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Weller BM, Shaddix BP, Oschman A, Johnson PN, Neely SB, Chaaban H, Williams PK, Miller J. A Pilot Evaluation of the Possible Association of Metronidazole With Neurodevelopmental Outcomes in Premature Neonates. J Pediatr Pharmacol Ther 2021; 26:455-459. [PMID: 34239396 PMCID: PMC8244961 DOI: 10.5863/1551-6776-26.5.455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Metronidazole is recommended as a first-line treatment of necrotizing enterocolitis (NEC) in neonates. Metronidazole-associated neurotoxicity has been reported, but long-term neurodevelopmental effects in neonates have not been explored. The primary objective was to evaluate the relationship of cumulative metronidazole dose with each Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) composite score in neonates with NEC. Secondary objectives included comparison of seizure rates, mean Bayley-III scores, and neurodevelopmental impairment defined as 2 of 3 Bayley-III composite scores ≤ 79 or 1 score ≤ 70 between the metronidazole exposed and non-exposed groups. METHODS This multisite, retrospective cohort study compared infants with a birth weight < 1500 grams between January 1, 2011, and December 31, 2016, who developed stage 2 or greater NEC or spontaneous intestinal perforation and were followed up at a developmental clinic visit at approximately 1 year of age. Patients were excluded if admitted >72 hours of life, had congenital neurodevelopmental anomalies, hypoxic ischemic encephalopathy, grade III or IV intraventricular hemorrhage, or seizures prior to treatment of NEC. Included patients were stratified into 2 groups based on metronidazole exposure versus no metronidazole. Data were assessed using descriptive and inferential statistical techniques, using SAS 9.4. RESULTS Forty-one patients were included. Seven patients received metronidazole and 34 patients were in the non-metronidazole group. The only statistical difference noted between groups was for gestational age, with the non-exposed group being more premature. There was no statistical difference in Bayley-III scores, seizure rates, or neurodevelopmental impairment between groups. CONCLUSION No differences in neurodevelopmental outcomes were found between those with and without metronidazole exposure. Further studies are needed to validate our results.
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Harkin M, Miller J, Lim SY, Neely S, Walsh C, Johnson PN. "Reply: Conversion From Continuous Infusion Fentanyl to Hydromorphone in the Pediatric Intensive Care Unit". Ann Pharmacother 2021; 56:370-371. [PMID: 34165365 DOI: 10.1177/10600280211028672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Nguyen AL, Johnson PN, Neely SB, Hughes KM, Sekar KC, Welliver RC, Miller JL. Comparison of Amikacin Pharmacokinetics in Neonates With and Without Congenital Heart Disease. J Pediatr Pharmacol Ther 2021; 26:372-378. [PMID: 34035682 DOI: 10.5863/1551-6776-26.4.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The primary objective was to compare the volume of distribution (Vd), clearance (CL), elimination rate (Ke), and half-life (t½) of amikacin in neonates with cyanotic defects, acyanotic defects, and controls, adjusted for gestational and postnatal age. Secondary objectives were to compare the incidence of acute kidney injury (AKI) between controls and the congenital heart disease (CHD) group and to identify potential risk factors. METHODS This retrospective cohort study included neonates receiving amikacin from January 1, 2013 to August 31, 2016. Patients were excluded if concentrations were not appropriately obtained or if AKI or renal anomalies were identified prior to amikacin initiation. Congenital heart disease was classified as acyanotic or cyanotic. Patients with CHD were matched 1:1 with non-CHD controls according to postmenstrual age. Bivariate analyses were performed using Wilcoxon-Mann-Whitney test, Pearson χ2 tests, or Fisher exact as appropriate with a p value <0.05. Regression analyses included logistic and analysis of covariance. RESULTS Fifty-four patients with CHD were matched with 54 controls. Median (IQR) postnatal age (days) at amikacin initiation significantly differed between CHD and controls, 3.0 (1.0-16.0) versus 1.0 (1.0-3.0), p = 0.016. After adjusting for gestational and postnatal age, there was no difference in the mean (95% CI) Vd (L/kg) and CL (L/kg/hr) between CHD and controls, 0.47 (0.44-0.50) versus 0.46 (0.43-0.49), p = 0.548 and 0.05 (0.05-0.05) versus 0.05 (0.05-0.05), p = 0.481, respectively. There was no difference in Ke or t½ between groups. There was no difference in AKI between the CHD and controls, 18.5% versus 9.3%, p = 0.16. CONCLUSIONS Clinicians should consider using standard amikacin dosing for neonates with CHD and monitor renal function, since they may have greater AKI risk factors.
