RESUMO
Acute kidney injury (AKI) is a common medication adverse event, particularly in patients with pre-existing medical conditions taking nephrotoxic medications. However, little is known about the differences in the risk of nephrotoxic medication-related complications in children with autism spectrum disorder (ASD) compared to the general pediatric population. A nine-year-old non-verbal boy with ASD was hospitalized for scrotal cellulitis requiring vancomycin and piperacillin/tazobactam due to a lack of clinical response to cephalosporins. His history is significant for being an extremely selective eater, and his appetite decreased over four months prior to presentation. Poorly controlled scrotal pain, despite acetaminophen use, was suspected based on his facial expressions and maternal assessment, especially considering his non-verbal status. Consequently, a non-steroidal anti-inflammatory drug was initiated. The hospital course was complicated by the development of a scrotal abscess, minimal enteral intake, hypoalbuminemia-induced intravascular dehydration, oliguria, and generalized edema. His creatinine increased to 5.11 mg/dL from 0.51 mg/dL despite early discontinuation of nephrotoxic medications and fluid resuscitation, which led to hemodialysis due to worsening AKI. Subsequently, urinary output and edema improved. Creatinine improved to <1 mg/dL with careful creatinine monitoring and concomitant furosemide and albumin infusion in the pediatric intensive care unit. Children with comorbidities, such as malnutrition, who require nephrotoxic medications, need extra attention. Implementing clinical decision support tools or quality improvement programs can promote the prevention of nephrotoxic medication exposure and decrease the incidence of AKI. An alert within an electronic health record system for multiple nephrotoxic drugs and daily multidisciplinary huddles during patient-centered rounds could help reduce and eliminate adverse events. In particular, for non-verbal patients or those with limited communication skills, such as children with ASD, rigorous and close monitoring of vital signs, physical condition, pain, medication intake, and lab results, in addition to a nephrotoxic medication screening and notification system, should be key to optimizing patient care.
RESUMO
Introduction: Residents have been known to report a lack of self-efficacy in their ability to provide care for limited English proficiency (LEP) patients. Interpreters must be utilized to help navigate these patient encounters, but many institutions do not have a curriculum focused on utilizing interpreters effectively. Methods: We created a 3-hour workshop for physician learners working with the pediatric population. It included a panel discussion, best-practices presentation, video demonstration, observing scenarios, and pre- and postworkshop objective structured clinical exams (OSCEs). The first OSCE introduced learners to a scenario (4-day-old with jaundice with an LEP parent) where interpreter use was imperative. The second OSCE allowed learners to perform another case (12-year-old with an abscess with an LEP parent) and practice newly obtained skills from the workshop. Both OSCEs were scored using a 16-item yes/no checklist. All pediatric residents filled out an eight-item survey to evaluate the workshop; a subset of that group performed the pre- and postworkshop OSCEs. Results: Forty pediatric residents attended the workshop and completed the survey. The workshop was well received, with the majority of residents stating they would change their current interpreter usage practices. Ten pediatric residents performed the pre- and postworkshop OSCEs; all improved their scores. Discussion: The workshop was effective in improving how residents navigated LEP encounters. It is applicable to learners of all levels who want to improve their communication skills to provide better care for LEP patients and can be tailored to fit the needs of a specific institution.