Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, ... more Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, with known effects on morbidity, wound healing, infection, and length of hospitalization. Provision of adequate nutrition support presents several unique challenges in the pediatric cardiac population. Pediatric patients hospitalized with congenital heart disease are usually born at normal weight but rapidly develop malnutrition (undernutrition). In fact, nearly half of children admitted for cardiac surgery are malnourished. Risk factors for preoperative growth failure in these patients include; the underlying cardiac physiology, the presence or absence of congestive heart failure, anorexia, poor oral feeding coordination, gastrointestinal abnormalities or dysfunction, and the presence or absence of genetic disease. Infants with single ventricle physiology are at particular risk for malnutrition, which is known to increase their risk for interstage mortality. Many of these children experience malabsorption due to decreased cardiac output, hypoxia, elevated right-sided cardiac pressure, and subsequent gastrointestinal dysfunction. Infants and children undergoing cardiac surgery may go on to develop further deterioration of their nutrition status due to postoperative fluid restrictions, interruptions to feeding for procedures, feeding intolerance, and delays initiating enteral nutrition due to provider concern for gastrointestinal complications of early postoperative enteral nutrition, such as necrotizing enterocolitis. Acute malnutrition that develops postoperatively further increases the risk of poor outcomes after surgical repair or palliation of congenital heart disease. Interstage monitoring programs for children with single ventricle physiology focus on screening for malnutrition and assessment of nutrition status, enteral nutrition interventions targeted to maintain normal growth, dietician care, and family engagement. Interstage monitoring programs are associated with improved malnutrition indices and with improved outcomes, including improved survival.
The journal of pediatric pharmacology and therapeutics, Oct 1, 2012
OBJECTIVES Pharmacies encounter challenges when ensuring safe, timely medication dispensing to pa... more OBJECTIVES Pharmacies encounter challenges when ensuring safe, timely medication dispensing to patients in the pediatric intensive care unit, when high-alert medications are needed in emergent situations. Removal of these medications from nursing stock presented challenges to providing timely administration to critical patients. The project's purpose was to develop a new method for reducing dispensing time while improving patient safety in pediatric intensive care units. METHODS A committee of physicians, nurses, a clinical pharmacist, and pharmacy administration collaborated for process development. The process established a list of compounded, ready-to-use infusions stored in the pharmacy, immediately available for dispensing. The dispensing mechanism includes ordering and dispensing processes using an ''Urgent Drip Request'' form. Most frequently ordered infusions (dopamine, epinephrine, norepinephrine) were added to automated dispensing cabinets in critical care units in concentrations that could be safely infused centrally or peripherally. RESULTS During the initial 4 months, 71 ''Urgent Drip Request'' sheets were processed. Drug utilization evaluation demonstrated a dispensing time of less than 1 minute for drip medications leaving the pharmacy after the form was received. No sheets processed exceeded the institutional 30-minute turnaround time, nor were errors or delays documented. Limited turnaround time data existed preimplementation but was not robust enough for analysis. It was not ethically feasible to perform a head-to-head comparison with the previous method, as it might have resulted in delay of therapy and negative patient outcomes. CONCLUSIONS This program allows high-alert medication infusion availability in an expedited manner, removes potential for compounding errors at the bedside, and assures clean room preparation. This has improved pharmacy efficiency in provision of safe patient care to critically ill pediatric patients.
Introduction: Portal hypertension (PHT) and its complications in children are thought to be disti... more Introduction: Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children. Areas Covered: The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored. Expert opinion: Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.
This chapter is intended to review the vasoactive medications that are described as inotropes, lu... more This chapter is intended to review the vasoactive medications that are described as inotropes, lusitropes, vasoconstrictors, and vasodilators. The inotropes include dobutamine, dopamine, epinephrine, norepinephrine, isoproterenol, dopexamine, and digoxin. The lusitropes include milrinone and inamrinone. The vasoconstrictors include phenylephrine and vasopressin, and the vasodilators include enalapril, esmolol, hydralazine, labetalol, nitroglycerin, nitroprusside, sildenafil, and verapamil. The chapter will provide an overview of the medications and primarily focus on the drug's mechanism of action, therapeutic uses, pediatric drug dosing, and adverse effects associated with their use.
