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6Practical Problems in Pediatric Parenteral Drug Administration Pediatric needs vary from adults due to:smaller dose volumes (smaller doses based on body wt. or body surface area)reduced fluid requirements (as per organ function + excretion rates)
7Subcutaneous Injections Use intermittent: insulin, heparin,MMR vac.continuous: morphine, deferoxamine5\8 inch, < 25 gauge needle1.5 mL max volumeinto the thigh of infants or deltoid area of older children beneath skin and fat but above muscle
8Intramuscular Injections Use:medications that are irritating if given scfaster absorption and larger volume than scif IV route not available for some medscompliance if patient not taking oral medsadministration of vaccines (i.e..DPT polio)
9Intramuscular Injections 23 gauge, 1 inch needle3 mL maximum volume (5mL in adults)0.5 mL max. volume for deltoid areainfants - anterolateral thigh provides largest muscle mass or the rectus femoris (more painful) - avoid medial thigh due to major blood vessels and nerves
10Intramuscular Injections 2-3yr - the ventrogluteal area (not into buttock due to sciatic nerve) or deltoid areaolder children - the deltoid muscle or the posterolateral aspect of the gluteal area(not into buttock)
11Injecting Subcutaneous Medication Via An Insuflon Use:Many sc medications: i.e. heparin, low molecular weight heparin, DDAVP, filgrastim (G-CSF), and interferonUsed in adults for insulin administrationNot appropriate for all drugs: i.e. growth hormone as induration around insuflon will occur
13Advantages of SC Administration via an Insuflon Catheter dead space is very small mLFlush medication into patient with small amount of compatible solution if necessary7 days max. indwelling time(3 days for insulin in adults)rotate insertion sites to avoid tissue damageallows daily sc administration into canula without daily needle poke
14Advantages of Intravenous Injections Complete and rapid drug absorption with rapid onset of actionImmediate access to cardiovascular systemUseful in neonates with little muscle massLess painful route for frequent injectionsAdminister drugs which cannot be given by another route
15Disadvantages of IV Route Rapid drug/fluid delivery means immediate onset of adverse reactions and inability to withdraw infused solutionsRisk infusion of air, microorganisms, pyrogens and particulate matterRisk sepsis (infection), phlebitis (venous irritation), extravasation/infiltration (leaking outside of the vein)
16IV Access Sites Peripheral Sites: -vein in hand or forearm -scalp vein or foot vein in infant (possible but central IV site preferred in neonates)Central IV Sites: subclavian vein into superior vena cava-central line inserted peripherally-umbilical vein in neonates
17Central Venous IV Linewww_geocities_com-lambda_med-medical_art_previews-4_gif.htmCentral Venous IV Line
18Factors Influencing IV Drug Delivery small dose volumeslow infusion ratedead space volumedrug specific gravityinfusion device used
19Small Dose Volumesmany pharmaceutical manufacturers do not provide suitable concentrations of meds for pediatric administrationrequire prior dilution in order for dose to be measurable (ie. Dose volume < 0.5 mL)potential for dosing errors secondary to unsuitable drug formulations and dilution procedures
21Small Dose Volumesaccurate dose measurement (i.e. with appropriate syringe)small syringe with integral hubless needle for volumes < 0.5mLprovide 0.05 mL drug overfill in syringe to fill needle hub if needle must be attached(include overfill information on label)
25When Dose Volume is Less Than Fluid Volume in IV Tubing Provide medication device with 24hr drug volume + extra volume equal to tubing losschange tubing and prime with fresh supply of drug Q24hafter 24h - tubing is discarded for infection control and because the drug in the tubing has reached it’s expiry timedrug must be stable in selected diluent for 24h at room temperature
26Slow IV Infusion Ratescause an increase in the time required to deliver the doseSlow/low flow rates (1-10ml\hr) commonly used with neonates and fluid restricted patientspotential for drug to disperse or layer out within macrobore IV tubing when IV flow rate is slow (use microbore tubing instead)use of microbore (low volume) tubing (diameter cm) will minimize this effect
27Residual Volume (Dead Space) > 0.05 mL of volume found in hub of needle, stopcocks, Y-type or T-type injection ports or in-line filtersoverdosing by 0.05 mL may occur if syringe is milkedunder dosing by 0.05 mL may occur if needle is changed after the exact dose is measured (dosing error =5% for a 1 mL dose volume)
29Drug Specific Gravityin slow moving fluid, the specific gravity can cause the drug to settle, float or pool in a bend of IV tubing and not be administered on schedule
30IV Infusion Deviceslarge volume (e.g. Gemini) or small volume (e.g. CADD) infusion pumpssyringe pumps are accurate for small volume deliveryvolumetric infusion devices (Buretrol) used for small total fluid requirements and slow rates of administrationchoice of device also depends on frequency of dose (ie.intermittent vs continuous infusion), whether the drug or its vehicle requires special containers and administration sets,and the latex allergy status of the patient.
