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Peds and Geriatrics > Week 1 > Flashcards

Week 1 Flashcards

1
Q

Pediatric vital signs in comparison to adults

A

Newborn:
HR: ~120-160
RR: 30-50
BP: ~60/37

Infant (1-12 months)
HR: ~100-140
RR: 20-40
BP:~70-100/ 50-70
Temp:

Toddlers (1-3 years)
HR: 100-130
RR:20-30
BP: 80-110/50-70
Temp:

Preschooler (3-5 years)
HR: 80-120
RR:20-30
BP: ~95/70
Temp:

School Age (6-12)
HR: 70-110
RR: 20-25
BP:100-120/75
Temp:

Adolescent
HR: 60-100
RR: 12-20
BP:110-120/80
Temp:

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2
Q

Vital sign differences in peds vs adults

A

HR and RR are higher in peds than adults, lower and normalize when they become adult ages

BP is lower in peds than adults, increase as they get older

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3
Q

How to Assess pain in Peds patients

A

physiologic markers
*RR, HR, O2 sat, behvior (grimacing, highi pitched crying)

Standardized scales
children </4:
*neonate pain scale (NIPS)
*Face, Legs, Activity, Cry , Consolability (FLACC)

Children>4 y.o :
*wong baker FACES

Children >10 y.o:
*visual analog scale
*numeric pain scale

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4
Q

common caculations for peds

A

BSA:
BMI: (weight/height^2)x10000
IBW: (height^2)x1.65)/1000
***eGFR:
use bedside Schwartz equation in <18 y.o
[0.413xheight]/SCr

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5
Q

challenges in ped pharmacotherapy

A

PKPD differences
*drug sleection
*dosage

psychosocial influences on drug therapy
*child vs adolescent

caregiver mediation administraion hesitance
*cultural beliefs
*socioeconomic status

dosage formulation selections

off label medicaion use

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6
Q

what is off-label medication use

A

use of a medicationoutside of FDA approved labeled indication

only 1/4 fda approved drugs indicated for ped patients

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7
Q

limitations to off label drug usage

A

potential for denied insurance proider coverage

liability for adverse effects

limited experience in specific conditions or age gorups

limited available dosage formulations

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8
Q

evidence Considerations for off label med use

A

use guidelines (NAEPP and NHlbi when available

use of primary literatureis critical in providing evidence based care to infants, children and adolescents (most data fro retrospecive cohort studies

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9
Q

medication adherance reasons

A

apprehension regarding med AE

caregiver inability or unavailability to adminster drugs

caregivers may be overwhelmed confused

inappropriate measurements of medication dose

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10
Q

straegies to improve adherance in peds

A

educatin of caregiver at several points

ease of amdinistration (palatable dosage forms, less frequent dosing)

decreased child resistance (reward systems, positive reinforcement

empowering older children adolescents

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11
Q

Dosage form considerations

Parenteral

A

volume of iv fluids
(infants and newborns susceptible to volume overload) pick concentrated versions of doses

vehicle safety (ex: propylene glycol can ccumulate in newborns and infnts causing AE)

iv acces ( difficult to obtain and maintain in newborns and infants)

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12
Q

dosage form considerations

oral

A

manufactured liquid preparations

extemporaneously compounded liquid preparations

volume of po fluids

chewable tablets

tablets

capsules

granules
*make sure these solid dosage forms can be manipulated

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13
Q

dosage form considerations

palatbility

A

children have different preferences

mixing with food
*peanut butter
*crystal lite

flavoring
*flavor rx

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14
Q

Considerations for extemporaneous preparations

A

USP:water containing formulations prepared from solid ingredients should have a bud no later than 14 days when stored at cold temps

*ISMP: List of oral dosage forms that should not be crushed)

injectable solutions administered orally
*ok if both formulations (IV and PO) contain same salt form w. similar bioavailability
*ex: glycopyrrolate broide injection (adminstered PO)

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15
Q

determining pediatric dosages

A

ALWAYS ASK FOR WEIGHT

*max pediatric dose=adult dose

doses may be also based on gestational age, actual age, patient weight ranges

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16
Q

Assessment of kidney function in peds

A

calculate eGFR: bedside schwartz equation

Uurine output: reported ml/kg/day for intake
ml/kg/hr: for output

anuria: zero output
oligouria: <0.5-1mL/kg/hr
normal urine output: 1mL/kg/hr
polyuria= 4mL/kg/hr