Patients with multiple organ dysfunction syndrome (MODS) are severely ill and efficacy of medicat... more Patients with multiple organ dysfunction syndrome (MODS) are severely ill and efficacy of medication therapies is crucial to outcomes. The physiologic changes that accompany MODS have many effects on medication dosage. Hemodynamic alterations and increased volume as well as organ function deterioration cause pharmacokinetic and pharmacodynamic modifications of drugs. Chemical properties of a medication dictate to what extent that medication is affected. There are many confounders present when tailoring medication management that will be especially as number of failing organ systems increases. Constant evaluation for efficacy and toxicity is imperative. Successful medication management involves maximizing efficacy while minimizing adverse effects. The objective of this chapter is to discuss concepts of pharmacodynamics and pharmacokinetics that affect medication management of patients experiencing MODS and practical applications of those concepts to persons receiving extracorporeal membrane oxygenation (ECMO) and/or renal replacement therapies.
ABSTRACT Nutrition is an important factor in critically ill pediatric cardiac patients, which has... more ABSTRACT Nutrition is an important factor in critically ill pediatric cardiac patients, which has been shown to affect morbidity, wound healing, infection, and length of hospitalization [1, 2]. Pediatric patients hospitalized with congenital heart disease are at increased risk of becoming malnourished for a number of reasons. These patients often have poor enteral intake originating from fatigue and dyspnea. Anorexia is also common in patients with congenital heart disease, and it is greatest in infants with cyanotic cardiac defects [3]. Many of these children experience malabsorption due to decreased cardiac output, hypoxia, elevated right-sided cardiac pressure, and gastrointestinal dysfunction. These feeding limitations are often compounded by increased energy expenditure often associated with tachycardia and tachypnea [3, 4]. Infants and children undergoing cardiac surgery may be especially at risk of malnutrition due to fluid restrictions as part of their preoperative and postoperative management [5]. Previous studies have shown that protein malnutrition alone can result in poor outcomes in patients with cardiovascular disease [4].
Pharmacologic manipulation of afterload or systemic vascular resistance (SVR) has become increasi... more Pharmacologic manipulation of afterload or systemic vascular resistance (SVR) has become increasingly important in the management of pediatric cardiac patients, just as it has for adult cardiac patients.
This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive... more This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive care unit. The list is not intended to be all-inclusive, and one should use clinical judgment and consult additional references for validation and additional information.
ABSTRACT Introduction Portal hypertension (PHT) and its complications in children are thought to ... more ABSTRACT Introduction Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children. Areas Covered The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored. Expert opinion Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.
Critical Care of Children with Heart Disease, 2020
Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, ... more Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, with known effects on morbidity, wound healing, infection, and length of hospitalization. Provision of adequate nutrition support presents several unique challenges in the pediatric cardiac population. Pediatric patients hospitalized with congenital heart disease are usually born at normal weight but rapidly develop malnutrition (undernutrition). In fact, nearly half of children admitted for cardiac surgery are malnourished. Risk factors for preoperative growth failure in these patients include; the underlying cardiac physiology, the presence or absence of congestive heart failure, anorexia, poor oral feeding coordination, gastrointestinal abnormalities or dysfunction, and the presence or absence of genetic disease. Infants with single ventricle physiology are at particular risk for malnutrition, which is known to increase their risk for interstage mortality. Many of these children experience malabsorption due to decreased cardiac output, hypoxia, elevated right-sided cardiac pressure, and subsequent gastrointestinal dysfunction. Infants and children undergoing cardiac surgery may go on to develop further deterioration of their nutrition status due to postoperative fluid restrictions, interruptions to feeding for procedures, feeding intolerance, and delays initiating enteral nutrition due to provider concern for gastrointestinal complications of early postoperative enteral nutrition, such as necrotizing enterocolitis. Acute malnutrition that develops postoperatively further increases the risk of poor outcomes after surgical repair or palliation of congenital heart disease. Interstage monitoring programs for children with single ventricle physiology focus on screening for malnutrition and assessment of nutrition status, enteral nutrition interventions targeted to maintain normal growth, dietician care, and family engagement. Interstage monitoring programs are associated with improved malnutrition indices and with improved outcomes, including improved survival.
