Pediatric IV Therapy Amy E Irwin DNP MS

Pediatric IV Therapy Amy E. Irwin, DNP, MS, RN Denver School of Nursing

Purpose of IV Therapy • • Correct fluid and electrolyte imbalances Administer medications Administer blood products Administer nutrients

Principles of IV Access • The largest visible vein is not necessarily the preferred one • Consider the comfort of the patient • Consider the position and extent restraint • Consider the vessel’s ability to maintain a needle • Consider the solution to be infused

Developmental Considerations • INFANT – Handle infant gently, speak softly – Avoid arm used for thumb sucking – Cuddle immediately after insertion – Don’t feed immediately prior to insertion – Avoid presence of extra personnel to minimize stranger anxiety

Developmental Considerations • TODDLER/PRESCHOOLER: – Prepare child immediately prior to procedure – Give simple explanations in concrete terms – Explain that you will help child hold still – Emphasize that the IV is not punishment

Developmental Considerations • SCHOOL-AGER – Prepare child ahead of time, but on the day of insertion only – Give the child choices as appropriate – Give positive reinforcement after completion

Developmental Considerations • ADOLESCENT – Prepare teenager several hours to a day before procedure – Approach discussions on a more adult level – Discuss fears related to procedure – Include teen in decisions

Pediatric Optimal Locations • • Hands Forearm Feet Scalp **Note if the child is a thumb sucker, etc

Pediatric Catheter Gauges • Use the largest catheter you can successfully insert • Catheter Sizes: Newborn: 24, 22 gauge Infant < 1 year: 24, 22 gauge 1 – 8 years: 22, 20, 18 gauge 8 years and older: 20, 18, 16 gauge

EMLA Cream • Minimizes or prevents pain from needle puncture for an IV, blood sample, or implanted port access. • Apply EMLA cream to the selected site 60 minutes before the procedure. • Cover at least two sites in case the first attempt is not successful.

Complications of PIVs • Mechanical factors predispose IV infusion to shorter dwelling time • Mechanical factors include: Insertion site Length of catheter Size of vessel Vessel fragility Activity level of the patient Forceful administration of boluses of fluid Infusion of vessicants or irritants through small vessels

Complications of IV Therapy • Infiltration (extravasation) – Fluid leaks into subcutaneous tissue

Complications of IV Therapy • Catheter Occlusion – Blockage usually by clotted blood or precipitate • Air Embolism – Air enters circulation & travels to right side of heart • Phlebitis – Injury to vein without clot – Inflammation of the blood vessel

Complications of IV Therapy • Thrombophlebits – Inflammation of a blood vessel with thrombus formation • Infection – Introduction of pathologic organisms locally or systemic • Metabolic derangement – Imbalance in electrolytes, minerals, glucose & proteins

Venous Access Devices

Intraosseous Infusion • Used in emergency situations when a peripheral vein cannot be accessed • Needle is inserted into the medullary cavity of a bone • Used to administer fluid and medications • Safe and reliable method for rapid administration

Intraosseous Infusion Site Tips • Using aseptic technique, prep site with povidone-iodine solution • Use 18 gauge in infants < 3 months of age • Use firm, gentle pressure in a twisting motion to insert needle • Insert perpendicular to site, or at a slight angle away from nearest joint • Stop when you feel a “pop” and attempt to aspirate and/or flush • Secure tubing to leg to prevent pulling on insertion site • Flush meds with 5 – 10 cc NS • Requires pressure for fluids to run

Characteristics of Pediatric Administration Sets • Calibrated volume & control chamber with a limited capacity & an automatic shutoff mechanism – Ie. Buretrol, Metriset • Standard of Practice – All IV meds should be placed on a syringe pump if child is < 6 months

Buretrol Administration Set

Characteristics of Pediatric Administration Sets • Drip chamber with microdropper delivering 60 gtts/min or 60 cc/hr • Tubing compatible with pump, catheter adapter for needleless systems • Standard of practice: All IV sites should be checked and reprogrammed every hour • Armboards are utilized to maintain integrity of IV site (may also require restraints)

Principles of IV Fluid Therapy • IV fluids are administered for the following reasons: – To provide water, electrolytes, nutrients – To replace water, correct electrolyte deficits (replacement)

Composition of Fluids • Isotonic: electrolyte content approximately 310 meq/L – Examples: D 5 W, D 10 W, NS, LR • Hypotonic: electrolyte content less than 250 meq/L (never used in children) – Examples: No examples in pediatrics • Hypertonic: electrolyte content exceeds 375 meq/L – Examples: 3% saline, D 5. 45 Na. Cl, D 5. 9 Na. Cl

Maintenance Fluid Requirements • Fluid calculations are based on weight in kilograms Maintenance Fluid Intake 0 – 10 kg weight needs 4 cc/kg/hr 11 – 20 kg weight needs 2 cc/kg/hr additional 21 kg plus weights needs 1 cc/kg/hr additional

Example 23 kg Child Calculate: • 10 x 4=40 • 10 x 2=20 • 3 x 1=3 Total maintenance fluid requirements=63 cc/hr

Example 22 kg Child who is “fluid-restricted” at 2/3 maintenance due to kidney failure Calculate: 10 x 4 = 40 10 x 2 = 20 1 x 2 = 22 Total maintenance fluid = 62 cc/hr At 2/3 maintenance = ?

