Methylprednisolone dosing for pediatric critical asthma: a single-center cohort study.

OBJECTIVE: We aimed to characterize intravenous (IV) methylprednisolone (MP) dosing regimens and clinical outcomes for children hospitalized for critical asthma (CA). METHODS: A single-center, retrospective review was performed of children admitted to the pediatric intensive care unit (PICU) for CA between September 2015 and October 2019. Patients 5-to 17-year-olds, initiated on continuous nebulized albuterol, and prescribed at least one dose of IV MP were included. The primary outcome was to characterize PICU MP dosing. Cohorts were then compared by MP dosing: conservative-dose methylprednisolone (CDMP, ≤ 0.5 mg/kg/dose every 6 h) and standard-dose methylprednisolone (SDMP, > 0.5 mg/kg/dose every 6 h). Clinical efficacy endpoints were the duration of continuous nebulized albuterol and PICU length of stay (LOS). Safety endpoints included corticosteroid-related adverse events. RESULTS: Of 168 children studied, 50 (29.8%) were prescribed CDMP and 118 (70.2%) SDMP. The overall mean MP dose was 31.3 ± 19.6 mg (weight-adjusted: 0.77 ± 0.32 mg/kg/dose). Compared to those prescribed SDMP, those prescribed CDMP had a shorter median duration of continuous nebulized albuterol (12.8 [IQR: 10.5-20] versus 17.3 [IQR: 11.3-29.7] hours, p = 0.019) and median PICU LOS (0.9 [IQR: 0.7-1.4] versus 1.2 [IQR: 0.9-1.8] days, p = 0.012). No corticosteroid-related adverse events were observed. In adjusted models, weight-adjusted IV MP dose was not associated with PICU LOS or duration of continuous nebulized albuterol. CONCLUSIONS: Intravenous MP dosing for pediatric CA varied widely in our study sample. Prospective, controlled trials are required to validate our observations including clinical efficacy and safety endpoints.

Increasing Alprostadil Requirements in a Neonate With Cardiac Anomalies and Co-administration of Rectal and Oral Acetaminophen.

A patent ductus arteriosus (PDA) results from the failure of the ductus arteriosus to close within 72 hours after birth. In most neonates, a PDA can lead to significant morbidities and often warrants pharmacologic intervention for closure. Common pharmacologic interventions include indomethacin, ibuprofen, and acetaminophen. In cases of ductal-dependent congenital heart defects (CHDs), such as hypoplastic left heart syndrome, it is imperative to keep the ductus arteriosus patent to maintain adequate pulmonary or systemic circulation until surgical intervention can be performed. The only proven pharmacologic agent used for this indication is prostaglandin E1 (PGE1) commonly in the form of intravenous alprostadil. This case report describes a neonate with multiple cardiac and genetic anomalies that required increased alprostadil infusion after exposure to rectal and oral acetaminophen. The patient initially presented with a large PDA on echocardiogram (ECHO); however, after an incidental finding of a small PDA on ECHO, the administration of as needed rectal acetaminophen was discontinued out of concern for its effects on patency. After a few days of increased prostaglandin therapy and 2 reassuring ECHO results, the patient was given oral acetaminophen on an as needed basis. Within 24 hours of restarting the acetaminophen, the repeated ECHO showed a reduction in PDA and flow. In patients with ductal-dependent cardiac lesions, it is important to maintain PDA patency and, therefore, introducing a medication with antiprostaglandin properties should be avoided.