Acetazolamide in critically ill neonates and children with metabolic alkalosis.

BACKGROUND: Acetazolamide is an option for hypochloremic metabolic alkalosis, but there are limited reports in children. OBJECTIVE: To describe the acetazolamide regimen and outcomes in critically ill children with metabolic alkalosis. METHODS: This was a descriptive, retrospective study of patients <18 years of age who received ≥3 doses of acetazolamide for metabolic alkalosis (ie, pH > 7.45 and bicarbonate [HCO3] > 26 mEq/L). Patients receiving other treatments for metabolic alkalosis within 24 hours of acetazolamide were excluded. The primary objective was to identify the mean dose and duration of acetazolamide. Secondary objectives were to determine the number of patients with treatment success (ie, serum HCO3 22-26 mEq/L) and occurrence of adverse events. RESULTS: Thirty-four patients were included for analysis, the median age was 0.25 years (range = 0.05-12 years). The acetazolamide regimen included a mean dose of 4.98 ± 1.14 mg/kg for a mean number of 6.1 ± 5.3 (range = 3-24) doses. The majority (70.6%) received acetazolamide every 8 hours. Treatment success was achieved in 10 (29.4%) patients. Statistically significant differences were noted between the pre-acetazolamide and post-acetazolamide pH and HCO3, 7.51 ± 0.05 versus 7.37 ± 0.05 (P < .001) and 39.4 ± 6.1 mEq/L versus 31.4 ± 7.5 mEq/L (P < .001), respectively. CONCLUSIONS: This is the first study to evaluate acetazolamide dosing for metabolic alkalosis in children with and without cardiac disease. Acetazolamide treatment resulted in improved HCO3, but the majority of patients did not achieve our definition of treatment success. Future studies should elucidate the optimal acetazolamide regimen.

Implementation of a bowel regimen protocol in critically ill children: A pilot study.

No studies have evaluated the outcomes of a bowel regimen (BR) in critically ill children receiving enteral nutrition. In fall 2010, a comprehensive feeding protocol and BR protocol were initiated in our institution. Six age-based BR protocols were developed, each of which included a four-step approach. This retrospective study evaluated children <18 years of age who received the BR between July 18, 2010 and April 31, 2012. The primary objective was to determine the percentage of patients requiring BR escalation beyond the initial step in the protocol (Step 1). Secondary objectives included the number of patients with a protocol deviation and the frequency of adverse events. Fifty-four patients were included. The majority were male with a median age of 0.25-year-old (range 0.08-15 yr). Forty-three (79.6%) patients received opioid continuous infusions. The BR was initiated on pediatric intensive care unit day 1 (range 1-25 d). Thirty patients (55.6%) required escalation beyond "Step 1". All patients who received "Step 2" and "Step 3" had a protocol deviation. Opioid duration was significantly associated with protocol escalation (odds ratio, 0.83; 95% confidence interval 0.689-0.997; P = 0.047). This pilot study is the first to describe the outcomes of the implementation of a four-step BR in critically ill children. Future studies should focus on the optimal regimen to alleviate constipation in critically ill children.