Policy: All Fairview Home Infusion (FHI) pediatric patients will receive consistent and appropriate care when receiving home infusion therapy.

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1 Department Policy Code: D: PC-5645 Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Pediatric Home Infusion Therapy Purpose: To provide guidelines for the care of pediatric home infusion patients. Policy: All Fairview Home Infusion (FHI) pediatric patients will receive consistent and appropriate care when receiving home infusion therapy. Points of Information: I. Home Infusion therapy for the pediatric patient presents clinicians with unique challenges. Each age group displays various physical, physiological, developmental, cognitive and emotional characteristics. The specific care issues include but are not limited to: A. Access devices and infusion equipment Catheter type, insertion site and infusion rates must all be considered to assure safety. Considerations may include: 1. Emotional needs (thumb sucking); mobility (walking, crawling) and other developmental considerations are equally as important as size and condition of veins, type of therapy, expected length of therapy, and rate of infusion. 2. Catheter and connection securement and monitoring are necessary to avoid accidental or intentional removal/ disconnection. 3. Visualization of the site and catheter protection from contaminants (diapers) is necessary so that the site can be monitored for complications and to prevent infection. 4. Equipment should be selected based on safety features and medication administration requirements. Promoting the child s ability to maintain normal activities should also be considered. B. Medication Administration the most commonly used calculations for medication administration are those based on body weight and body surface area. Dosing is usually calculated by body weight or body surface area (BSA).

2 C. Fluid and electrolyte imbalance because the metabolic rate in infants and children is higher than that in adults, fluid losses are also greater. Considerations in the determination of fluid replacement include: 1. Pre-illness and current weight 2. Clinical signs of fluid deficit a. Poor skin turgor b. Sunken eyes c. Dry mucous membranes d. Depressed fontanels e. Low blood pressure f. Altered neurological status (lethargic, irritable) 3. Reason for fluid loss (gastroenteritis) 4. Effects on metabolism (fever) 5. Sources of evaporative loss (increased respiratory rate) D. Growth and development stages - Each age group and developmental stage express different characteristics that require specific nursing interventions, refer to Attachment I. Procedure: I. The assessment and reassessment of the pediatric patient may include: A. Weight, height, head circumference B. Vital signs, refer to Attachment II C. Condition of skin, mucous membranes, and fontanels D. Nutritional status E. Urine output F. Neurological status G. Growth and developmental level, emotional needs refer to Attachment I H. Special considerations that might affect IV access, such as hand dominance or thumb sucking refer to Attachment III I. Family or guardian expectations for involvement in patient care and services. II. Parents or caregivers must be responsible for constant supervision, observing, and reporting signs and symptoms of complications, since young children have a limited awareness of what is happening to their bodies and the ability to express their concerns (i.e., feeling hot or cold). III. When placing a peripheral intravenous device, actual method of venipuncture is the same for children as for adults, but certain techniques enhance the successful placement and securement of the device. A. There is no recommended timeframe for rotation of pediatric peripheral IV s. Peripheral IV catheters should be removed any time there are symptoms of phlebitis, infiltration, extravasation, suspected contamination or; after therapy is completed or access is not used for over 24 hours. B. When establishing peripheral venous access in an infant or a

3 young child it is imperative to have at least one other person present for the venipuncture. If the caregiver is unable or unwilling to assist in the procedure, the patient must be taken to the clinic or emergency room. The prescriber and caregivers will be notified of this plan to maintain the peripheral IV device. C. The smallest gauge catheter, adequate to deliver the prescribed therapy, should be used whenever possible. D. Secure extremity with normal joint position maintained. Use caution not to impair circulation with stabilization. Caregivers will be educated to check joint stabilization device and skin integrity. IV. Central venous access devices are recommended for home infusion therapy that is to extend beyond a few days and/ or as indicated by the ordered therapy (TPN, vesicants). A. The most common complications of central venous catheters in children include occlusion, thrombosis and infection. B. Securement of the device and any tubing connections is important to prevent infection. C. Lumens or extensions of the catheter should be secured out of the child's reach to prevent accidental or intentional catheter/ needle removal. D. Pediatric patients should be assessed regularly for proper central venous catheter tip placement due to growth and development causing the tip to move out of the superior vena cava. V. Access Device Care: A. Skin antisepsis with Chlorhexidine and use of Biopatch are recommended for full term infants and premature infants with a corrected age of > 37 weeks. Specific orders will be obtained from the provider for any infant < 37 weeks corrected age. B. Use smaller dressing or Biopatch for infants and toddlers. VI. For Pediatric patients requiring Alteplase, for catheter clearance or absence of a blood return Clinical staff will refer to manufacturer s specific information and consult with the prescriber to determine dosage when the dose must be based on the actual catheter prime volume--specifically for patients younger than three months and/ or those weighing less than 10 kg.refer to Policy Central Vascular Access Device Clearance for information related to catheter clearance. VII. Lab Specimen Collection: A. Discard volume for patients 10kg is 3ml. B. Discard volume for patients > 10kg is 5ml. C. Utilize Push/Pull method to minimize blood loss in at risk patients. D. Refer to Laboratory Guide for specific lab test E. F.

