Maxime Thibault

Parenteral Nutrition-Associated Liver Disease: a Retrospective Study of Ursodeoxycholic Acid Use in Neonates

OBJECTIVES To verify the effect of ursodeoxycholic acid (UDCA) on the duration of neonatal parenteral nutrition-associated liver disease. METHODS Retrospective cohort study of neonates in intensive care between 2004 and 2007 presenting with parenteral nutrition-associated liver disease. RESULTS Of 118 eligible infants, 64 received UDCA. Cholestasis lasted longer in the UDCA group (79 vs. 50 days, p=0.001). However, treatment was delayed for a median of 24 days after cholestasis onset. Multivariate Cox regression analysis showed no association between UDCA and cholestasis duration. The rate of decline of conjugated bilirubin was greater in treated patients (median 0.084 mg/dL/day vs. 0.60 mg/dL/day; p=0.009) and weight gain was greater (22.8 vs. 17.7 g/kg/day, p=0.010). CONCLUSIONS UDCA therapy was not associated with the duration of parenteral nutrition-associated liver disease. A delay in treatment initiation might explain this result. UDCA therapy was associated with a faster decline of conjugated bilirubin and greater weight gain.

Failure Mode, Effect, and Criticality Analysis of the Parenteral Nutrition Process in a Mother-Child Hospital: The AMELIORE Study

BACKGROUND The parenteral nutrition (PN) process is complex and involves multiple steps and substeps, especially in pediatrics and neonatology, given the particular needs of these patients. The objective of this study was to perform a critical analysis of the PN process at the Centre Hospitalier Universitaire Sainte-Justine to determine which potential pitfalls are related to this process and which should be prioritized when implementing corrective measures. METHODS This is a Failure Mode, Effect, and Criticality Analysis (FMECA) study. A multidisciplinary team assessed each step of the PN process and identified associated failure modes. Adapted rating scales were used to determine severity, frequency, and detectability of the failure modes. Ratings were established through multidisplinary consensus, and a criticality index (CI) was calculated for each failure mode. RESULTS A total of 265 failure modes were identified in the 5 major steps of the PN process. The failure mode with the highest CI was the inscription of an inaccurate weight at prescription, with a CI of 800. The step with the highest cumulative CIs was administration to patients, with a CI sum of 7691. Various recommendations aimed at minimizing the risks associated with the PN process were made following this FMECA. Additional interventions are expected to emanate from this project because data will be presented throughout the departments involved. CONCLUSION This study is a successful example for other hospitals interested in carrying out the same kind of healthcare improvement initiative.

Automated compounding of parenteral nutrition for pediatric patients: characterization of workload and costs.

OBJECTIVES Parenteral nutrition (PN) compounding in large hospital centers is now largely automated using volumetric pump systems. No study has examined the pharmacy workload and costs associated with this process. This study was designed to characterize these elements at our center and to identify areas for potential improvement. METHODS We retrospectively analyzed all PN orders compounded from May 19, 2007, to June 25, 2010. Patients were divided into groups according to the ward where PN was initiated. RESULTS The age and weight of patients at initiation of PN were similar throughout the study, except in neonatology, where initiation now occurs earlier in life (age 1.3 ± 2.7 days in 2010 vs. 3.4 ± 9.4 in 2007; p=0.003). An average of 894 orders per month were compounded. A total of 59% of orders were for neonatal patients. The average cost of source solutions per PN order increased from Can

Opioids After Discharge in Pediatric Patients.

23.27 in 2007 to Can

Conformity of commercial oral single solid unit dose packages in hospital pharmacy practice

37.78 in 2010. Partially used source solutions discarded at the end of the day represented between 7.7% and 9.2% of total source solution cost. Amino acids in 3-L bags were responsible for the largest waste, with Can

Possible Incompatibility between Amino Acids and Copper in Solutions for Pediatric Parenteral Nutrition.

953 to Can

Asynchronous validation and documentation of sterile compounding in a hospital pharmacy.

1048 wasted monthly. CONCLUSIONS PN compounding at our center represents an important workload and increasing costs. A reduction in source solution waste, for example, by reducing the use of large source solution containers, would be beneficial.

Utilisation du bilan comparatif des médicaments en chirurgie ambulatoire pédiatrique

The authors thank Thibault et al.1 for confirming several of the findings in our study, particularly that pediatric providers may be dispensing far more medicine than is needed (or used) to treat pain.2,3 Furthermore, their work and our ongoing research (M. Yaster et al., unpublished data, 2015, abstract A1056, presented at the annual meeting of the American Society of Anesthesiologists, San Diego, CA) confirms the work of Bates et al.4 who in interviews of postoperative, adult, urology patients found that only 58% of the postoperative pain medication was actually consumed. This excess of “leftover” medication may be contributing to the epidemic of nonmedical use of prescription opioids, which is now one of the most serious public health problems in the United States.5,6 “Obvious things that nobody by any chance observed.” However, my colleagues and I would urge caution against treatment pendulum swings (Pain is the fifth vital sign and patients are undertreated for pain versus opioids are too dangerous to provide to patients who may or may not need them.). Patients, both pediatric and adults, in moderate to severe pain have legitimate analgesic needs that are often best treated with opioids. What is really missing is evidence to provide physicians and their surrogates data that better define how much opioid is needed, how well opioids work, and how much needs to be prescribed and dispensed for the many acute and chronic pain conditions we treat.

Tarification à l’activité : mise à jour des outils financiers en pharmacie hospitalière

BACKGROUND There are limited published data on the labelling of single unit dose packages in hospitals. SETTING AND PARTICIPANTS The study was conducted in three large hospitals (two adult and one paediatric) in the metropolitan Montreal area, Quebec, Canada. OBJECTIVE The objective is to evaluate the labelling of commercial oral single solid unit dose packages available in Canadian urban hospital pharmacy practice. METHOD The study endpoint was the labelling conformity of each unit dose package for each criterion and overall for each manufacturer. Complete labelling of unit dose packages should include the following information: (1) brand name, (2) international non-proprietary name or generic name, (3) dosage, (4) pharmaceutical form, (5) manufacturers name, (6) expiry date, (7) batch number and (8) drug identification number. We also evaluated the ease with which a single unit dose package is detached from a multiple unit dose package for quick, easy and safe use by pharmacy staff. Conformity levels were compared between brand-name and generic packages. RESULTS A total of 124 different unit dose packages were evaluated. The level of conformity of each criterion varied between 19 and 50%. Only 43% of unit dose packages provided an easy-to-detach system for single doses. Among the 14 manufacturers with three or more unit dose packages evaluated, eight (57%) had a conformity level less than 50%. CONCLUSION This study describes the conformity of commercial oral single solid unit dose packages in hospital pharmacy practice in Quebec. A large proportion of unit dose packages do not conform to a set of nine criteria set out in the guidelines of the American Society of Health-System Pharmacists and the Canadian Society of Hospital Pharmacists.