Implementation of a training program to improve pharmacy services for high-risk neonatal and maternal populations.

PURPOSE: A training program aimed at increasing pharmacists' role in the care of high-risk maternal, neonatal, and pediatric patients is described. SUMMARY: In preparation for the planned expansion of a large Ohio hospital's maternal and neonatal critical care services, the pharmacy department developed a training program to increase the knowledge and skill sets of staff pharmacists, especially those who lacked residency training. The program also supported the department's transition to an integrated patient-centered pharmacy practice model. Clinical practice guidelines, policy statements, and other sources were used to develop a series of 57 one-hour lectures on a wide range of topics in maternal-neonatal critical care. The lectures were delivered one morning each week, every other week, over 30 months, with additional case-based homework assigned; a passing score (80%) on all module examinations and homework assignments was required for continued course participation. Trainees who completed the voluntary program earned a certificate from the department head and continuing-education credit from the Ohio State Board of Pharmacy, and they were eligible to engage in expanded rounding and patient counseling activities. The program appeared to have a positive impact on patient satisfaction and efforts to reduce medication misadventures in the neonatal intensive care unit. CONCLUSION: The implementation of a training program to educate non-residency-trained pharmacists in selected areas of maternal, neonatal, and pediatric health care helped enable the expansion of pharmacy services to include admission, daily, and discharge counseling.

Neonates with hypoplastic left heart syndrome have ultrasound evidence of abnormal superior mesenteric artery perfusion before and after modified Norwood procedure.

OBJECTIVE: To a) describe superior mesenteric artery resistive index, as an estimate of perfusion, before and after modified Norwood; and b) assess incidence of diastolic flow reversal in the superior mesenteric artery before and after modified Norwood. DESIGN: Prospective observational trial. SETTING: Children's hospital pediatric intensive care unit. PATIENTS: Ten newborns with hypoplastic left heart syndrome. INTERVENTIONS: Ultrasound documentation of superior mesenteric artery diastolic flow direction and measurement of superior mesenteric artery resistive index 24-48 hrs before and 24-48 hrs after modified Norwood. MEASUREMENTS AND MAIN RESULTS: Seven males and three females were enrolled. There was no change between the superior mesenteric artery resistive index pre- vs. postoperatively-0.99 (95% confidence interval, 0.85, 1.12) vs. 1.07 (95% confidence interval, 1.0, 1.15) (p = .13). Incidence of retrograde diastolic blood flow in the superior mesenteric artery was not different pre- vs. postoperatively (70% vs. 50%, p = .41). No patients developed necrotizing enterocolitis and all survived to hospital discharge. CONCLUSIONS: Ultrasound measurements in neonates with hypoplastic left heart syndrome suggest that superior mesenteric artery perfusion, as measured by resistive index, is impaired. Superior mesenteric artery diastolic flow reversal is common before and immediately after modified Norwood.

Frequency and preventability of adverse drug reactions in paediatric patients.

PURPOSE: To evaluate the frequency, severity and preventability of adverse drug reactions (ADRs) in paediatric patients during the 6-year period from 1 January 1994 to 31 December 1999. METHODS: Data on patient demographics, documented allergies, suspected drug, American Hospital Formulary Service drug classification and dosage regimen were collected retrospectively from ADRs reported to a hospital surveillance programme. ADRs were categorised by severity, preventability and causality. Analysis was conducted by Chi-square and Wilcoxon rank sum (Mann-Whitney) tests. RESULTS: During the 6-year period, 565 ADRs were reported at a rate of 0.85 ADRs per 100 admissions. The mean patient age was 9.6 years. No history of allergies was documented in 87.4% of the cases, although 2.8% of patients had a documented allergy to the suspected medication. Opioids (narcotics) [n = 65, 11.5%], anticonvulsants (n = 67, 11.9%) and antibiotics (n = 149, 26.4%) were the most frequently implicated drug classes. Over 50% of the reported ADRs resulted in treatment intervention and/or temporary patient harm and of these, 73% required drug therapy. Causality was classified as 'definite' (44.1%), 'probable' (49.9%) or 'possible' (6.0%). Of the reported ADRs, 20.7% were preventable. CONCLUSIONS: ADRs resulted in treatment intervention or temporary patient discomfort in >50% of patients. The incidence of preventable ADRs is similar to that found in adult literature. No single drug caused >5% of reported ADRs. Opioids, anticonvulsants and antibiotics were the most common drug classes associated with ADRs. Thus, strategies targeting these drug classes and interventions during the medication ordering and administration processes may reduce the number of ADRs and possibly the associated costs. Even though preventable ADRs may not be entirely eliminated, the goal should be to increase ADR awareness and encourage early detection and intervention to minimise patient discomfort.

Lipodystrophy in HIV-infected pediatric patients receiving protease inhibitors.

BACKGROUND: In adults with HIV infection, lipodystrophy syndrome may develop, characterized by peripheral wasting in the extremities, central obesity, hyperlipidemia, and insulin resistance. This syndrome occurs in HIV-positive pediatric patients who take protease inhibitors (PIs). However, the full characteristics of the syndrome in this population is not fully understood. OBJECTIVE: To evaluate the association between the use of PIs and the occurrence of lipodystrophy in HIV-infected children. METHODS: Pediatric patients attending an outpatient HIV clinic between 1994 and 2000 were prospectively enrolled. All patients were between 1 and 17 years of age and had received a PI for at least 1 month. The medical records were reviewed monthly for 3 months before PI therapy was started and then monthly for 36 months. At each evaluation, serum total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, triglycerides, and blood glucose concentrations were recorded, as well as physician-documented physical examination findings including subcutaneous fat in the arms, face, and legs, and abdominal girth. Baseline clinical and laboratory data were compared with follow-up data using a paired t-test. RESULTS: Twenty-one pediatric patients received a PI. Of these, 2 developed lipodystrophy, one at 15 months and one at 18 months after PI therapy was started. Neither child had had lipodystrophy before therapy. Twelve children who were taking ritonavir or nelfinavir, including 1 who developed lipodystrophy, developed abnormally high total cholesterol and triglyceride blood concentrations. All patients receiving indinavir also experienced a substantial increase in their triglyceride concentrations at follow-up evaluations, but no significant increases in total cholesterol occurred. Blood glucose concentrations were not significantly different between baseline and follow-up examinations in our patients. CONCLUSIONS: Lipodystrophy may occur in some HIV-infected children receiving PIs, and dyslipidemias may also develop in some patients taking these drugs.