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Miller JL, Stephens K, Johnson PN, Medina M. Teaching residents how to deliver active learning during didactic lectures. Am J Health Syst Pharm 2021; 78:944-948. [PMID: 33755109 DOI: 10.1093/ajhp/zxab100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lim SY, Miller JL, Henry E, Heltsley R, Woo S, Johnson PN. Analysis of fentanyl pharmacokinetics, and its sedative effects and tolerance in critically ill children. Pharmacotherapy 2021; 41:359-369. [PMID: 33604895 DOI: 10.1002/phar.2515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Fentanyl pharmacokinetic and pharmacodynamic data are limited in mechanically ventilated children. This study aimed to assess the fentanyl pharmacokinetics (PK), the sedation outcome, and the development of tolerance in children receiving fentanyl continuous infusion. METHODS This study included children admitted to the pediatric or cardiovascular intensive care unit between January 1 and October 31, 2016, who were >30 days to <18 years of age, receiving ventilatory support via endotracheal tube or tracheostomy, and receiving a fentanyl infusion. Population PK analysis was performed using a nonlinear mixed-effects model. The relationship between initial sedation outcome using State Behavioral Scale (SBS) and fentanyl exposure was assessed, and the observations consistent with tolerance were described. RESULTS Seventeen children, with a median age of 0.83 years (range: 0.1-12) and weight of 8.7 kg (range: 3.4-52), were included. The fentanyl PK was adequately described by a weight-based allometry model with the power of 0.75 for clearance (CL=89.8 L/hr/70 kg) and distributional CL, and 1 for volumes of distribution. In infants <6.6 months, age was an additional factor for CL (31.4 L/h/70 kg) to account for age-related maturation. Seven of twelve nonparalyzed patients achieved goal sedation, defined as >80% of SBS scores ≤0 per 24 h, on the first day of fentanyl infusion with a median plasma concentration of 1.29 ng/ml (interquartile range: 0.78-2.05). Eight of the nine tolerant patients developed tolerance within a day of reaching goal sedation. CONCLUSION Different weight-based fentanyl dosing rates may be required for infants and children of different ages to achieve similar plasma concentrations. Using SBS scores may guide the dosing titration of fentanyl that resulted in plasma concentrations within the therapeutic range of 1-3 ng/ml. For those who developed tolerance to fentanyl and/or a sedative, it was noted one day after goal sedation was achieved.
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Harkin M, Miller JL, Lim SY, Neely SB, Walsh CK, Johnson PN. Conversion From Continuous Infusion Fentanyl to Continuous Infusion Hydromorphone in the Pediatric Intensive Care Unit. Ann Pharmacother 2021; 55:1439-1446. [DOI: 10.1177/10600280211003170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Opioid rotations from fentanyl to hydromorphone may reduce opioid/sedative exposure in critically ill children. Objective: The primary objective was to determine the conversion percentage from fentanyl to hydromorphone infusions using equianalgesic conversions (0.1 mg fentanyl = 1.5 mg hydromorphone). Secondary objectives included identification of the median time and hydromorphone rate at stabilization (defined as the first 24-hour period no hydromorphone rates changed, 80% of State Behavioral Scale [SBS] scores between 0 and −1, and <3 hydromorphone boluses administered). Additional outcomes included a comparison of opioid/sedative requirements on the day of conversion versus the three 24-hour periods prior to conversion. Methods: This retrospective study included children <18 years old converted from fentanyl to hydromorphone infusions over 6.3 years. Linear mixed models were used to determine if the mean cumulative opioid/sedative dosing differed from the day of conversion versus three 24-hour periods prior to conversion. Results: A total of 36 children were converted to hydromorphone. The median conversion percentage of hydromorphone was 86% of their fentanyl dose (interquartile range [IQR] = 67-100). The median hydromorphone rate at stabilization was 0.08 mg/kg/h (IQR = 0.05-0.1). Eight (22%) were stabilized on their initial hydromorphone rate; 8 (22%) never achieved stabilization. Patients had a significant decrease in opioid dosing on the day of conversion versus the 24-hour period prior to conversion but no changes in sedative dosing following conversion. Conclusion and Relevance: A median 14% fentanyl dose reduction was noted when transitioning to hydromorphone. Further exploration is needed to determine if opioid rotations with hydromorphone can reduce opioid/sedative exposure.
