Impact of Sugammadex Introduction on Using Neuromuscular Blockade and Endotracheal Intubation in a Pediatric Hospital: A Retrospective, Observational Cross-Sectional Study.

BACKGROUND: Sugammadex is a neuromuscular blockade (NMB) reversal agent introduced in the United States in 2016, which allows the reversal of deep NMB, not possible with neostigmine. Few data describe associated practice changes, if any, in NMB medication use that may have resulted from its availability. We hypothesized that after institutional introduction, use of NMB agents increased. Furthermore, as NMB medication is typically used when the airway has been secured with an endotracheal tube (ETT), we speculated that ETT use may have also increased over the same time period as a result of sugammadex availability. METHODS: This was a single-center cross-sectional study of patients ages 2 to 17 years undergoing general anesthesia for surgical cases where anesthesia providers often have discretion over NMB medication use or whether to use an ETT versus a laryngeal mask airway (LMA), comparing the time periods 2014 to 2016 (presugammadex) to 2017 to 2019 (early sugammadex) and 2020 to 2022 (established sugammadex). Outcomes included use of (1) any nondepolarizing NMB medication during the case and (2) an ETT versus LMA. We used generalized linear mixed models to examine changes in practice patterns over time. We also examined whether patient age group and in-room provider (resident versus certified registered nurse anesthetist [CRNA]) were associated with increased NMB medication or ETT use. RESULTS: There were 25,638 eligible anesthetics. Patient and surgical characteristics were similar across time periods. In adjusted analyses, the odds of NMB medication use increased from 2017 to 2019 (odds ratio [OR], 1.55, 95% confidence interval [CI], 1.38-1.75) and 2020 to 2022 (OR, 5.62, 95% CI, 4.96-6.37) relative to 2014 to 2016, and were higher in older children (age 6-11 years vs 2-5 years OR, 1.81, 95% CI, 1.63-2.01; age 12-17 years vs 2-5 years OR, 7.01, 95% CI, 6.19-7.92) and when the primary in-room provider was a resident rather than a CRNA (OR, 1.24, 95% CI, 1.12-1.37). The odds of ETT use declined 2017 to 2019 (OR, 0.69, 95% CI, 0.63-0.75) and 2020 to 2022 (OR, 0.71, 95% CI, 0.65-0.78), more so in older children (age 6-11 years vs 2-5 years OR, 0.45, 95% CI, 0.42-0.49; age 12-17 years vs 2-5 years OR, 0.28, 95% CI, 0.25-0.31). Resident presence at induction was associated with increased odds of ETT use (OR, 1.50, 95% CI, 1.38-1.62). CONCLUSIONS: The decision to use NMB medication as part of an anesthetic plan increased substantially after sugammadex became available, particularly in older children and cases staffed by residents. ETT use declined over the study period.

Safety, Efficacy, and Cost of 0.4-mg Versus 2-mg Intranasal Naloxone for Treatment of Prehospital Opioid Overdose.

BACKGROUND: Intranasal naloxone is commonly used to treat prehospital opioid overdose. However, the optimal dose is unclear, and currently, no study exists comparing the clinical effect of intranasal naloxone at different doses. OBJECTIVE: The goal of this investigation was to compare the safety, efficacy, and cost of 0.4- versus 2-mg intranasal naloxone for treatment of prehospital opioid overdose. METHODS: A retrospective, cross-sectional study was performed of 218 consecutive adult patients receiving intranasal naloxone in 2 neighboring counties in Southeast Michigan: one that used a 0.4-mg protocol and one that used a 2-mg protocol. Primary outcomes were response to initial dose, requirement of additional dosing, and incidence of adverse effects. Unpooled, 2-tailed, 2-sample t-tests and χ2 tests for homogeneity were performed with statistical significance defined as P <0.05. RESULTS: There was no statistically significant difference between the 2 populations in age, mass, gender, proportion of exposures suspected as heroin, response to initial dose, required redosing, or total number of doses by any route. The overall rate of adverse effects was 2.1% under the lower-dose protocol and 29% under the higher-dose protocol (P < 0.001). The lower-dose protocol was 79% less costly. CONCLUSION AND RELEVANCE: Treatment of prehospital opioid overdose using intranasal naloxone at an initial dose of 0.4 mg was equally effective during the prehospital period as treatment at an initial dose of 2 mg, was associated with a lower rate of adverse effects, and represented a 79% reduction in cost.

Piloting Medication Histories in a Pediatric Postanesthesia Care Unit.

