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Page 1: Pediatric Preparations
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Chapter 12Pediatric Preparations

2012 Paradigm Publishing

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Learning Objectives Recognize the origins of pediatric medicine and pharmacy. Identify the special situations and actions that must be

considered when preparing medicine for pediatric use. Identify the USP Chapter <797> procedures that must be

performed when compounding pediatric preparations. Demonstrate correct technique in preparing a pediatric special

dilution.

2012 Paradigm Publishing

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Topics Learning Objectives Introduction Pediatric CSPs Pediatric Dosing Pediatric Formulations Administration of Pediatric CSPs Potential Complications of Pediatric CSPs USP Chapter <797> Guidelines for Pediatric

CSPs Understand the Resources and Supplies Preview the Lab Procedure Chapter Summary

2012 Paradigm Publishing

In Slide Show view, click the desired topic to the left to link directly to the related slide. To return to this slide at any point in the presentation, click the Topics button below.

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Introduction

Pediatric medicine, as well as pediatric pharmacy, acknowledges the specific healthcare needs of children by providing specialized sterile preparations that are safe and effective for this patient population

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Pediatric CSPs

Pediatric CSPs are sterile solutions that typically have a volume of 500 mL or lessthe most commonly prepared pediatric CSPs include IV

push antibiotics, LVP solutions for hydration, and total parenteral nutrition solutions

the physical and chemical properties of parenteral pediatric medications vary somewhat, but most of these medications are generally isotonic, isoosmotic, and pH neutral

2012 Paradigm Publishing

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Pediatric Dosing

During child growth and development, the biochemical and physiological processes that control drug disposition undergo important changesthis is especially true for the first three years of a child’s

lifeat this young age, drugs may be absorbed or eliminated

more slowly or more rapidly than in adults

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Pediatric Dosing…/2

Many factors must be considered when determining pediatric dosing for a patient, including:pediatric anatomy and physiologybody weight or body surface area

(BSA)agediagnosisdrug dispositionorgan functioning

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Pediatric Formulations

Pediatric dosing has long been based on adult-strength formulations of medications

This method of dosing continues to be used today, with prescribers using body weight or BSA to help them determine appropriate dosages for parenteral medications

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Pediatric Formulations…/2

2012 Paradigm Publishing

The high concentrations of adult-strength medications make reduction to child-sized doses difficult

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Pediatric Formulations…/3

Many manufacturers have reformulated certain adult-strength medications into diluted concentrations, or pediatric-strength formulations, making pediatric dose preparation easier and more accurate

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Pediatric Formulations…/4

Regardless of whether the pediatric medication is based on an adult-strength formulation or a pediatric-strength formulation, all drugs for pediatric use are required to undergo studies prior to approval by the Food and Drug Administrationthis federal law—included in a 2007 amendment to the

Federal Food, Drug, and Cosmetic Act— was established to improve the safety and efficacy of pediatric medications

2012 Paradigm Publishing

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Administration of Pediatric CSPs

Pediatric CSPs are primarily given as continuous IV infusions or as intermittent doses using the IV push route of administration

Continuous IV Infusion Many pediatric patients receive a continuous IV

infusion during their hospitalizationare generally comprised of an IV base solution to which an

additive, such as potassium chloride, is injected during sterile compounding procedures

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Administration of Pediatric CSPs…/2

Continuous IV Infusion…continued Administration of a Continuous IV Infusion

a peripheral access point is establishedfor some pediatric patients, it may be more practical for

the nursing staff to establish a central line or gain IV access through a femoral line or umbilical line

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Administration of Pediatric CSPs…/3

Continuous IV Infusion…continued Administration of a Continuous

IV Infusion…continuedonce an access point has been

established, nursing personnel use an IV pump programmed to deliver the medication at a flow rate designated by the prescriber

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Administration of Pediatric CSPs…/4

Intermittent CSP Administration Parenteral medications

requiring intermittent dosing are commonly administered by the IV push route

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Administration of Pediatric CSPs…/5

Intermittent CSP Administration…continued Compounded Syringes

compounded syringes are syringes of medication that are compounded in the pharmacy and then sent to a nursing unit for patient administration

are typically sent without an attached needleusing a syringe cap rather than a capped needle is a

precautionary measure taken to avoid a needle stick from the accidental dislodgment of the needle cap during transport

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Administration of Pediatric CSPs…/6

Intermittent CSP Administration…continued Compounded Syringes…

continuedonce the syringe cap is

attached, an IVA syringe seal is then placed over the cap to ensure that the contents of the syringe remain sterile

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Administration of Pediatric CSPs…/7

Intermittent CSP Administration…continued Empty Evacuated Containers

often, a pediatric IV push medication is compounded into patient-specific vials or empty plastic bags known as empty evacuated containers (EECs)

useful for neonatal patients whose size dictates further dilution of a pediatric-strength drug with preservative-free (PF) sterile water or NS

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Administration of Pediatric CSPs…/8

Intermittent CSP Administration…continued Empty Evacuated Containers…continued

EECs have several advantages for nursing and pharmacy personnel:• EECs can still be used if the patient dosage changes• EECs are transported as vials, not as syringes• preparing batches of EECs is easier and more

convenient one disadvantage of EECs is that they are more costly than

the syringe dosage form

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Administration of Pediatric CSPs…/9

Intermittent CSP Administration…continued Administration of Pediatric

Push Medicationsshould be administered

either by a syringe pump or by the use of a buretrol

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Administration of Pediatric CSPs…/10

Intermittent CSP Administration…continued Administration of Pediatric Push Medications…

continueda buretrol is a special type of tubing that contains a large,

tube-shaped cylinderthe IV push medication is injected into the cylinder, where

it mixes with a specific volume of fluid from the patient’s primary IV solution

the diluted medication is then administered through the tubing via a pump programmed to slowly inject the medication over a preset period

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Your Turn

2012 Paradigm Publishing

1) Often, a pediatric IV push medication is compounded into patient-specific vials or empty plastic bags known as this.a. CCEsb. CEEsc. ECCsd. EECs

2) This is a special type of tubing that contains a large, tube-shaped cylinder.a. buretrolb. special dilutionc. nasogastricd. secondary

In Slide Show view, click here to see the answer to Question 1. Then click again to advance to Question 2.

