Infusion In Pediatric Patients Research Articles

Outcomes following intravenous bisphosphonate infusion in pediatric patients: A 7-year retrospective chart review.

Intravenous bisphosphonates (IV BP) have been used to treat children with osteoporosis for many years. Favorable side effect profile and improvements in bone mineral density (BMD) have been demonstrated in patients with osteogenesis imperfecta (OI), a primary form of osteoporosis in pediatrics. Less is known about the safety of IV BP in children with secondary osteoporosis or glucocorticoid-induced osteoporosis (GIO). We aimed to determine the prevalence of both acute and long-term side effects and assess the efficacy of IV BP treatment to increase bone mineral density in pediatric patients with varying presentations of compromised bone health. We conducted a retrospective chart review of pediatric patients (<21 years old) treated for osteoporosis with intravenous pamidronate (PAM) or zoledronic acid (ZA) at Cincinnati Children's Hospital Medical Center from 2010 to 2017. Patient demographics, diagnosis, infusion type and dose, acute phase reactions (APR), electrolyte abnormalities, and bone density measurements were collected from the electronic medical records. Diagnoses were grouped into 3 categories: primary osteoporosis, secondary osteoporosis, and GIO. Descriptive characteristics and adverse events were compared among categories. Change in bone mineral density (BMD) over time was compared among groups. 123 patients (56% male) received 942 infusions (83% PAM and 17% ZA). APR was reported in 7% of all infusions and more common in secondary osteoporosis (16%, p < 0.0001). There was a higher percentage of acute adverse events after the first infusion (27% vs 5%, p < 0.0001). Hypocalcemia following IV BP infusions occurred in 7% (27/379) of infusions and was significantly associated with ZA use (p = 0.04). Severity of hypocalcemia was generally mild, requiring intravenous calcium in 3% (13/379) of infusions. Hypophosphatemia occurred frequently, however rarely required intravenous supplementation. In 468 patient years of IV BP exposure, there were no reports of osteonecrosis of the jaw (ONJ) nor atypical femoral fracture (AFF). Lumbar spine (LS) aBMD Z-score 1 year after IV BP initiation increased overall for all groups (p < 0.0001) but did not significantly differ for those who did or did not fracture following IV BP treatment. APR due to intravenous BP treatment for pediatric osteoporosis were infrequent and generally mild. APR were more likely to occur in patients with secondary osteoporosis, a group who may require closer monitoring. A higher proportion of hypophosphatemia occurred in the patients with GIO. Long-term serious adverse events including ONJ and AFF were not identified in our patient population. LS aBMD Z-score increased following initiation of IV BP. However, the change in BMD was not associated with risk of fracture during the follow-up interval. These data provide reassurance and suggest that IV BP can be safely used in pediatric patients with osteoporosis.

Clinical Outcomes With Continuous Nafcillin Infusions in Children.

The primary objective of this study was to describe the clinical outcomes of continuous nafcillin infusion in pediatric patients. This was a retrospective case study performed at a freestanding, tertiary care children's hospital. Subjects were included if they were at least 30 days old and had received more than 1 dose of nafcillin by continuous infusion (CI) between January 1, 2009, and December 31, 2012. Clinical and microbiological data were extracted from the medical record. Documented adverse events potentially associated with nafcillin were recorded. Treatment success was defined by any one of the following outcomes without the presence of conflicting data: microbiological cure, prescriber-documented treatment success, or normalization of abnormal clinical or laboratory parameters. Forty subjects with a median of 9 (interquartile range [IQR], 2.3-12) years of age were included. Median length of stay (in days) for all indications observed was 7 (IQR, 5-21.8) days. Extended lengths of stay, indicated by ≥10 days, were more common in cases of endocarditis, skin and soft tissue infection, and bacteremia. Adverse reactions were documented in 20% of patients. In this pediatric study, overall treatment success was observed in 92.5% of patients. Microbiological cure was documented in 91.3% of patients by using follow-up cultures. Length of stay may be positively impacted by CI nafcillin. Continuously infused nafcillin appears to be an acceptable alternative to intermittently infused nafcillin in children. Further studies are needed to address the question of whether clinical outcomes of CI nafcillin are superior to those of conventional infusion.

