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APPENDIX 2

Medications Administered to Critically Ill Pediatric Patients and Recommendations for Time Interval to Testing After Discontinuation

MedicationInfants/Children Elimination ½ lifeNeonates Elimination ½ life
Intravenous induction, anesthetic, and sedative agents   
    Thiopental Adults: 3–11.5 hours (shorter ½ life in children)  
    Ketamine 2.5 hours  
    Etomidate 2.6–3.5 hours  
    Midazolam 2.9–4.5 hours 4–12 hours77,–,80  
    Propofol 2–8 minutes, Terminal ½ life 200 minutes (range 300–700 minutes)  
    Dexmedetomidine Terminal ½ life 83–159 minutes79,–,81  Infants have faster clearance81,–,83  
    Antiepileptic drugs   
    Phenobarbital Infants: 20–133 hours* 45–500 hours*79,84,85  
 Children: 37–73 hours*  
    Pentobarbital 25 hours*  
    Phenytoin 11–55 hours* 63–88 hours* 
    Diazepam 1 month–2 years: 40–50 hours 50–95 hours79,86,87  
 2 years–12 years: 15–21 hours  
 12–16 years: 18–20 hours  
    Lorazepam Infants: 40.2 hours (range 18–73 hours) 40 hours86  
 Children: 10.5 hours (range 6–17 hours)  
    Clonazepam 22–33 hours  
    Valproic Acid Children > 2 months: 7–13 hours* 10–67 hours* 
 Children 2–14 years: Mean 9 hours; range 3.5–20 hours  
    Levetiracetam Children 4–12 years: 5 hours  
Intravenous narcotics   
    Morphine sulfate Infants 1–3 months: 6.2 hours (5–10 hours) 7.6 hours (range 4.5–13.3 hours)79,89,–,91  
 6 months–2.5 years: 2.9 hours (1.4–7.8 hours)  
 Children: 1–2 hours  
    Meperidine Infants < 3 months: 8.2–10.7 hours (range 4.9–31.7 hours) 23 hours (range 12–39 hours) 
 Infants 3–18 months: 2.3 hours  
 Children 5–8 years: 3 hours  
    Fentanyl 5 months–4.5 years: 2.4 hours (mean) 0.5–14 years: 21 hours (range 11–36 hours for long term infusions) 1–15 hours 
    Sufentanil Children 2–8 years: 97 ± 42 minutes 382–1162 minutes 
Muscle relaxants   
    Succinylcholine 5–10 minutes  
 Prolonged duration of action in patients with pseudocholinesterase deficiency or mutation  
    Pancuronium 110 minutes  
    Vecuronium 41 minutes 65 minutes 
    Atracurium 17 minutes 20 minutes 
    Rocuronium 3–12 months: 1.3 ± 0.5 hours  
 1 to < 3 years: 1.1 ± 0.7 hours  
 3 to < 8 years: 0.8 ± 0.3 hours  
 Adults: 1.4–2.4 hours  
MedicationInfants/Children Elimination ½ lifeNeonates Elimination ½ life
Intravenous induction, anesthetic, and sedative agents   
    Thiopental Adults: 3–11.5 hours (shorter ½ life in children)  
    Ketamine 2.5 hours  
    Etomidate 2.6–3.5 hours  
    Midazolam 2.9–4.5 hours 4–12 hours77,–,80  
    Propofol 2–8 minutes, Terminal ½ life 200 minutes (range 300–700 minutes)  
    Dexmedetomidine Terminal ½ life 83–159 minutes79,–,81  Infants have faster clearance81,–,83  
    Antiepileptic drugs   
    Phenobarbital Infants: 20–133 hours* 45–500 hours*79,84,85  
 Children: 37–73 hours*  
    Pentobarbital 25 hours*  
    Phenytoin 11–55 hours* 63–88 hours* 
    Diazepam 1 month–2 years: 40–50 hours 50–95 hours79,86,87  
 2 years–12 years: 15–21 hours  
 12–16 years: 18–20 hours  
    Lorazepam Infants: 40.2 hours (range 18–73 hours) 40 hours86  
 Children: 10.5 hours (range 6–17 hours)  
    Clonazepam 22–33 hours  
    Valproic Acid Children > 2 months: 7–13 hours* 10–67 hours* 
 Children 2–14 years: Mean 9 hours; range 3.5–20 hours  
    Levetiracetam Children 4–12 years: 5 hours  
Intravenous narcotics   
    Morphine sulfate Infants 1–3 months: 6.2 hours (5–10 hours) 7.6 hours (range 4.5–13.3 hours)79,89,–,91  
 6 months–2.5 years: 2.9 hours (1.4–7.8 hours)  
 Children: 1–2 hours  
    Meperidine Infants < 3 months: 8.2–10.7 hours (range 4.9–31.7 hours) 23 hours (range 12–39 hours) 
 Infants 3–18 months: 2.3 hours  
 Children 5–8 years: 3 hours  
    Fentanyl 5 months–4.5 years: 2.4 hours (mean) 0.5–14 years: 21 hours (range 11–36 hours for long term infusions) 1–15 hours 
    Sufentanil Children 2–8 years: 97 ± 42 minutes 382–1162 minutes 
Muscle relaxants   
    Succinylcholine 5–10 minutes  
 Prolonged duration of action in patients with pseudocholinesterase deficiency or mutation  
    Pancuronium 110 minutes  
    Vecuronium 41 minutes 65 minutes 
    Atracurium 17 minutes 20 minutes 
    Rocuronium 3–12 months: 1.3 ± 0.5 hours  
 1 to < 3 years: 1.1 ± 0.7 hours  
 3 to < 8 years: 0.8 ± 0.3 hours  
 Adults: 1.4–2.4 hours  

Modified from Ashwal and Schneider.57 

Metabolism of pharmacologic agents may be affected by organ dysfunction and hypothermia.

Physicians should be aware of total amounts of administered medication that can affect drug metabolism and levels.

*

Elimination ½ life does not guarantee therapeutic drug levels for longer acting medications or medications with active metabolites. Drug levels should be obtained to ensure that levels are in a low to mid therapeutic range prior to neurologic examination to determine brain death. In some instances this may require waiting several half-lives and rechecking serum levels of the medication before conducting the brain death examination.

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