Efficacy of a Flavored Lubricating Oral Spray on Medication Swallowing in Older Individuals.

Background Difficulty swallowing occurs in up to 35% of patients 50 years of age or older and can contribute to medication nonadherence and other alterations. The use of a flavored lubricating spray, available over-the-counter and found to be helpful in children to swallow oral solid medications, is not well studied in older adults. Objective To evaluate the effect of a flavored lubricating spray on the ability to swallow oral solid medication in older people. Methods A randomized, open-label, crossover study included community-dwelling individuals 65 to 88 years of age who took at least one solid oral medication daily and were not diagnosed with dysphagia, Parkinson's disease, or esophageal tumor. Participants were randomized to the strawberry-flavored lubricating spray or usual care and then crossed over to the alternate option. The median rating for swallowing difficulty for their regular medications was compared using a Likert scale, from 1 (very difficult) to 5 (very easy). To provide a degree of standardization between participants, all participants were also instructed to swallow a vitamin C (1,000 mg) tablet both with and without the flavored spray and rate their difficulty swallowing the tablet using the same Likert scale. Results There were 39 (90.7%) participants who completed the study. The median rating for swallowing difficultly was 5 (very easy) with the spray vs. 4 (easy) with usual care (P < 0.0001). For the 66.7% who took the vitamin C tablets, the median rating for swallowing difficulty was 5 (very easy) with the spray vs. 3.5 (between neutral and easy) without (P < 0.0001). There were 94.8% of participants who found the spray easy/ very easy to use, and 89.7% reported it tasted okay to delicious. Conclusion The use of a flavored lubricating spray provided an effective and easy-to-use tool to make medication swallowing easier in community-dwelling older adults without a diagnosis associated with difficulty swallowing.

Medical Outcomes of Acute Aspirin Single Substance Poisoning in Pediatric Patients.

BACKGROUND: A consensus guideline on salicylate poisoning recommends referring patients to the emergency department if they ingested 150 mg/kg of aspirin. The dose of aspirin associated with severe poisoning in pediatric patients has not been investigated. OBJECTIVE: This study aims to associate medical outcomes with aspirin overdoses in patients 5 years old and younger. METHODS: A retrospective review of data on pediatric patients with single substance aspirin exposures reported from poison centers across the country was conducted. The primary endpoint was to associate aspirin doses with medical outcomes. Secondary endpoints included evaluation of the signs, symptoms, and treatments of ingestion and their association with medical outcomes. RESULTS: There were 26 488 included exposures with aspirin exposures resulting in no effect (92.5%), minor effect (6.0%), moderate effect (1.4%), major effect (0.2%), and death (0.02%). There were 8921 cases with available weight-based dosing information. Median doses associated with no effect, minor effects, moderate effects, major effects, and death ranged between 28.4 and 40.9 mg/kg, 52.5 and 82.3 mg/kg, 132.1 and 182.3 mg/kg, 132.3 and 172.8 mg/kg, and 142.2 and 284.4 mg/kg, respectively. Minor effect and moderate effect exposures were more likely to have alkalinization documented compared to no effect exposures (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.41-2.17; OR = 1.79, 95% CI = 1.12-2.86). There was no difference in rates of alkalinization between minor and moderate exposures (OR = 1.02, 95% CI: 0.61-1.7). CONCLUSIONS AND RELEVANCE: Reevaluation of the current recommendation of 150 mg/kg for referral to a healthcare facility is necessary for pediatric acute salicylate overdoses.

Pediatric Practitioner Knowledge of Arsenic in Baby Food.

OBJECTIVE: Rice, one of the first solid foods introduced to infants, is 10 times more absorbent of inorganic arsenic than any other grain. An evaluation has not been performed about practitioner knowledge of arsenic content in infant foods. The purpose of this survey was to determine pediatric practitioners' knowledge of current US Food and Drug Administration (FDA) recommendations to limit exposure to arsenic-containing foods in infants. METHODS: This was a convenience sample of pediatric practitioners conducted as an online survey. The survey contained 19 questions related to knowledge of arsenic-containing foods, FDA recommendations, practitioner recommendations on feeding infants, and demographic information. Participants were recruited using organization list servs. Participants were reminded to complete the survey 2 months after the initial email. An infographic on arsenic was provided at the end of the survey. RESULTS: One hundred thirty-seven individuals completed the survey. The majority of respondents were physicians or pharmacists and have been in practice less than 6 years. Nine percent of respondents (11/123) stated the FDA arsenic limit of 100 ppb. Sixteen percent (20/123) identified white rice as having a lower inorganic arsenic content than brown rice and 27% (36/132) identified that there is no difference in inorganic arsenic content between organic infant rice cereal and conventional infant rice cereal. CONCLUSIONS: The vast majority of participants were not aware of the FDA's proposed limit on arsenic consumption or the concern of heavy metals in baby foods. More education is needed to increase knowledge regarding arsenic in baby foods.

