Pediatric Parenteral Medication

Question 1

IM Route Considerations

Answer 1

Altered blood flow (compromised circulation reduces absorptive potential)
Smaller muscle mass than adults (limit volumes to 0.5 mL for infants and 1 mL for children)

Question 2

Intraosseous route Considerations

Answer 2

Used in emergency situations to gain rapid vascular access

Proximal site = optimal site

Question 3

What can be given intraosseous route?

Answer 3

Crystalloid/colloid solutions
Blood products
Meds

Question 4

Upper extremities peripheral line placement

Answer 4

Forearm, dorsal veins of hands, antecubital fossa

Question 5

Lower extremities peripheral line placement

Answer 5

Saphenous vein at the ankle or dorsal part of foot

Question 6

Peripheral Line Consideration

Answer 6

Remain in place for a few days
Veins are small and fragile (thrombophlebitis, infiltration, extravasation, bleeding, bruising, phlebitis)
Limit drug solution (900-1000 mOsm)

Question 7

Osmolarity

Answer 7

Most drugs will have to be diluted

Question 8

pH Considerations

Answer 8

Drugs outside of 7.35-7.45 can increase thrombophlebitis risk

Question 9

Central line placement

Answer 9

Internal jugular vein
Subclavian vein
Femoral vein

Question 10

Central line considerations

Answer 10

For prolonged IV therapy
Number of lumens, lumen size and length
Less extravasation and infiltration
Heparin to prevent catheter occlusion

Question 11

Complications of central line usage

Answer 11

Line infection
Sepsis
DVT
Embolism

Question 12

Placement of Peripherally Inserted Central Catheters (PICC)

Answer 12

Median cubital vein and tip advanced centrally
Infuses into the superior vena cava
Single, double, triple lumen catheters

Question 13

PICC Limitations

Answer 13

Placement requires specialty trained nurses or a physician and must be confirmed with x-ray
Require heparin flushes

Question 14

PICC Benefits

Answer 14

Longer duration of use compared with peripheral line (2-8 weeks)
Tolerate higher osmolar solutions

Question 15

Placement of Central Venous Catheters (CVC)

Answer 15

Generally require surgical placement
Infuse into the superior vena cava
Can be single, double, or triple lumen

Question 16

CVC Limitations

Answer 16

Surgical placement
Higher cost
Require heparin flushes

Question 17

CVC Benefits

Answer 17

Best for long term use

Tolerate higher osmolar solutions

Question 18

Pediatric-friendly formulations

Answer 18

Geometric dilution must be utilized to oaccurately deliver small doses

Question 19

Dilutions

Answer 19

Often administering less than 1 mL of drugs

Can accurately measure 2 mg of drugs

Question 20

Drug Volume Limitations

Answer 20

Drug volume must be minimized to allow for nutrition

High potential for error when dose volumes less than 1 mL

Question 21

Syringe Pump Devices

Answer 21

Pressure controls infusion rate
Microbore tubing (infusion rate is limited due to lumen size)
Pediatric benefits (improved accuracy at rates less than 10 mL/hr & limit delayed drug delivery

Question 22

Dead space

Answer 22

Drug can be hidden or lost with small volumes in the IV set
Within the hub of the needle, Y-site injection ports, in-line filters
So need to allow for priming volume and to account for dead space during preparation

Question 23

Dead space volume policies

Answer 23

Priming volume equal to anticipated dead space

Dispense medication in exact volume and then flush line after drug infusion completed

Question 24

Intermittent Infusions are:

Answer 24

Administered via slow infusion over a set time period using a syringe pump or gravity

Question 25

Continuous infusions:

Answer 25

Require close infusions | Infused via syringe pump for accurate control of rates

Question 26

Pediatric Medication Errors Formulation Issues

Answer 26

Most are designed/studied for adults Few correct strengths available Can require complex calculations and dilutions

Question 27

Dosing can vary according to:

Answer 27

Age Degree of prematurity in neonates Weight Clinical conditions

Question 28

Calculation errors:

Answer 28

10 fold and 100 fold dosing errors Misplacement of decimal point Inappropriate use of zeros Incorrect units

Question 29

Benzyl Alcohol

Answer 29

Additive Excreted via the urine but newborns have immature conjugation pathways so their is accumulations 5 mg/kg/d

Question 30

Propylene Glycol

Answer 30

Additive Excreted via the urine but neonates have prolonged metabolism Rapid infusion can cause hypotension, arrhythmias and seizures

Question 31

Methylparaben

Answer 31

Preservative/additive Displaces bilirubin from albumin Impossible to avoid

Question 32

Aluminum

Answer 32

Contaminant May leach out of glass containers, tubing sets, needles, syringes Cause osteomalacia, anemia, encephalopathy

Question 33

How do you limit contamination of aluminum?

Answer 33

Rotate stock Limit exposure Select plastic containers

Question 34

DEHP

Answer 34

Additive | Used to make PVC plastic bags and tubing soft/flexible and can leach out of these products

Question 35

Premature infants + DEHP

Answer 35

Toxic to reproductive system, lungs, kidney and liver

Question 36

Known meds commonly associated with errors:

Answer 36

``` IV meds Analgesics (narcotics) Abx Fluids/electrolytes Digoxin Heparin ```

Question 37

What can you do as a pharmacists?

Answer 37

Require weights on peds orders Require orders in mg/kg/dose and calculated doses Add check system for IV solution for peds Final concentration verification Use preservative free products