PURPOSE: Develop a medication history process for pediatric postanesthesia care unit (PACU) patients to identify discrepancies between home and inpatient medications and prevent medication errors. DESIGN: Pilot an evidence-based practice change to perform PACU medication histories. METHODS: Inpatients or surgical admissions to general care units at a pediatric tertiary care 348-bed hospital ages 2-18 years were included. Parents/guardians were asked about their child's prescription and over-the-counter medications, allergies, and adherence. Data included patient age, surgery, medication categories, and error classifications. Information was compared to the patient's medical record. FINDINGS: From June to July 2016, 75 medication histories were performed, covering 44.6% of eligible cases within the period. Seventy-four discrepancies were found, the most frequent being omission. The medication category with the most errors was vitamins/herbals/supplements. CONCLUSION: The workflow designed assessed discrepancy frequency and type in surgical patients' medication lists when transitioning from the PACU to general care units.

Acetaminophen clearance during ex vivo continuous renal replacement therapies.

Intravenous acetaminophen is an adjuvant to opioid use in critically ill and surgical patients requiring continuous renal replacement therapy (CRRT). The objective of this study was to determine the ex vivo transmembrane clearance of intravenous acetaminophen during continuous hemofiltration and hemodialysis. Transmembrane clearance was assessed using a validated ex vivo bovine blood model for CRRT using an F8 or HF1400 hemodiafilter. Ultrafiltrate and dialysate flow rates were 1, 2, and 3 L/h. Urea and acetaminophen clearances were calculated and compared. Acetaminophen was readily cleared by continuous hemofiltration with both hemodiafilters. Acetaminophen clearance rates were 92-98% of ultrafiltrate production rates. Similarly, dialytic acetaminophen clearances approximated dialysate flow rates for both hemodiafilters. Acetaminophen is readily cleared by CRRT. Patients receiving CRRT and acetaminophen may require increased doses for adequate pain control.

Control of Surface-Localized, Enzyme-Assisted Self-Assembly of Peptides through Catalyzed Oligomerization.

Localized self-assembly allowing both spatial and temporal control over the assembly process is essential in many biological systems. This can be achieved through localized enzyme-assisted self-assembly (LEASA), also called enzyme-instructed self-assembly, where enzymes present on a substrate catalyze a reaction that transforms noninteracting species into self-assembling ones. Very few LEASA systems have been reported so far, and the control of the self-assembly process through the surface properties represents one essential step toward their use, for example, in artificial cell mimicry. Here, we describe a new type of LEASA system based on α-chymotrypsin adsorbed on a surface, which catalyzes the production of (KL)nOEt oligopeptides from a KLOEt (K: lysine; L: leucine; OEt ethyl ester) solution. When a critical concentration of the formed oligopeptides is reached near the surface, they self-assemble into ß-sheets resulting in a fibrillar network localized at the interface that can extend over several micrometers. One significant feature of this process is the existence of a lag time before the self-assembly process starts. We investigate, in particular, the effect of the α-chymotrypsin surface density and KLOEt concentration on the self-assembly kinetics. We find that the lag time can be finely tuned through the surface density in α-chymotrypsin and KLOEt concentration. For a given surface enzyme concentration, a critical KLOEt concentration exists below which no self-assembly takes place. This concentration increases when the surface density in enzyme decreases.

In vitro effects of an extracorporeal membrane oxygenation circuit on the sequestration of ϵ-aminocaproic acid.

OBJECTIVE: To assess the in vitro effects of drug sequestration in extracorporeal membrane oxygenation (ECMO) on ϵ-aminocaproic acid (EACA) concentrations. METHODS AND DESIGN: This in vitro study will determine changes in EACA concentration over time in ECMO circuits. A pediatric dose of 2,500 mg was administered to whole expired blood in the simulated pediatric ECMO circuit. Blood samples were collected at 0, 30, 60, 360 and 1440-minute intervals after initial administration equilibration from three different sites of the circuit: pre-oxygenator (PRE), post-oxygenator (POST) and PVC tubing (PVC) to determine the predominant site of drug loss. The circuit was maintained for two consecutive days with a re-dose at 24 hours to establish a comparison between unsaturated (New) and saturated (Old) oxygenator membranes. Comparisons between sample sites, sample times and New versus Old membranes were statistically analyzed by a linear mixed-effects model with significance defined as a p-value <0.05. RESULTS: There were no significant differences in EACA concentration with respect to sample site, with PRE and POST samples demonstrating respective mean differences of 0.30 mg/ml and 0.34 mg/ml as compared to PVC, resulting in non-significant p-values of 0.373 [95% CI (-0.37, 0.98)] and 0.324 [95% CI (-0.34, 1.01)], respectively. The comparison of New vs. Old ECMO circuits resulted in non-significant changes from baseline, with a mean difference of 0.50 mg/ml, 95% CI (-0.65, 1.65), p=0.315. CONCLUSION: The findings of this study did not show any significant changes in drug concentration that can be attributed to sequestration within the ECMO circuit. Mean concentrations between ECMO circuit sample sites did not differ significantly. Comparison between New and Old circuits also did not differ significantly in the change from baseline concentration over time. Sequestration within ECMO circuits appears not to be a considerable factor for EACA administration.

