Practical Problems in Pediatric Parenteral Drug Administration

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Practical 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)

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Subcutaneous Injections

• Use intermittent insulin, heparin,MMR vac.
• continuous morphine, deferoxamine
• 5\8 inch, lt 25 gauge needle
• 1.5 mL max volume
• into the thigh of infants or deltoid area of
  older children beneath skin and fat but above
  muscle

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Intramuscular Injections

• Use
• medications that are irritating if given sc
• faster absorption and larger volume than sc
• if IV route not available for some meds
• compliance if patient not taking oral meds
• administration of vaccines (i.e..DPT polio)

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Intramuscular Injections

• 23 gauge, 1 inch needle
• 3 mL maximum volume (5mL in adults)
• 0.5 mL max. volume for deltoid area
• infants - anterolateral thigh provides largest
  muscle mass or the rectus femoris (more painful)
  - avoid medial thigh due to major blood vessels
  and nerves

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Intramuscular Injections

• 2-3yr - the ventrogluteal area (not into buttock
  due to sciatic nerve) or deltoid area
• older children - the deltoid muscle or the
  posterolateral aspect of the gluteal area
• (not into buttock)

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Injecting Subcutaneous Medication Via An Insuflon

• Use
• Many sc medications i.e. heparin, low molecular
  weight heparin, DDAVP, filgrastim (G-CSF), and
  interferon
• Used in adults for insulin administration
• Not appropriate for all drugs i.e. growth
  hormone as induration around insuflon will occur

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Advantages of SC Administration via an Insuflon

• Catheter dead space is very small 0.0075mL
• Flush medication into patient with small amount
  of compatible solution if necessary
• 7 days max. indwelling time(3 days for insulin in
  adults)
• rotate insertion sites to avoid tissue damage
• allows daily sc administration into canula
  without daily needle poke

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Advantages of Intravenous Injections

• Complete and rapid drug absorption with rapid
  onset of action
• Immediate access to cardiovascular system
• Useful in neonates with little muscle mass
• Less painful route for frequent injections
• Administer drugs which cannot be given by another
  route

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Disadvantages of IV Route

• Rapid drug/fluid delivery means immediate onset
  of adverse reactions and inability to withdraw
  infused solutions
• Risk infusion of air, microorganisms, pyrogens
  and particulate matter
• Risk sepsis (infection), phlebitis (venous
  irritation), extravasation/infiltration (leaking
  outside of the vein)

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IV 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

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www_geocities_com-lambda_med-medical_art_previews-
4_gif.htmCentral Venous IV Line
Central Venous IV Line

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Factors Influencing IV Drug Delivery

• small dose volume
• slow infusion rate
• dead space volume
• drug specific gravity
• infusion device used

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Small Dose Volumes

• many pharmaceutical manufacturers do not provide
  suitable concentrations of meds for pediatric
  administration
• require prior dilution in order for dose to be
  measurable (ie. Dose volume lt 0.5 mL)
• potential for dosing errors secondary to
  unsuitable drug formulations and dilution
  procedures

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Drug Available Diluent
Final Conc. Conc.

• .

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Small Dose Volumes

• accurate dose measurement (i.e. with appropriate
  syringe)
• small syringe with integral hubless needle for
  volumes lt 0.5mL
• provide 0.05 mL drug overfill in syringe to fill
  needle hub if needle must be attached
• (include overfill information on label)

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When Dose Volume is Less Than Fluid Volume in IV
Tubing

• Provide medication device with 24hr drug volume
  extra volume equal to tubing loss
• change tubing and prime with fresh supply of drug
  Q24h
• after 24h - tubing is discarded for infection
  control and because the drug in the tubing has
  reached its expiry time
• drug must be stable in selected diluent for 24h
  at room temperature

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Slow IV Infusion Rates

• cause an increase in the time required to deliver
  the dose
• Slow/low flow rates (1-10ml\hr) commonly used
  with neonates and fluid restricted patients
• potential 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
  0.06 - 0.14 cm) will minimize this effect

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Residual Volume (Dead Space)

• gt 0.05 mL of volume found in hub of needle,
  stopcocks, Y-type or T-type injection ports or
  in-line filters
• overdosing by 0.05 mL may occur if syringe is
  milked
• under 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)

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Dead Space
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Drug Specific Gravity

• in 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

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IV Infusion Devices

• large volume (e.g. Gemini) or small volume
  (e.g. CADD) infusion pumps
• syringe pumps are accurate for small volume
  delivery
• volumetric infusion devices (Buretrol) used for
  small total fluid requirements and slow rates of
  administration
• choice 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.

