Although the article in this issue of the Journal by Nievas and colleagues entitled “Treatment of asthma when it becomes severe and requires intensive care” provides a summary of a logical sequence of medications for severe acute asthma, we need to be acutely aware that the best impatient care for asthma, whether in the emergency room, general unit in the hospital, or in the Pediatric Intensive Care Unit (PICU) is never good care—it is always damage control. see related article on page 88 The unfortunate reality is that hospitalization of children with asthma continues at a high rate despite the
Seizures in the pediatric population commonly occur, and when proper rescue medication is not administered quickly, the risk of neurologic compromise emerges. For many years, rectal diazepam has been the standard of care, but recent interest in a more cost-effective, safe alternative has led to the investigation of intranasal midazolam for this indication. Although midazolam and diazepam are both members of the benzodiazepine class, the kinetic properties of these 2 anticonvulsants vary. This paper will review available data pertaining to the efficacy, safety, cost, and pharmacokinetics of intranasal midazolam versus rectal diazepam as treatment for acute seizures for children in the prehospital, home, and emergency department settings.
An increasing prevalence of pediatric asthma has led to increasing burdens of critical illness in children with severe acute asthma exacerbations, often leading to respiratory distress, progressive hypoxia, and respiratory failure. We review the definitions, epidemiology, pathophysiology, and clinical manifestations of severe acute asthma, with a view to developing an evidence-based, stepwise approach for escalating therapy in these patients. Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980–2012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital. Patients with asthma require continuous monitoring of their cardiorespiratory status via noninvasive or invasive devices, with serial clinical examinations, objective scoring of asthma severity (using an objective pediatric asthma score), and appropriate diagnostic tests. All patients are treated with β-agonists, ipratropium, and steroids (intravenous preferable over oral preparations). Patients with worsening clinical status should be progressively treated with continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline and/or aminophylline, coupled with high-flow oxygen and non-invasive ventilation to limit the work of breathing, hypoxemia, and possibly hypercarbia. Sedation with low-dose ketamine (with or without benzodiazepines) infusions may allow better toleration of non-invasive ventilation and may also prepare the patient for tracheal intubation and mechanical ventilation, if indicated by a worsening clinical status. Severe asthma can be a devastating illness in children, but most patients can be managed by using serial objective assessments and the stepwise clinical approach outlined herein. Following multidisciplinary education and training, this approach was successfully implemented in a tertiary-care, metropolitan children's hospital.OBJECTIVES
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Hypotonic intravenous (IV) fluids in children are a mainstay of therapy based on a recommendation made in 1957 by Holliday and Segar. Since that time, hospital-acquired hyponatremia caused by hypotonic IV fluids has been found to be an additional risk factor in the cause of death and neurological impairment in acutely ill children. This article reviews and critically evaluates the literature regarding the association of hyponatremia and hypotonic IV fluids in pediatric hospitalized, postoperative, and critical care patients.
To validate the recently described Mercy method for weight estimation in an independent cohort of children living in the United States. Anthropometric data including weight, height, humeral length, and mid upper arm circumference were collected from 976 otherwise healthy children (2 months to 14 years old). The data were used to examine the predictive performances of the Mercy method and four other weight estimation strategies (the Advanced Pediatric Life Support [APLS] method, the Broselow tape, and the Luscombe and Owens and the Nelson methods). The Mercy method demonstrated accuracy comparable to that observed in the original study (mean error: −0.3 kg; mean percentage error: −0.3%; root mean square error: 2.62 kg; 95% limits of agreement: 0.83–1.19). This method estimated weight within 20% of actual for 95% of children compared with 58.7% for APLS, 78% for Broselow, 54.4% for Luscombe and Owens, and 70.4% for Nelson. Furthermore, the Mercy method was the only weight estimation strategy which enabled prediction of weight in all of the children enrolled. The Mercy method proved to be highly accurate and more robust than existing weight estimation strategies across a wider range of age and body mass index values, thereby making it superior to other existing approaches.OBJECTIVES