Localized Supramolecular Peptide Self-Assembly Directed by Enzyme-Induced Proton Gradients.

Electrodes are ideal substrates for surface localized self-assembly processes. Spatiotemporal control over such processes is generally directed through the release of ions generated by redox reactions occurring specifically at the electrode. The so-used gradients of ions proved their effectiveness over the last decade but are in essence limited to material-based electrodes, considerably reducing the scope of applications. Herein is described a strategy to enzymatically generate proton gradients from non-conductive surfaces. In the presence of oxygen, immobilization of glucose oxidase (GOx) on a multilayer film provides a flow of protons through enzymatic oxidation of glucose by GOx. The confined acidic environment located at the solid-liquid interface allows the self-assembly of Fmoc-AA-OH (Fmoc=fluorenylmethyloxycarbonyl and A=alanine) dipeptides into ß-sheet nanofibers exclusively from and near the surface. In the absence of oxygen, a multilayer nanoreactor containing GOx and horseradish peroxidase (HRP) similarly induces Fmoc-AA-OH self-assembly.

Bioactive Seed Layer for Surface-Confined Self-Assembly of Peptides.

The design and control of molecular systems that self-assemble spontaneously and exclusively at or near an interface represents a real scientific challenge. We present here a new concept, an active seed layer that allows to overcome this challenge. It is based on enzyme-assisted self-assembly. An enzyme, alkaline phosphatase, which transforms an original peptide, Fmoc-FFY(PO4 (2-) ), into an efficient gelation agent by dephosphorylation, is embedded in a polyelectrolyte multilayer and constitutes the "reaction motor". A seed layer composed of a polyelectrolyte covalently modified by anchoring hydrogelator peptides constitutes the top of the multilayer. This layer is the nucleation site for the Fmoc-FFY peptide self-assembly. When such a film is brought in contact with a Fmoc-FFY(PO4 (2-) ) solution, a nanofiber network starts to form almost instantaneously which extents up to several micrometers into the solution after several hours. We demonstrate that the active seed layer allows convenient control over the self-assembly kinetics and the geometric features of the fiber network simply by changing its peptide density.

A retrospective description of anesthetic medication dosing in overweight and obese children.

INTRODUCTION: Pediatric obesity is a major health concern in the United States and as many as 34% of those who require general anesthesia are overweight or obese (OW). The lack of data and recommendations for dosing medications in obese children leaves significant gaps in the understanding of correct dosing in the clinical setting. OBJECTIVE: To determine whether OW children were more likely to receive doses of medications outside the recommended range. METHODS: Following IRB approval, patient medical records were queried to identify children 2 through 17 years who underwent noncardiac surgeries and received at least one medication of interest. Children with hepatic disease, renal disease, neurological impairment, sleep-disordered breathing, or missing height or weight measurements were excluded. Children were stratified into weight categories based on age and gender percentiles as per CDC guidelines. Those ≥85th percentile were classified as overweight/obese. Ideal and lean weight (for age, gender) were calculated. Drug doses were stratified as under-dosed (>10% below minimum recommended dose), overdosed (>10% above maximum recommended dose), or within recommended dose (dose ± 10%). Actual doses were compared to recommended doses as per actual, ideal, or lean weight (as recommended for specific drugs) in the overweight/obese groups vs the control weight (CW) group. RESULTS: Ten thousand five hundred and nine doses were reviewed. Overweight/obese children were more likely to receive doses outside the recommended dose range than the CW group. CONCLUSIONS: Overweight/obese children were more likely to receive doses of common anesthetic medications outside the recommended doses potentially adding risk of adverse outcomes in these children.

Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population.

