Does circle priming improve smart infusion pump and electronic health record interoperability for chemotherapy in a pediatric hematology/oncology setting?

INTRODUCTION: The objective of this project was to assess the percentage of interoperability compliance within our pediatric hematology/oncology patient care areas for intravenous chemotherapy medications before and after the implementation of circle priming. METHODS: We conducted a retrospective quality improvement project at an inpatient pediatric hematology/oncology floor and outpatient pediatric infusion center before and after implementation of circle priming. RESULTS: There was a statistically significant increase in percent interoperability compliance for the inpatient pediatric hematology/oncology floor from 4.1% prior to implementation of circle priming to 35.6% after (odds ratio 13.1 (95% CI, 3.96-43.1), p < 0.001), as well as for the outpatient pediatric infusion center from 18.5% to 47.3%, respectively (odds ratio 3.9 (95% CI, 2.7-5.9), p < 0.001). CONCLUSION: Implementation of circle priming has significantly increased the percentage of interoperability compliance for intravenous chemotherapy medications in our pediatric hematology/oncology patient care areas.

An Overview of Type B Lactic Acidosis Due to Thiamine (B1) Deficiency.

Type B lactic acidosis can occur secondary to several factors, including thiamine deficiency, and is not as common as type A. Recognizing thiamine deficiency-associated lactic acidosis is challenging because serum thiamine concentrations are not routinely obtained, and a thorough and specific history is necessary for clinicians to suspect thiamine deficiency as a root cause. Furthermore, the appropriate dose and duration of thiamine treatment are not well defined. Untreated thiamine deficiency-associated lactic acidosis can lead to critical illness requiring lifesaving extracorporeal therapies. Additionally, if thiamine and glucose are not administered in an appropriate sequence, Wernicke encephalopathy or Korsakoff syndrome may occur. This review aims to summarize therapeutic treatment for thiamine deficiency-associated lactic acidosis, based on case reports/series and nutritional guidance. After a literature search of the PubMed database, 63 citations met inclusion criteria, of which 21 involved pediatric patients and are the focus of this review. -Citations describe dosing regimens ranging from 25 to 1000 mg of intravenous (IV) thiamine as a single dose, or multiple daily doses for several days. Specific guidance for critically ill adults recommends a thiamine range of 100 mg IV once daily to 400 mg IV twice daily. Although there are no specific recommendations for the pediatric population, given the relative safety of thiamine administration, its low cost, and our review of the literature, treatment with thiamine 100 to 200 mg IV at least once is supported, with ongoing daily doses based on clinical response of the patient, regardless of age.

Inappropriate vancomycin therapeutic drug monitoring in hospitalized pediatric patients increases pediatric trauma and hospital costs.

OBJECTIVES: The objective of this study was to measure the appropriateness of vancomycin monitoring in a pediatric tertiary care center and to evaluate the effectiveness of two interventions, autonomous pharmacy therapeutic drug monitoring and health care provider education, in reducing avoidable pediatric patient trauma and hospital cost. METHODS: A retrospective chart review evaluating vancomycin therapeutic drug monitoring (TDM) in pediatric inpatients was performed before and after the introduction of an autonomous pharmacy TDM program and health care provider (HCP) education. RESULTS: Thirty-five patients were included in our study, prior to any intervention. Of these, 9% of patients had trough concentrations appropriately deferred. Of the total of 64 trough concentrations obtained, 94% were considered to be inappropriate. After the start of the autonomous pharmacy TDM program, of the 54 eligible patients (111 troughs), 9% had trough concentrations appropriately deferred, and 34% were inappropriate. In the 3-month period following the introduction of HCP education in combination with pharmacy TDM, we identified 27 eligible patients. Among those, 15% of the patients had trough concentrations appropriately deferred. Of the 43 trough concentrations obtained, only 9% were considered to be inappropriate. The combination of pharmacy TDM with HCP education decreased annualized hospital cost by 60%, from $13,080 to $5232. CONCLUSIONS: Inappropriate vancomycin TDM occurs commonly in our institution, resulting in unnecessary hospital cost and patient trauma. The combination of pharmacy TDM and HCP education significantly improved clinical practice; however, results were short-lived. Further interventions, such as computer based order entry, will likely be needed to reinforce and improve long-term TDM practice in pediatric patients.

Rhabdomyolysis associated with phentermine.

PURPOSE: A case of rhabdomyolysis associated with the use of phentermine is reported. SUMMARY: A 32-year-old Caucasian man with a recent history of strenuous exercise sought treatment for significant back, shoulder, and radiating inguinal pain. The patient's home medications included the following, administered orally: esomeprazole, levothyroxine, irbesartan- hydrochlorothiazide, metoprolol succinate, metoclopramide, dicyclomine, oxycodone-acetaminophen, and oxycodone extended-release. He also used testosterone topical gel. During the hospital stay, it was discovered that the patient had been taking phentermine hydrochloride 37.5 mg twice daily, double the recommended dosage, for approximately one week before and on the day his symptoms started. His initial laboratory test values were as follows: troponin I, 17.46 ng/mL; creatine kinase (CK), 114,383 units/L; CK-MB, 745.5 ng/mL; and serum creatinine (SCr), 2.8 mg/dL. The patient was diagnosed with rhabdomyolysis of the left deltoid muscle, shoulder, posterior scapula, and upper thorax and with secondary acute renal failure. The patient's urine output was initially poor and rapidly declined to anuria on day 2 of admission. He received i.v. hydration with 0.45% sodium chloride at an initial rate of 200 mL/hr with 75 meq/L of sodium bicarbonate for urinary alkalinization. He did not require renal replacement therapy, and his urine output began to improve to 0.5 mL/kg/hr on hospital day 5 and was 1.42 mL/kg/hr before discharge. Use of the Naranjo et al. adverse-event probability scale revealed that phentermine was the probable cause of the patient's rhabdomyolysis. CONCLUSION: A 32-year-old man developed rhabdomyolysis after ingesting double the recommended dosage of phentermine for a week in addition to engaging in strenuous activity.