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Inadvertent overdosing of neonates as a result of the dead space of the syringe hub and needle
  1. V Bhambhani,
  2. R S Beri,
  3. J M Puliyel
  1. Department of Paediatrics, St Stephen’s Hospital, New Delhi, India
  1. Correspondence to:
    Dr Bhambhani

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Chappell and Newman1 have asked for urgent initiatives to ensure the manufacture of neonatal targeted products to reduce the risks associated with intravenous drug administration. We endorse their view and report a little recognised problem with the use of adult formulations in neonatal nurseries.

This investigation was conducted after we noticed symptoms of digoxin overdose (bradyarrhythmia) in a neonate. Retrospective review of the case suggested that the overdose received was due to the unaccounted for drug in the dead space of a 1 ml syringe.

The nursing drug dose manual Pediatric drugs and nursing implications2 gives the maintenance dose of intravenous digoxin as 2.5 μg/kg/dose. The nursing instruction3 states that the dose must be diluted, with at least four times the volume, using normal saline or 5% dextrose, and the drug must be given over five minutes. In practice, for a 2 …

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  • Competing interests: none declared