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Miller JL, Lewis TV, Walling J, O'Donnell A, Neely SB, Johnson PN. Publication Rates of Pediatric-Focused Resident Research Projects Presented at The Pediatric Pharmacy Association Bruce Parks Memorial Residency Showcase. J Pediatr Pharmacol Ther 2021; 26:163-171. [PMID: 33603580 PMCID: PMC7887887 DOI: 10.5863/1551-6776-26.2.163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 06/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The primary objective was to identify the number of residency projects presented at the Pediatric Pharmacy Association (PPA) Bruce Parks Memorial Residency Showcase that were subsequently published. Secondary objectives included a comparison of subsequent publications after residency completion between those who did and did not publish their residency project and an analysis of factors associated with subsequent publications. METHODS This was a descriptive study including all pediatric-focused resident projects presented at the PPA Bruce Parks Memorial Residency Showcase from 2006 to 2015. Literature searches for all the pediatric-focused residency projects and any subsequent publications were performed. Data collection included residency type (i.e., postgraduate year 1 [PGY1], postgraduate year 2 [PGY2]), project category, and initial position after residency. A zero-inflated Poisson regression was used to analyze subsequent publication status while controlling for other factors. Statistical analyses were performed using SAS/STAT, with a priori p value < 0.05. RESULTS There were 434 projects presented by 401 residents. Seventy-four (17.1%) were published, with the majority being PGY2s (74.3%). Subsequent publications were identified for 162 residents (40.4%), with a higher percentage in those who published their pediatric-focused residency project versus those who did not, 59.5% versus 32.8%, p < 0.001. Factors associated with subsequent publications were those who published their residency project, initial position in academia, and PGY2s. CONCLUSIONS Of the residency projects presented at the showcase <20% were subsequently published. Those who published their residency research project were more likely to have subsequent publications. Future efforts should be taken to ensure that residents have the tools/confidence to independently publish their research/scholarship.
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Fox AN, Nation BE, Autry MT, Johnson PN. Possible role for acetylcysteine as a treatment for acute liver failure secondary to antitubercular medication use. Am J Health Syst Pharm 2020; 77:1482-1487. [PMID: 32885827 DOI: 10.1093/ajhp/zxaa202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Drug-induced liver injury (DILI) that progresses to acute liver failure (ALF) has a high mortality rate, and therapeutic options are limited. Acetylcysteine has a labeled indication for use as an antidote for acetaminophen toxicity and has also been used with limited success in treatment of non-acetaminophen-induced liver injury, with small clinical trials indicating an increase in transplant-free survival. Recommendations for management of non-acetaminophen-induced DILI include withdrawal of the offending agent and supportive care. Treatment guidelines generally discourage a rechallenge with an offending medication, except in cases where there are no other therapeutic options for management of a serious disease, such as active tuberculosis (TB). SUMMARY This case report describes the reversal of ALF due to DILI in a patient receiving antitubercular agents for active TB. After withdrawal of initially prescribed antitubercular agents, the patient was switched to a less hepatotoxic anti-TB regimen and intravenous acetylcysteine pending results of antimicrobial susceptibility testing. After stabilization of the patient's liver enzyme levels, intravenous acetylcysteine was discontinued and oral acetylcysteine was continued for 5 days without an increase in hepatic enzyme levels or clinical deterioration. After 5 days, oral acetylcysteine was discontinued due to patient-reported nausea and vomiting. CONCLUSION Given the limited number of therapeutic interventions shown to be beneficial in ALF and data suggesting a protective effect against DILI with initiation of acetylcysteine at the start of treatment with anti-TB medications, acetylcysteine can be considered for patients with anti-TB - associated DILI.