Factors Influencing Pediatric Drug Administration • Children vs. Adults • Physiological differences • Immature kidney and liver function

Factors Influencing Pediatric Drug Administration • Slow gastric emptying time. • Decreased gastric acid secretion in children under 3 years of age • Lower concentration of plasma proteins

Additional Variations to consider with Pediatric IV medications • Patient weight in kilograms • Patient fluid status/maintenance rate • Patient diagnosis (fluid restriction? ) – Renal – Cardiac • Additional medications to administer • Volume of IV tubing – Need to flush med through after administration

IV Drug Administration • 1. Calculate Safe dose (mg/kg) • 2. Calculate amount to administer (cc) • 3. Calculate final concentration or dilution for IV medications • 4. Calculate rate of infusion • 5. Set pump accordingly • 6. Flush med! (same rate as administered)

Patient Example • 12 kg child – 825 mg Ancef q 8 h • Follow each step! – 1. Safe dose? – 2. Amount to administer? – 3. Final concentration? – 4. Rate of infusion? – 5. Does it make sense?

1. Calculate Safe Dosage • Mg/kg x patient weight • Example: 12 kg Child Ordered: Ancef 825 mg IV q 8 h Recommended 200 -400 mg/kg/Day Dose on hand: 200 mg/cc Pt wt. = 12 kg 200 x 12 = 2400 mg/Day 400 x 12 =4800 mg/Day

Calculate Safe Dosage • Divide by 3 (for Q 8 hours) for the safe dose: – 2400 divided by 3 = 800 mg/kg/dose – 4800 divided by 3 = 1600 mg/kg/dose – Therefore the DOSE IS SAFE because it falls within the range

2. Calculate the Amount to Administer • Dose on hand (concentration from pharmacy) = 200 mg/cc • 200 mg : 825 mg =4. 12 cc to administer 1 cc x 200 x = 825 x=4. 12 cc

3. Calculate Final Concentration (Dilution) Recommended: 125 mg / 5 cc infuse over 30” 125 mg : 825 mg = 33. 0 cc dilution required 5 cc x

4. Calculate Rate of Infusion • Volume – 4. 12 cc med + 33. 0 cc dilution = 37. 12 total – Desired minutes: 30 37. 12 x 60 = 74 cc/hr 30 Set pump at 74 cc/hr

5. Don’t Forget…… • After completing all of your calculations…. • DOES IT MAKE SENSE? ?

Blood Products • It is the RNs responsibility to know 1. Why a specific product is being given 2. A safe volume over a safe time has been ordered 3. The common side effects of giving the product • No solutions other than normal saline and 5% albumin should be in IV tubing used to administer blood products

Blood Products Continued • Once a blood product has been issued from the blood bank, the transfusion must be completed within 4 hours • Tubing is changed after blood products are given unless one unit is followed immediately by the next, in that case multiple units can be given with the same infusion set

Blood Products Continued • Most infusion sets are limited to 4 units, and all infusion sets are limited to 4 hours (whichever occurs first). • All blood components must be administered through an infusion set with an in-line filter designed to retain blood clots and particles potentially harmful to the recipient • Platelets, fresh frozen plasma, and cryoprecipitate do not need to be cross-matched; however, a blood type is necessary to pick the appropriate products. If the patient has a blood bank history, no specimen is required.

Assessment, Administration, and Tranfusion Reactions: • Complete assessment prior to starting the transfusion including: Vital Signs (Temp, HR, RR, BP), Skin (color, temp, and condition), Breath sounds, Description of the IV infusion site • Observe the patient during the first 5 -10 minutes of the transfusion to watch for immediate signs of acute reaction • Complete reassessment at 15 minutes into transfusion

Assessment, Administration and Transfusion Reactions (Cont. ) • Then hourly VS and IV site checks, as well as 1 hour after transfusion • Document: physical assessment and reason for transfusion, VS prior to and at 15 min/ and hourly • If a transfusion reaction is suspected immediately STOP the transfusion and notify a physician.

Blood Compatibilities Blood Group Compatible RBC’s Compatible Plasma/Platelets O O O, A, B, AB A A, O A, AB B B, O B, AB AB AB, A, B, O AB Rh Type RBC Rh Type Plasma Rh Type for Transfusion Positive or Negative Negative Positive or Negative