Development of a Limited Sampling Strategy for the Estimation of Exposure to High-Dose Etoposide After Intravenous Infusion in Pediatric Patients.

Etoposide (VP-16), a podophyllotoxin derivative, is used in conditioning regimens before allogeneic hematopoietic stem cell transplantation in children with acute lymphoblastic leukemia. The aim of this study was to develop a limited sampling strategy (LSS) suitable for the prediction of exposure to VP-16 defined as area under time-concentration curve (AUC). The study included 28 pediatric patients with acute lymphoblastic leukemia, who were administered a 4-hour infusion of 60 mg/kg VP-16. VP-16 concentrations were determined in samples collected 4-124 hours after the beginning of infusion. On obtaining the pharmacokinetic (PK) profiles, a population PK model was developed in NONMEM (ICON Development Solutions, Hanover, MD) with first-order conditional estimation with interaction algorithm. LSSs were chosen by means of a multivariate regression analysis and cross-validated with a leave-one-out approach. Predictive performance of LSSs was assessed by calculating relative prediction error (PE), mean PE, mean absolute PE, and root mean squared PE for model-predicted and observed AUC. VP-16 PKs was best described by a 2-compartment first-order model, and a large variability in the PK parameters was observed. A 3-sample strategy allowed the estimation of VP-16 with highest accuracy and precision (mean relative PE = 0.18%, 95% confidence interval, 1.73%-2.09%; mean absolute relative PE = 3.47%, 95% confidence interval, 2.28%-4.66%; root mean squared PE = 4.43%). The final equation was AUC = 6.85 × C6 h + 3.88 × C12 h + 46.11 × C28 h + 282.0 (adjusted R = 0.9540). In conclusion, developed LSS allows accurate and precise estimation of VP-16 AUC and might be useful for therapeutic drug monitoring.

Comparison of the Effects of Intralipid 10% and 20% on Peripheral Catheter Ablation in a Pediatric Intensive Care Unit

Background: Energy deficit is a common and serious problem in pediatric intensive care units. Parenteral nutrition, either alone or in combination with enteral nutrition, can improve nutrient delivery in critically ill patients by preventing or correcting the energy deficit and improving the outcomes. Intralipid 10% and 20% are lipid emulsions, widely used in parenteral nutrition. Despite several clinical advantages, intravenous Intralipid therapy has been associated with several complications.In this study, we aimed to investigate the effects of Intralipid 10% and 20% on peripheral intravenous catheter ablation in children receiving Intralipid in a pediatric intensive care unit. Methods: In this observational study, 96 patients were recruited through simple non-random sampling over six months. In total, 48 patients received intravenous Intralipid 10%, while 48 patients were administered Intralipid 20% as part of their parenteral nutrition plan. Through separate peripheral intravenous catheters, 0.5-3 g/kg/day of Intralipid was administered at an infusion rate of 0.5 g/kg/h. Length of hospital stay and intravenous catheter ablation were compared between the two groups. Results: Age of the patients ranged between two days and eight years. Esophageal atresia was the most common condition among patients receiving intravenous Intralipid infusion (8.3%). The mean duration of catheter survival was significantly shorter in patients receiving Intralipid 20% (28.77 vs. 68.23 h, P<0.001), while length of hospital stay was not significantly different between the two groups (P=0.48). Conclusion: Based on the findings, concentration of Intralipid infusion in pediatric patients, receiving parenteral nutrition, might be associated with intravenous catheter ablation.

Dexmedetomidine Is Associated With Lower Incidence of Acute Kidney Injury After Congenital Heart Surgery.

