A novel approach to reducing admissions for children with sickle cell disease in pain crisis through individualization and standardization in the emergency department.

BACKGROUND: Vaso-occlusive crisis (VOC) is frequent in children with sickle cell disease (SCD) creating significant burden on patients, families, and emergency departments (ED). The objective of the project was to reduce the admission rate for children with SCD presenting to our ED with VOC by >20% within 6 months of initiating individualized pain plans (IPP). METHODS: A multi-disciplinary quality improvement team was assembled. A Plan-Do-Study-Act (PDSA) format was employed. The IPP document was created in a unique folder within the electronic medical record. IPPs were created through retrospective chart review for our 80 highest resource users. Pediatric residents, ED residents, and ED attending physicians were instructed on use of the IPPs. Our study measured the presence of an IPP, adherence to the IPP, and time to opiate administration. Our primary outcome was admission rate. Length of stay and 72-hr return to the ED were assessed as balancing measures. RESULTS: Overall, admission rate decreased by 24% following implementation compared with the previous 5 years (P = 0.046). IPPs were created for 78% of patients and followed by ED staff in 86% of visits. Admission rate was significantly lower for patients receiving a second opiate dose within 45 min of the first dose (P < 0.01). There was no difference in readmission rate or 72-hr return rate to ED. CONCLUSIONS: This study presents an effective strategy to reduce admission rate for children with SCD presenting with VOC. Shorter time to second opiate dosing was also associated with reduced risk of admission.

Evaluation of Postoperative Pain Management Using an Opioid-Sparing Protocol in Pediatric Surgical Patients.

BACKGROUND: Since the 1990s, the U.S. has faced increasing rates of opioid overuse, misuse, and overdose deaths. To combat the opioid epidemic, there have been national initiatives to limit prescribing of opioids. At our institution, we implemented an opioid-sparing protocol in pediatric surgical patients and sought to evaluate its impact on postoperative opioid prescribing patterns. METHODS: A retrospective chart review of the electronic medical record was performed for 9- to 18-year-old patients who underwent a laparoscopic appendectomy or cholecystectomy before and after the implementation of an opioid-sparing protocol. Data on postoperative opioids administered during the hospitalization and prescribed at discharge, postoperative pain control, use of non-opioid analgesics, and safety were collected. RESULTS: A total of 81 patient charts were analyzed. The median amount of opioids administered during hospitalization was 8 MMEs and 15 MMEs in the pre-implementation and post-implementation, respectively (P = 0.310). The median amount of opioids prescribed at discharge was 150 MMEs and 60 MMEs in the pre-implementation and post-implementation, respectively (P = 0.006). Patients reported mild pain scores throughout the hospitalization in both groups. DISCUSSION: Among young patients who underwent laparoscopic appendectomy or cholecystectomy, the administration of opioids during hospitalization for postoperative pain was minimal. The opioid sparing protocol did not reduce the amount of inpatient postoperative opioids administered but found a decrease in the amount of opioids prescribed at discharge. The study findings identified further areas of intervention and education to optimize postoperative opioid prescribing after these common pediatric surgical procedures.

Long-term Use of Eculizumab for Prolonged Hemolysis Following a Delayed Hemolytic Transfusion Reaction in Pediatric Sickle Cell: A Case Report.

Complement activation has been implicated in delayed hemolytic transfusion reaction (DHTR) in patients with sickle cell disease (SCD), and eculizumab has been reported as an effective treatment for patients with DHTR. Previously reported patients with SCD and DHTR responded well after a few doses of eculizumab. We report on the long-term use of eculizumab in a pediatric sickle cell patient with prolonged hemolysis of unknown etiology after a DHTR who had a slow and less sustained response. Long-term use of eculizumab in this young patient with SCD was successful with limited adverse effects.

Levofloxacin for Antibacterial Prophylaxis in Pediatric Patients With Acute Myeloid Leukemia or Undergoing Hematopoietic Stem Cell Transplantation.

