Jared Cash

Standard Drug Concentrations and Smart-Pump Technology Reduce Continuous-Medication-Infusion Errors in Pediatric Patients

Objective. To determine if combining standard drug concentrations with “smart-pump” technology reduces reported medication-infusion errors. Design. Preintervention and postintervention comparison of reported medication errors related to infusion therapies during the calendar years 2002 and 2003. Setting. A 242-bed university-affiliated tertiary pediatric hospital. Intervention. Change in continuous-medication-infusion process, comprising the adoption of (1) standard drug concentrations, (2) “smart” syringe pumps, and (3) human-engineered medication labels. Main Outcome Measures. Comparison of reported continuous-medication-infusion errors before and after the intervention. Results. The number of reported errors dropped by 73% for an absolute risk reduction of 3.1 to 0.8 per 1000 doses. Preparation errors that occurred in the pharmacy decreased from 0.66 to 0.16 per 1000 doses; the number of 10-fold errors in dosage decreased from 0.41 to 0.08 per 1000 doses. Conclusions. The use of standard drug concentrations, smart syringe pumps, and user-friendly labels reduces reported errors associated with continuous medication infusions. Standard drug concentrations can be chosen to allow most neonates to receive needed medications without concerns related to excess fluid administration.

Enteral methadone to expedite fentanyl discontinuation and prevent opioid abstinence syndrome in the PICU.

Study Objective. To determine if enterally administered methadone can facilitate fentanyl discontinuation and prevent withdrawal in children at high risk for opioid abstinence syndrome.

A survey of the utilization of anti-pseudomonal beta-lactam therapy in cystic fibrosis patients.

The purpose of this study was to characterize the utilization of anti‐pseudomonal beta‐lactam antibiotics in the treatment of acute pulmonary exacerbations (APE) among Cystic Fibrosis Foundation (CFF)‐accredited care centers. An anonymous national cross‐sectional survey of CFF‐accredited care centers was performed using an electronic survey tool (SurveyMonkey.com®). One hundred and twenty‐one of 261 centers completed the survey (46%) representing 56% (14,856/26,740) of patients in the CFF Patient Registry. One hundred and nineteen of 121 (98%) respondents reported using beta‐lactams for the treatment of APE. Intermittent dosing regimens constituted 155/167 (93%) reported regimens, while extended infusions were 12/167 (7%). Ceftazidime was the most commonly utilized beta‐lactam comprising 74/167 (44%) of all infusions (intermittent and extended) of which 70/74 (95%) were intermittent infusions. The majority of intermittent ceftazidime regimens (56/70; 80%) were at doses lower than CFF and European guidelines recommended doses. In conclusion, a great majority of respondents use intermittent anti‐pseudomonal beta‐lactam antibiotics, with over half of respondents utilizing lower than guidelines recommended doses. While this is of concern, it is not known if optimization of dosing strategies according to guidelines recommendations will result in clinical benefit. Pediatr. Pulmonol. 2011; 46:987–990.

A cost analysis of enterally administered lorazepam in the pediatric intensive care unit.

OBJECTIVE To determine the cost savings of replacing intravenous midazolam with enterally administered lorazepam in mechanically ventilated children who require long-term continuous sedation. DESIGN Retrospective review of patients treated according to a preestablished pediatric intensive care unit (ICU) sedation protocol. SETTING Twenty-six-bed pediatric ICU in a tertiary care childrens hospital. PATIENTS The records of 30 mechanically ventilated children were analyzed. The median age was 1.5 yrs and the median weight was 8.0 kg. Patients required continuous sedation for a total of 16 days (median). INTERVENTIONS According to our pediatric ICU sedation protocol, midazolam infusion was continued until the hourly midazolam requirement was stable for at least 24 hrs. Thereafter, patients with a nasojejunal tube who were likely to require a minimum of three additional days of continuous sedation were transitioned from intravenous midazolam to enterally administered lorazepam. The goal in transitioning therapy was to titrate the lorazepam dose and reduce midazolam administration while maintaining an unchanged level of sedation. MEASUREMENTS AND MAIN RESULTS The rate of midazolam administration was significantly (p<.05) reduced beginning on day 1 of lorazepam treatment. Midazolam was successfully discontinued in 24 (80%) patients in 3 days (median), and adequate and appropriate sedation was maintained with lorazepam monotherapy. Six patients in whom midazolam could not be discontinued experienced a 52% reduction in the rate of midazolam administration as a result of adding lorazepam. Total projected midazolam utilization was defined as the sum of midazolam administration before initiating lorazepam and the projected midazolam requirement after initiating lorazepam. Projected midazolam cost was calculated as the product of total projected midazolam utilization and midazolam acquisition cost. Actual expenditures for both midazolam and lorazepam were subtracted from the projected midazolam cost to calculate the estimated cost savings. Overall, midazolam utilization (in milligrams) was reduced by 46.7+/-27.6% (median 52). Total projected midazolam cost for the 30 patients was

Pharmacokinetics and pharmacodynamics of ranitidine in critically ill children.

90,771. The actual cost of midazolam and lorazepam combined was

Failure of nasogastric omeprazole suspension in pediatric intensive care patients.

47,867, resulting in a cost savings of

Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children’s Hospital After Implementation of Electronic Ordering and Compounding

42,904. CONCLUSIONS Transitioning from intravenous midazolam to enterally administered lorazepam in critically ill children who require long-term sedation results in significant cost savings. The oral formulation of lorazepam was convenient to use, inexpensive, and effective in maintaining a continuous and appropriate level of sedation once midazolam was discontinued.