4 G. Refer to the following laboratory policy for specific pediatric blood loss volumes p VIII. Since a child may not be able to communicate symptoms of an allergic reaction, all requests for First Doses in the home will be reviewed for safety. In most cases it is preferred that the first dose be administered in a controlled setting. IX. Infusion pumps may be used in the pediatric population to avoid fluid overload and enhance precise administration of the IV therapy over the prescribed period of time. Use of a pump is recommended when infusing vancomycin, amphotericin, aminoglycosides, TPN, hydration, or electrolytes. The medication ordered as well as the patient's weight, age, and intravenous access device should be considered when determining appropriate volumes, administration rate, and when choosing an infusion method or device. Overfill volume should be used sparingly. X. Intramuscular injections: A. The sites for intramuscular injection vary with age group. 1. Up to one year old anterolateral thigh 2. 1 year or older - anterolateral thigh, deltoid, ventrogluteal The ventrogluteal site is located by placing the palm of the hand over the greater trochanter, index finger over anterior iliac tubercle and middle finger over the crest of ileum posteriorly, spreading fingers as far as possible. Inject into the center of the V formed by fingers. B. Needle gauge and length should be determined based on the patient's weight and actual muscle mass. The length of the needle must be sufficient to assure the medication is administered within the muscle tissue. In general; Infants 5/8 inch-1 inch; Toddlers and children 5/8to 1 1/2inch. C. Site rotation for intramuscular injections is strongly recommended to avoid damage to the muscle and surrounding tissue. D. Volume to be administered should be determined based on patient age, muscle mass and medication to be administered. In general, infants less than 12 months volume should be 1 ml or less per site. XI. Subcutaneous injections: A. Subcutaneous injections can be given anywhere there is subcutaneous tissue; common sites include: 1. Center/ lateral aspect of the upper arm 2. Abdomen 3. Center/anterior aspect of the thigh B. Needle gauge and length should be determined based on the patient's weight and amount of subcutaneous tissue. In general; ½ inch needle, gauge or smaller. C. Site rotation is generally recommended however in some

5 cases use of a subcutaneous catheter device may be appropriate (i.e. Insuflon). Consult with prescriber and obtain order for use as indicated. D. Volume to be administered is generally 1 ml or less per site. XII. Nursing documentation at the SOC, ROC or Reassessment visit will be completed using specific pediatric documents to ensure age appropriate assessments. XIII. The pediatric patient will be case managed using an interdisciplinary team, and may include a pharmacist, nurse, dietitian, or other referred services as appropriate. External Ref: Joint Commission applicable standards Policies and Procedures for Infusion Nursing of the Pediatric Patient; 2014 Infusion Nurses Society Infusion Nursing An Evidence-Based Approach, 3 rd Edition, 2010 Wong s Nursing Care of Infants and Children, 9 th Edition, 2011 Pediatric Dosage Handbook, 13 th Edition, Internal Ref: Fairview Pharmacy Services Resource Center; on line access: Refer to Policy: Subcutaneous Catheters: Insertion, Use and Care Fairview Laboratory Policies Source: FHI Clinical Managers, Quality Department Approved by: Director of Operations, Medical Directors Date Effective: Date Revised: 09/09/2000, 1/1/2002, 4/04, 6/08, 12/2011, 4/2012, 12/2012, 4/2015, 5/2018 Date Reviewed: 12/2011, 4/2012, 12/2012, 4/2015, 5/2018

