RESUMEN
OBJECTIVE: To identify and evaluate dose errors on medication orders that bypassed pharmacist verification in a pediatric emergency department (PED). METHODS: Descriptive, retrospective study about dose errors in an academic PED over 1 year. A report of automatically verified orders (those that bypassed pharmacist verification) was obtained from the electronic medical record. Potential medication dose errors were defined as those greater than 20% above or below standard dose ranges by age or weight. A retrospective chart review was performed for all identified dose errors. For orders deemed erroneous, additional metrics collected included order time of day and day of week and provider training level. RESULTS: A total of 46,185 medication orders were placed; 32,928 (71%) bypassed pharmacist review. Altogether, 676 orders (2%) were outside standard dose ranges. Ondansetron represented 569 of the 676 orders; most were doses rounded down to 4 mg and technically qualifying as underdoses, but were attributed to practice variance and not further analyzed. The number of orders deemed potentially erroneous was 107: most were wrong dose (75 overdose and 21 underdose), 5 were wrong patient, and 6 were wrong formulation. Ibuprofen, benzodiazepine, and corticosteroid orders had the most errors. No errors resulted in identifiable harm to the patient: 49 were near misses, and 47 reached the patient with no evident harm. CONCLUSIONS: The overall number of dose errors in autoverified orders was low. Certain medications or ordering modalities may be targeted to enhance patient safety and satisfaction.
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Errores de Medicación , Farmacéuticos , Niño , Registros Electrónicos de Salud , Servicio de Urgencia en Hospital , Humanos , Estudios RetrospectivosRESUMEN
OBJECTIVES: To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost. DESIGN: This is a pre- and postimplementation quality improvement study. SETTING: An 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital. PATIENTS: Patients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion. INTERVENTIONS: Change in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs. MEASUREMENTS AND MAIN RESULTS: Timing studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p < 0.01). Nursing satisfaction increased from 19.3% pre- to 100% post implementation. Safety was assessed via barcode scanning compliance, which decreased by 1.4% for patients and 1% for medications, and smart pump limit overrides. The percentage of infusion pump bolus overrides increased as expected, with the majority (99%) of these exceeding soft maximum limits by less than two-fold. Central line entries were unaffected post implementation. To assess medication utilization, a total of 50 patients in each intervention group were selected for retrospective chart review. Daily fentanyl boluses increased from one to three (p = 0.021). However, midazolam infusion dose and fentanyl infusion duration decreased (p = 0.026 and p = 0.005, respectively). Medication utilization was otherwise unchanged post implementation (p > 0.05). Annualized cost avoidance was $124,160. CONCLUSIONS: Implementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.
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Cuidados Críticos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Mejoramiento de la Calidad/estadística & datos numéricos , Atracurio/administración & dosificación , Atracurio/análogos & derivados , Niño , Preescolar , Dexmedetomidina/administración & dosificación , Femenino , Fentanilo/administración & dosificación , Humanos , Lactante , Infusiones Intravenosas , Inyecciones Intravenosas , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Masculino , Midazolam/administración & dosificación , Morfina/administración & dosificación , Bromuro de Vecuronio/administración & dosificaciónRESUMEN
OBJECTIVE: To evaluate the efficacy and safety of alteplase infusions and alteplase local instillations (dwells) to clear partially occluded central venous catheters in critically ill children. DESIGN: Retrospective study. SETTING: PICU in a single, tertiary care, academic children's hospital. PATIENTS: Retrospective review of the medical records of all critically ill pediatric patients less than 18 years old who received an alteplase infusion or dwell as the treatment for a partial central venous catheter occlusion. The typical infusion regimen was to administer 0.1 mg/kg of body weight (maximum, 2 mg/dose) of alteplase in 25 mL of 0.9% sodium chloride over 3 hours. The standard dwell was to administer and aspirate alteplase in a 1 mg/mL concentration as a fixed dose as ordered by the prescriber (maximum, 2 mg/dose). Efficacy was defined as documentation of positive blood return from the catheter. Radiology reports, nursing and physician documentation, and laboratory values were reviewed to assess for bleeding events. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred fifty occlusion events were included for analysis. Overall, 72 of 84 alteplase infusions (86%) and 53 of 66 alteplase dwells (80%) resulted in resolution of the lumen occlusion event as documented by positive blood return from the catheter after a maximum of two doses (p = 0.39). One major bleeding event occurred in each arm; both were deemed unlikely related to alteplase. CONCLUSIONS: Alteplase infusions to clear partially occluded central venous catheters appear to be as efficacious as alteplase dwells in critically ill children. In occlusions treated with an infusion, more occlusions resolved in older and larger patients and in patients with catheters in place less than 7 days. In occlusions treated with a dwell, more occlusions resolved in smaller catheters. The safety profile for both infusions and dwells was acceptable for the pediatric critically ill population.