A method for the tribological assessment of oral pharmaceutical liquids.

OBJECTIVE: Patient acceptance of pediatric formulations is critical to compliance and consequently therapeutic outcomes; thus, having an in vitro method to evaluate sensory perception of pharmaceutical products would be beneficial. The objective of this research is to develop a sensitive and reproducible tribological method to characterize pharmaceutical suspensions at low force and sliding speeds. METHODS: The discriminating potential of the method was examined using tribology profiles (coefficient of friction (COF) vs. sliding speed) for commercially available products and products made for this study with widely varying sweetness, thickness, and grittiness; these formulations were used to judge the sensitivity of the method. Samples were measured using 3M Transpore™ surgical tape to simulate the tongue surface, steel half ring geometry, constant gap setting, target axial force of 2 N in a 600 s exponential ramp for rotation speed. RESULTS: The COF ranged from 0.1 to 0.6. For the speeds studied, the high viscosity commercial suspension ibuprofen drops and acetaminophen suspension show a classic Stribeck curve with an increasing COF at the higher rotation speeds, which indicates these formulations entered the hydrodynamic lubrication phase, while the lower viscosity suspensions only reached the mixed lubrication phase. CONCLUSION: The contribution of particles affects the COF in a dynamic tribologic pattern compared to products that are categorized as either low gritty or high viscosity. These results are important as they provide a potentially rapid in vitro method for screening pediatric medications and help to identify the factors that affect the palatability of pediatric formulations.

Performance of Verigene Rapid Diagnostic Testing for Detection of Inpatient Pediatric Bacteremia.

OBJECTIVE: Verigene blood culture panels comprise rapid diagnostic testing, which aids in early bacteremia species identification. This study determined the concordance of Verigene rapid diagnostic results compared with the Vitek reference standard in patients admitted to a children's hospital. METHODS: This was a 3-year retrospective observational study of neonatal and pediatric patients ≤18 years admitted to a children's hospital with confirmed bacteremia for whom Verigene testing was performed. Verigene testing was conducted on cultures with reported growth on Gram stain and final organism speciation confirmed via Vitek. Percent concordance and positive percent agreement with 95% CIs were calculated for Verigene panel-identifiable organisms. Negative percent agreement with 95% CIs was calculated for non-panel organisms. Time-to-result was calculated from Gram stain reporting to both Verigene and Vitek final organism susceptibility. RESULTS: One hundred thirty-five Gram-positive (GP) and 51 Gram-negative (GN) isolates were identified through Vitek. Verigene GP panel-detectable organisms were correctly identified 96.9% (125/129) at the genus level and 95.3% (123/129) at the species level. Overall positive percent agreement was 95.3 (CI: 90.2-98.3). Negative percent agreement was 83.3 (CI: 35.9-99.6) for the 6 non-panel GP organisms. All GN isolates were correctly identified on Verigene. Median time-to-result was 2.9 hours (IQR 2.6, 3.2) and 44.4 hours (IQR: 35.4, 52.5) for Verigene and final susceptibilities, respectively. There was a statistically significant time savings of 41.5 hours (CI: 29.8-53.2) for identification and detection of resistance markers (p < 0.0001). CONCLUSION: Verigene concordance at our institution aligns with results from previously published studies and can be considered a reliable clinical decision-support tool.

Validation of neonatal and paediatric antimicrobial stewardship treatment algorithms in rapid diagnostic-detected bacteraemia.

