Acetazolamide-Associated Acute Kidney Injury in Critically Ill Pediatric Patients.

OBJECTIVE: Our objective was to determine the incidence and risk factors for intravenous acetazolamide-associated acute kidney injury (AKI). METHODS: We utilized a retrospective cohort study including patients <19 years of age initiated on intravenous acetazolamide while admitted to an ICU. Data collection included patient demographics, clinical variables, acetazolamide dosing, and serum creatinine (SCr) values. Incidence of AKI was assessed per Kidney Disease Improving Global Outcomes criteria. Descriptive statistical analysis and ordinal logistic regression analysis were performed to determine the incidence of AKI and variables associated with AKI. RESULTS: A total of 868 patients met study criteria (male 55.8%, median age 0.66 years [IQR 0.19, 3.0 years]). Intravenous acetazolamide was administered at 5.1 ± 2.8 mg/kg/dose for a median of 4 doses (IQR 2, 6). Median baseline SCr was 0.28 mg/dL (IQR 0.22, 0.37), corresponding to a creatinine clearance of 115 ± 55 mL/min/1.73 m2. Acute kidney injury occurred in 26.8% (n = 233) of patients (stage I = 20.1%, stage II = 3.7%, stage III 3.1%), and no patients received renal replacement therapy. An ordinal logistic regression model identified an increased odds of AKI with cyclosporine, ethacrynic acid, and piperacillin-tazobactam administration. CONCLUSIONS: Acute kidney injury occurs frequently in critically ill pediatric patients receiving intravenous acetazolamide.

Impact of Body Habitus on the Outcomes of Pediatric Patients With Diabetic Ketoacidosis.

OBJECTIVE: To determine whether obese and overweight pediatric patients with new onset diabetic ketoacidosis (DKA) treated with continuous infusion insulin have increased time to subcutaneous insulin initiation or adverse events as compared with patients with normal body habitus. METHODS: A retrospective, cohort study was designed that included patients 2 to 18 years of age admitted with new onset DKA who received continuous infusion insulin from January 1, 2011, to December 31, 2017. Patients were stratified according to BMI percentile with the primary outcome of time to initiation of subcutaneous insulin. Secondary endpoints included time to minimum beta-hydroxybutyrate, and incidence of hypoglycemia or other adverse events. RESULTS: A total of 337 patients (46.6% male, 9.6 ± 3.8 years of age) met study criteria. Patients were classified by body habitus as obese (7.7%, n = 26), overweight (7.1%, n = 24), normal body weight (58.8%, n = 198), or underweight (26.4%, n = 89), based on BMI percentile. Most patients were initiated on insulin at 0.1 unit/kg/hr (86.7%) for 16.7 ± 7.0 hours. Time from continuous infusion insulin initiation to subcutaneous insulin was not different between body habitus groups, nor was hypoglycemia or the use of mannitol (p > 0.05). Median time to lowest beta-hydroxybutyrate was greater for obese (26.4, IQR [13.9, 41.9]) and overweight (32.4, IQR [18.3, 47.0]) groups than for normal body habitus patients (16.5, IQR [12.3, 23.8]) (p < 0.05). CONCLUSIONS: Time to subcutaneous insulin and adverse events was not associated with body habitus, but obese and overweight patients may have delayed beta-hydroxybutyrate clearance.

The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives.

BACKGROUND: High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. PURPOSE: This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. METHOD: An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. FINDINGS: A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. DISCUSSION: A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

Cytokine response to diabetic ketoacidosis and its treatment.

The objectives of this study were to monitor plasma cytokines as markers of cellular activation and as potential markers for the progression of the acute complications of diabetic ketoacidosis (DKA). Blood samples were obtained prior to, during and after treatment of severe DKA (pH < 7.2) in six children and adolescents. Plasma IL-10, IL-1beta, TNF-alpha, IL-6, IL-8 and IL-2 cytokine levels were assayed by ELISA at each of the time points. Prior to treatment, elevations of multiple cytokines were found, the highest being IL-10. Treatment of DKA resulted in a significant decrease of IL-10 at 6-8 h (p = 0.0062), and further increases in the inflammatory cytokines at 6-8 h and/or 24 h vs 120 h (baseline): IL-1beta (p =.0048); TNF-alpha (p =.0188) and IL-8 (p =.0048). This study strengthens the hypothesis that the metabolic crisis of DKA, and its treatment, have differential effects on cellular activation and cytokine release. The time frame for the increase in inflammatory cytokines correlates with the reported progression of subclinical brain edema, interstitial pulmonary edema and the development of clinical brain edema.

Lipid peroxidation and antioxidant vitamins prior to, during, and after correction of diabetic ketoacidosis.

Oxidative stress plays an important role in the chronic complications of insulin-dependent diabetes mellitus (IDDM). Hyperketonemia, as well as hyperglycemia, is involved in the generation of oxygen-free radicals. We have studied the degree of oxidative stress in six patients before, during, and after correction of diabetic ketoacidosis (DKA) by determining the plasma ratios of C20 and C18 fatty acids to C16 fatty acids in the cholesteryl esters of the lipoproteins as well as in the plasma concentrations of the antioxidant vitamins A, C, and E. Lipid peroxidation was slightly increased prior to treatment. However, the C20/C16 ratio at 120 h was significantly decreased in comparison to the ratio at pretreatment (P<.025), at 6-8 h (P<.005), and at 24 h (P<.025). The C18/16 ratio at 120 h was also decreased in comparison to the ratio at 6-8 h (P<.025), indicating an increase in lipid peroxidation after correction of DKA. Vitamin A was below normal at pretreatment and was increased at 120 h (P<.05). Vitamin C was normal at pretreatment and decreased to low normal at 24 h (P<.005). Vitamin E was normal at pretreatment and decreased to below normal at 24 and 120 h, although the changes were not statistically significant. These data demonstrate that there is an increase in lipid peroxidation after the correction of DKA and therefore support the position that administering antioxidant vitamins during the treatment of DKA could be beneficial in minimizing oxidative stress and possibly both the acute and chronic complications of IDDM.