Home Intravenous Therapy

Home intravenous (IV) therapy programs started in the 1970s and are spreading annually as the cost savings compared to hospitalization increase.Advances in technology have resulted in the ability to manage patients at home safely with IV  therapy.Many patients prefer to receive infusion at home rather than the hospital.Infusion therapies include antibiotics,pain therapy,chemotherapy,and parenteral nutrition (PN).Blood transfusions and blood products tend to be given in the hospital because of the higher risk of complications.The physician is the medical case manager with responsibility for ordering the plan of care and usually writes the orders.

Peripheral PN regimens can only be used for low-osmolarity solution (300-900 mOsm/L). Higher osmolarity solutions must be larger veins with faster blood flow to avoid sceloris and inflammation of the vein wall. Central lines may be placed percutaneously and the pheriperally inserted central catheters (PICC lines) are increasingly being used for intermediate (days to weeks) usage. Central lines also may be surgically inserted, often with a subcutaneous tunnel to reduce the chance of skin bacteria infecting the vein. The Hickman and Broviac catheter can be inserted surgically of through a needle. Catheters such as the mediport or portacath may be implanted under the skin. These catheters are best used when there is interminttent need fo IV infusion, such as a course of antibiotics or chemotherapy. The Groshong catheter has a patented 3-position valve near the closed tip which opens inward during blood  withdrawal and outdward during infusion. The valve closes automatically when not in use because venous pressure is not enough to spontaneously open the valve inward. The result is that if the catheter becomes disconected, blood loss or air embolus is prevented.

Catheter-related complications are not uncommon. It is important to check the position of the tip or the catheter before solutions are infused. Air embolus is an infrequent complication as filters and connections have reduced this occurrence. Thrombophlebitis is common with peripheral catheter and thrombus formation may occur with statis associated with central catheters. Infection related to central catheters is a major complication. If there is fever, catheter-related sepsis must be considered. Blood cultures can be drawn from the line and peripherally at the same time. If there is evidance of fungal line sepsis, the catheter needs to be removed. Sometimes antibiotic treatment can be given to eradicate bacterial colonization of the catheter, but it is often necessary to remove the catheter.

Monitoring of laboratory paremeters needs to be planned. Blood levels of antibiotics or other medications should be checked at appropriate intervals and hematology and biochemical studies can be drawn during a home visit or the patient can go for blood drawing at a clinic or hospital.

IV tubing should be changed every 24-48 hours. Central catheters should be flushed monthly to reduce the potential for blocking off by thrombus formation.

The gravity system is the simplest for home infusion therapy. The solution is hung on a pole and the rate of flow is adjusted by using an in-line clamp and by watching the number of drips in a drip chamber to estimate the rate. This is not an accurate method and there are no alarms. Some systems use an ambulatory infusion pump which is portable and battery-powered. Complications of IV therapy can be minimized with careful protocols. Infiltration of periheral lines is common in children with pain and swelling at the site. Phlebitis is more common if the fluid is hypertonic or irritating.

If antibiotics are to be continued for more than 3 weeks, some form of central line is necessary. If there is a history of allergy, the initial dose of an antibiotic should be given in an environment where anaphylaxis can be treated.

Patients with diseases involving kidneys, liver, heart, lungs, or blood should be monitored more closely for side effects. Chemotherapy is usually administered in an infusion center initially and some chemotherapy medications should always be administered in the presence of personnel who can handle emergency situations. Unused drugs should not be disposed of down the drain or toilet but should be treated as hazardous waste.

Pain medications can be administered by IV, IM, subcutaneously, intrathecally and by epidural catheter. Infusion pumps for narcotics can be set up so that the patient can activate the pump at intervals depending on the need for pain control. The pumps are called patient-controlled activation (PCA).