OBJECTIVES: Blood culture rapid diagnostic testing (RDT) aids in early organism identification and resistance gene detection. This information allows quicker transition to tailored antimicrobial therapy, improved patient outcomes and prevention of antimicrobial resistance. An antimicrobial treatment algorithm based on RDT results and local antibiograms can serve as a valuable clinical decision-support tool. This study assessed the proportion of appropriate antibiotic therapy recommendations using a novel paediatric RDT-guided treatment algorithm compared with standard care (SC) in paediatric bacteraemia. METHODS: This was a retrospective, observational study of admitted paediatric patients who received antibiotics for RDT-confirmed bacteraemia. Appropriateness of SC was compared with algorithm-recommended treatment. Antimicrobial appropriateness was defined as in vitro susceptibility to the organism identified through traditional microbiology. Clinical appropriateness took into consideration the ability to tailor therapy within 12 h of RDT results. Appropriateness was evaluated by two blinded, independent reviewers. KEY FINDINGS: Eighty-six blood cultures were included with 15 unique Gram-positive and Gram-negative species or genus identified. Comparative antimicrobial appropriateness of SC and algorithm-recommended treatment was 94.2% (81/86) and 100% (86/86), respectively (P = 0.06). Clinical assessment determined 39.5% (34/86) of SC patients were on appropriate therapy within 12 h of RDT result. Algorithm-recommended therapy was clinically appropriate in 97.7% (84/86) of patients (P < 0.001). There was a median time savings of 42.7 h (IQR 40.6, 49.4) for the patients able to be de-escalated as compared with waiting on final sensitivities. CONCLUSIONS: Algorithm-guided treatment may allow most patients to be de-escalated to organism-tailored therapy earlier in their therapeutic course.

Post-operative non-steroidal anti-inflammatory drug use for pain in infant and paediatric cardiac surgery patients.

BACKGROUND: Pain control is an important element of care for patients after surgery, leading to better outcomes, quicker transitions to recovery, and improvement in quality of life. The purpose of this study was to evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs in children after cardiac surgery. MATERIALS AND METHODS: Patients between the ages of 1 month and 18 years of age, who received intravenous or oral non-steroidal anti-inflammataory drugs after cardiac surgery, from November 2015 until September 2017 were included in this study. The primary endpoints were non-steroidal anti-inflammataory drug-associated renal dysfunction and post-operative bleeding. Secondary endpoints examined the effect of non-steroidal anti-inflammataory drug use on total daily dose of narcotics, number of intravenous PRN narcotic doses received, and pain assessment score. Data were analysed using descriptive statistics for frequencies and ranges. Multivariate analysis was performed to measure the association of all predictors and outcomes. Wilcoxon singed-rank test was performed for secondary outcomes. RESULTS: There was no association between the incidence of renal dysfunction and the use of or duration of non-steroidal anti-inflammataory drugs; in addition no association was found with increased chest tube output. There was a statistically significant reduction of patients' median Face, Legs, Activity, Cry, Consolability (FLACC) scores (2-0; p = 0.003), seen within first 24 hours after initiation of ketorolac, and a significant reduction of morphine requirements seen from day 1 to day 2 (0.3 mg/kg versus 0.1 mg/kg; p < 0.001) and number of as-needed doses. CONCLUSION: Non-steroidal anti-inflammataory drugs in paediatric cardiac surgery patients are safe and effective for post-operative pain management.

Assessing the Understanding of Pediatric-Oriented Medication Education Materials Versus Standard Available Education Materials.

OBJECTIVES: The objective of this study was to determine if education material targeting children would improve understanding of medication indication, administration, and common side effects in pediatric subjects. METHODS: This cross-sectional pilot study included students 7 to 11 years old from a suburban elementary school. Study participants were read either the US Food and Drug Administration-approved adult medication leaflet or a pediatric medication leaflet created at a first-grade reading level for levetiracetam (Keppra, UCB, Inc, Atlanta, GA). Students were asked a set of standardized survey questions to evaluate comprehension of side effects, medication indication, dosing frequency, administration, and overall impression of the leaflet. RESULTS: Fifty-eight children were included. Fifty percent of the children were male, 79% were Caucasian, and the average age was 9 years. There was no statistical difference for demographics in the adult leaflet versus the pediatric leaflet group. Children correctly stated the indication for the medication in 30% of participants (9/30) in the adult leaflet group and 79% of participants (22/28) in the pediatric leaflet group, p = 0.002. The administration frequency question was answered correctly in 93% of the pediatric leaflet group (26/28) as compared to 73% in the adult leaflet group (22/30), p = 0.05. For questions about side effects and how to administer the medication, there was no difference between the groups. The responses regarding readability and understanding of the leaflets were significantly different in the pediatric leaflet group compared to the adult leaflet group, p = 0.001 and p = 0.001, respectively. CONCLUSIONS: Leaflets designed for pediatric patients resulted in an improvement in the understanding of the indication for levetiracetam.

