Pediatric Medication Administration

1. Pediatric Medication Administration UNRS 314 Jan Bazner-Chandler CPNP, CNS, MSN, RN

2. Review • 1 teaspoon = 5 mL / cc • 1 tablespoon = 15 mL / cc • 1 ounce = 30 mL /cc • Remember the clock! grains to grams to milligrams. • How to calculate medication dose using ration / proportion. • 16 oz = 1 pound (body weight)

3. IV Fluid Calculation Adult (Review) Step # 1 Total number of milliliters ordered = ml / hr number of hours to run Step # 2 Milliliters per hour x tubing drip factor = gtt/min Minutes

4. Pounds to Kilograms • Pounds to kilograms = pounds 2.2 In pediatrics you need to carry out to the hundredths (do not round especially in the infant or small child)

5. Kilogram Example • 20 pounds 5 ounces • First need to convert 5 ounces to a fraction of a pound 5 divided by 16 = 0.31 • 20.31 pounds divided by 2.2 = 9.23 kilograms • Notes medication would be calculated based on 9.23 kilograms. DO NOT ROUND to 9.2

6. New Calculations • Mg / kg dosing based on weight (kg) • Safe dosing ranges • IV pediatric infusion rates • IV administration of meds per volutrol or syringe pump. • 24 hour fluid calculation

7. Calculations of pounds to kilograms • If a child weighs 84 lbs, what is the weight in kg? • 84lb : x kg • 84 divided by 2.2 = 39.18 kg • If a child weights 6 lbs 6 ounces what is the weight in kg? • 6 ounces = 0.37 pounds 16 ounces • 6.37 pounds divided by 2.89 = kg

8. Medication dosage • For a dosage of medication to be safe, it must fall within the safe range as listed in a Drug Handbook, PDR or other reliable drug reference.

9. Dosage based on mg/kg and Body Surface Area • The dose of most pediatrics drugs is based on mg/kg body weight or Body Surface Area (BSA) in meters squared. • For testing purposed mg / kg will be used. • BSA method of calculations may be seen in NICU, ICU and high acuity areas.

10. Safe Medication Dose • Calculate daily dose ordered (Physician orders) • Calculate the low and high parameters of safe range (from drug book) • Compare the patient’s daily dose to the safe range to see if it falls within the safe zone.

11. Calculation • A child is 2 years and weighs 36 lbs is receiving Amoxicillin 215 mg po tid for a bilateral otitis media (ear infection). • Patient weight in kg = 16.36 kg • Davis drug guide: PO (children) < 40 kg: 6.7 to 13.3 mg / kg q 8 hours. • (low range)16.36 x 6.7 = 109.6 mg q 8hours • (high range)16.36 x 13.3 = 217.5 mg q 8 hours • Safe range: 109.6 to 217.5 mg of Amoxicillin Q 8 hours. • Is the dose safe? Yes, it falls within the safe range.

12. How much medication do you give? • Physician order Amoxicillin 215 mg every 8 hours. • Suspension comes 250 mg per 5 ml. • 250 mg215 mg 5 ml = x ml • 1075 250x • Give 4.3 mL / cc po every 8 hours

13. Safe Dose Ranges • Read the medication ranges carefully • Some are the dose range for 24 hours • Some are the dose range for q 8 hours • Some are the dose range for q 12 hours

14. Fluid Control • Crucial in the pediatric population • Units often have policies that children under a certain age are on a fluid control pump.

15. Key concepts • Fluid overload must be avoided • Time over which a medication should be administered is critical information • Minimal dilution (end concentration of medication) is important for medications such as aminoglycosides. • Collecting therapeutic blood levels

16. Fluid overload • Know what the IV rate is. • Hourly recording of IV fluid intake. • Don’t try and catch up on fluids. • Calculate fluids used to administer IV medications into the hourly fluid calculations.

17. Daily Fluid Needs • Fluid needs should be calculated on every patient to assure that the infant / child is receiving the correct amount of fluids. • Standard formula for pediatrics needs to be memorized.

18. IV fluid calculations • The maintenance dose for administration of IV fluids is based on the following formula: • 100 ml of fluid for the 1st 10 kg of weight • 50 ml of fluid for the 2nd 10 kg of weight • 20 ml of fluid for and additional kg • You need to memorize this

19. Practice problem • Jose weighs 16 pounds • Weight in kg = 7.27 kg • Using the formula provided how many mls of fluid would he need in 24 hours.

20. Fluid Calculation • 7.27 kilograms • 100 mL x 7.27 kg = 727 mL 727 mL / 24 hours or 30 mL per hour

21. Fluid Calculation • 64 pound child • Convert pounds to kilograms = 29.09 kg • Fluid calculations: • 100 mL x 10 kg = 1000 mL • 50 ml x 10 kg = 500 mL • 20 ml x 9.09 kg = 181 mL 1681 mL / 24 hours or 70 mL / hour

22. Fluid Calculations Fluid calculations can be rounded. You cannot administer a fraction of a mL. • In child #1 the calculated hourly rate of 29.7 would be rounded to 30 mL / hour. • In child #2 the calculated hourly rate of 70.04 would be rounded to 70 mL / hour.