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Cox CL, Todd TJ, Lubsch L, Klein KC, Prescott WA, Knoderer CA, Johnson PN, Meyers R, Cole JW, LaRochelle JM, Worthington MA, Smith K. Joint Statement on Pediatric Education at Schools of Pharmacy. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2020; 84:ajpe7892. [PMID: 32934387 PMCID: PMC7473221 DOI: 10.5688/ajpe7892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/04/2020] [Indexed: 05/07/2023]
Abstract
Providing health care for children is a unique specialty, and pediatric patients represent approximately 25% of the population. Education of pharmacy students on patients across the lifespan is required by current Accreditation Council for Pharmacy Education standards and outcomes; thus, it is essential that pharmacy students gain a proficiency in caring for children. A collaborative panel of pediatric faculty members from schools and colleges of pharmacy was established to review the current literature regarding pediatric education in Doctor of Pharmacy curricula and establish updated recommendations for the provision of pediatric pharmacy education. This statement outlines five recommendations supporting inclusion of pediatric content and skills in Doctor of Pharmacy curricula.
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Harkin M, Shaddix BP, Neely SB, Peek LA, Stephens K, Barker P, McMullan L, Gormley A, Johnson PN. Evaluation of dosing and safety outcomes of low-dose prophylactic warfarin in children after cardiothoracic surgery. Am J Health Syst Pharm 2020; 77:1018-1025. [PMID: 32470108 DOI: 10.1093/ajhp/zxaa111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Prophylactic warfarin with an International Normalized Ratio (INR) goal of 1.5 to 2.0 is one antithrombotic therapy utilized in children after cardiothoracic surgery (CTS); published sources suggest a dose of 0.1 mg/kg per day to achieve this goal. However, few studies have evaluated dosing in this population. The purpose of this study was to evaluate dosing and safety outcomes in children receiving warfarin after CTS. METHODS A descriptive, retrospective review was conducted to evaluate warfarin dosing and INR outcomes in patients 18 years of age or younger who underwent CTS and received prophylactic warfarin with an INR goal of 1.5 to 2.0 from January 2014 through December 2018. The primary objective was to determine the median initial warfarin dose. Secondary objectives included identifying the percentage of documented INR values that were outside the therapeutic range, the percentage of patients with therapeutic INRs at discharge, and the 30-day readmission rate. RESULTS Twenty-six patients were included in the review. The median initial warfarin dosage was 0.07 mg/kg/d (interquartile range [IQR], 0.05-0.10 mg/kg/d). Of the total of 177 INR values collected during the entire study period, 67 (37.9%) were therapeutic, 64 (36.2%) were subtherapeutic, and 46 (26.0%) were supratherapeutic. Eighteen patients (69.2%) had at least 1 supratherapeutic INR at any point during the study period, most frequently on days 2 through 4 of therapy. At discharge, 11 patients (42.3%) had therapeutic INRs. Four patients (15.4%) were readmitted within 30 days, with bleeding documented in 2 patients during their readmission. CONCLUSION The majority of patients received an initial warfarin dose less than that specified in published recommendations but still had a supratherapeutic INR at least once during the study period. When initiating warfarin after CTS, a dosage of <0.1 mg/kg per day and frequent monitoring may be needed to achieve an INR goal of 1.5 to 2.0.
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Nguyen TT, Bergeron E, Lewis TV, Miller JL, Hagemann TM, Neely S, Johnson PN. Descriptive study of discharge medications in pediatric patients. SAGE Open Med 2020; 8:2050312120927945. [PMID: 32547752 PMCID: PMC7271562 DOI: 10.1177/2050312120927945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/27/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Limited studies have evaluated medications in children discharged from
hospitals. Knowledge of the number of medications and dosage forms could
provide a baseline to establish a medication discharge prescription
program. Objectives: To identify the median number of discharge prescriptions per patient.
Secondary objectives included an evaluation of the dosage formulations and
frequency, and comparisons of the prevalence of unrounded medication doses
between service type (medical vs surgical) and physician provider level
(trainees vs attendings). Methods: This retrospective study included children <18 years receiving
>1 discharge prescription during 4 selected
months over a 1-year time frame. Comparisons were made via Pearson’s
chi-square tests, Fisher’s Exact tests, and Kruskal–Wallis nonparametric
rank tests as appropriate with a priori p value of
<0.05. Results: A total of 852 patients were evaluated, with most (78.8%) on a medical
service. The median (interquartile range) number of new medications at
discharge was 2 (1–3), with the median total number of discharge medications
of 3 (2–6). There was no difference in the net change of the median number
of home medications stopped and new medications started between service
types. The majority (72.2%) received >1 oral
liquid medications. There was no difference in prescribing rates per service
type and provider level. There was a difference in the number of unrounded
doses between trainees versus attendings, 17.8% versus 9.5%,
p = 0.048. Conclusion: Patients were discharged on a median of three medications, and most received
>1 oral liquid medications. These data can be
used to target children who would benefit from medication discharge
prescription programs.