This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive... more This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive care unit. The list is not intended to be all-inclusive, and one should use clinical judgment and consult additional references for validation and additional information.
Neurostimulant medications are commonly prescribed following traumatic brain injury (TBI) in adul... more Neurostimulant medications are commonly prescribed following traumatic brain injury (TBI) in adults; little is known about their use in children with TBI. Our objective was to analyze neurostimulant prescribing practices from 2005 to 2015 in children admitted to the intensive care unit (ICU) with TBI. We hypothesized that neurostimulant prescriptions have increased over time and are associated with older age and injury severity. A retrospective cohort study of patients age 1 month to 18 years with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis code for TBI admitted to the ICU between 2005 and 2015 in 37 pediatric hospitals included in the Pediatric Health Information System was conducted. Variables examined include patient and injury characteristics and neurostimulant medication use. Descriptive statistics and multi-variable logistic regression testing were used to determine variables associated with neurostimulant prescription. Of 30,881 patients with TBI, most were male (64%) and age 0-4 years (43%). In patients with mechanism of injury reported (n = 21,998), TBI was most frequently due to falls (36%) and motor vehicle collisions (36%). One thousand sixty-four neurostimulants were prescribed to 878 (3%) patients with 41% of prescriptions for amantadine and 38% for methylphenidate. Neurostimulants were prescribed a median (interquartile range) of 17 (8-35) days post-injury and increased over the study decade (R2 = 0.806). In a multi-variable analysis, variables most strongly associated with receipt of a neurostimulant were age 14-18 years (odds ratio 5.8, 95% confidence interval [4.3,7.8]), motor vehicle collision (3.1, [2.4,4.2]), intracranial pressure (ICP) monitor (3.8, [3.1,4.5]), and mechanical ventilation (3.4, [2.7,4.3]). Use of neurostimulants following pediatric TBI is uncommon, has increased over time, and is associated with indicators of higher severity of illness. Knowledge of prescribing practices may assist in optimizing the design of efficacy and outcome studies that will inform clinical guidelines.
Infectious Diseases Society of America guidelines recommend that key antimicrobial stewardship pr... more Infectious Diseases Society of America guidelines recommend that key antimicrobial stewardship program (ASP) personnel include an infectious disease (ID) physician leader and dedicated ID-trained clinical pharmacist. Limited resources prompted development of an alternative model by using ID physicians and service-based clinical pharmacists at a pediatric hospital. The aim of this study was to analyze the effectiveness and impact of this alternative ASP model. The collaborative ASP model incorporated key strategies of education, antimicrobial restriction, day 3 audits, and practice guidelines. High-use and/or high-cost antimicrobial agents were chosen with audits targeting vancomycin, caspofungin, and meropenem. The electronic medical record was used to identify patients requiring day 3 audits and to communicate ASP recommendations. Segmented regression analyses were used to analyze quarterly antimicrobial agent prescription data for the institution and selected services over time. I...
The statement “Children are not little adults” is a foundation of pediatric drug therapy referrin... more The statement “Children are not little adults” is a foundation of pediatric drug therapy referring to well-documented differences in pharmacokinetics and pharmacodynamics existing between children and adults [1, 2, 3, 4, 5, 6]. It is therefore important to understand the influence of age on drug disposition, especially in neonates and infants, and resulting effects on drug activity. This chapter will provide brief discussions of principles of pediatric pharmacokinetics and knowledge of the effects of disease states upon disposition of cardiovascular drugs affecting safe and effective drug therapy.
Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, ... more Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, with known effects on morbidity, wound healing, infection, and length of hospitalization. Provision of adequate nutrition support presents several unique challenges in the pediatric cardiac population. Pediatric patients hospitalized with congenital heart disease are usually born at normal weight but rapidly develop malnutrition (undernutrition). In fact, nearly half of children admitted for cardiac surgery are malnourished. Risk factors for preoperative growth failure in these patients include; the underlying cardiac physiology, the presence or absence of congestive heart failure, anorexia, poor oral feeding coordination, gastrointestinal abnormalities or dysfunction, and the presence or absence of genetic disease. Infants with single ventricle physiology are at particular risk for malnutrition, which is known to increase their risk for interstage mortality. Many of these children experience malabsorption due to decreased cardiac output, hypoxia, elevated right-sided cardiac pressure, and subsequent gastrointestinal dysfunction. Infants and children undergoing cardiac surgery may go on to develop further deterioration of their nutrition status due to postoperative fluid restrictions, interruptions to feeding for procedures, feeding intolerance, and delays initiating enteral nutrition due to provider concern for gastrointestinal complications of early postoperative enteral nutrition, such as necrotizing enterocolitis. Acute malnutrition that develops postoperatively further increases the risk of poor outcomes after surgical repair or palliation of congenital heart disease. Interstage monitoring programs for children with single ventricle physiology focus on screening for malnutrition and assessment of nutrition status, enteral nutrition interventions targeted to maintain normal growth, dietician care, and family engagement. Interstage monitoring programs are associated with improved malnutrition indices and with improved outcomes, including improved survival.
The journal of pediatric pharmacology and therapeutics, Oct 1, 2012
OBJECTIVES Pharmacies encounter challenges when ensuring safe, timely medication dispensing to pa... more OBJECTIVES Pharmacies encounter challenges when ensuring safe, timely medication dispensing to patients in the pediatric intensive care unit, when high-alert medications are needed in emergent situations. Removal of these medications from nursing stock presented challenges to providing timely administration to critical patients. The project's purpose was to develop a new method for reducing dispensing time while improving patient safety in pediatric intensive care units. METHODS A committee of physicians, nurses, a clinical pharmacist, and pharmacy administration collaborated for process development. The process established a list of compounded, ready-to-use infusions stored in the pharmacy, immediately available for dispensing. The dispensing mechanism includes ordering and dispensing processes using an ''Urgent Drip Request'' form. Most frequently ordered infusions (dopamine, epinephrine, norepinephrine) were added to automated dispensing cabinets in critical care units in concentrations that could be safely infused centrally or peripherally. RESULTS During the initial 4 months, 71 ''Urgent Drip Request'' sheets were processed. Drug utilization evaluation demonstrated a dispensing time of less than 1 minute for drip medications leaving the pharmacy after the form was received. No sheets processed exceeded the institutional 30-minute turnaround time, nor were errors or delays documented. Limited turnaround time data existed preimplementation but was not robust enough for analysis. It was not ethically feasible to perform a head-to-head comparison with the previous method, as it might have resulted in delay of therapy and negative patient outcomes. CONCLUSIONS This program allows high-alert medication infusion availability in an expedited manner, removes potential for compounding errors at the bedside, and assures clean room preparation. This has improved pharmacy efficiency in provision of safe patient care to critically ill pediatric patients.
Introduction: Portal hypertension (PHT) and its complications in children are thought to be disti... more Introduction: Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children. Areas Covered: The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored. Expert opinion: Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.
This chapter is intended to review the vasoactive medications that are described as inotropes, lu... more This chapter is intended to review the vasoactive medications that are described as inotropes, lusitropes, vasoconstrictors, and vasodilators. The inotropes include dobutamine, dopamine, epinephrine, norepinephrine, isoproterenol, dopexamine, and digoxin. The lusitropes include milrinone and inamrinone. The vasoconstrictors include phenylephrine and vasopressin, and the vasodilators include enalapril, esmolol, hydralazine, labetalol, nitroglycerin, nitroprusside, sildenafil, and verapamil. The chapter will provide an overview of the medications and primarily focus on the drug's mechanism of action, therapeutic uses, pediatric drug dosing, and adverse effects associated with their use.