Recent data have suggested an association between the use of dexmedetomidine and a decreased incidence of acute kidney injury in adult patients after cardiopulmonary bypass. However, no study has focused on this association among pediatric populations where the incidence of acute kidney injury is particularly high and of critical significance. The primary objective of this study was to assess the relationship between the use of postoperative dexmedetomidine and the incidence of acute kidney injury in pediatric patients undergoing cardiopulmonary bypass. The secondary objective was to determine whether there was an association between dexmedetomidine use and duration of mechanical ventilation or cardiovascular ICU stay. Single-center retrospective matched cohort study. A 20-bed quaternary cardiovascular ICU in a university-based pediatric hospital in California. Children less than 18 years old admitted after cardiac surgery with cardiopulmonary bypass between January 1, 2012, and May 31, 2014. None. Data from a cohort of 102 patients receiving dexmedetomidine during the first postoperative day after cardiac surgery were compared to an age- and procedure-matched cohort not receiving dexmedetomidine. Cohorts had similar baseline and demographic characteristics. Patients receiving dexmedetomidine were less likely to develop acute kidney injury (24% vs 36%; odds ratio, 0.54; 95% CI, 0.29-0.99; p = 0.046). After adjusting for age, bypass time, nephrotoxin use, and vasoactive inotropic score, the use of dexmedetomidine was associated with a lower incidence of acute kidney injury with adjusted odds ratio of 0.43 (95% CI, 0.27-0.98; p = 0.048). There was no difference between the cohorts with respect to the duration of mechanical duration (1 d each; p = 0.98) or cardiovascular ICU stays (5 vs 6 d; p = 0.91). The use of a dexmedetomidine infusion in pediatric patients after congenital heart surgery was associated with a decreased incidence of acute kidney injury; however, it was not associated with changes in clinical outcomes. Further prospective study is necessary to validate these findings.

Initial Observations of the Effects of Calcium Chloride Infusions in Pediatric Patients with Low Cardiac Output.

Myocardial contractility and relaxation are highly dependent on calcium homeostasis. Immature myocardium, as in pediatric patients, is thought to be more dependent on extracellular calcium for optimal function. For this reason, intravenous calcium chloride infusions may improve myocardial function in the pediatric patient. The objectives of this study were to report the hemodynamic changes seen after administration of continuous calcium chloride to critically ill children. We retrospectively identified pediatric patients (newborn to 17 years old) with hemodynamic instability admitted to the cardiac ICU between May 2011 and May 2012 who received a continuous infusion of calcium chloride. The primary outcome was improvement in cardiac output, assessed by arterial-mixed venous oxygen saturation (A-V) difference. Sixty-eight patients, mean age 0.87 ± 2.67 years, received a total of 116 calcium infusions. Calcium chloride infusions resulted in significant improvements in primary and secondary measures of cardiac output at 2 and 6 h. Six hours after calcium initiation, A-V oxygen saturation difference decreased by 7.4 % (32.6 ± 2.1 to 25.2 ± 2.0 %, p < 0.001), rSO2 increased by 5.5 % (63.1 vs 68.6 %, p < 0.001), and serum lactate decreased by 0.9 mmol/l (3.3 vs 2.4 mmol/l, p < 0.001) with no change in HR (149.1 vs 145.6 bpm p = 0.07). Urine output increased 0.66 ml/kg/h in the 8-h period after calcium initiation when compared to pre-initiation (p = 0.003). Neonates had the strongest evidence of effectiveness with other age groups trending toward significance. Calcium chloride infusions improve markers of cardiac output in a heterogenous group of pediatric patients in a cardiac ICU. Neonates appear to derive the most benefit from utilization of these infusions.

Intrabone Infusion of Umbilical Cord Blood Stem Cells to Improve Hematopoietic Recovery after Allogeneic Umbilical Cord Blood Transplantation in Children