31Health Risks Caused By DEHP Affects developing reproductive tract (testes) of male fetus, male infants and potentially of pre-pubertal malesinfants especially premature infants more susceptible to toxic effectscardiac toxicity - may affect cardiac transplant patients of all agespatients receiving multiple transfusions for trauma, hemodialysis patients also at risk
32LEACHING OF PLASTICIZER (DEHP) Medications which are lipophilic or are in vehicles containing lipophilic surfactants (e.g. soy oil emulsion, polysorbate 80) leach significant amounts of DEHP from PVC containers & administration setsUse glass bottles, polyolefin IV bags (P.A.B. IV bags-B Braun Mc Gaw), ethyl vinyl acetate (EVA) IV bags, polyethylene lined PVC administration sets, or polypropylene syringes.
33Drug Incompatibility with Infusion Device adsorption of drug onto plastic or glass infusion devicea significant portion of the dose may be lost to adsorption if very dilute solutions of the drug are infusedflush device and tubing first with drug infusion solution to saturate binding sites prior to starting infusionchoose low sorbing administration set & tubing , titrate the dose to clinical response
35Volume Control Set (Buretrol) Disadvantages:dose may have to flow through up to 20 mL of tubingsmall volume doses given at slow infusion rates will have delayed deliveryAdvantages:dilute drug to specific volume appropriate for the dose (maximum volume 150mL in the mixing chamber)Y-in the dose close to patient and/or use microbore tubing
36Minibags or Bottles Advantages: convenient to dilute the dose in a prefilled IV bagavailable in standard sizes 25 mL, 50 mL, 100 mL of D5W or Normal saline
39Disadvantages of Minibags or Bottles may contain more fluid than pt. can toleratefixed dilution may provide inappropriate final drug concentrationinaccurate dose delivery due to manufacturer’s overfill unless entire bag is given (25mL bag contains 27-33mL or a 24% volume difference)
40Disadvantages of Minibags or Bottles IV set used to administer the dose may retain up to 7mL of fluid (23% of dose in 25mL bag). This could be flushed into the patient using additional fluid or discarded with a set change or given at the start of the next dose after possible drug degradation.if attached to primary infusion line, the extra fluid volume causes additional delay in drug reaching the patient
41Syringes for Manual IV Injection Advantage:can inject very small volumes into tubing at injection site near pt.administration rate controlled by primary IV solution flow rate.
42Syringes Manual IV Injection Disadvantages time for drug delivery depends on drug volume and flow rate of primary IV solutionamount of drug delivered depends on amount lost to dead space at the injection siterequires microbore tubing to decrease delays in deliverymore labour intensive – requires flush
44Syringe Pumps Advantages prepare drug in syringe at required dilution and give via microbore tubing at connection close to patient (reduced fluid volume)dose given accurately at a rate independent of primary IV solutionused for both intermittent and continuous therapy
45Syringe Pumps Disadvantages only for small volumes < 50mLtubing will retain part of the doseinitial capital investment required
46TDM Implications of Factors Influencing IV Drug Delivery Actual time for dose delivery may be longer than the predicted time due to increases in the distance between the drug injection site and the patient, the total volume to be infused, the specific gravity of the drug, or a slow IV flow rate.Dose and dose timing errors may occur due to dead space volume errors.