Patients with multiple organ dysfunction syndrome (MODS) are severely ill and efficacy of medicat... more Patients with multiple organ dysfunction syndrome (MODS) are severely ill and efficacy of medication therapies is crucial to outcomes. The physiologic changes that accompany MODS have many effects on medication dosage. Hemodynamic alterations and increased volume as well as organ function deterioration cause pharmacokinetic and pharmacodynamic modifications of drugs. Chemical properties of a medication dictate to what extent that medication is affected. There are many confounders present when tailoring medication management that will be especially as number of failing organ systems increases. Constant evaluation for efficacy and toxicity is imperative. Successful medication management involves maximizing efficacy while minimizing adverse effects. The objective of this chapter is to discuss concepts of pharmacodynamics and pharmacokinetics that affect medication management of patients experiencing MODS and practical applications of those concepts to persons receiving extracorporeal membrane oxygenation (ECMO) and/or renal replacement therapies.
ABSTRACT Nutrition is an important factor in critically ill pediatric cardiac patients, which has... more ABSTRACT Nutrition is an important factor in critically ill pediatric cardiac patients, which has been shown to affect morbidity, wound healing, infection, and length of hospitalization [1, 2]. Pediatric patients hospitalized with congenital heart disease are at increased risk of becoming malnourished for a number of reasons. These patients often have poor enteral intake originating from fatigue and dyspnea. Anorexia is also common in patients with congenital heart disease, and it is greatest in infants with cyanotic cardiac defects [3]. Many of these children experience malabsorption due to decreased cardiac output, hypoxia, elevated right-sided cardiac pressure, and gastrointestinal dysfunction. These feeding limitations are often compounded by increased energy expenditure often associated with tachycardia and tachypnea [3, 4]. Infants and children undergoing cardiac surgery may be especially at risk of malnutrition due to fluid restrictions as part of their preoperative and postoperative management [5]. Previous studies have shown that protein malnutrition alone can result in poor outcomes in patients with cardiovascular disease [4].
Pharmacologic manipulation of afterload or systemic vascular resistance (SVR) has become increasi... more Pharmacologic manipulation of afterload or systemic vascular resistance (SVR) has become increasingly important in the management of pediatric cardiac patients, just as it has for adult cardiac patients.
This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive... more This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive care unit. The list is not intended to be all-inclusive, and one should use clinical judgment and consult additional references for validation and additional information.
ABSTRACT Introduction Portal hypertension (PHT) and its complications in children are thought to ... more ABSTRACT Introduction Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children. Areas Covered The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored. Expert opinion Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.
Critical Care of Children with Heart Disease, 2020
Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, ... more Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, with known effects on morbidity, wound healing, infection, and length of hospitalization. Provision of adequate nutrition support presents several unique challenges in the pediatric cardiac population. Pediatric patients hospitalized with congenital heart disease are usually born at normal weight but rapidly develop malnutrition (undernutrition). In fact, nearly half of children admitted for cardiac surgery are malnourished. Risk factors for preoperative growth failure in these patients include; the underlying cardiac physiology, the presence or absence of congestive heart failure, anorexia, poor oral feeding coordination, gastrointestinal abnormalities or dysfunction, and the presence or absence of genetic disease. Infants with single ventricle physiology are at particular risk for malnutrition, which is known to increase their risk for interstage mortality. Many of these children experience malabsorption due to decreased cardiac output, hypoxia, elevated right-sided cardiac pressure, and subsequent gastrointestinal dysfunction. Infants and children undergoing cardiac surgery may go on to develop further deterioration of their nutrition status due to postoperative fluid restrictions, interruptions to feeding for procedures, feeding intolerance, and delays initiating enteral nutrition due to provider concern for gastrointestinal complications of early postoperative enteral nutrition, such as necrotizing enterocolitis. Acute malnutrition that develops postoperatively further increases the risk of poor outcomes after surgical repair or palliation of congenital heart disease. Interstage monitoring programs for children with single ventricle physiology focus on screening for malnutrition and assessment of nutrition status, enteral nutrition interventions targeted to maintain normal growth, dietician care, and family engagement. Interstage monitoring programs are associated with improved malnutrition indices and with improved outcomes, including improved survival.