Umbilical cord blood transplantation (UCBT) has been used to treat malignant and non-malignant diseases. UCBT offers the advantages of easy procurement, immediate availability, and acceptable partial HLA mismatches. Still, patients treated with UCBT show delayed hematopoietic and immunological recoveries, and have higher rates of infection. The problem of slower hematopoietic recovery post-UCBT has been addressed using different approaches: infusion of two CB units, ex-vivo expansion of CB, transplantation of a UCB combined with a selected CD34+ peripheral stem cell unit from an haplo-identical donor.Intrabone (IB) injection is a known emergency access route for infusion of fluids and drugs in children. Frassoni et al published a study on the IB injection of a single unit of CB into 32 adult patients (Frassoni F, et al. Lancet Oncol. 2008) and showed a neutrophil (0.5x10^9/L) and platelet (20x10^9/L) recoveries with a median of 23 and 36 days, respectively, with a median nucleated cell dose of only 2.6 x 10^7 cells/kg. These results have been confirmed in a retrospective study comparing IB infusion of CB with infusion of two units of CB in adult patients (Rocha V, et al. Transplantation. 2013). The only data of IB infusion in pediatric patients is a case report of 5 patients (Saglio F, et al. J Pediatr Hematol Oncol. 2012).In order to confirm the role of IB infusion of CB to improve hematopoietic reconstitution after UCBT in pediatric patients, we started a Phase II single arm, exploratory clinical trial (NCT01711788). Our primary hypothesis is that use of IB infusion of CB reduces stem cell trapping seen with IV infusion, maximizing the number of stem cells and providing a faster short- and robust long-term engraftment. Inclusion criteria includes age up to 21 years, diagnosis of hematopoietic disorders (malignant or not), availability of a single CB with at least 3 x 10^7 nucleated cells (NCs)/kg at freezing (use of two CB units is allowed provided a single CB unit fulfilling the above criteria is not available), and use of a myeloablative-conditioning regimen.On the day of UCBT, frozen CB unit is thawed, washed and re-suspended in 20 ml of a saline/albumin solution and aliquoted into four 5-ml syringes. Patient is sedated with propofol and ketamine according to the current protocol for sedation in children. After sedation, a first aliquot of CB stem cell suspension is injected into the bone marrow, followed by a of 0.5-1 ml saline solution rinse. This procedure is repeated for all remaining aliquots at different places and can be performed in one or both iliac crests, depending on patient size. Each injection is performed within a 2-minute timeframe. If patient requires two CB units, one unit is infused IB while the second unit is infused IV after recovery from sedation. G-CSF is given from D+7.A total of 12 patients has been included since Nov/2012. Eight were male, and median age was 7 (2 - 15) years. Diagnosis were AML (n=6), ALL (n=4) and sickle cell anemia (n=2). Most UCB were unrelated (n=10) and 6/6, 5/6 and 4/6 HLA matching comprised four, five and three UCBT. Busulfan-based conditioning was used in eight patients. Ten patients received a single unit UCB. Median NC infused was 3.4 (2.17-8.4) x 10^7/kg. There was no toxicity related to IB infusion.Engraftment occurred in 10 out of 12 patients and median time to engraftment (neutrophil ≥ 0.5x10^9/L) was 14.5 days. Platelet recovery (≥ 50x10^9/L) occurred in just 6/12 patients (due mainly to early relapse) and median time to recovery was 41 (28-77) days. Three patients presented a grade II aGVHD. There were three relapses. Ten out of twelve patients are alive, one patient died from UCBT complication (ARDS) and other from relapse.In conclusion, IB infusion of UCB is feasible in pediatric patients without any particular toxicity and there is a positive impact on neutrophil recovery. Inclusion of more patients are needed to confirm the impact of IB-UCBT on platelet recovery, duration of hospitalisation, and survival. IB-UCBT might be a more affordable alternative to improve hematopoietic recovery comparing to other methods of UCB expansion. DisclosuresNo relevant conflicts of interest to declare.

Safety and efficacy of sodium nitroprusside during prolonged infusion in pediatric patients