BACKGROUND AND OBJECTIVES: Few studies have been conducted in pediatric patients evaluating efficacy of prophylactic antibiotics for prevention of surgical site infection (SSI). This retrospective study was undertaken to determine the effect of antibiotic prophylaxis in the prevention of SSI in children. METHODS: With IRB approval, our perioperative electronic clinical information database was queried. Pediatric patients (≤18 years) undergoing general surgery, cardiac surgery, and spinal surgery at Mott Children's Hospital from January 2000 to April 2010 were included. Demographics and preoperative data were obtained from the Centricity Intraoperative Database, and any episodes of SSI were obtained by review of the infection control records. RESULTS: A total 5023 pediatric patients underwent surgery from January 2000 to April 2010. The average age of the children in the sample was 4.16 ± 5.5 years, and of these, 57% were boys. Overall, 119 (2.37%) cases of SSI were identified. There were no associations between the various patient factors and the development of SSIs. Children for whom antibiotics were administered incorrectly had a 1.7-fold increased risk of SSIs compared with children who received antibiotics within the recommended guidelines (P < 0.02). Children who received antibiotics were more likely to suffer an SSI compared with those who did not. CONCLUSIONS: Proper administration of preoperative antibiotics in pediatric patients is one of the few modifiable and significant factors in prevention of SSI.

Early adjuvant use of nonopioids associated with reduced odds of serious postoperative opioid adverse events and need for rescue in children.

OBJECTIVES: Examine factors associated with opioid adverse drug events (ADE) in children. SPECIFIC AIMS: Examine whether adjuvant nonopioid use is associated with a decreased probability of opioid-ADEs and need for rescue. BACKGROUND: Opioid-ADEs contribute to serious preventable harm for hospitalized children. Adjuvant nonopioid use may mitigate opioid risk postoperatively, yet few studies support this notion. METHOD: This nested case-control study included children who required intervention or rescue from opioid-ADEs and procedure-matched controls. Data were recorded from medical records and primary outcomes included serious opioid-ADEs (over-sedation and respiratory depression) and need for rescue (e.g., naloxone, rapid response team). Hierarchical logistic regression (HLR) models examined relationships between factors and opioid-ADEs. Early clinical signs and symptoms of deterioration were examined. RESULTS: Twenty five children with opioid-ADEs and 98 children without events were included. ASA-PS remained an independent risk factor (odds ratio, 2.56 [1.09, 6.03]; P = 0.031), while adjuvant nonopioids a risk reduction factor for opioid-ADEs (OR, 0.16 [0.05, 0.47]; P = 0.001) and need for rescue (0.14 [0.04, 0.47]; P = 0.001). Supplemental oxygen use at PACU discharge was associated with an increased odds of opioid-ADEs (OR, 3.72 [1.35, 10.23]; P = 0.007) and need for rescue (5.5 [1.7, 17.82]; P = 0.002). CONCLUSIONS: Findings from this study suggest that strategies such as early use of adjuvant nonopioids may reduce risk of opioid-ADEs postoperatively. Furthermore, children who require supplemental oxygen early postoperatively may be at heightened risk of later events.

Neurokinin-1 receptor antagonists for the prevention of postoperative nausea and vomiting.

Despite the availability of several classes of antiemetics, postoperative nausea and vomiting (PONV) remains a substantial burden for patients following surgery, resulting in patient dissatisfaction and prolonged stays in post-anesthesia care units and ultimately increasing the cost of care. Enhanced recovery protocols and PONV management guidelines are now centered on the assessment of the individual patient's risk for developing PONV, as well as multimodal prophylaxis using antiemetics targeting different mechanisms of action. Over the last two decades, the neurokinin-1 receptor (NK1R) has emerged as a therapeutic target for the management of PONV. This review of the literature explains the role of the NK1R and its ligand-substance P-in vomiting, describes the pharmacologic and pharmacokinetic properties of NK1R antagonists (NK1RAs) and summarizes the clinical evidence supporting NK1RAs for PONV prophylaxis in patients undergoing surgery. In particular, we discuss the therapeutic application of NK1RA in PONV prophylaxis protocols owing to their advantages over other antiemetic classes in efficacy, duration of efficacy, safety, pharmacology, and ease of administration. Future studies will be aimed at further investigating the efficacy and safety of NK1RA-based multimodal combinations, particularly among vulnerable populations (e.g., children and elderly).

Comparative Effectiveness of Amiodarone and Lidocaine for the Treatment of In-Hospital Cardiac Arrest.