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17
Q

Peds PK

Absorption-Oral

A

*most common route for drug delivery
*children will reject meds based on color, taste, texture, and temperature

taste:
birth: ability to detect sweet
by 2y.o: can detect bitter/salty/sour
by1-2 y.o: can detect texture and temp

smell: by 5-7 y.o: affective response to colors

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18
Q

Effects of gastric pH on oral absorption in peds

A

varies with growth.
after birth, ph in stomach is high (basic)

can effect acid labile medications (ex acid labile med such as PCN can have higher concentrations in newborns)

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19
Q

effects of gastric emptying on oral absorption in peds

A

increased gastric emptyingduring first week of life . increased drug delivery to site of absoprtion

frequency and amplitue of intstinal contractions reduced in newborns and young infant
*adult motility occurs by 6-8 mo.)

reduced gastirc eptying and poorly coordinated intestinal contractility = decreased rate of drug absoprtion

20
Q

extra-oral routes of adminisration considerations

A

rectal: higher amplituse contractions in infants which expells drug. maydecrease drug absoprtion time. decreases bioavaiabilty

percutaneous: ;arger surface area per unit mass, greater degree of hydratation of skin, higher perfusion rates, enhanced drug permeability

IM: greater capillary densiy in young children compared to older childrn: greater iM bioavailability.

21
Q

refresher on pka and ph

A

if drug is basic in a basic environment, the drug will notionize

if drug is basic in an acid environment, the drug will ionize

if drug is acid in an acidic environment, will not ionize

if drug is acid in a basic environment, drug will ionize

22
Q

ped consdierationds for distribution

A

increased tbw in neonates (75-85% vs adults (55-60%)

extracellul;ar fluid is greater in neonates (35-45% vs adults (20%)

new borns have much less muscle fat.
overall, increase of vs for hydrophyllic drugs and decrease of vd for lipophyllic drugs

examples: AG’s are hydrophyllic drugs… so will need more drug to achieve same conc as adult.

neonates: 4-5 mg/kg/dose
infants: 2.5 mg/kg/dose
adults: 1-2.5 mg/kg/dose

23
Q

protein binding and distribution

A

in new borns, decreased concentration of albumins and binding affinity of fetal albumin to substances…

increases the free fraction of drug, enhancing pharmacologic effects

also increases risk to adverse effects…

ex: ceftriaxone and sulfonamides in infants <2 months of age can displace bilirubin form fetal albumin,,, puts baby at risk for kernicterus (albumin deposits in the brain) can cause cell atrophy and neurologic damage.

drugs that may be affected: phenytoin which is 90-95% bound to albumin and tp range of 10-20

24
Q

metabolism considerations in peds

A

hanges in phase 1 and phase 2 preesent in new borns in conmparison to adults

CYP3A4: doesnt reach adult acitivty levels until 1 year of age. causes decreased metabolism

CYP2C19: activity increased during first 6 months of life( ex PPIs may need to be given more frequently

CYP2E1: approx 80% of adult levels by year 1 of age

CYP1A2: absent in neonates, 25% pf adult levels by year 1, 55% of adult levels by year 9

UGT: in children <12 years of age, less susceptable to APAP toxicity due to use of sulfation pathway for metabolism into nontoxic metabolite instead of just saturating regular glucuronic pathway

25
Q

elimination considerations in peds

A

nephrogenesis completes by 26 weeks

decreased renal blood flow, leads to decreased substrate delivery to kidneys

decreased gfr

decreased tubular secretions

overall causes lower clearance of drugs and longer half lives. drugs can be given at longer dosing intervals, or less frequently.

ex: fluconazole t1/2 in prematur infants: =88 hrs
t1/2 in full term is less

26
Q

challenges peds pts face for drug deliuvery and dosage forms

A

nay require manipulation form tailored to ability to swallow

may require dosage forms tailed to smaller dose

may require alteration sin stability

may not be palatable

27
Q

considerations for enteral formulation use

tablets

A

is manipulation feasble or alters med delivery

is it extended relewase? can it be split

28
Q

considerations forenteral formulations

capsules

A

must determine contents

ex: powder, beads, enteric coating, gel capsules

29
Q

considerations for eneteral formulations

liquid dosage forms: pros and cons

A

most used dosage form in children
pros: dose flexibility
easy to swallow

cons: lack of controlled release mechanisms
volume required
accuracy of measuring devices

challenges: not all meds have commercially available suspensions, single concentrations vs extemporaneous compounds