目的 硝普钠(sodium nitroprusside，SNP)是直接作用血管扩张药，用于手术室及ICU降压治疗。几乎没有随机对照研究分析其在儿科患者的有效性。本研究评估患儿静点SNP至少1 2h后的有效性和安全性。设计 随机对照，双盲安慰剂停药法研究。场所 重症监护病房。对象 17岁以下患儿。干预措施 开放式静点SNP 12～24 h后以最后液速改为盲法静点SNP或安慰剂30 min。测量方法和主要结果 有效性指标主要为平均动脉压(mean arterial blood pressure)控制力，如其在盲法静点期是否高于外周基线血压并持续2 min。安慰剂组MAP失控患儿比例显著高于SNP组(15/19，79% vs. 9/20，45%；P＝0.048).3例患儿于盲法静点期出现反跳性高血压，均发生于安慰剂组。严重药物不良反应(serious adverse event，SAE)发生率低(7/52，13%)，且仅有1例被现场研究员判定为SNP相关。14例(27%)患儿全血氰化物浓度>0.5 mcg/ml，氰化物浓度和液速高度相关(0.7)，但临床未见氰化物中毒表现。结论 静点SNP 12 h可有效控制儿童MAP。尽管氰化物浓度升高患儿比例较高，但未见氰化物中毒表现。 设计 随机对照，双盲安慰剂停药法研究。 场所 重症监护病房。 对象 17岁以下患儿。 干预措施 开放式静点SNP 12～24 h后以最后液速改为盲法静点SNP或安慰剂30 min。 测量方法和主要结果 有效性指标主要为平均动脉压(mean arterial blood pressure)控制力，如其在盲法静点期是否高于外周基线血压并持续2 min。安慰剂组MAP失控患儿比例显著高于SNP组(15/19，79% vs. 9/20，45%；P＝0.048).3例患儿于盲法静点期出现反跳性高血压，均发生于安慰剂组。严重药物不良反应(serious adverse event，SAE)发生率低(7/52，13%)，且仅有1例被现场研究员判定为SNP相关。14例(27%)患儿全血氰化物浓度>0.5 mcg/ml，氰化物浓度和液速高度相关(0.7)，但临床未见氰化物中毒表现。 结论 静点SNP 12 h可有效控制儿童MAP。尽管氰化物浓度升高患儿比例较高，但未见氰化物中毒表现。

Safety and efficacy of sodium nitroprusside during prolonged infusion in pediatric patients.

Sodium nitroprusside is a direct-acting vasodilator used to lower blood pressure in the operating room and ICU. The efficacy of sodium nitroprusside has been analyzed in few pediatric randomized trials. This study assesses the efficacy and safety of sodium nitroprusside following at least 12 hours of IV infusion in children. Randomized, double-blind withdrawal to placebo study. ICUs. Pediatric patients younger than 17 years. Following 12-24 hours of open-label sodium nitroprusside titration, a blinded infusion of sodium nitroprusside or placebo was administered (at the stable rate used at the end of the open-label phase) for up to 30 minutes. The primary efficacy measure was whether control of mean arterial blood pressure was lost, that is, increased above ambient baseline for two consecutive minutes during the blinded phase. The proportion of patients who lost mean arterial blood pressure control in the placebo group (15/19; 79%) was significantly different than those in the sodium nitroprusside group (9/20; 45%) (p = 0.048). Three patients experienced rebound hypertension during the blinded phase, and all were in the placebo group. Serious adverse event rates were low (7/52; 13%), and in only one patient was the serious adverse event determined to be related to sodium nitroprusside by the site investigator. Fourteen patients (27%) had whole blood cyanide levels above 0.5 μg/mL, with high correlation (0.7) between infusion rate and cyanide levels, but there were few clinical signs of cyanide toxicity. Sodium nitroprusside is efficacious in maintaining mean arterial blood pressure control in children following a 12-hour infusion. Although a high proportion of patients were found to have elevated cyanide levels, toxicity was not observed.

Stability of epinephrine at standard concentrations.

To minimize medication errors, standard concentrations are recommended for medications intended for continuous infusion in pediatric patients. Premixing of epinephrine (commonly used to manage septic shock in children) would improve timeliness, safety, and cost-effectiveness. However, information about the stability of epinephrine at standard concentrations is limited. To evaluate the stability of epinephrine in 5% dextrose in water at standard concentrations and to extend its expiration date after storage in infusion bags at 4°C and 25°C for up to 30 days. A total of 6 infusion bags were prepared with 200 mL of epinephrine solution, 2 bags for each of 3 standard concentrations (25, 50, and 100 μg/mL). Three bags (one for each concentration) were stored under refrigeration (4°C), and the remaining 3 bags were stored at room temperature (25°C). Physical characteristics (including pH, colour, and presence of precipitate) were evaluated daily for the first 14 days and every 1 to 5 days thereafter until day 30. Three 1.5-mL samples were collected from each bag immediately after preparation (time 0), every 24 h (at 24 h, 48 h, 72 h, 96 h, etc.) for the first 14 days, and every 1 to 5 days thereafter until day 30. Each sample was analyzed by stability-indicating high-performance liquid chromatography. A solution was considered stable if it maintained at least 90% of its initial concentration. No notable changes in pH, colour, or precipitation were observed in any of the solutions after storage at 4°C or 25°C for up to 30 days. All formulations maintained more than 95% of the initial epinephrine concentration on day 30. In addition, the calculated lower limit of the 95% confidence interval indicated that 93% or more of the initial concentration remained on day 30. Preparations of epinephrine were stable for up to 30 days, with or without refrigeration. Because stability alone does not guarantee bioavailability or efficacy of a drug, future clinical studies are recommended to evaluate the pharmacokinetics and pharmacodynamics of these formulations.

