Standarization and characterization of intravenous drug dilutions in critically ill pediatric patients

To standardize the drug dilutions administered intravenously in a Pediatric Intensive Care Unit and to characterize these dilutions based on their pH, osmolarity, and vesicant nature. This aims to guide the selection of the most appropriate vascular access device, minimizing associated complications, and preserving the patient's venous capital.

Through a consensus between Pharmacy and Pediatric Services, the most frequently administered intravenous drugs in the Pediatric Intensive Care Unit were selected. Two different dilutions were established for each drug, followed by the determination of their respective osmolarity and pH values. The vesicant nature of each drug was assessed according to the classification proposed by Clark et al. Additionally, vascular access device selection was guided by the algorithm proposed by Manrique et al., which considers the drug's properties, the duration of intravenous therapy, and the patient's venous capital status.

A total of 60 dilutions corresponding to 30 drugs from the following therapeutic groups were analyzed: antimicrobials (56%), antiepileptics (13%), sedatives (7%), diuretics (7%), anti-inflammatory and analgesics (7%), and others (10%). Twenty-five percent of the dilutions exhibited at least one high-risk factor for phlebitis (osmolarity >600 mOsm/L or pH < 4 or > 9), while 35% were classified as intermediate risk (osmolarity 450-600 mOsm/L or pH 4-5 or > 7.5-9). Only 10% of the analyzed drugs were classified as vesicants (acyclovir, phenytoin, and vancomycin). Seventeen dilutions of nine different drugs were identified that should not be administered through a peripheral venous catheter, even in short-term treatments. Of these, 15 had a high risk of causing phlebitis, while 2 had an intermediate risk.

The physicochemical properties (osmolarity and pH) and vesicant nature of drugs are key factors contributing to the development of phlebitis in critically ill pediatric patients. Standardizing and characterizing drug dilutions will facilitate the selection of the most appropriate vascular access device, improving the safety and effectiveness of intravenous therapy.