23. Fluid Calculations • Since children are in the hospital for various illnesses they will often have increased fluid needs: dehydration, fever, vomiting, diarrhea, inability to take po fluids. • 24 hour fluid calculations may be 1 ½ to 2 times maintenance.

24. Fluid Calculations • Child number #1 maintenance fluid needs are 713 mL / 24 hours. • 1 ½ time maintenance would be 713 x 1 ½ = 1069 mL / 24 hours or 45 mL / hour.

25. Fluid Calculation • In child # 2 maintenance fluid needs are 1681 mL / 24 hours. • 1 ½ times maintenance would be 1681 x 1 ½ = 2522 mL / 24 hours or 105 mL / hour.

26. IV bolus • A 6 year old with dehydration is admitted to your unit. The referring hospital has an adult IV set-up. (drip factor of 15 gtt/ml) The physician order is to infuse 90 mL of normal saline over 1 hour. At what rate will you set the IV rate? • (90 ml x 15 gtts) divided by 60 minutes • Hourly rate would be 23 gtts/minute

27. IV Buretrol

28. IV Buretrol • A buretrol or volutrol is an inline receptacle between the client’s IV catheter set and the bag of fluids. • Capacity is 120 to 150 mL • Rationale: the nurse can fill the buretrol to a certain level and if the IV pump malfunctions, only the volume in the buretrol will flow to the client.

29. Syringe Pump

30. Parenteral Pediatric Medications • Step 1: Convert lb to kg • Step 2: Determine the safe range in mg/kg • Step 3: Decide whether the dose is safe by comparing the order with safe dose range • Step 4. Calculate the dose needed • Step 5. Check reference for diluent and duration for administration.

31. Example #1 • Child: 5 years: weight 44 lbs • Order: famotidine (Pepcid) 5 mg IV bid • Drug guide: 0.25 mg / kg q 12 hr IV up to 40 mg/day.

32. Example #1 • Convert pounds to kg: 44 lb = 20 kg • Determine safe dose: • 20 kg x 0.25 mg = 5 mg • 5 mg is safe it meets mg / kg rule and does not • exceed 40 mg/day. • 5 mg bid = total of 10 mg/day

33. Example #1 • Calculate the dose • Pepcid is provided as 10 mg/mL • 10 mg = 5 mg 1 mL x mL 5 = 10x 0.5 mL of Pepcid

34. Example #1 • Drug guide: dilute with 5 or 10 mL and infuse over 2 minutes. • The medication would be injected directly into the tubing of actively running IV; inject slowly over 1 to 2 minutes.

35. Example #2 • Child: 4 years: weight 17 kg • Physician order: Fortaz (Ceftazidime) 280 mg IV q 8 hours • Drug guide: • Safe dose 30 to 50 mg/kg/day • 50 mg/mL over 30 minutes • Drug supplied as 1 gram powder. Directions: Dilute with 10 mL of sterile water to equal 95 mg/mL.

36. Example #2 Safe dose is 30 to 50 mg/kg/day • Low range: 17 kg x 30 mg = 510 mg/day • High range: 17 kg x 50 mg = 859 mg/day Safe range is 510 to 859 mg/day or 170 to 286 per dose. If the order is to give the drug q 8 hours you would need to divide the safe range by 3 or multiple the q 8 hour dose x 3.

37. Example #2 Drawing up the medication: 1 gram / 10 mL or 95 mg / 1 mL 95 mg = 280 mg280 1 mL x mL 95x = 2.94 mL

38. Example # 2 • Adding medication to the volutrol • Take the 2.94 mL of Ceftazidine – inject it into the port on the volutrol and add additional IV fluid to = 10 mL.

39. Example # 2 The flush: evidence based practice has demonstrated that in an effort to get the IV medication from the volutrol to the patient the line needs to be flushed with 20 mL of IV fluid after the medication is into the IV line.

40. What about the flush? • THE PHYSICIAN ORDER WILL NEVER STATE TO FLUSH THE LINE – YOU MUST DO THIS WITH EACH IV MEDICATION

41. Example #2 • The drug guide states that the drug can be safely administer over 30 minutes. • Formula: • 10 mL (medication) + 20 mL flush following the medication = 30 mL of fluid that needs to infuse over 30 minutes. • The pump would need to be set at 60 mL for the medication + the flush to be infused over ½ hour.

42. NG – cc/cc replacement • In and infant or child has a nasogastric tube in that is draining fluid the physician will often write and order for: • NG drainage – cc/cc replacement What does this mean?

43. Nasogastric Output • NG output is measures q 4 hours. • At the beginning of the shift the night nurse reports that the drainage was 150 cc’s for the last 4 hours and you need to replace this over the next four hours. • Note: this is in addition to the IV hourly rate ordered.

44. Sample problem • IV hourly rate is 115 mL/hour • NG output to be replaced over the next 4 hours is 150 cc’s or 37 mL/hour. • You IV would be set at 115 mL + 37 mL = 152 mL / hour for the next four hours.

45. Practice Problems • Do the practice problems. • Can be done individually or in groups. • Testing will be on like problems. • You must achieve 80% or better to be able to safely administer medications in the clinical setting.