Application of indwelling needles in infusion for infants at pediatric clinics

Objective To investigate the application effect of indwelling needles in infusion for infants at clinics.Methods The indwelling needles were used for infusion in infants who needed continuous infusions twice daily for longer than 3 days,with poor venous condition,crying,irritation,or infusion duration ≥4 hours.Results The use of indwelling needles for infusion was 409 person/time,successful completion of course with indwelling needles was 381 person/time,and failure of indwelling was 28 person/time.No infections occurred.Conclusions In pediatric clinics,uses of indwelling needles for infusion in pediatric patients who meet the application standards can relieve the pain induced by repeated punctures,reduce swelling caused by infusion leaking in infants with restlessness.By strengthened management of risks,accidental needle removal,tube plugging,exudation,infection or nurse-patient disputes can be avoided.So it is a safe and effective method for infusion. Key words: Indwelling needles; Infants; Infusion

Donor Lymphocyte Infusions in Pediatric Patients with Malignant and Non-Malignant Diseases After Allogeneic Bone Marrow Transplantation: A Single Center Experience

Donor Lymphocyte Infusions in Pediatric Patients with Malignant and Non-Malignant Diseases After Allogeneic Bone Marrow Transplantation: A Single Center Experience

Efficacy of Intravenous Lidocaine to Reduce Pain and Distress Associated With Propofol Infusion in Pediatric Patients During Procedural Sedation

Research suggests that young children experience an increased incidence and severity of discomfort during propofol infusion. Evaluations of varied interventions to reduce or eliminate this discomfort with adult subjects suggest that premedication with intravenously administered lidocaine (0.5 mg/kg) offers the best overall effectiveness. Because this regimen's efficacy in a pediatric population is undocumented, we conducted a randomized, double-blind, placebo-controlled study to determine the effectiveness of intravenous lidocaine pretreatment to alleviate pain in pediatric subjects before propofol infusion. Subjects (aged 2-7 years) scheduled for painless diagnostic procedures received either a saline placebo or 1 of 2 lidocaine doses before administering propofol. To capture the patient's baseline behavioral state, a trained observer administered the validated face, legs, activity, cry, consolability pain assessment scale before propofol infusion. During deep sedation induction, the sedating physician, a trained research assistant, and the patient's parent documented maximum distress using a 100-mm visual analog scale (VAS). Ninety-one subjects participated. We found no difference in VAS pain scores between groups pretreated with lidocaine 0.25 mg/kg, lidocaine 0.5 mg/kg, and placebo. Statistical analysis also found no interrater differences between parents, physician, or observer VAS scores. Our data do not support using lidocaine pretreatment to alleviate pain/discomfort in pediatric patients during propofol infusion.

High-dose magnesium sulfate infusion protocol for status asthmaticus: a safety and pharmacokinetics cohort study

To assess the safety and pharmacokinetics of high-dose magnesium sulfate (MgSO(4)) infusion in pediatric patients with status asthmaticus. A prospective cohort study within a 20-bed pediatric intensive care unit in an academic community hospital. Patients 2-18 years of age admitted with status asthmaticus between 10/2009 and 8/2010 were included in the study. All patients received standard therapy for asthma, while the treatment group received an intravenous magnesium sulfate bolus of 50-75 mg/kg (0.2-0.3 mmol/kg) followed by 40 mg/kg/h (0.16 mmol/kg/h) for 4 h. Patients were monitored for cardiorespiratory complications. The treatment group underwent four blood draws to assess pharmacokinetic parameters. Nineteen patients were in the treatment group and 38 patients in the control group after exclusion criteria and consenting were completed. No clinically significant differences were found between groups. There were no interventions or discontinuations of MgSO(4) due to adverse events. In the treatment group, three patients had mild infusion-related reactions. Heart rate and respiratory rate were statistically significantly lower in the magnesium treatment group. The continuous infusions of MgSO(4) were safe at the studied doses and maintained serum magnesium (SrMg) and ionized magnesium levels similar to levels required to produce smooth muscle relaxation in other clinical settings. Further studies are needed to investigate the efficacy of high-dose continuous MgSO(4) infusion as an adjunctive treatment for severe asthma treatment and determine the SrMg level required to maintain airway smooth muscle relaxation.