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Moore E, Mayes R, Harkin M, Miller JL, Johnson PN. Extended Duration Ketamine Infusions in Critically Ill Children: A Case Report and Review of the Literature. J Pediatr Intensive Care 2020; 10:221-227. [PMID: 34395041 DOI: 10.1055/s-0040-1713144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022] Open
Abstract
Ketamine is an N -methyl-D-aspartate receptor antagonist that has been used as an adjunct analgesic and sedative in critically ill children. Previous reports noted that ketamine has been used for a variable duration of 12 to 408 hours for this indication. We report on the use of ketamine infusions for >720 hours as a second-line sedative in addition to an opioid and dexmedetomidine infusion in a 2-month old and 17-month old. The purpose of this case report and review of the literature is to highlight the prolonged ketamine exposure of these two patients and to provide awareness to clinicians on the potential of withdrawal with extended ketamine administration. These children were started on initials doses of 5 and 15 µg/kg/min and titrated to peak doses of 20 and 25 µg/kg/min, respectively. They were continued for a total of 987 and 792 hours, respectively. No adverse events were noted during the ketamine infusions. One patient developed possible withdrawal symptoms 17 hours after ketamine discontinuation despite tapering of the infusion. These symptoms resolved with administration of as needed intravenous opioids and benzodiazepines, and the agitation normalized within 24 hours after ketamine discontinuation. Clinicians should consider tapering ketamine infusions in children receiving >72 hours of a continuous infusion by 5 µg/kg/min every 8 to 12 hours. Patients should be monitored for potential withdrawal symptoms including anxiety, allodynia, hyperalgesia, sweating, and drowsiness.
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Shaddix BP, Harkin M, Miller JL, Johnson PN. Which PGY1 Pharmacy Residency Is Right for Me? Advantages and Disadvantages of Pediatric-Focused and Traditional PGY1 Pharmacy Programs. J Pediatr Pharmacol Ther 2020; 25:273-277. [DOI: 10.5863/1551-6776-25.4.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Students interested in pediatric pharmacy may face difficulty choosing a postgraduate year 1 (PGY1) Pharmacy residency program. These students can complete their PGY1 Pharmacy residency in a traditional PGY1 Pharmacy program, a program with less than 50% of pediatric rotation experiences, or a pediatric-focused PGY1 Pharmacy program, a program with at least 50% of pediatric rotation experiences. These programs differ in rotational experiences, types of projects available, service commitment, and preceptor backgrounds. This article provides potential advantages and disadvantages that students may consider when selecting between these 2 different PGY1 Pharmacy residency programs. In addition, the article includes advice for students to consider when evaluating the best fit for themselves, and many of the recommendations were developed following a presentation that was given to students at the Pediatric Pharmacy Association's Annual Meeting in April 2019. Ultimately, the best residency program fit for a student interested in pediatrics should be based on each student's priorities, preferences, and career goals.
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Capino AC, Thomas AN, Baylor S, Hughes KM, Miller JL, Johnson PN. Antipsychotic Use in the Prevention and Treatment of Intensive Care Unit Delirium in Pediatric Patients. J Pediatr Pharmacol Ther 2020; 25:81-95. [PMID: 32071582 PMCID: PMC7025750 DOI: 10.5863/1551-6776-25.2.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To describe the antipsychotics, route of administration, dosage regimen, and outcomes reported to prevent or treat delirium in hospitalized children. METHODS Medline, Embase, and International Pharmaceutical Abstracts were searched using the keywords "haloperidol," "olanzapine," "quetiapine," "risperidone," "ziprasidone," and "delirium." Articles evaluating the use of these agents to manage delirium in hospitalized children that were published between 1946 and August 2019 were included. Two authors independently screened each article for inclusion. Reports were excluded if they were published abstracts or included fewer than 3 patients in the report. RESULTS Thirteen reports that included 370 children receiving haloperidol, quetiapine, olanzapine, and/or risperidone for delirium treatment were reviewed. Most children received haloperidol (n = 131) or olanzapine (n = 125). Significant variability in dosing was noted. A total of 23 patients (6.2%) had an adverse drug event, including 13 (56.5%) who experienced dystonia and 3 (13.0%) with a prolonged corrected QT interval. Most reports described improvement in delirium symptoms; however, only 5 reports used a validated screening tool for PICU delirium to evaluate antipsychotic response. CONCLUSIONS Most reports noted efficacy with antipsychotics, but these reports were limited by sample size and lacked a validated PICU delirium tool. Future research is needed to determine the optimal agent and dosage regimen to treat PICU delirium.
