full comparison with mechanism, efficiency, pros/cons, which drugs work in each
3. Technique	Step-by-step setup, fill volume (4 mL rule), flow rate (6-8 L/min), positioning, breathing pattern (slow/deep/mouth), mouthpiece vs. mask, ventilator nebulisation (ICU), NIV nebulisation
4. Drugs	Salbutamol, Ipratropium, Budesonide, Adrenaline/Epinephrine, Hypertonic saline (3%/7%), Dornase alfa, NAC, Magnesium sulphate, Tobramycin, Colistin, Aztreonam, Amphotericin, Pentamidine, Ribavirin - all with adult + paediatric doses
5. Clinical Protocols	Acute severe asthma (back-to-back), COPD exacerbation, Croup (Westley severity), Bronchiolitis (RSV), Pneumonia, Neonatal nebulisation, Special situations
6. Drug Compatibility	What can/cannot be mixed in one cup
7. Cleaning	Infection control protocol, replacement schedules
8. Common Errors	15 critical errors with consequences and corrections
9. Nebuliser vs. MDI + Spacer	Evidence-based comparison - when to choose each
10. Quick Reference	One-page summary table of all nebulised drugs

Key pearls to remember:

Optimal particle size = 1-5 μm MMAD for bronchial delivery
Fill volume = 4 mL always; flow rate = 6-8 L/min
Sit upright, breathe slow and deep, use mouthpiece when possible
Ultrasonic nebuliser cannot be used for suspensions (budesonide, steroids)
Always pre-treat with salbutamol before hypertonic saline
Rinse mouth after every ICS nebulisation
In COPD: use air-driven or controlled O2 (not high-flow pure O2)
Nebulised adrenaline in croup = must admit for 4-hour rebound observation

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