6 Attachment I Developmental Stages of Childhood and Nursing Implications for Painful Procedures Age group Developmental Stage Concept of Pain Considerations Infant (birth to 1 yr) Toddler (1 3 yr) Preschool (4 6 yr) School age (6 12 yr) Adolescence (13 19 yr) Infants younger than 6 months seem to have no memory of previous painful experiences. After 6 months of age a child s pain response is felt to be influenced by prior experience. Older infants may use whatever motor activity they are capable of to attempt to escape the procedure. Toddlers tend to react to intrusive procedures with intense emotional upset and physical resistance. Pain may be exhibited as restless or overactive behavior. Reactions to pain in this age group are similar to that of toddlers. Preschoolers are more responsive to pre- procedural preparation than younger children. School age children like to have a sense of control and participation during procedures. In addition to concerns of pain this age group is concerned with the benefits and effects of the procedure. By the age of 9 or 10 most children show less fright and resistance to painful procedures Adolescents typically react to pain with much selfcontrol. They may be reluctant to disclose their pain making observation of physical indications of pain necessary. Keep infants warm and swaddled Consider use of a pacifier A topical anesthetic like EMLA may be applied prior to a needle stick, consider application to more than one site at the same time in case the first attempt is unsuccessful Administration of oral sucrose before, during and after procedures has been shown to decrease procedural pain - Avoid feeding just prior to a procedure to avoid the risk of vomiting/ aspiration Infants may be soothed by a parents touch or voice encourage parents to interact with child during and after the procedure Prepare needed supplies and equipment out of view of the child Use simple and honest explanations Positioning during the procedure may increase comfort, if willing parents may hold the child Use transitional objects to provide comfort (blanket, toy). Use rewards (stickers) Prepare needed supplies and equipment out of view of the child Use play to prepare the child, allowing the child to handle equipment or to practice the procedure on a doll helps familiarize the child with the frightening aspects of the procedure Explain that it is okay to cry and that holding still is a big help, praise cooperation Explaining the procedure will generally decrease the child s anxiety Discuss what distractions the child would like during the procedure If interested, allow the child to help and give tasks, such as ripping tape, holding still, slow breathing Offering choices increases the child s sense of control. Reassure that crying is okay Explaining the procedure will generally decrease the child s anxiety Show equipment, explain function and allow time for questions explain therapy as to an adult patient Offer choices such as site location, if peers or family can be present Sources: Wong s Nursing Care of Infants and Children Ninth Edition 2011; Infusion Nursing An Evidence-Based Approach Third Edition 2010

7 Attachment II Temperature Pediatric Vital Signs (Normal Values) Age Fahrenheit Celsius Pulse rate (Beats/min) Respiratory Rate (Breaths/min) Blood Pressure (mmhg) Newborn (axillary) (axillary) Systolic: (Doppler) Diastolic: months to 3 years (axillary) (axillary) Girls Systolic: Diastolic: Boys Systolic: Diastolic: to 10 years (oral) (oral) Girls Systolic: Diastolic: Boys Systolic: Diastolic: years to adult (oral) (oral) Girls Systolic: Diastolic: Boys Systolic: Diastolic: Adapted with permission from Wong s Nursing Care of Infants and Children Ninth Edition 2011

8 Attachment III Intravenous Sites in Children Site Patient Age Veins Used Considerations Scalp Infant, < 9 months of age; used only if other sites are not accessible Superficial temporal, frontal, posterior auricular Foot Infant, toddler Great saphenous, median marginal, dorsal venous arch Hand All ages Dorsal venous arch, network with tributaries Average of 4-8 sites on the scalp Hands kept free, sites in temporal/forehead area do not interfere with side-to-side head movement Hair may need to be removed, do not shave Difficult to secure device Greater family anxiety Must have assistance for successful insertion Average of 1-2 sites on the foot Hands kept free Can be more visible in chubby infants Decreases mobility with walking Risk of phlebitis in older patients Catheter must be placed in the direction of the blood flow In younger children vein location can be difficult because of subcutaneous fat and small vein size In older children hand veins are generally easily accessible and readily visible Catheters placed in the hand of an infant can be difficult to anchor Potentially interferes with child s activity Forearm All ages Cephalic, Basilic, Keeps hands free In younger children vein location can be difficult because of subcutaneous fat and small vein size Antecubital All ages Cephalic, Basilic, Median cubital General Considerations: Larger veins visible and palpable Elbow joint must be maintained in extended position which limits activity Limits sites for drawing lab specimens May interfere with peripherally inserted central catheter placement Utilize the most distal available site first to preserve proximal sites Avoid sites over a joint whenever possible Choose a site that restricts movement as little as possible Sources: Wong s Nursing Care of Infants and Children Ninth Edition 2011; Infusion Nursing An Evidence-Based Approach Third Edition 2010