Pediatric Preparations

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Chapter 12
Pediatric 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.

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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
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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 less
the 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

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Pediatric Dosing
 During child growth and development, the
biochemical and physiological processes that control
drug disposition undergo important changes
this is especially true for the first three years of a child’s life
at 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 physiology
body weight or body surface area
(BSA)
age
diagnosis
drug disposition
organ 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
 The high concentrations of adult-strength medications
make reduction to child-sized doses difficult

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 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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 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 Administration
this 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

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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 hospitalization
are 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 established
for 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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Continuous IV
Infusion…continued
 Administration of a Continuous
IV Infusion…continued
once 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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Intermittent CSP
Administration
 Parenteral medications
requiring intermittent
dosing are commonly
administered by the IV
push route

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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 needle
using 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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Intermittent CSP
Administration…continued
 Compounded
Syringes…continued
once 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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 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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 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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Intermittent CSP
Administration…continued
 Administration of Pediatric
Push Medications
should be administered
either by a syringe pump or
by the use of a buretrol

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 Administration of Pediatric Push
Medications…continued
a buretrol is a special type of tubing that contains a large,
tube-shaped cylinder
the 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
1) Often, a pediatric IV push medication is compounded into patient-
specific vials or empty plastic bags known as this.
a. CCEs
b. CEEs
c. ECCs
d. EECs
2) This is a special type of tubing that contains a large, tube-shaped
cylinder.
a. buretrol
b. special dilution
c. nasogastric
d. secondary
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Potential Complications of Pediatric
CSPs
 All patients receiving parenteral therapy should be
monitored for the following complications:
nosocomial infection
allergic reaction (including anaphylaxis)
phlebitis
tissuing
embolism
extravasation
cellulitis
Stevens-Johnson syndrome
nephrotoxicity

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CSPs…/2
Preparation Risks
 During the compounding of pediatric preparations,
pediatric CSP ingredients must be considered
benzyl 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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CSPs…/3
Preparation Risks…continued
 The compounding of pediatric CSPs requires
additional oversight to ensure the accuracy of
pharmacy calculations
because 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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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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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 result
the cause of such an error is most commonly a nursing or
IV pump error

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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 patients
in addition, facilities limit the
size of an IV bag to 250 or
500 mL for neonates

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USP Chapter <797> Guidelines
for Pediatric CSPs
 IV technicians must adhere to strict dosage
verification and aseptic protocols when preparing
pediatric CSPs
any breach in these protocols may result in medication
errors, sepsis, or, possibly, death for patient recipients
as 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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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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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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Supplies…/4
 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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Supplies…/5
 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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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 supplies
identifying 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 Procedures
verifying the CSP label against the medication order
performing correct pharmacy calculations to determine
type, size, and number of supply items needed
gathering and cleaning of supplies
performing aseptic garbing and hand washing
donning a sterile gown
 Clean Room Preparatory Procedures
cleansing hands with sterile, foamed 70% IPA
donning sterile gloves
cleaning the hood

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Preview the Lab Procedure…/2
 Pediatric Special Dilution Compounding Procedure
bring the PF gentamicin vial into the direct compounding
area (DCA)
you are now ready to begin the compounding procedure
in 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

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Your Turn
3) Many hospitals avoid accidental fluid overload by prohibiting the use of
these IV bags with pediatric patients.
a. 50-mL
b. 500-mL
c. 1000-mL
d. 100-mL
4) This is the type of diluent most often used when preparing pediatric
CSPs.
a. sterile water
b. dextrose
c. lactated Ringer’s
d. normal saline
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Pediatric Preparations

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