ABSTRACT
OBJECTIVES: This study aims to determine the prevalence and factors associated with unrounded doses ordered via a computerized prescriber order entry (CPOE) system among children during a 1-week reference period. METHODS: This retrospective, cross-sectional study included children younger than 18 years admitted during a 7-day period. An unrounded dose was defined as an unrounded actual dose (eg, dose calculated to the tenths place for non-neonatal intensive care (non-NICU) patients and dose calculated to the hundredth place for NICU patients) or unrounded volume per dose [eg, <0.1 mL for non-NICU patients and <0.01 mL for NICU patients]. A multilevel logistic regression model was used to determine the prevalence and factors associated with unrounded doses via a CPOE system with adjustment for clustering effects. RESULTS: A total of 395 patients were admitted with 391 receiving medications. The overall prevalence of unrounded doses was 30% among the 2426 doses administered. Patients on the NICU team had the highest prevalence of unrounded doses. The odds of an unrounded dose were 4% (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.98) lower with each additional kilogram increase in weight after controlling for age, route, scheduled versus as-needed administration, and cluster effects. CONCLUSIONS: The prevalence of unrounded doses was higher than in previous studies. It was higher in smaller children after controlling for age, medication-related variables, and clustering. Future studies should focus on the role of CPOE in preventing unrounded and unmeasurable doses and if these strategies affect clinical outcomes (eg, adverse drug events).
ABSTRACT
Tolerance is a complication of fentanyl continuous infusions (CINs) in critically ill children, but the incidence and time of onset are lacking. The primary objective was to identify the incidence of tolerance. Secondary objectives were to determine the onset time and compare risk factors between children with tolerance versus no tolerance and between children with early (< 24 hours) versus late tolerance. Children aged 0 to 17 years, receiving fentanyl CIN > 3 days from May 1, 2012 to June 30, 2013 were included. Tolerance was defined as a doubling of the fentanyl CIN dose. Descriptive and inferential statistics were performed. A logistic regression model was used to assess the relationship between the development of tolerance and independent variables. A total of 59 CINs were included. Tolerance occurred in 46 CINs (78%), with median time to tolerance of 26 hours (range: 1-160 hours). Early tolerance was identified in 21 CINs (45.7%). Patients with tolerance had higher peak CIN doses (p < 0.001), final CIN doses (p = 0.031), and cumulative exposure (p = 0.017). No significant differences were noted between those with early versus late tolerance. The regression model noted factors associated with the odds of development of tolerance were lower initial fentanyl dose (p = 0.007; odds ratio [OR]: 0.011, 95% confidence interval [CI]: 0.0004-0.29) and higher cumulative exposure (p = 0.009; OR: 1.01, 95% CI: 1.001-1.01). Tolerance developed in 78% of children, and half developed it within 24 hours. Lower initial opioid dose and higher cumulative exposure were independently associated with tolerance.
ABSTRACT
Recent reports have described increased risk of acute kidney injury (AKI) in adults receiving concomitant vancomycin and piperacillin/tazobactam, but few reports exist in children. We describe an 8-year-old girl who was admitted to the pediatric intensive care unit with respiratory distress secondary to pneumonia. She began treatment with vancomycin and piperacillin/tazobactam. She developed AKI, and piperacillin/tazobactam and vancomycin were discontinued. Following a furosemide infusion, her AKI resolved and serum creatinine returned to baseline. She later resumed piperacillin/tazobactam monotherapy for multidrug-resistant tracheitis with no evidence of AKI and was eventually discharged to a long-term care facility. The Naranjo probability scale supports a probable drug-related adverse event. Clinicians must be aware of the possibility of AKI with this combination and should monitor renal function and vancomycin concentrations vigilantly. Future prospective studies are needed to explore the incidence and clinical characteristics associated with AKI after this combination in children.
ABSTRACT
OBJECTIVE: Intrathecal (IT) morphine improves pain control and decreases opioid requirements in children following thoracic and abdominal surgery. However, studies in children report variable durations of analgesia following IT morphine. The purpose of this study is to describe the duration of analgesia in children undergoing surgical correction of idiopathic scoliosis. DESIGN: Retrospective chart review. SETTING: Pediatric hospital within a tertiary care academic medical center. PARTICIPANTS: Forty-four pediatric patients with idiopathic scoliosis who received IT morphine following posterior spinal fusion (PSF). MAIN OUTCOME MEASURE(S): Mean opioid exposure 0-12 hours and 13-24 hours post-IT morphine. RESULTS: Mean opioid exposure was significantly increased during the 13-24-hour compared to the 0-12-hour time period (23.0 ± 12.5 mg parenteral morphine vs 15.9 ± 1.7 mg; p = 0.0006). The only factors significantly associated with morphine exposure during the 0-12-hour period included the median pain score (0-12 hours) (odds ratio [OR], 1.92; 95% confidence interval [CI], 0.033-3.80; p = 0.046) and total acetaminophen dose (OR, 0.003; 95% CI, 0.0008-0.005; p = 0.011). CONCLUSIONS: These data indicate that patients experienced improved analgesia for at least 12 hours following IT morphine. Increased use of adjuvant analgesics such as acetaminophen may reduce opioid requirements following PSF procedures. More studies are needed to investigate the combination of adjuvants and IT morphine to reduce postoperative pain in this population.