Pharmacist and Pediatrician Knowledge of Codeine Use in Children.

OBJECTIVES: In 2011, approximately 1.7 million pediatric patients had a codeine-containing prescription filled at a US retail pharmacy. Numerous cases involving serious adverse effects or fatalities have been reported in children who have been prescribed codeine. In 2013, the US Food and Drug Administration added a boxed warning to avoid codeine in children after a tonsillectomy. The purpose of this study is to determine pharmacists' and pediatricians' knowledge of the boxed warning for codeine in children. METHODS: Two separate surveys were administered to community pharmacists in Maryland, pediatricians, and pediatric residents at a single institution in Maryland. Both surveys consisted of questions regarding knowledge of the boxed warning for codeine in children. RESULTS: There was no difference in the awareness of the boxed warning between pharmacists (48.9%, n = 43) and pediatricians (51.3%, n = 41, p = 0.88). More pharmacists knew that ultrarapid metabolizers have the risk for increased adverse events from codeine (39.5% pharmacists vs. 20% pediatricians, p = 0.01). In addition, 36% of pharmacists and 33% of pediatricians noted that it was never appropriate to use codeine in a child (p = 0.73). CONCLUSIONS: Only half of pharmacists and pediatricians surveyed were aware of the boxed warning for codeine. One third of pharmacists and pediatricians in this study would never use codeine in a child. Therefore, more education is needed for pharmacists and pediatricians regarding the dangers of using codeine in children.

Identification of Factors Associated With the Desire to Participate in a Pediatric Pharmacy Practice-Based Research Network.

OBJECTIVES: To evaluate the practice-based research network (PBRN) potential within the Pediatric Pharmacy Advocacy Group (PPAG) membership and to identify characteristics associated with member willingness to join a PPAG PBRN. METHODS: In October 2016, a 21-question survey was sent by email to approximately 900 PPAG pharmacist members (excluding students) using contact information contained in the PPAG membership database. The survey elucidated information regarding training, clinical and research experience, practice site information, and willingness to participate in a PPAG PBRN. Descriptive statistics described the potential PBRN and multivariate logistic regression determined respondent characteristics associated with willingness to join the PBRN. RESULTS: Of 145 survey respondents (a 16% survey response rate), 92 selected "yes" regarding their willingness to participate in the PPAG PBRN. Acute care general pediatrics was the most common area where respondents desired to perform research (44.6% of "yes" respondents), with over 2500 patients/day collectively available. The most common selected limitations to research were time and size of available patient populations (59.8% and 47.8% of "yes" respondents, respectively). Cumulative hours/week members would be willing to devote to the PBRN was approximately 77 to 206. Publication of a retrospective study (OR 10.4, 95% CI 2.1-51.9, p = 0.004), research protected time (OR 4.9, 95% CI 1.4-17.8, p = 0.015), and affiliation with an academic medical center (OR 3.32, 95% CI 1.05-10.45, p = 0.04) were independently associated with willingness (a "yes" response) to join a PPAG PBRN. CONCLUSIONS: Within the PPAG membership, there is sufficient interest, expertise, patient exposure, and member time to develop a PBRN focused on pediatric pharmacotherapy. The identified characteristics associated with willingness to join the PBRN can help focus efforts for member involvement, education, and recruitment to ensure sustainability of the PPAG PBRN.

Pharmacists and Pediatric Medication Adherence: Bridging the Gap.

Pediatric medication nonadherence is a major problem in the United States health care system. Age of the child, lack of understanding about the disease or treatment, culture, socioeconomic status, family structure, schedule of medications, and taste can all contribute to this problem. Strategies that target interventions to the individual patient and family can be most effective. Pharmacists are at the forefront of patient care and can help children become more adherent to their medications through counseling and building a trusting relationship with the family. This article highlights some common problems to adherence and some solutions to increase adherence.

Vancomycin AUC/MIC and Corresponding Troughs in a Pediatric Population.