Home Care and Technology Dependence

Home care for children with chronic illness involves a number of considerations.The concept of providing care at home for children with chronic illness has resulted from a desire to save cost as well as to look after children in an environment that is more conducive to optimal development. There can be nursing visits to provide care, especially after discharge from the hospital. There can be hospice care for the terminally sick. The need for technology-dependent home care has increased as a result of improved survival of trauma and severe illness, improvements in cancer outcome, and more aggressive care for neuromuscular disorders. Although the cost of providing medical care in the hospital. The other main advantage of home care has been that the results have been successful.
The family needs to want to manage the child in the home setting. They must be motivated to provide care and often they will have to make sacrifices to make it work. There is a need for trust between the provider and the family. This may take time to learn to trust the nurse and once they do they may be reluctant to trust others. Many families learn a great deal about the child's condition and may feel that the nurse that comes for an 8-hour shift may not be as committed as they would like. It is helpful to have case management so that there is an individual who is responsible for the coordination of care. The family needs someone they can contact should there be a disagreement about the treatment of the child.
The benefits of home care in addition to cost reduction include:
- A shorter hospital stay
- Improved quality of life
- Involving patient and family in care
- Allowing technology-dependent patients to be managed in a comfortable and familiar setting.

Substance Abuse

Surveys of older adolescents indicate that almost all (95 percent) try alcohol and about half have tried marijuana. Only a small minority of teenagers progress to substance abuse with the potential for addiction. Individuals who abuse one drug or substance are likely to abuse others as well. Adolescents with chronic illness, especially mental health, and disabilities have the potential to abuse alcohol and drugs.

Alcohol has two major problems for adolescents. Ingestion during pregnancy is associated with effects on the fetus and may result in physical malformations and mental retardation (fetal alcohol syndrome). The other problem results from risky behaviors accidents are often precipitated by alcohol. Alcohol results in more deaths of adolescents than all illicit drugs combined.

Illicit drugs (excluding marijuana) are used by up to 5 percent of adolescents. Cocaine and stimulants (especially amphetamines) are the most common.

It is important to recognize substance abuse disorders at an early stage. There is often a delay because the symptoms may be nonspecific and there may be medical or mental health problems which camouflage the substance abuse.

Urine or blood may be screened for drug metabolites. Urine test can reveal cocaine, methadone, amphetamines, diazepam, opiates, and barbiturates. Alcohol can only be tested in the blood or by breath test. It is controversial whether it is acceptable to perform drug testing without consent.

Management of alcohol and substance abuse problems is fraught with difficulty. Adolescents tend to deny that they have a problem. Therapy is expensive and motivation to succeed is often lacking.

Pain Control

Pain management is often an important component of care. It is difficult to assess pain because it is subjective and there are no objective measures of pain. Children are more difficult to manage because their response to pain is so varied and they have problems verbalizing exactly what they are feeling.

There are various means of assessment of pain in children which vary especially with the age of the child. Children can often indicate the severity and location of pain if the questions are appropriate. It is important to reduce the stress and emotional component so that the specific problem of pain can be separated. Pain often induces fear in the child. It must be remembered that some children will deny pain if they are likely to receive an injection for treatment and may deny it to a stranger but admit it to the parent.

By 3 or 4 years of age, children may be able to accurately point to the site pain or to indicate the position on a drawing and this age can use a pain scale to indicate severity. The commonest pain scales for young children involve facial expressions. It is important that the clinician not make a judgment about the amount of pain that a child might have based on behavior alone. Older children may be able to rate pain on score of 1 to 10 and then changes in the pain will usally relate to changes in the number that they assign to the pain.

It is important to be aware of symptoms of pain in the child who is non-verbal. This includes the child who is very young or neourologically impaired. In this situation, abnormal movements or behaviors, such as agitation or restlessness, may indicate pain. Crying or verbalization may suggest pain. Physiologic changes may be uselful signs, including increased heart rate, blood pressure, or respirations. There may be sweating or pupillary changes. All of these indicators may be present when there is pain and absent when the pain is gone or controlled.

Fear of addiction is realistic if there is going to be chronic use of opiate medications. For acute or short-term usage, addiction is unlikely in children.

Teenage Pregnancy

About 1 million teenage girls become pregnant in the United States each year. One-third of them are less 15 years of age. Half continue to term and half choose elective termination.
The pregnancy outcome needs to be discussed with the teenager and a social worker is usually helpful in outlining the options. Adolescent pregnancy is, by definition, high risk and associated with a higher-than-usual rate of complications, including low-birth weight and premature delivery. If the pregnancy is planned to continue to term, prenatal care needs to be initiated. Contraception is recommended after completion of pregnancy.

