Daniel A. Notterman

Dopamine clearance in critically ill infants and children: Effect of age and organ system dysfunction

To learn if there are age‐related differences in the pharmacokinetic behavior of dopamine, plasma dopamine clearance was determined in 27 acutely ill infants and children who were receiving a continuous intravenous infusion of the drug. Steady‐state clearance was calculated from dopamine concentration in arterial blood. Dopamine clearance was 60.7 ± 28.1 ml/kg/min. The age of the patient exerted an effect on clearance of dopamine (r = − 0.63; p < 0.05), and dopamine clearance was nearly twice as rapid in children younger than 2 years as it was in older children (82.3 ± 27.7 ml/kg/min versus 45.9 ± 17.0 mg/kg/min). Conjugated bilirubin exerted an age‐independent effect on clearance of dopamine; clearance was 44.8 ± 28.6 ml/kg/min in children with abnormal conjugated bilirubin (≥0.9 mg/dl) and 70.1 ± 2.56 ml/kg/min in children with normal conjugated bilirubin (<0.9 mg/dl). Clearance was lowest (29.8 ± 5.7 ml/kg/min) in the four children who had both hepatic and renal dysfunction. Age is an important determinant of dopamine clearance, explaining in part the clinical observation that infants and young children require higher infusion rates.

Sedation wlth Intravenous Midazolam in the Pediatric Intensive Care Unit

Physical and emotional distress can have important effects on patients in the pediatric intensive care unit (ICU). Intravenous (IV) infusion of benzodiazepines is an important adjunct to assisted ventilation and other potentially distressing ICU procedures. Combined with intermittent or continuous infusion of opioids, the benzodiazepines provide smooth control of anxiety, pain, and agitation. Intravenous midazolam (Versed® Roche Laboratories) is distinguished from diazepam (Valium® Roche Products) by its water solubility, short elimination half-life, and generally short duration of action. These pharmacological properties, which are also shared, in part, with the more slowly eliminated drug lorazepam (Ativan® Wyeth-Ayerst), facilitate titration of the rate of infusion against patient response and permit regulation of the depth of sedation. The major adverse effects of long-term benzodiazepine infusion are withdrawal symptoms and, occasionally, delayed awakening. The dosage needed to initiate and maintain sedation must be adjusted to body weight, degree of sedation desired, and concomitant medications, as well as to underlying health and cardiovascular status. Benzodiazepines, such as midazolam and lorazepam, represent important choices among drugs used for sedation in the pediatric ICU.

Pediatric critical care and hospital costs under reimbursement by diagnosis-related group: Effect of clinical and demographic characteristics

OBJECTIVEnTo determine the relationship of demographic and clinical variables to cost, to revenue based on diagnosis-related groups, and to profit in patients in a pediatric intensive care unit (PICU).nnnDESIGNnProspective collection of clinical and demographic data of patients sampled. Detailed financial data for all patients discharged from the hospital were compiled by the office of financial planning. A combined data set was used for analysis.nnnSETTINGnA multidisciplinary PICU within a general, tertiary-care, teaching hospital in an urban environment.nnnPATIENTSnConsecutive sample of 1174 pediatric patients discharged from the PICU during a 24-month period.nnnMEASUREMENTS AND MAIN RESULTSnHospital cost (not charges) determined according to industry standards. Revenue was determined by the DRG system. Of the 1174 cases identified, DRG coding and financial data were 97% complete. The mean loss (negative profit) per patient was

Length/serum creatinine ratio does not predict measured creatinine clearance in critically ill children

9218 +/-

Atrial natriuretic peptide response to postural change and medication in familial dysautonomia.

33,676. Profit was significantly and adversely affected by outlier status, death, high risk of death, interhospital transfer, emergency admission, young age, and mechanical ventilation. Multivariate analysis revealed that duration of stay, death, interhospital transfer, and age negatively correlated with profit.nnnCONCLUSIONnUnder a DRG-based reimbursement system, the operation of an active PICU with a broad referral base may not be desirable from a financial perspective. Similar studies at other institutions could help establish a data base with which the DRG system can be refined.

Prevention and management of pain and stress in the neonate

Information regarding renal function is important in critically ill children to adjust the dosage of drugs that are eliminated by the kidneys. Methods for estimating glomerular filtration rate (GFR) based on age and serum creatinine level have shown good agreement with measured creatinine clearance (CLCR) in children without critical illness but have not been examined in critically ill children.

Use of codeine- and dextromethorphan-containing cough remedies in children

Circulating atrial natriuretic peptide (ANP) was assayed before and after postural change and exercise in 54 patients with familial dysautonomia (FD) and 20 controls. ANP levels were compared with blood pressure, heart rate, plasma catecholamines and parameters of renal function. Compared with controls supine FD subjects had elevated blood pressures, heart rates and ANP levels (39 ± 4 pg/ml vs. 23 ± 3 pg/ml,p < 0.01). With the erect posture and exercise in FD subjects, blood pressure fell below control values, with ANP lowered. In FD subjects, blood pressure was correlated with ANP levels when supine and when erect and with heart rate post exercise. In controls, ANP levels did not correlate with other parameters. In FD patients on metoclopramide, supine and erect blood pressure and ANP levels were higher. FD subjects treated with fludrocortisone, had elevated supine and erect noradrenaline (p < 0.05 andp = 0.06); and those on diazepam had lower erect and post exercise noradrenaline (p < 0.05), but ANP levels were similar. In conclusion, sympathetic denervation may increase FD patients responsiveness to other regulators of cardiovascular integrity, such as ANP. In addition, circulating ANP and catecholamines in FD subjects appear to be influenced by commonly used medications, such as metoclopramide.