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Health Risks Caused By DEHP

• Affects developing reproductive tract (testes) of
  male fetus, male infants and potentially of
  pre-pubertal males
• infants especially premature infants more
  susceptible to toxic effects
• cardiac toxicity - may affect cardiac transplant
  patients of all ages
• patients receiving multiple transfusions for
  trauma, hemodialysis patients also at risk

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LEACHING 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 sets
• Use 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.

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Drug Incompatibility with Infusion Device

• adsorption of drug onto plastic or glass infusion
  device
• a significant portion of the dose may be lost to
  adsorption if very dilute solutions of the drug
  are infused
• flush device and tubing first with drug infusion
  solution to saturate binding sites prior to
  starting infusion
• choose low sorbing administration set tubing ,
  titrate the dose to clinical response

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Volume Control Set (Buretrol)

• Disadvantages
• dose may have to flow through up to 20 mL of
  tubing
• small volume doses given at slow infusion rates
  will have delayed delivery

• Advantages
• 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

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Minibags or Bottles

• Advantages
• convenient to dilute the dose in a prefilled IV
  bag
• available in standard sizes 25 mL, 50 mL, 100 mL
  of D5W or Normal saline

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Disadvantages of Minibags or Bottles

• may contain more fluid than pt. can tolerate
• fixed dilution may provide inappropriate final
  drug concentration
• inaccurate dose delivery due to manufacturers
  overfill unless entire bag is given (25mL bag
  contains 27-33mL or a 24 volume difference)

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Disadvantages 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

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Syringes forManual IV Injection

• Advantage
• can inject very small volumes into tubing at
  injection site near pt.
• administration rate controlled by primary IV
  solution flow rate.

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Syringes Manual IV Injection Disadvantages

• time for drug delivery depends on drug volume and
  flow rate of primary IV solution
• amount of drug delivered depends on amount lost
  to dead space at the injection site
• requires microbore tubing to decrease delays in
  delivery
• more labour intensive requires flush

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Syringe PumpsAdvantages

• 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 solution
• used for both intermittent and continuous therapy

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Syringe PumpsDisadvantages

• only for small volumes lt 50mL
• tubing will retain part of the dose
• initial capital investment required

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TDM 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.

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Total 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

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Time for Delivery of Chloramphenicol Using
Buretrol IV Set with TubingVolume 18 mL

• .

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Predicted time of chloramphenicol delivery with a
Buretrol set

• Predicted time to delivery of drug dose
  (minutes)
• Med. volume volume of set x 60min
• IV Rate (mL\hour)
• i.e.. 10 mL 18 mL x 60min 336 minutes
• 5 mL/hr

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Time 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

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• The 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 tubing
• Use 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 patient
• Administer dose plus flushes over required dose
  administration time

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• 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?

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Solution

• Digoxin dose and proposed dose change are
  appropriate
• Digoxin is available as 50mcg/mL Inj
• Cannot measure a 10 dose change with the
  commercially available product
• Dilute Digoxin with NS to 10mcg/mL so 10 dose
  change is measurable
• Device - 1cc syringe, manual IV injection into
  Y-site nearest to patient

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• 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/mL
• 0.05mL 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.

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References

• 1. 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.

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• 4. 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 2823-34.
• 6. The Hospital for Sick Children. Policies and
  Drug Information for Nurses Manual. Parenteral
  therapy - not intravenous. Toronto
  20004.01-4.03.

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• 7. 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.

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• 9. http//www.hc-sc.gc.ca/hpb-dgps/therapeut/zfil
  es/english/advcomm/eap/dehp/eap-dehp-final-report-
  2002-jan-11_e.html Health Canada Expert
  Advisory Panel On DEHP In Medical Devices, Final
  Report 220 January 11, Health Canada, 2002.
• 10. http//www.fda.gov/cdrh/ost/dehp-pvc.pdf
  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.