OBJECTIVES: Adult guidelines suggest an area under the curve/minimum inhibitory concentration (AUC/MIC) > 400 corresponds to a vancomycin trough serum concentration of 15 to 20 mg/L for methicillin-resistant Staphylococcus aureus infections, but obtaining these troughs in children are difficult. The primary objective of this study was to assess the likelihood that 15 mg/kg of vancomycin every 6 hours in a child achieves an AUC/MIC > 400. METHODS: This retrospective chart review included pediatric patients >2 months to <18 years with a positive S aureus blood culture and documented MIC who received at least two doses of vancomycin with corresponding trough. Patients were divided into two groups: group 1 initially receiving ≥15 mg/kg every 6 hours, and group 2 initially receiving any other dosing ranges or intervals. AUCs were calculated four times using three pharmacokinetic methods. RESULTS: A total of 36 patients with 99 vancomycin trough serum concentrations were assessed. Baseline characteristics were similar between groups. For troughs in group 1 (n = 55), the probability of achieving an AUC/MIC > 400 ranged from 16.4% to 90.9% with a median trough concentration of 11.4 mg/L, while in group 2 (n = 44) the probability of achieving AUC/MIC > 400 ranged from 15.9% to 54.5% with mean trough concentration of 9.2 mg/L. The AUC/MICs were not similar between the different pharmacokinetic methods used; however, a trapezoidal equation (Method A) yielded the highest correlation coefficient (r2 = 0.59). When dosing every 6 hours, an AUC/MIC of 400 correlated to a trough serum concentration of 11 mg/L. CONCLUSIONS: The probability of achieving an AUC/MIC > 400 using only a trough serum concentration and an MIC with patients receiving 15 mg/kg every 6 hours is variable based on the method used to calculate the AUC. An AUC/MIC of 400 in children correlated to a trough concentration of 11 mg/L using a trapezoidal Method to calculate AUC.

Abuse and Misuse of Selected Dietary Supplements Among Adolescents: a Look at Poison Center Data.

OBJECTIVE: The use of dietary supplements has increased and is associated with adverse effects. Indications for use include recreation, body image concerns, mood enhancement, or control of medical conditions. The risk of adverse effects may be enhanced if agents are used improperly. The objective of this study was to determine the frequency of abuse and misuse of 4 dietary substances among adolescents reported nationally to poison centers. Secondary outcomes included an assessment of medical outcomes, clinical effects, location of treatments provided, and treatments administered. METHODS: This descriptive retrospective review assessed data concerning the use of garcinia (Garcinia cambogia), guarana (Paullinia cupana), salvia (Salvia divinorum), and St John's wort (Hypericum perforatum) among adolescents reported nationally to poison centers from 2003 to 2014. Adolescents with a singlesubstance exposure to one of the substances of interest coded as intentional abuse or misuse were included. Poison center calls for drug information or those with unrelated clinical effects were excluded. Data were collected from the National Poison Data System. RESULTS: There were 84 cases: 7 cases of Garcinia cambogia, 28 Paullinia cupana, 23 Salvia divinorum, and 26 Hypericum perforatum. Garcinia cambogia was used more frequently by females (100% versus 0%), and Paullinia cupana and Salvia divinorum were used more frequently by males (61% versus 36% and 91% versus 9%, respectively). Abuse, driven by Salvia divinorum, was more common overall than misuse. Abuse was also more common among males than females (p <0.001). Use of these agents fluctuated over time. Overall, use trended down since 2010, except for Garcinia cambogia use. In 62 cases (73.8%), the medical outcome was minor or had no effect or was judged as nontoxic or minimally toxic. Clinical effects were most common with Paullinia cupana and Salvia divinorum. Treatment sites included emergency department (n = 33; 39.3%), non-healthcare facility (n = 24; 28.6%), admission to a health care facility (n = 8; 9.5%), and other/unknown (n = 19; 22.6%). CONCLUSIONS: Abuse and misuse of these dietary supplements was uncommon, and outcomes were mild. Further research should be performed to determine use and outcomes of abuse/misuse of other dietary supplements in this population.

Appropriate Use of Vancomycin in NICU Despite Free-for-All Policy.