BACKGROUND: American Heart Association Advanced Cardiac Life Support (ACLS) guidelines support the use of either amiodarone or lidocaine for cardiac arrest caused by ventricular tachycardia or ventricular fibrillation (VT/VF) based on studies of out-of-hospital cardiac arrest. Studies comparing amiodarone and lidocaine in adult populations with in-hospital VT/VF arrest are lacking. RESEARCH QUESTION: Does treatment with amiodarone vs lidocaine therapy have differential associations with outcomes among adult patients with in-hospital cardiac arrest from VT/VF? STUDY DESIGN AND METHODS: This retrospective cohort study of adult patients receiving amiodarone or lidocaine for VT/VF in-hospital cardiac arrest refractory to CPR and defibrillation between January 1, 2000, and December 31, 2014, was conducted within American Heart Association Get With the Guidelines-Resuscitation (GWTG-R) participating hospitals. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were 24 h survival, survival to hospital discharge, and favorable neurologic outcome. RESULTS: Among 14,630 patients with in-hospital VT/VF arrest, 68.7% (n = 10,058) were treated with amiodarone and 31.3% (n = 4,572) with lidocaine. When all covariates were statistically controlled, compared with amiodarone, lidocaine was associated with statistically significantly higher odds of the following: (1) ROSC (adjusted OR [AOR], 1.15, P = .01; average marginal effect [AME], 2.3; 95% CI, 0.5 to 4.2); (2) 24 h survival (AOR, 1.16; P = 004; AME, 3.0; 95% CI, 0.9 to 5.1); (3) survival to discharge (AOR, 1.19; P < .001; AME, 3.3; 95% CI, 1.5 to 5.2); and (4) favorable neurologic outcome at hospital discharge (AOR, 1.18; P < .001; AME, 3.1; 95% CI, 1.3 to 4.9). Results using propensity score methods were similar to those from multivariable logistic regression analyses. INTERPRETATION: Compared with amiodarone, lidocaine therapy among adult patients with in-hospital cardiac arrest from VT/VF was associated with statistically significantly higher rates of ROSC, 24 h survival, survival to hospital discharge, and favorable neurologic outcome.

Treating Prehospital Pain in Children: A Retrospective Chart Review Comparing the Safety and Efficacy of Prehospital Pediatric Ketamine and Opioid Analgesia.

Prior to 2020, pain management in the Washtenaw/Livingston County Medical Control Authority (W/L MCA) Emergency Medical Service (EMS) system in Southeast Michigan was limited to morphine, fentanyl, ketorolac, and acetaminophen. Based on the increasing evidence describing its safety and efficacy, ketamine was added to local protocols for pain management. This study aimed to evaluate differences in pain management and adverse effects of ketamine and opioid administration. Data from pediatric patients who received ketamine or an opioid in the W/L MCA EMS system from October 2019 to March 2021 were analyzed. The primary outcome was the difference in pain score, and the secondary outcome was adverse effects observed after analgesic administration. The decrease in pain scores was greater among ketamine patients (mean: 5.2) compared to opioid patients (mean: 2.9), p < 0.001. The prevalence of adverse effects was higher among patients in the ketamine group (28.6%) compared to patients in the opioid group (2.4%, p < 0.001). Of 14 patients who received ketamine, one 17-year-old male experienced mild anxiety (7.1%), two teenage females experienced mild dissociation (14.3%), and one 20-year-old female experienced mild nausea (7.1%). Overall, ketamine is a safe and effective option compared to opioids for pediatric patients experiencing moderate to severe prehospital pain.

Implementation Strategies for Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) to Prevent Neonatal Medication-Induced Kidney Injury.

Acute kidney injury (AKI) is a common complication among patients admitted to the neonatal intensive care unit. Nephrotoxic medications (NTMs) are known to increase the incidence of AKI, but the use of these -medications is often unavoidable. Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) is a -quality improvement (QI) project that may be implemented at individual institutions and aims to systematically identify AKI in neonates and infants receiving NTMs. The purpose of this review is to describe nephrotoxic AKI in the neonatal population, introduce the Baby NINJA QI project and its potential to reduce neonatal AKI, and outline strategies for effective implementation of Baby NINJA.

A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.