Sexual Disorders

Sexual activity is common in high school students with over 60 percent of males and about 50 percent of females participating in sexual activity. This leads to unwanted pregnancies, sexually transmitted diseases, and HIV infection.

All sexually active teenagers should be considered for regular syphilis screening. There should be yearly Papanicolaou smears to evaluate for human papillomavirus, cervicitis, and malignancy. Cervical cultures for gonorrhea and Chlamydia test should be performed regularly. If there is vaginal discharge, this should be checked for yeast or bacterial vaginitis and trichomonas. If there are multiple sexual partners, testing should be done  more frequently than once a year. If pregnancy is suspected, the beta human chorionic gonadotrophin (BHCG) should be measured. If the over the counter urine pregnancy test is positive, BHCG should be checked if confirmation is required.

Teenage males require urinalysis and the leukocyptesterase test is positive in sexually acquired urethritis. If there  are symptoms with penile discharge or dysuria, gonorrhea culture and Chlamydia test are indicated.

If vaginal of penile lesions are suggestive of herpess infection, a Tzanck test and culture should be performed.

An adolescent who requires treatment for sexually transmitted disease (STD) is entitled to confidential care in the United States. The sexual partner(s) also requires treatment and there should be follow-up after treatment to ensure that there has been resolution. This is important because of the potential for failure to comply with the treatment prescribed.

Mortality and Suicide

The leading medical cause of death in the adolescent is malignancy. This cause only ranks fourth overall with injures, homicide, and suicide all being more common. Half of adolescent deaths are due to injures and many of these are alcohol-related. Younger adolescents are more likely to die from drowning and from weapons of violence including guns and knives.

Suicide is the third leading cause of adolescent death. In many cases there is a history of depression and often a conflict either with the family or of a romantic nature. Adolescents who attempt suicide should be hospitalized. The risk behaviors in adolescents that lead to morbidity, rather than mortality, include substance abuse and sexual activity.

Stress

Stress in childhood takes many forms but the symptoms displayed may be similar to those of children who are abused or depressed. Children are vunerable to changes in the family situation and the environment. Disruptions, such  as divorce, moving, or changing schools may be associated with turmoil within the family that results in stress in the child. The stress of childhood is varied and considerable. There may be stress that is specific of the child, such as a chronic illness.

Coping is the term to describe the respone to stress and individuals react differently. Children develop coping strategies to help them manage stress in many ways similar to adults. The problems relate to the fact that they may not be able to change their situation as easily and so may not be able to avoid stressful situations. Children do cope by reading or playing video games as well as by becoming more introspective and withdrawn. Some children resort to risky behaviors in response to stress and may lie or cheat to avoid stressful situations.

The response to the media has changed how children respond to the environment. Role models are not necessarily teh parents but may be the latest personalities or characters on television shows or video games. Comic books are not felt to exert as much influence on children's behavior as movies and television. Television has most impact on behavior with programs and the United States spends more than 20 hours per week watching television. It is likely that TV has both beneficial (educational) and adverse effects that child's development.

Mental Health Problems

Mental health problems will focus on global issues of chronic illness and the resultant mental health problems. Chronic fatigue syndrome and fibromyalgia are included because their causes are unknown, not because the are mental health disorders.

Behavior Patterns
Both normal and abnormal behavior of children and adolescents comprise a major amount of routine pediatric care. Behavior is influenced by genetic, neurologic and biologic factors and even more so by social and environmental factors.