OBJECTIVES: Because of increases in antimicrobial resistance, the use of vancomycin in late-onset sepsis has come under scrutiny. The primary outcome of this study was to determine if vancomycin for the treatment of late-onset sepsis in the neonatal intensive care unit (NICU) was being discontinued within 72 hours according to the existing protocol. Secondary outcomes included the appropriateness of therapeutic drug monitoring associated with vancomycin, and renal dysfunction associated with the use of vancomycin in the NICU outside of the 72-hour policy. METHODS: A retrospective chart review was completed for patients in the NICU who received vancomycin for the treatment of late-onset sepsis between the dates of January 1, 2014, and July 1, 2014. RESULTS: There were 125 vancomycin treatment courses, of which 97 were included. Appropriate use of vancomycin, per policy, occurred in a total of 87 of 97 courses (89.6%). Therapeutic drug monitoring was evaluated by the number of appropriate troughs, determined using renal function and previous trough concentrations. There was not a statistically significant difference in the number of inappropriate troughs drawn between those that were continued on vancomycin appropriately (n = 17 courses; 4 of 44 inappropriate troughs) versus inappropriately (n = 10 courses; 1 of 22 inappropriate troughs; p = 0.66), despite the large number of troughs drawn. Adverse renal outcomes were not statistically significant in patients continued inappropriately on vancomycin (p = 1.0). CONCLUSIONS: Vancomycin use in the NICU for late-onset sepsis is appropriate per the existing antibiotic policy. Therapeutic drug monitoring could be improved, and adverse renal outcomes due to inappropriate continuation of vancomycin are rare.

Time to first antimicrobial administration after onset of sepsis in critically ill children.

OBJECTIVES: Delay of antimicrobial administration in adult patients with severe sepsis and septic shock has been associated with a decrease in survival to hospital discharge. The primary objective of this investigation was to determine the time to first antimicrobial administration after the onset of sepsis in critically ill children. Secondary objectives included appropriateness of empiric antimicrobials and microbiological testing, fluid resuscitation during the first 24 hours after onset of sepsis, intensive care unit and hospital length of stay, and mortality. METHODS: Retrospective, chart review of all subjects less than or equal to 18 years of age admitted to the pediatric intensive care unit (PICU) with a diagnosis of sepsis between January 1, 2011, and December 31, 2012. RESULTS: A total of 72 subjects met the inclusion criteria during the study period. Median time to first antimicrobial administration by a nurse after the onset of sepsis was 2.7 (0.5-5.1) hours. Cultures were drawn prior to administration of antimicrobials in 91.7% of subjects and were repeated within 48 hours in 72.2% of subjects. Empiric antimicrobial regimens were appropriate in 91.7% of cases. The most common empiric antimicrobial regimens included piperacillin/tazobactam plus vancomycin in 19 subjects (26.4%) and ceftriaxone plus vancomycin in 15 subjects (20.8%). Median PICU length of stay was 129 (64.6-370.9) hours, approximately 5 days, and median hospital length of stay was 289 (162.5-597.1) hours, approximately 12 days. There were 4 deaths during the study period. CONCLUSIONS: Time to first antimicrobial administration after onset of sepsis was not optimal and exceeded the recommendations set forth in international guidelines. At our institution, the process for treating pediatric patients with severe sepsis and septic shock should be modified to increase compliance with national guidelines.

Effects of Clonidine on Withdrawal From Long-term Dexmedetomidine in the Pediatric Patient.

OBJECTIVE: To compare withdrawal symptoms among pediatric intensive care patients receiving clonidine to those not receiving clonidine while being weaned from long-term dexmedetomidine. METHODS: This retrospective analysis evaluated Withdrawal Assessment Tool-1 (WAT-1) scores and hemodynamic parameters in pediatric patients on dexmedetomidine for 5 days or longer between January 1, 2009, and December 31, 2012. The primary objective was to compare withdrawal symptoms based on the number of elevated WAT-1 scores among patients on clonidine to those not on clonidine, while being weaned from long-term dexmedetomidine. The secondary objective was to describe withdrawal symptoms associated with long-term dexmedetomidine use. RESULTS: Nineteen patients (median age, 1.5 years; interquartile range [IQR], 0.67-3.3) received 20 treatment courses of dexmedetomidine for at least 5 days. Clonidine was received by patients during 12 of the treatment courses. The patients in the clonidine group had an average of 0.8 (range, 0-6) elevated WAT-1 scores 24 hours post wean compared to an average of 3.2 (0-8) elevated WAT-1 scores in the no clonidine group (p = 0.49). There were no significant difierences between prewean and postwean systolic or diastolic blood pressures among the 2 groups. The average heart rate during the postwean period was 112 beats per minute (bpm) (range, 88.5-151.5) in the clonidine group compared to 138.4 bpm (range, 117.8-168.3) in the no clonidine group (p = 0.003). In the clonidine group, the mean change in heart rate postwean compared to prewean was an increase of 3.6 bpm (range, -39.6 to 47.5), compared to a mean increase of 29.9 bpm (range, 5.5-74.7) in the no clonidine group (p = 0.042). CONCLUSIONS: There was no difierence in WAT-1 scores between groups, with the clonidine group displaying a trend towards fewer elevated WAT-1 scores during the 24 hours post dexmedetomidine wean. Patients who received clonidine had significantly lower heart rates than the no clonidine group.

