Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit.

INTRODUCTION: Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population. METHODS: We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission. RESULTS: Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff. CONCLUSIONS: Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

Therapeutic Drug Monitoring of Inhaled Tobramycin in a Post-Hematopoietic Cell Transplant Patient With Bronchiolitis Obliterans and End-Stage Renal Disease.

There are no widely accepted dose alterations for inhaled tobramycin in the setting of renal dysfunction, and serum concentrations are not typically monitored. Herein we describe a case report of a 16-year-old female with a history of 2 hematopoietic cell transplants and a kidney transplant who received inhaled tobramycin for chronic Pseudomonas aeruginosa management. The patient developed chronic kidney disease, and tobramycin concentrations were monitored. Initially she received a reduced dose of inhaled tobramycin, with repeated doses based on serum concentrations. The dose was increased, but serum concentrations obtained the following day remained higher than desired, leading to a suspicion of delayed systemic absorption. Tobramycin administration was changed from immediately prior to dialysis to the evening prior to the next day's dialysis session, and serum concentrations were consistently <1 mg/L postdialysis. In conclusion, systemic absorption of inhaled tobramycin in non-cystic fibrosis (CF) patients may differ compared to that observed in CF patients. Renal dysfunction may lead to systemic accumulation of inhaled tobramycin, and the timing of inhaled tobramycin administration with respect to dialysis has a potentially significant influence on drug clearance. Thus, monitoring may be required. Further cases are required to verify these observations.

Assessment of Initial Vancomycin Dosing in Pediatric Oncology Patients.

This was a retrospective audit assessing vancomycin dosing of 60 mg/kg/day in the attainment of therapeutic concentrations between 10-20 mcg/mL among 56 pediatric oncology patients. Twelve patients (21%) achieved therapeutic concentrations of 10-20 mcg/mL, while 44 patients (79%) obtained trough levels below 10 mcg/mL despite the addition of nephrotoxic agents.