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Stephens K, Barker P, Bergeron E, Miller JL, Hagemann TM, Lewis TV, Neely S, Johnson PN. Comparison of Clinical Outcomes and Medication Use of Obese Versus Nonobese Children Admitted to the Pediatric Intensive Care Unit. Hosp Pharm 2019; 56:287-295. [PMID: 34381263 DOI: 10.1177/0018578719893373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Few studies have compared clinical outcomes and medication use between obese and nonobese children in the pediatric intensive care unit (PICU). Objectives: The primary objective was to compare clinical outcomes including mortality, PICU length of stay (LOS), and mechanical ventilation (MV) requirement between obese and nonobese children. Secondary objectives included analysis of factors associated with these outcomes and medication use between groups. Methods: This retrospective study included children 2 to 17 years old admitted to the PICU over a 1-year time frame. Patients were categorized as obese, body mass index (BMI) ≥ 95th percentile, and nonobese (BMI < 95th percentile). Three binary regression models assessed the impact of obesity on clinical outcomes. Results: There were 834 admissions, with 22.1% involving obese children. There was no difference in mortality, MV requirement, or PICU LOS between groups. There were no associations with obesity and clinical outcomes found, but an association was noted for medication classes and receipt of continuous infusions on clinical outcomes. There was no difference noted in the median number (interquartile range [IQR]) of medications between obese and nonobese children, 8 (6-13) versus 9 (6-15), P = .38, but there was a difference in patients receiving a continuous infusion between obese and nonobese children, 24.4% versus 8.8%, P < .01. The 15 most used medications in both groups included analgesics, antimicrobials, corticosteroids, bronchodilators, and gastrointestinal agents. Conclusions: One-fifth of all admissions included obese children. Obesity was not associated with mortality, PICU LOS, and MV requirement, but the number of medication classes and continuous infusions were associated with these outcomes.
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Johnson PN, Gildon BL, Condren M, Miller JL, Hagemann TM, Lewis TV, John B, Farmer K. A survey of pediatric degree option program graduates in a doctor of pharmacy curriculum: Confidence and initial employment position. CURRENTS IN PHARMACY TEACHING & LEARNING 2019; 11:1296-1302. [PMID: 31836156 DOI: 10.1016/j.cptl.2019.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/28/2019] [Accepted: 09/07/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND PURPOSE Graduates from the pediatric degree option program (PDOP) were tracked to identify confidence with pediatric pharmacotherapy and categorize initial employment following graduation. EDUCATIONAL ACTIVITY AND SETTING The PDOP was established in 2011 and requires 16 credits of pediatric-focused didactic coursework and advanced pharmacy practice experiences. Thirty PDOP graduates completed a 30-item questionnaire to assess confidence in pediatric pharmacotherapy knowledge and skill statements and employment position following graduation. Responses were compared between those completing post-graduate pediatric pharmacy training and those who did not. FINDINGS Nineteen (63.3%) graduates responded. All expressed "very high" or "high" confidence with dose calculations, first-line treatment selection for otitis media, and counseling caregivers on medications. However, <75% expressed "very high" or "high" confidence with identification of pharmacokinetic differences in neonates vs. children, utilization of growth charts, and counseling children. Ten (52.6%) respondents completed post-graduate training, and the remainder had an initial position in community or hospital pharmacy. There were no significant differences in pharmacotherapy skill and knowledge statements between those completing residency vs. those who did not. The most beneficial experiences reported were gaining clinical experience in pediatric pharmacy and medication safety. SUMMARY Overall, PDOP graduates noted high confidence in pediatric pharmacotherapy skills and knowledge. Most felt that the PDOP influenced their initial career plans and made them more competitive for their initial position following graduation. The PDOP was well received and provided an opportunity for additional knowledge and skill development for students interested in pediatrics.