High dose intermittent ticarcillin–clavulanate administration in pediatric cystic fibrosis patients

ObjectiveTo determine the pharmacokinetics and pharmacodynamics of ranitidine in critically ill children and to design a dosage regimen that achieves a gastric pH ≥4. DesignProspective, open-label, pharmacokinetic-pharmacodynamic study. SettingPediatric intensive care unit in a tertiary care children’s hospital. PatientsMechanically ventilated, critically ill children ≥10 kg who required intravenous ranitidine for stress ulcer prophylaxis. InterventionsRanitidine pharmacokinetics were determined after a single intravenous dose. Gastric pH was monitored hourly via nasogastric pH probe. After the last blood sample, patients received an intravenous bolus of ranitidine (0.5 mg/kg) followed by a continuous infusion (0.1 mg·kg−1·hr−1). The infusion was increased incrementally (0.05 mg·kg−1·hr−1) until reaching gastric pH ≥4 for ≥75% of a 24-hr period, after which steady-state plasma concentrations were measured. Plasma concentrations were analyzed by high-pressure liquid chromatography. Measurements and Main Results Twenty-three children (ranging in age from 1.4 to 17.1 yrs) were studied. Pharmacokinetic variables included a clearance of 511.7 ± 219.7 mL·kg−1·hr−1, volume of distribution of 1.53 ± 0.99 L/kg, and half-life of 3.01 ± 1.35 hrs. After the single intravenous dose (1.52 ± 0.47 mg/kg), gastric pH increased from 1.6 ± 1.0 to 5.1 ± 1.1 (p < .001), which was associated with a plasma concentration of 373 ± 257 ng/mL. Based on the pharmacokinetic variables, the dose of intravenous ranitidine required to target 373 ng/mL as the average steady-state concentration is 1.5 mg/kg administered every 8 hrs. During the continuous infusion, the mean steady-state ranitidine concentration associated with gastric pH ≥4 was 287 ± 133 ng/mL. This concentration may be achieved with an intravenous loading dose of 0.45 mg/kg followed by a continuous infusion of 0.15 mg·kg−1·hr−1. ConclusionsThe pharmacokinetics of ranitidine in critically ill children are variable. The description of ranitidine’s pharmacokinetics and pharmacodynamics in this study may used to design an initial ranitidine dosage regimen that targets a gastric pH ≥4. Thereafter, gastric pH should be monitored and the dose of ranitidine adjusted accordingly.

Population Pharmacokinetic and Pharmacodynamic Modeling of High-Dose Intermittent Ticarcillin-Clavulanate Administration in Pediatric Cystic Fibrosis Patients

Objectives: To determine the efficacy of nasogastric administration of omeprazole suspension in raising the gastric pH >4 in critically ill pediatric patients and to determine the most appropriate dosing regimen for this indication. Design: Open-label pharmacodynamic study. Setting: Twenty-six bed tertiary-care pediatric intensive care unit. Patients: Mechanically ventilated children aged 1–18 yrs with an additional risk factor for stress ulcer formation. Interventions: Continuous gastric pH monitoring was performed during administration and dose titration of omeprazole suspension to achieve the goal of gastric pH >4 for greater than 75% of the dosing interval. Measurements and Main Results: Data were collected from 18 patients. Subjects were categorized based on the pharmacologic response to nasogastric administration of 1 mg/kg omeprazole suspension (maximum 20 mg) as rapid (n = 9), late (n = 5), and nonresponders (n = 4). Rapid responders required 0.72 mg/kg per day omeprazole suspension to achieve adequate gastric pH elevation for stress ulcer prophylaxis. Late responders required 1.58 mg/kg per day. Nonresponders did not achieve adequate elevation of gastric pH for stress ulcer prophylaxis. Conclusions: Nasogastric administration of omeprazole suspension has variable efficacy in critically ill pediatric patients. Half of the studied subjects either required significant dose titrations to achieve gastric acid suppression or did not respond to nasogastric administration of omeprazole suspension.

Dose Standardization of Oral Liquid Medications in a Pediatric Hospital

INTRODUCTION The Institute for Safe Medication Practices has stated that parenteral nutrition (PN) is considered a high-risk medication and has the potential of causing harm. Three organizations--American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), American Society of Health-System Pharmacists, and National Advisory Group--have published guidelines for ordering, transcribing, compounding and administering PN. These national organizations have published data on compliance to the guidelines and the risk of errors. The purpose of this article is to compare total compliance with ordering, transcription, compounding, administration, and error rate with a large pediatric institution. METHOD A computerized prescriber order entry (CPOE) program was developed that incorporates dosing with soft and hard stop recommendations and simultaneously eliminating the need for paper transcription. A CPOE team prioritized and identified issues, then developed solutions and integrated innovative CPOE and automated compounding device (ACD) technologies and practice changes to minimize opportunities for medication errors in PN prescription, transcription, preparation, and administration. Thirty developmental processes were identified and integrated in the CPOE program, resulting in practices that were compliant with A.S.P.E.N. safety consensus recommendations. Data from 7 years of development and implementation were analyzed and compared with published literature comparing error, harm rates, and cost reductions to determine if our process showed lower error rates compared with national outcomes. RESULTS The CPOE program developed was in total compliance with the A.S.P.E.N. guidelines for PN. The frequency of PN medication errors at our hospital over the 7 years was 230 errors/84,503 PN prescriptions, or 0.27% compared with national data that determined that 74 of 4730 (1.6%) of prescriptions over 1.5 years were associated with a medication error. Errors were categorized by steps in the PN process: prescribing, transcription, preparation, and administration. There were no transcription errors, and most (95%) errors occurred during administration. CONCLUSION We conclude that PN practices that conferred a meaningful cost reduction and a lower error rate (2.7/1000 PN) than reported in the literature (15.6/1000 PN) were ascribed to the development and implementation of practices that conform to national PN guidelines and recommendations. Electronic ordering and compounding programs eliminated all transcription and related opportunities for errors.