30
Q

additional enteral formulation sthat are ideal but not perfect in peda

A

chewable tabs: pro minimizes need for additional liquids
con: relies on ability to chew

minitablets: eases swallowing tabs
con: limited dosage flexibility

ODT:L quick dissolve

orodispersible films (ODFs)

powder packets

sprinkle capsules/granules

31
Q

Special considerations for enteral formulations in peds

A

palability!!!

depends on preferences of the individual pt
manipulation can change taste
flavor rx: commercially available

  1. admin via tube
    *ex: gtube, jtube, ngtube, ndtube
    what is the site of absorption of the drug, can medication contact plastic?
    will med clog the tube (
32
Q

parenteral formulations used in peds

IV administration

A

allows for immediate entry into bloodstream

most common parenteral admin used

33
Q

parenteral formulations used in peds

IM or SQ

A

muscle and fat mass are factors affecting utility

can be used in ana emergency or for single med asmin such a svaccines

limitations exist related to volume allowed per injection based on age

34
Q

additonal considerations for parenteral formulations

A

volume is a common challenge: is dose measurable ?

IV access-central vs peripheral vs number of lines available

35
Q

other formulations that pose challenges in peds

A

inhalation: devices designed for adults
nebulizers preffered but cumbersome and require additonal education

nasal: devices designed for adults
difficult to admin based on age

rectal: lmited dosage forms, neonates/infants size restrictions, increased stool count

topical:
need to consider BSA ratio, potential for systemic absorption

transdermal:
lmited dosage forms
ability to cut/cover
age restrictions
behavior

36
Q

risiks associated w. excipiennts

benzoyl alcohol

role as excipient:
effects:
example:

A

risiks associated w. excipiennts

role as excipient: preservative, to protect microbial contamination
effects:neurotoxicity and metabolic acidosis, especially in concerning neonatal population
example: IV lorazepam (2% benzoyl alcohol)

37
Q

risiks associated w. excipiennts

ehtNOL
role as excipient:
effects:
example:

A

risiks associated w. excipiennts

role as excipient: solvent
effects: neurotoxicity
example: dexamethasone intensol solution (30%) alcohol

38
Q

risiks associated w. excipiennts

polysorbate

role as excipient:
effects:
example:

A

risiks associated w. excipiennts

role as excipient: surfactant, increases solubility of one agent w. another agent

effects: liver and kidney failure, thrombocytopenia, ascites, and pulmonary deterioration

example: IV amiodarone (PS80 300mg and PS20 20mg)

39
Q

BUD Dating of extemporaneous compounding in peds

A

USP 795

non preserved aqueous dosage forms: 14 days in fridge

preserved acquous dosage forms: 35

39
Q

risiks associated w. excipiennts

propylene glycol

role as excipient:
effects:
example:

A

risiks associated w. excipiennts

role as excipient: solvent
effects:seizures, hyperosmorality, metabolic acidosis, and neurotoxicity

example:IV phenobarbitol (67.8% propylene glycol)

39
Q

other ocmpounded preparations benficial for peds pts

A

powder papers (used crushed tablets, may or may not need filter

injectable meds used as oral solution (ph dependent)

oral suspensio: when not commercially available. can use crushed tablets, bulk powders, or filled capsules. need to avoid using extended release products, hard geletin capsules, or capsules w. time released beads

39
Q

risiks associated w. excipiennts

Sorbitol

role as excipient:
effects:
example:

A

risiks associated w. excipiennts

role as excipient: sweetner, to mask taste and palatability

effects:seizures, hyperosmorality, metabolic can lead to osmotic diarrhea

example:loperamide

40
Q

age ranges

A

neonate: birth -30 days old

infant: 1mo-1yr

child: 1-12 y.o

adolescent: 12-18 years old

41
Q

neonatal dosing

A

gestational age: “how for along in pregnancy

post -natal age: chronilogical age, time in days, weeks, months from birth

post menstrual age: combo of GA and PNA

42
Q

important eq for peds

A

weight ocnversion: 1kg=2.205 lbs
1 inch=2.54 cm

bsa
m^2=(weightxheight/3600)^1/2

43
Q

commonly used components of a drug monograph

A

dosing section: recommendations

preparation for administration
*info on concentrations and appropriate diluents for reconstitution/dilution of parenteral meds

administration:
*instructions for mixing w. food, missed doses, parenteral info

adverse reactions

extemporaneous compiunding: if applicable, provided published reference for compounding recommendations into oral solution/suspension from tabs or capsules

PK/moa

dosage forms, US and canada : shows available products on market, brand name and generic strengths availability

Peds and Geriatrics (5 decks)

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