Evaluation of Enoxaparin Dosing and Monitoring in Pediatric Patients at Children's Teaching Hospital.

OBJECTIVES: The primary objective of this study was to evaluate whether empirical enoxaparin doses according to Chest guidelines resulted in therapeutic antifactor Xa concentrations in pediatric patients. Secondary objectives were to determine the median enoxaparin dose that resulted in therapeutic anticoagulation, the median time to therapeutic concentrations, and the percentage of patients who experienced major bleeding. METHODS: Patients in a tertiary medical center who were <18 years of age and received treatment doses of enoxaparin between July 2007 and June 2010 were included. Patients with <2 antifactor Xa concentrations or with only supratherapeutic concentrations and doses that were higher than recommended by the guidelines were excluded. Subgroup analysis was conducted by dividing children into 4 age groups: <2 months of age, 2 months to <1 year of age, 1 year to <3 years of age, and 3 to 17 years of age. RESULTS: Thirty-two patients were included in the study. Thirty-seven percent of the patients achieved a therapeutic drug level with empirical dosing. The therapeutic dose ranged from 1 to 1.9 mg/kg in patients <1 year old, and 0.6 to 1.5 mg/kg in those =1 year of age. Comparison of the median therapeutic doses for patients 2 months to <1 year to that for patients =1 year old using the Mann-Whitney U test showed the median doses to be significantly difierent between the 2 groups (p=0.01). The antifactor Xa level became therapeutic on day 5 (median). There were no major bleeding events. CONCLUSION: Less than 40% of patients were therapeutic with empirical dosing, which supports findings from other studies that suggest a need for modification of empirical treatment dosing of enoxaparin in children.

Drug utilization, dosing, and costs after implementation of intravenous acetaminophen guidelines for pediatric patients.

OBJECTIVES: The objectives of this evaluation of medication use were to characterize the use of intravenous acetaminophen at our institution and to determine if acetaminophen was prescribed at age-appropriate dosages per institutional guidelines, as well as to evaluate compliance with restrictions for use. Total acquisition costs associated with intravenous acetaminophen usage is described as well. METHODS: This retrospective study evaluated the use of acetaminophen in pediatric patients younger than 18 years of age, admitted to a tertiary care hospital, who received at least 1 dose of intravenous acet-aminophen between August 1, 2011, and January 31, 2012. RESULTS: A total of 52 doses of intravenous acetaminophen were administered to 31 patients during the 6-month study period. Most patients were admitted to the otorhinolaryngology service (55%), and the majority of doses were administered either in the operating room (46%) or in the intensive care unit (46%). Nineteen doses (37%) of intravenous acetaminophen were administered to patients who did not meet institutional guidelines' eligibility criteria. Three patients received single doses of intravenous acetaminophen that were greater than the dose recommended for their age. One patient during the study period received more than the recommended 24-hour maximum cumulative dose for acetaminophen. Total acquisition cost of intravenous acetaminophen therapy over the 6-month study period was $530.40. CONCLUSIONS: Intravenous acetaminophen was used most frequently among pediatric patients admitted to the otorhinolaryngology service during the perioperative period. Nineteen doses (37%) were administered to patients who did not meet the institutional guidelines' eligibility criteria. Our data support reinforcing the availability of institutional guidelines to promote cost-effective use of intravenous acetaminophen while minimizing the prescription of inappropriate doses.