Feasibility of Short-Term Infusion of Magnesium Sulfate in Pediatric Patients With Status Asthmaticus

This report describes the feasibility of high-dose magnesium sulfate infusion in pediatric patients with status asthmaticus. Retrospective chart review over a 3-year period of all patients younger than 18 years of age with status asthmaticus who underwent a high-dose magnesium sulfate infusion for 4 hours. All patients were breathing spontaneously but were refractory to conventional therapy. The magnesium sulfate infusion regimen was 50 mg/kg (for patients weighing >30 kg) or 75 mg/kg (for those weighing ≤30 kg) over a period of 30 to 45 minutes, followed by a continuous infusion of 40 mg/kg/hr for 4 hours. Information regarding vital and clinical respiratory signs, serum magnesium (SrMg), ionized magnesium (iMg), electrocardiograms, and cardiac troponin levels were retrieved. We analyzed the relationship between SrMg and iMg by using linear regression analysis. Nineteen patients were included. At the end of the infusion, SrMg levels were 4.4 ± 0.8 mg/dL, and iMg levels were 0.95 ± 0.2 mmol/L. SrMg levels only moderately predicted iMg (r(2) = 0.541). There were no reports of hypotension, respiratory failure, neurological problems, or nausea. Discomfort at the site of infusion was reported in three cases. Troponin levels (n = 12) and electrocardiograms (n = 12), when available, were noted at the end of the infusion and were normal in all patients p=0.01. In this case series, short-term high-dose administration of magnesium sulfate in the context of status asthmaticus was feasible, and we did not observe clinical complications with its use. Total SrMg was inadequate to reflect the active form of magnesium, iMg. The dose used achieved theoretical therapeutic levels of iMg.

249 Distal Femur Site Is a Viable Option for IO Vascular Access in Pediatric Patients

Study Objective: Historically, many bones have been successfully used for intraosseous (IO) vascular including the proximal tibia, sternum, distal tibia, radius, clavicle, proximal humerus, olecranon, calcaneous, iliac crest; as well as the distal Though approved by the European Union, no device has been approved by the US FDA for use in the distal femur location. Since that location is a preferred site for vascular access among many pediatric emergency physicians and other health care professionals, we sought to determine the relative effectiveness of the site for delivery of fluids and medications. Methods: Using PubMed, a literature review was conducted using keywords intraosseous, IO access, and femur. We also consulted with the Science & Clinical department of one device company (Vidacare Corporation, Shavano Park, TX) to gain additional data and perspectives on access through the distal femur apart from those published in the clinical literature. The company shared results of 2 company-sponsored, institutional review board-approved, clinical trials, and a post-mortem study to determine if the EZ-IO could consistently and safely be inserted into the pediatric distal femur for infusion by physicians, nurses, and paramedics. Results: PubMed listed 661 articles describing vascular access. Among those, 21 articles describe the distal femur as an acceptable site for vascular particularly in the pediatric population. In a 2008 retrospective study of 95 pediatric patients, 13 patients were provided vascular access through the distal Patient ages ranged from Conclusion: Clinical literature, clinical studies, and a post-mortem study confirm that the distal femur is a viable option for infusion in pediatric patients.