In Slide Show view, click here to see the answer to Question 2.

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Potential Complications of Pediatric CSPs

All patients receiving parenteral therapy should be monitored for the following complications:nosocomial infectionallergic reaction (including anaphylaxis)phlebitistissuingembolismextravasationcellulitisStevens-Johnson syndromenephrotoxicity

2012 Paradigm Publishing

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Potential Complications of Pediatric CSPs…/2

Preparation Risks During the compounding of pediatric preparations,

pediatric CSP ingredients must be consideredbenzyl alcohol may cause damage to multiple organ

systems, potentially triggering a life-threatening condition called benzyl alcohol gasping syndrome

for this reason, only preservative- free (PF) ingredients should be used in pediatric CSPs

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Potential Complications of Pediatric CSPs…/3

Preparation Risks…continued The compounding of pediatric CSPs requires

additional oversight to ensure the accuracy of pharmacy calculationsbecause of the small size and delicate nature of pediatric

patients, even minor errors in dosage calculation of a pediatric CSP could be fatal

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Potential Complications of Pediatric CSPs…/4

Administration Risks Because children, especially

neonates, are so small, the total volume of parenteral fluid being administered to this patient population must be significantly smaller than the fluid volumes given to adult patients

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Potential Complications of Pediatric CSPs…/5

Administration Risks…continued If too much fluid were to be administered to a

neonate too quickly (generally referred to as accidental rapid administration), hypervolemia, cardiac arrest, or death may resultthe cause of such an error is most commonly a nursing or

IV pump error

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Potential Complications of Pediatric CSPs…/6

Administration Risks…continued Many hospitals avoid

accidental fluid overload by enacting policies that prohibit the use of 1000-mL IV bags with pediatric patientsin addition, facilities limit the

size of an IV bag to 250 or 500 mL for neonates

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USP Chapter <797> Guidelinesfor Pediatric CSPs

IV technicians must adhere to strict dosage verification and aseptic protocols when preparing pediatric CSPsany breach in these protocols may result in medication

errors, sepsis, or, possibly, death for patient recipientsas an IV technician, you bear primary responsibility for the

preparation and integrity of the CSPs

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Understand the Resources and Supplies

Essential Supplies Most sterile compounding procedures require the

same essential supply items to be available for use in both the anteroom and the clean room

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Understand the Resources and Supplies…/2

Procedure-Specific Supplies The type, number, and

amount of procedure-specific supply items are determined by the IV technician prior to performing the procedure, based on information provided on the CSP label and the medication additive label

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Understand the Resources and Supplies…/3

Procedure-Specific Supplies…continued Pediatric Special Dilution Supplies

the process of compounding certain pediatric CSPs involves the manipulation of regular needles and, in particular, medication, diluent, and EEC vials

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Understand the Resources and Supplies…/4

Procedure-Specific Supplies…continued Pediatric Special Dilution Supplies…continued

PF Gentamicin Vial - check the vial’s medication label for the word Pediatric (or Pedi) and for the words preservative-free or the abbreviation PF

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Understand the Resources and Supplies…/5

Procedure-Specific Supplies…continued Pediatric Special Dilution Supplies…continued

PF Diluent Vial—the type of diluent most often used when preparing pediatric CSPs is normal saline (NS)

EECs—are used to prepare custom-made CSPs• pediatric special dilutions provide accurate parenteral

medication dosing

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Understand the Resources and Supplies…/6

Critical Sites of Essential Supplies and Pediatric CSP Supplies Before beginning preparatory procedures in the

anteroom or clean room, the IV technician must recall the critical sites of the suppliesidentifying the critical site of each supply item helps you

determine the proper procedure for handling the supply item once you have entered the clean room and begin working in the hood

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Preview the Lab Procedure

Anteroom Preparatory Proceduresverifying the CSP label against the medication orderperforming correct pharmacy calculations to determine

type, size, and number of supply items neededgathering and cleaning of suppliesperforming aseptic garbing and hand washingdonning a sterile gown

Clean Room Preparatory Procedurescleansing hands with sterile, foamed 70% IPAdonning sterile glovescleaning the hood

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Preview the Lab Procedure…/2

Pediatric Special Dilution Compounding Procedurebring the PF gentamicin vial into the direct compounding

area (DCA)you are now ready to begin the compounding procedurein preparation for the verification check, position the filled

and capped diluent syringe next to the diluent vial on the hood’s work surface

after the verification check, reposition the EEC vial upon completion of the pediatric special dilution

compounding procedure, dispose of used vials and supply items in the appropriate waste container

2012 Paradigm Publishing

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Your Turn

2012 Paradigm Publishing

3) Many hospitals avoid accidental fluid overload by prohibiting the use of these IV bags with pediatric patients.a. 50-mLb. 500-mLc. 1000-mLd. 100-mL

4) This is the type of diluent most often used when preparing pediatric CSPs. a. sterile waterb. dextrosec. lactated Ringer’sd. normal saline

In Slide Show view, click here to see the answer to Question 3. Then click again to advance to Question 4.

In Slide Show view, click here to see the answer to Question 4.