OBJECTIVE: This study aimed to evaluate the use of levofloxacin for the prevention of bacterial infections in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. METHODS: This study was a single-center, retrospective review designed to assess the frequency of bacteremia with levofloxacin prophylaxis compared with historical controls that used other, clinician-directed antibacterial prophylaxis. The primary outcome of the study was microbiologically documented bacteremia. Secondary outcomes included febrile neutropenia, clinically documented infection, duration of neutropenia, treatment antibiotic exposure days, Clostridioides difficile infection, and infection-related mortality. RESULTS: Of the 60 patients included, 24 patients with 32 hospital admissions received levofloxacin and 36 patients with 48 hospital admissions received clinician-directed prophylaxis. There was no difference found in the frequency of bacteremia between levofloxacin and clinician-directed prophylaxis (15.6% vs 10.4%, p = 0.49). There was no difference in the incidence of febrile neutropenia, clinically documented infection, treatment antibiotic exposure days, or 30-day infection-related mortality between the 2 groups. The levofloxacin group had a longer mean duration of neutropenia compared with clinician-directed prophylaxis (26.8 days vs 16.4 days, p = 0.01). CONCLUSIONS: There was no difference in bacteremia between levofloxacin prophylaxis and clinician-directed prophylaxis in pediatric patients with acute myeloid leukemia or those undergoing hematopoietic stem cell transplantation. Levofloxacin prophylaxis is an appropriate alternative for the prevention of serious bacterial infections in this patient population, although further studies are needed to confirm these results.

Extended Interval Tobramycin Pharmacokinetics in a Pediatric Patient With Primary Ciliary Dyskinesia Presenting With an Acute Respiratory Exacerbation.

The pharmacokinetics of tobramycin in patients with ciliary dyskinesia have not been previously reported. A 10-year-old female patient with primary ciliary dyskinesia was admitted to the general pediatrics floor with an acute respiratory exacerbation after several months of worsening lung function that was unresponsive to oral antibiotics. Extrapolating from cystic fibrosis dosing regimens, she was given intravenous tobramycin 320 mg (10.3 mg/kg/day) on admission as a result of concern for a Pseudomonas aeruginosa infection. Two-point pharmacokinetic monitoring revealed a maximum serum concentration (Cmax) of 18.9 mg/L and a 24-hour area under the curve (AUC0-24hr) of 58.8 (mg × hr)/L, as well as a volume of distribution (Vd) of 0.5 L/kg and an elimination rate (Ke) of 0.34 hr-1. After a dosage increase to tobramycin 400 mg (12.8 mg/kg/day), pharmacokinetic parameters on 2 assessments were as follows: Vd 0.37 to 0.39 L/kg, Ke 0.33 to 0.39 hr-1, Cmax 27.8 to 28.7 mg/L, and AUC0-24h 78.4 to 89.4 (mg × hr)/L. This was the first case report of aminoglycoside pharmacokinetics in a patient with ciliary dyskinesia. The administration of larger doses (up to 12.8 mg/kg/day) of extended-interval tobramycin, similar to the treatment recommendation of at least 10 mg/kg/day for cystic fibrosis patients, was necessary in this patient to achieve serum concentrations that were appropriate for treatment.

Effect of Plasmapheresis on the Anti-Factor Xa Activity of Enoxaparin in an Obese Adolescent Patient.

To our knowledge, the effect of plasmapheresis on the anti-factor Xa activity of enoxaparin has never been reported. We describe a 13-year-old, obese (92-kg) girl who was treated with enoxaparin for a pulmonary embolism while receiving plasmapheresis for suspected autoimmune encephalitis and who experienced clinically significant reductions in anti-factor Xa activity after plasmapheresis. She received five courses of plasmapheresis, with the final two administered during treatment with enoxaparin. Her anti-factor Xa concentrations were highly variable, and we hypothesized that plasmapheresis was affecting these levels. To test this hypothesis, anti-factor Xa concentrations were measured before and immediately after the patient's last plasmapheresis treatment, and then again 2 days after plasmapheresis. The rate of anti-factor Xa activity decline was 0.28 IU/mL/hour with plasmapheresis and only 0.088 IU/mL/hour on the day without plasmapheresis, representing a greater than 3-fold difference. The changes in anti-factor Xa activity due to plasmapheresis altered the final enoxaparin dosage required to remain in the therapeutic range of 0.5-1 IU/mL (0.98 mg/kg/dose while receiving plasmapheresis vs 0.69 mg/kg/dose without plasmapheresis). Our patient's data suggest that plasmapheresis can significantly alter enoxaparin's anticoagulant effect as measured by anti-factor Xa concentrations, which could cause a decreased anticoagulant effect during plasmapheresis and an increased risk of bleeding on plasmapheresis discontinuation. If concurrent enoxaparin-based anticoagulation and plasmapheresis are necessary, close monitoring of anti-factor Xa levels is advisable. Dose escalations and reductions of enoxaparin may be necessary when initiating and discontinuing plasmapheresis, respectively.