BACKGROUND: As with the use of any therapy involving opioids, patient-controlled analgesia (PCA)-related errors can lead to overdose and even death. "Smart" (computerized) pumps have medication safety enhancements, particularly those related to operator errors during administration, to improve overall safety and efficacy. After the occurrence of PCA-related errors that occurred at a tertiary care academic medical center, an analysis of PCA errors was conducted. The introduction of smart pumps was identified as a possible solution, and the medical center adopted the technology in 2006. A study was conducted to investigate the impact of implementation. METHODS AND RESULTS: The study had three primary objectives: (1) to evaluate history logs stored in the smart PCA pumps to characterize the nature of hard and soft stop alerts and identify potential errors that may have been averted, (2) to examine the impact of smart PCA pumps on voluntarily reported PCA therapy-related errors, and (3) to assess nursing perceptions regarding the improvement in safety due to the introduction of smart PCA pumps. The smart pumps potentially prevented 159 errors for the January-June 2007 period; upper hard limits had the most number of alerts, representing avoidance of errors with the greatest potential to be detrimental to the patient. In addition, pump-programming errors due to wrong concentration were eliminated after implementation. Finally, nursing staff perceived smart pumps to be valuable in improving patient safety. CONCLUSIONS: Smart PCA pumps had an important positive impact on PCA-related patient safety at the medical center. Other facilities should adopt PCA devices with additional safety features such as bar-code verification of the drug and concentration, as well as dosage limits, to prevent pump-programming errors.

A systematic approach to improving medication safety in a pediatric intensive care unit.

Safety and quality improvement are major issues in children's hospitals. Improving pediatric medication safety often takes on a larger role in pediatric units than in adult units due to the larger size differences and dose ranges found in a pediatric intensive care unit. This article reviews the literature and our own experience at the CS Mott Children's Hospital, University of Michigan, to improve medication safety. The issues identified include (1) an effective pediatric medication safety governance structure within a larger hospital, (2) practice standardization strategies for physicians, nurses, and pharmacists, (3) use of pharmacy technicians as unit medication managers, which reduces medication costs and decreases nursing time spent hunting for medications, and (4) methods to improve the safety culture in a pediatric intensive care unit.

Transportation of a commercial premixed intravenous insulin product through a pneumatic tube system.

PURPOSE: Delivery of insulin products via pneumatic tubes is often avoided in health systems, as agitation may cause insulin proteins to destabilize, resulting in loss of function through denaturation, aggregation, or other processes. The actual loss of potency due to delivery via pneumatic tubes has not been reported for new, ready-to-use insulin products. METHODS: Samples were drawn from 7 commercial intravenous (IV) bags containing a 100 units/100 mL premixed solution of regular insulin in sodium chloride injection (Myxredlin, Baxter). The bags were then exposed to 7 unique long-distance pneumatic tube routes. The posttransportation bags were visually inspected for evidence of foaming. Samples were drawn from the posttransportation bags and insulin concentrations were analyzed via an enzyme immunoassay and compared to pretransportation concentrations. RESULTS: All seven posttransportation insulin samples were within 10% of their respective pretransportation sample. No foaming was observed in any of the Myxredlin bags after transportation through the pneumatic tube system. CONCLUSION: Transporting 100 unit/100 mL Myxredlin i.v. bags through a pneumatic tube system does not result in a clinically significant loss of potency. Therefore, delivery of this drug product via a pneumatic tube system to patient care areas can be considered in daily practice.

Low-Dose Ketamine Infusion as Adjuvant Therapy during an Acute Pain Crisis in Pediatric Patients.

Recent studies in pediatric patients have suggested that ketamine, an N-methyl-D-aspartate receptor (NMDA) antagonist, given at sub-anesthetic doses can effectively decrease pain scores, provide analgesic effects, and in some cases, reduce opioid requirements. Our study aims to assess impact of low-dose ketamine on reducing pain scores and total opioid requirements during an acute pain crisis in pediatric patients. From November 2016 to December 2018, eight patients between the ages of 2 and 17 years admitted to the pediatric intensive care unit (PICU) were treated with LDK infusions to manage severe, opioid-refractory, acute pain crises. Subjective pain scores and total morphine milligram equivalent (MME) intake before, during, and after ketamine infusion were collected through a structured chart review. Overall, the addition of ketamine appeared to reduce subjective pain scores and opioid requirements. Two patients were in palliative care and expired shortly after ketamine was started and two patients were discharged within 48 hours of LDK infusion cessation. Ketamine seemed to reduce heart rate and had no appreciable effect on respiratory rate, blood pressure, or oxygen saturation. Hallucination was reported in one patient which resolved upon dose reduction. LDK infusion could be considered as an adjuvant therapy to optimize pain control in pediatric patients experiencing acute pain crises. Further investigation with a larger patient population is warranted to establish the effects of LDK on pain improvement and reducing total opioid requirements.