This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive... more This chapter provides a guide to commonly prescribed medications in a pediatric cardiac intensive care unit. The list is not intended to be all-inclusive, and one should use clinical judgment and consult additional references for validation and additional information.
Neurostimulant medications are commonly prescribed following traumatic brain injury (TBI) in adul... more Neurostimulant medications are commonly prescribed following traumatic brain injury (TBI) in adults; little is known about their use in children with TBI. Our objective was to analyze neurostimulant prescribing practices from 2005 to 2015 in children admitted to the intensive care unit (ICU) with TBI. We hypothesized that neurostimulant prescriptions have increased over time and are associated with older age and injury severity. A retrospective cohort study of patients age 1 month to 18 years with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) discharge diagnosis code for TBI admitted to the ICU between 2005 and 2015 in 37 pediatric hospitals included in the Pediatric Health Information System was conducted. Variables examined include patient and injury characteristics and neurostimulant medication use. Descriptive statistics and multi-variable logistic regression testing were used to determine variables associated with neurostimulant prescription. Of 30,881 patients with TBI, most were male (64%) and age 0-4 years (43%). In patients with mechanism of injury reported (n = 21,998), TBI was most frequently due to falls (36%) and motor vehicle collisions (36%). One thousand sixty-four neurostimulants were prescribed to 878 (3%) patients with 41% of prescriptions for amantadine and 38% for methylphenidate. Neurostimulants were prescribed a median (interquartile range) of 17 (8-35) days post-injury and increased over the study decade (R2 = 0.806). In a multi-variable analysis, variables most strongly associated with receipt of a neurostimulant were age 14-18 years (odds ratio 5.8, 95% confidence interval [4.3,7.8]), motor vehicle collision (3.1, [2.4,4.2]), intracranial pressure (ICP) monitor (3.8, [3.1,4.5]), and mechanical ventilation (3.4, [2.7,4.3]). Use of neurostimulants following pediatric TBI is uncommon, has increased over time, and is associated with indicators of higher severity of illness. Knowledge of prescribing practices may assist in optimizing the design of efficacy and outcome studies that will inform clinical guidelines.
Infectious Diseases Society of America guidelines recommend that key antimicrobial stewardship pr... more Infectious Diseases Society of America guidelines recommend that key antimicrobial stewardship program (ASP) personnel include an infectious disease (ID) physician leader and dedicated ID-trained clinical pharmacist. Limited resources prompted development of an alternative model by using ID physicians and service-based clinical pharmacists at a pediatric hospital. The aim of this study was to analyze the effectiveness and impact of this alternative ASP model. The collaborative ASP model incorporated key strategies of education, antimicrobial restriction, day 3 audits, and practice guidelines. High-use and/or high-cost antimicrobial agents were chosen with audits targeting vancomycin, caspofungin, and meropenem. The electronic medical record was used to identify patients requiring day 3 audits and to communicate ASP recommendations. Segmented regression analyses were used to analyze quarterly antimicrobial agent prescription data for the institution and selected services over time. I...
The statement “Children are not little adults” is a foundation of pediatric drug therapy referrin... more The statement “Children are not little adults” is a foundation of pediatric drug therapy referring to well-documented differences in pharmacokinetics and pharmacodynamics existing between children and adults [1, 2, 3, 4, 5, 6]. It is therefore important to understand the influence of age on drug disposition, especially in neonates and infants, and resulting effects on drug activity. This chapter will provide brief discussions of principles of pediatric pharmacokinetics and knowledge of the effects of disease states upon disposition of cardiovascular drugs affecting safe and effective drug therapy.
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Papers by Carol Vetterly