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Obstrucción del Catéter , Catéteres Venosos Centrales , Fibrinolíticos/administración & dosificación , Activador de Tejido Plasminógeno/administración & dosificación , Cateterismo Venoso Central/instrumentación , Niño , Preescolar , Enfermedad Crítica , Femenino , Fibrinolíticos/efectos adversos , Humanos , Lactante , Infusiones Intravenosas , Instilación de Medicamentos , Masculino , Estudios Retrospectivos , Succión , Activador de Tejido Plasminógeno/efectos adversosRESUMEN
BACKGROUND: Despite the increasing incidence of venous thromboembolism (VTE) in hospitalized children, the risks and benefits of VTE prophylaxis, particularly for those hospitalized after trauma, are unclear. The Pediatric Trauma Society and the Eastern Association for the Surgery of Trauma convened a writing group to develop a practice management guideline on VTE prophylaxis for this cohort of children using the Grading of Recommendations Assessment, Development, and Evaluation framework. METHODS: A systematic review of MEDLINE using PubMed from January 1946 to July 2015 was performed. The search retrieved English-language articles on VTE prophylaxis in children 0 to 21 years old with trauma. Topics of investigation included pharmacologic and mechanical VTE prophylaxis, active radiologic surveillance for VTE, and risk factors for VTE. RESULTS: Forty-eight articles were identified and 14 were included in the development of the guideline. The quality of evidence was low to very low because of the observational study design and risks of bias. CONCLUSIONS: In children hospitalized after trauma who are at low risk of bleeding, we conditionally recommend pharmacologic prophylaxis be considered for children older than 15 years old and in younger postpubertal children with Injury Severity Score (ISS) greater than 25. For prepubertal children, even with ISS greater than 25, we conditionally recommend against routine pharmacologic prophylaxis. Second, in children hospitalized after trauma, we conditionally recommend mechanical prophylaxis be considered for children older than 15 years and in younger postpubertal children with ISS greater than 25 versus no prophylaxis or in addition to pharmacologic prophylaxis. Lastly, in children hospitalized after trauma, we conditionally recommend against active surveillance for VTE with ultrasound compared with routine daily physical examination alone for earlier detection of VTE. The limited pediatric data and paucity of high-quality evidence preclude providing more definitive recommendations and highlight the need for clinical trials of prophylaxis. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.
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Tromboembolia Venosa/etiología , Tromboembolia Venosa/prevención & control , Heridas y Lesiones/complicaciones , Adolescente , Factores de Edad , Niño , Niño Hospitalizado , Humanos , Puntaje de Gravedad del TraumatismoRESUMEN
BACKGROUND/PURPOSE: The aim of this study was to review evidence-based literature addressing pertinent questions about venous thromboembolism (VTE) after traumatic injury in children. METHODS: Data were obtained from English-language articles identified through Pubmed published from 1995 until November 2012, and from bibliographies of relevant articles. Studies were included if they contributed evidence to one of the following questions. In the pediatric traumatic injury population: (1) What is the overall incidence of VTE? (2) Is age (adolescence versus pre-adolescence) associated with higher VTE incidence? (3) Which risk factors are associated with higher VTE incidence? (4) Does mechanical and/or pharmacological prophylaxis impact outcomes? RESULTS: Eighteen articles were included in this systematic review. The evidence regarding each question was evaluated, graded by author consensus, and summarized. CONCLUSIONS: The overall incidence of VTE is low. Older (>13years) and more severely injured patients are at higher VTE risk. Additional factors including injury type or presence of a central venous catheter also place a patient at higher VTE risk. Implementation of a risk-based clinical practice guideline for VTE prophylaxis has been associated with reduced symptomatic VTE at one institution. Randomized, prospective trials analyzing outcomes of VTE prophylaxis in pediatric trauma victims are needed.
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Fibrinolíticos/uso terapéutico , Aparatos de Compresión Neumática Intermitente , Tromboembolia Venosa/prevención & control , Heridas y Lesiones/complicaciones , Adolescente , Factores de Edad , Cateterismo Venoso Central/efectos adversos , Niño , Terapia Combinada , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Factores de Riesgo , Resultado del Tratamiento , Tromboembolia Venosa/epidemiología , Tromboembolia Venosa/etiología , Heridas y Lesiones/terapiaRESUMEN
Illicit drug use continues to be a common problem among pediatric patients. Daily marijuana use among high school seniors is currently at a 30-year high. Marijuana use in adults has rarely been associated with cardiovascular adverse effects, including hypertension, tachycardia, arrhythmia, and myocardial infarction. Recently, abuse of synthetic cannabinoids, such as the incense "K2" or "Spice," has been increasingly reported in the lay press and medical literature. Overdose and chronic use of these substances may cause adverse effects including altered mental status, tachycardia, and loss of consciousness. Overdoses in adult patients have been described; however, limited reports in the pediatric population have been documented. A recent case series describes myocardial infarctions in pediatric patients, associated with synthetic cannabinoid use. In this report, we describe two adolescent patients admitted after they inhaled "K2," resulting in loss of consciousness, tachycardia, and diffuse pain.
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Consenso , Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/prevención & control , Guías de Práctica Clínica como Asunto , Tromboembolia Venosa/prevención & control , Heridas y Lesiones/complicaciones , Adolescente , Niño , Femenino , Humanos , Masculino , Estados Unidos , Tromboembolia Venosa/etiología , Heridas y Lesiones/cirugíaRESUMEN
Continuous renal replacement therapies (CRRT) are used to manage fluid overload and/or renal failure. The continuous nature of the fluid and solute removal has less impact on hemodynamic variables in critically ill patients, making CRRT preferred over intermittent hemodialysis for some patients in the intensive care arena. The impact of CRRT on drug removal is variable depending on the CRRT modality, the ultrafiltrate and dialysate flow rates, the filter, and the patient's residual renal function; all of these may change from patient to patient or even in the same patient depending on the clinical status. However, CRRT modalities are generally more efficient than intermittent hemodialysis at drug removal, in some cases approximating or even exceeding normal renal function, resulting in a significant risk of subtherapeutic dosing if conventional hemodialysis dosing recommendations are followed. This annotated bibliography provides a summary of publications analyzing drug removal during CRRT, including CRRT settings and drug clearance values found in each study. Caution is warranted as findings from one study may not be generalizable to all patients due to the many factors that influence drug removal. Serum drug concentrations should be monitored when available, and patient clinical status is exceedingly important for following expected and unexpected responses to drug therapies. Reviews on general drug dosing calculations in CRRT are available elsewhere.