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The purpose of this study was to examine the stability of a generic lansoprazole product in a 3 mg/mL sodium bicarbonate suspension under room temperature and refrigerated conditions. Lansoprazole suspensions (3 mg/mL) were prepared in triplicate using an 8.4% sodium bicarbonate vehicle for each storage condition (room temperature and refrigerated). During 1 month, samples from each replicate were periodically removed and analyzed for lansoprazole concentration by liquid chromatography–tandem mass spectrometry (LC-MS/MS). Each sample was spiked with 10 mg/L omeprazole to serve as the internal standard. A positive electrospray LC-MS/MS method was validated over the calibration range of 5 to 25 mg/L using Food and Drug Administration Guidance. The identities of the analyte and internal standard in the samples were verified by monitoring the MS/MS transitions of m/z 370 to m/z 252 and m/z 346 to m/z 198 for lansoprazole and omeprazole, respectively. Additionally, the pH of the suspensions was monitored throughout the study. The stability of lansoprazole in the oral sodium bicarbonate suspension under refrigeration is compromised prior to what has been previously reported in the literature. Samples kept at room temperature lost >10% of the lansoprazole after 48 hours compared with the refrigerated samples, which maintained integrity up to 7 days. No statistically significant difference was found between the pH of the room temperature and refrigerated suspension samples, indicating that this factor is not the cause for the differences in stability at these two conditions. This study suggests that the extemporaneously compounded lansoprazole oral suspension prepared in 8.4% sodium bicarbonate should not be stored in plastic oral syringes longer than 48 hours at room temperature and no longer than 7 days when refrigerated. These data indicate an expiration time earlier than that previously reported for the refrigerated product (14 days).OBJECTIVE
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A 17-year-old female developed hyperammonemic encephalopathy 2 weeks after valproic acid (VPA), 500 mg twice a day, was added to her regimen of topiramate (TPM), 200 mg twice a day. She presented to the emergency department (ED) with altered mental status, hypotension, bradycardia, and lethargy. Laboratory analysis showed mild non-anion gap hyperchloremic acidosis, serum VPA concentration of 86 mg/L, and urine drug screen result that was positive for marijuana. She was admitted to the pediatric intensive care unit for persistent symptoms, prolonged QTc, and medical history. Blood ammonia concentrations were obtained because of her persistent altered mental status, initially 94 μmol/L and a peak of 252 μmol/L. A serum carnitine profile was obtained at the time of hyperammonemia and was found to be normal (results were available postdischarge). VPA and TPM were discontinued on day 1 and day 2, respectively, as the patient's blood ammonia concentration remained elevated. On day 3, her mental status had returned to baseline, and blood ammonia concentrations trended downward; by day 4 her blood ammonia concentration was 23 μmol/L. VPA has been associated with numerous side effects including hyperammonemia and encephalopathy. Recently, drug interactions with TPM and VPA have been reported; however, serum carnitine concentrations have not been available. We discuss the possible mechanisms that VPA and TPM may affect serum ammonia and carnitine concentrations and the use of levocarnitine for patients or treating toxicity.
The drug of choice for treatment of Stenotrophomonas maltophilia is sulfamethoxazole/trimethoprim, and second-line therapy usually consists of a fluoroquinolone. However, in patients with glucose-6-phosphate dehydrogenase deficiency, neither sulfamethoxazole/trimethoprim nor a fluoroquinolone is a preferred option as it may result in hemolysis. Currently, there is a paucity of data regarding treatment of S maltophilia infection in these patients. This case report presents a patient who was successfully treated with doxycycline and inhaled colistimethate.
The purpose of this study is to describe the implementation of a pharmacist managed PN service at an urban, pediatric hospital, and discuss the effects of the service on patient care and outcomes. This Institutional Review Board approved study was completed in two phases. Phase one consisted of a retrospective chart review of medical andIMPLEMENTATION OF A PHARMACIST MANAGED PARENTERAL NUTRITION SERVICE FOR MEDICAL AND SURGICAL PATIENTS AT A PEDIATRIC HOSPITAL
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METHODS:
PPAG is pleased to announce the 2013 FPPAG Inductees. Fellows in the Pediatric Pharmacy Advocacy Group (FPPAG) are recognized for distinguished professional accomplishments in pharmacy practice, research, and education as well as service to the pediatric pharmacy profession, especially PPAG. The new Fellows was introduced during the 22nd PPAG Annual Conference on May 3, 2013 in Indianapolis, IN. Kimberley Benner, PharmD, BCPS, FPASHP, FPPAG has had a significant impact on pediatric pharmacy practice through her education, research, and service. Dr. Benner is a Professor at the SamfordFPPAG RECOGNIZES THE 2013 PPAG FELLOW INDUCTEES
Kimberley Benner, PharmD, BCPS, FPASHP, FPPAG