Biological factors affecting behavior include:
- Genetic (hereditary traits for temperament, for personality, and for cognitive ability)
- Genetic disorders
- Congenital CNS infection
- CNS injury (asphyxia or bleeding)
- Psychomotor retardation
- Chronic illness

Social and environmental influences include:
- Parents and siblings
- Home environment and discipline at home
- School
- TV, Computers

Behavior problems:

Young Children
- Sleep disorders
- Temper tantrums

Older Children
- Sexual conduct
- Substance or alcohol abuse
- Cigarette smoking
- Weapons (guns or knives)

Slipped Capital Femoral Epiphysis

There is separation of the proximal femoral epiphysis through the growth plate so that the head of the femur becomes displaced medially and posteriorly. Most cases (80 percent) result from a progressive chronic slip of the femoral epiphysis and 20 percent have the injury acutely following a traumatic event. It occurs in early adolescene and is most common in obese males. The presentation is a painful limp that may last for months. The pain commonly is referred to the thigh or even the medial side of knee. There is usually a limitation of internal rotation and abduction of the hip. The diagnosis is confirmed by X-ray.

Treatment is similiar to that of a fracture of the neck of the femur. If there has been an acute injury, traction may help and, in chronic cases, pinning the slip as it lies is preferred. Reduction of the chronic slip may lead to avascular necrosis of the femoral head. About 30 percent of patient have bilateral involvement so that slipping of the opposite side may occur and this could be 1-2 years after the initial injury.

Clubfoot

Congenital clubfoot occurs in 1 per 1.000 live births. It may be idiopathic, neurogenic, or associated with a syndrome (such as arthrogryposis multiplex congenita). It is called talipes equinovarus which means plantar flexion at the ankle joint with inversion of the foot at the heel and the forefoot. Treatment with splinting should begin a few days after birth. Initialy, this can be by splinting with strapping and later with casts that strecth the foot towards sequentially correcting the forefoot, heel and then ankle deformities. About 50 percent will require an operative procedure to lengthen structures within the foot

Developmental Dysplasia of The Hip Joint

This is a continuum of disorders and includes the term congenital dislocation of the hip which is not an accurate term because the dislocation tends to occur after birth. Developmental dysplasia of the hip joint results in an abnormal relationship between the proximal femur and the acetabulum (of the pelvis). The incidence is 1 per 1.000 live births. It is important to recognize the condition because if the hip is dislocated and not treated there may be permanent deformity. Ortolani described the maneuver of flexion of the hip to 90 derajat and then abduction, with the middle finger over the hipjoint and the thumb applying pressure to the medical aspect of the thigh. If the head of the femur slips out of the acetabulum it can be felt.
Dislocation or dysplasia can be treated by splinting the legs in a position of flexion and abduction. Treatment is indicated for months and when initiated early is very succesful. If dislocation is not recognized until the child starts to walk, a limp and lurching to the affected side will suggest the diagnosis.

Kyphosis and Lordosis

Kyphosis is curvature in the antero-posterior direction, usually in the thoracic region. There is a problem with ossification of the anterior portion of the vertebral body (Scheuermann kyphosis). Back pain is common and worse when standing. Bracing is usually succesful controlling the curvature. Minor degrees of kyphosis may occur in adolescent girls that can be corrected by improving their posture. Lordosis occurs in the lumbar region and tends not to be a major problem.

Scoliosis

This is a curvature of the spine of greater than 10 percent in the coronal (side-to-side) plance. There are many different casues. Idiophathic scoliosis is the most common cause and occurs during the adolescent growth spurt. It is more common is females and is painless. If the curve is less than 25%, observation is indicated. If the curveture is 25-40%, bracing should be considered and surgery is usually indicated for curves greater than 40-50%.

Congenital scoliosis usually results from abnormal vertebrae and the progression usually does not improve with bracing. Many are associated with renal, cardiac, or other anomalies wich should be looked for. Paralytic scoliosis results from neuromuscular disorders. If there is scoliosis with progression, it is usual to follow with X-rays every 6 months. The main reason to perform surgery is stop the progression of the curvature. Usually, posterior spinal fusion will be sufficient in idiopathic scoliosis. Neuromuscular disorders associated with scoliosis mar require anterior as well as posterior fusion. Metal rods, with hooks or wires, may supplement the fusion.

Poplietal Cyst (Baker Cyst)

This is an out-pouching of the synovial capsule of the knee joint under the medical head of the gastrocnemius muscle. It is usually asymptomatic and the main issue is that there is a 30 percent recurrence rate after surgery.