47Total Volume Infused and Injection Site Volume = Dose + Fluid in tubing + Flush (Y-site closest to patient = smallest volume, Y-site above Buretrol = largest volume)Injection site: to ensure 30 minute drug delivery in pediatric patients, inject IV manually or infuse IV using a syringe pump with microbore tubing at Y-site of IV set closest to patient
48Time for Delivery of Chloramphenicol Using Buretrol IV Set with TubingVolume 18 mL .
49Predicted time of chloramphenicol delivery with a Buretrol set Predicted time to delivery of drug dose (minutes)= Med. volume + volume of set x 60minIV Rate (mL\hour)i.e mL + 18 mL x 60min = 336 minutes5 mL/hr
50Time for Drug Delivery Via Buretrol IV Set Delivery of a drug added to a Buretrol is affected by slow IV flow rates and too small IV flush volumes.Medication does not flow toward the patient like a plug, pushing the maintenance IV fluid into the patient without mixing.Viscosity and specific gravity of medications and maintenance IV fluids vary so mixing will occur within the IV tubing
51The amount of mixing depends on the diameter of the IV tubing and IV flow rate When using a Buretrol set, increase IV flow rate and flush volume to compensate for the mixing occurring within the IV tubingUse a flush volume equal to approximately 1.5 to 2 times the volume of the IV set from the bottom of the Buretrol to the patientAdminister dose plus flushes over required dose administration time
52QUESTION: A 2 kg, 1 month old, neonate is receiving Digoxin 1 QUESTION: A 2 kg, 1 month old, neonate is receiving Digoxin 1.5mcg/kg/dose IV q12h. The physician wishes to increase the dose by 10%.Is the commercial preparation available in a suitable concentration to allow accurate measurement of a 10% change in the dose?Which drug delivery devices may be used?What are sources of error in dose delivery & what effect may this have on the reported Digoxin level?
53Solution Digoxin dose and proposed dose change are appropriate Digoxin is available as 50mcg/mL InjCannot measure a 10% dose change with the commercially available productDilute Digoxin with NS to 10mcg/mL so 10% dose change is measurableDevice - 1cc syringe, manual IV injection into Y-site nearest to patient
54Sources of error: syringe dead space volume (0 Sources of error: syringe dead space volume (0.05mL) and low IV flow rate (1-10ml\hr in neonate)3.3mcg dose = 0.33 mL of 10 mcg/mL0.05mL x 10 mcg/mL= 0.5mcg (dead space volume is 15% of dose )Digoxin level either 15% higher or lower than predicted if measuring inaccurate. Inappropriate timing of Digoxin levels and uninterpretable results if drug delivery delayed.
55References1. Comprehensive Pediatric Nursing. New York: McGraw-Hill; 1986: Appendix 1.2. Leff RD, Roberts RJ.Principles and techniques of IV administration. In Practical aspects of intravenous drug administration.ASHP 1992(2):4-41.3. Nahata M. Methods of intravenous drug infusion in pediatric patients. The Am J Intravenous Therapy & Clin N 1984: May: 6-7.
564. Hunt, Max L. Training Manual for Intravenous Admixture Personnel Fifth Edition.Baxter Healthcare Corporation & Precept Press, USA, 1995.5. Roberts RJ. Intravenous administration of medication in pediatric patients: problems and solutions. Ped Clin N Amer 1981; 28:23-34.6. The Hospital for Sick Children. Policies and Drug Information for Nurses Manual. Parenteral therapy - not intravenous. Toronto; 2000:
577. Rice, Stephen P., A Review of Parenteral Admixtures Requiring Select Containers and Administration Sets, International Journal of Pharmaceutical Compounding, Vol 6, No 2, March\April 2002.8. Turco, Salvatore J. , Editor. The Sourcebook for IV Therapy IVAC Corporation, San Diego, Ca, 1985.
589. Health Canada Expert Advisory Panel On DEHP In Medical Devices, Final Report 220 January 11, Health Canada, 2002.Safety Assessment of Di(2-ethylhexyl)phthalate (DEHP) Released from PVC Medical Devices Centre for Devices and Radiological Health, U.S. Food and Drug Administration, Rockville, MD, 2001.