Efficacy and Safety of Intravenous Sodium Valproate in Convulsive Status Epilepticus in Children in Shahid Sadoughi Hospital

Efficacy and Safety of Intravenous Sodium Valproate in Convulsive Status Epilepticus in Children in Shahid Sadoughi Hospital

Ferumoxytol Infusion in Pediatric Patients with Gastrointestinal Disorders: First Case Series

To report our preliminary experience using ferumoxytol as intravenous iron therapy for treating iron deficiency anemia in 6 pediatric patients with underlying gastrointestinal disease. Between October 2010 and February 2011, 6 patients aged 6 months to 16 years who had malabsorption and/or ongoing gastrointestinal blood loss were given ferumoxytol infusions at a dose of 5.8-12 mg elemental iron/kg over 15-60 minutes, followed by 1 hour of observation to monitor for adverse effects. Thirteen separate ferumoxytol administrations were given to 6 pediatric patients with various gastrointestinal diseases, including inflammatory bowel disease and short bowel syndrome, and/or chronic parenteral nutrition dependence. Twelve of 13 infusions were well tolerated at 5.8-12 mg elemental iron/kg/dose. No patient experienced adverse events that required clinical intervention. One patient developed mild pruritus that resolved spontaneously. Ferumoxytol doses of up to 12 mg elemental iron/kg administered over 15-60 minutes seem to be well tolerated in pediatric patients. Larger prospective studies are needed to determine the incidence and severity of adverse effects associated with ferumoxytol, both during administration and immediately after. Long-term studies will be required to assess to risk for iron overload toxicity.

Prevention of acute adverse events related to infliximab infusions in pediatric patients

To study whether premedication with an oral antifebrile agent (acetaminophen) and antihistamine (cetirizine) could decrease the frequency of acute infusion reactions in pediatric patients. All pediatric patients scheduled for infliximab infusions at the Helsinki University Central Hospital, a tertiary care center, were prospectively introduced to a standard oral premedication of acetaminophen (20 mg/kg) and cetirizine (10 mg) prior to infliximab infusions for a period of 1 year. All acute adverse events related to infliximab infusions given according to the guidelines of pediatric rheumatologists or gastroenterologists were registered for this time period and retrospectively during the preceding year. During the study period, infliximab infusions with premedication were given to 64 pediatric patients (48 with rheumatic disease and l6 with inflammatory bowel disease, mean age 13 years, n = 34 boys, and n = 30 girls). Infliximab was introduced to 14 children; the rest were on maintenance therapy. Twelve infusion reactions, 4 mild and 8 severe, were observed in 8 (12.5%) of the 64 subjects, and in 1 subject 4 times. During the preceding year, 60 pediatric patients had received infliximab infusions without premedication. In this latter group, infusion reactions occurred in 5 children (8.3%; P > 0.05). The presentation of an acute infusion reaction was not related to the sex or diagnosis of the patient. In pediatric patients, acute infusion reactions related to infliximab could not be prevented with premedication with oral acetaminophen and cetirizine.

Continuous incisional infusion of local anesthetic in pediatric patients following open heart surgery

To determine the efficacy and safety of a continuous subcutaneous local anesthetic (LA) infusion in pediatric patients following open heart surgery. The use of a continuous LA infusion has been shown to be beneficial following adult cardiac surgery. To date there are no studies in the pediatric population. Using a prospective, randomized, and double blind design, we compared LA, either 0.25% levobupivacaine or bupivacaine (Treatment Group) to saline (Placebo Group) delivered subcutaneously via a continuous infusion for 72 h after open heart surgery in 72 patients. Requirements for postoperative analgesics and pain scores were recorded for 72 h and plasma levels of local anesthetic were measured. Secondary outcomes measures included time to first oral intake, time to first bowel movement, time to urinary catheter removal, length of stay, requirements for antiemetics and additional sedation. Total morphine requirements over the first 24 h were less in the Treatment Group than the Placebo Group (0.05 mg x kg(-1) vs 0.2 mg x kg(-1), P = 0.007); this was true for all patient groups except those patients weighing less than 6.3 kg. The number of patients requiring no morphine was greater in the Treatment Group (7/35 vs 1/37, P = 0.02). The Treatment Group also received less midazolam, lorazepam, and ketorolac than the Placebo Group over 72 h due to the reduced clinical need for these agents in patients weighing less than 31 kg. There were no differences in secondary outcomes. A continuous incisional infusion of LA reduced postoperative analgesic requirement and sedative use in pediatric patients undergoing a median sternotomy incision. Dosed at a maximum rate of 0.4 mg x kg(-1) x h(-1), a continuous incisional infusion of LA is effective and safe for up to 72 h, with plasma levels of local anesthetic well below the toxic threshold.