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Johnson PN, Stephens K, Barker P, Bergeron E, Lim SY, Hagemann TM, Lewis TV, Neely S, Miller JL. Prescribing Patterns of Continuous Infusions in Nonobese versus Obese Children Admitted to the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2019; 8:226-232. [DOI: 10.1055/s-0039-1692669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022] Open
Abstract
AbstractThis retrospective study compared the continuous infusions prescribed for obese and nonobese children. Ninety-five (13.2%) received an infusion. A greater percentage of obese (n = 42/168) versus nonobese (53/552) children received infusions, p < 0.01. No difference was noted in the median number of infusions between the obese and nonobese groups, 2 versus 2, p = 0.975. The top 20 prescribed infusions included ten (50%) for sedation/analgesia or neuromuscular blockade and six (30%) for hemodynamic support. A literature search was performed for these 20 agents to determine pharmacokinetics, pharmacodynamics, and dosing in obese children and revealed six studies evaluating fentanyl (n = 2), midazolam (n = 1), and propofol (n = 3).
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Stephens K, Miller JL, Lewis TV, Neely S, Johnson PN. Hyponatremia With Intravenous Sulfamethoxazole/Trimethoprim in Children. Ann Pharmacother 2019; 54:351-358. [PMID: 31694388 DOI: 10.1177/1060028019887919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Intravenous (IV) sulfamethoxazole/trimethoprim (SMX/TMP) has been associated with hyponatremia in adults. Objective: The primary objective was to identify the number of patients with a serum sodium <135 mEq/L. Secondary objectives between the hyponatremic versus nonhyponatremic groups included demographic comparisons, median serum sodium concentrations, SMX/TMP cumulative dose, number of diuretics, and other medications causing hyponatremia. Methods: This was a retrospective study of children <18 years receiving IV SMP/TMX. Comparisons were conducted via Mann-Whitney-Wilcoxon and Mantel-Haenszel χ2 tests with an a priori P value <0.05. Results: Sixty-one patients received 66 total courses; 20 courses (30.3%) were associated with hyponatremia with a decrease in the median nadir serum sodium concentration of 133 and 138 mEq/L in the hyponatremic and nonhyponatremic groups, respectively (P<0.001). The median age (interquartile range) was lower in the hyponatremic versus nonhyponatremic group, but this was not statistically significant: 0.6 (0.1-5.5) versus 3.9 (0.3-11.0) years; P=0.077. There was no significant difference in the median cumulative dose (mg/kg) between groups; P=0.104. In addition, there was a significant difference in the number of children in the hyponatremic versus nonhyponatremic groups receiving diuretics (16 [80.0%] vs 23 [50.0%], P=0.023) and other medications that cause hyponatremia (7 [35.0%] vs 5 [10.9%], P=0.034), respectively. Furosemide was noted to be the medication most associated with hyponatremia. Conclusion and Relevance: Approximately one-third administered IV SMX/TMP developed hyponatremia. Concomitant furosemide administration was one of the most common risk factors. Clinicians should be aware of this potential adverse event when initiating IV SMX/TMP in children.
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Johnson PN, Miller JL. Small patients, big problems? Pediatric primer for the nonpediatric pharmacist. Am J Health Syst Pharm 2019; 76:1451-1452. [DOI: 10.1093/ajhp/zxz170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Blackmer AB, Siu A, Thornton A, Johnson PN, Nichols KR, Hagemann TM. Academic Careers in Pediatric Pharmacy: Part 2—Academic Advancement. J Pediatr Pharmacol Ther 2019; 24:183-193. [DOI: 10.5863/1551-6776-24.3.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An increasing number of pediatric clinical pharmacists are pursuing careers in academia. Once in an academic position, questions, challenges and benefits related to the processes of academic evaluation and advancement unique to pediatric academia often arise. This is the second article in a 2-part series that attempts to demystify pediatric faculty positions and address gaps in the literature regarding careers in pediatric-focused academic positions. The purpose of this article is to review key aspects pertaining to academic evaluation and the preparation for and process of academic advancement/promotion. A question and answer format is used to discuss common questions related to these processes and tips for success are provided. This article is primarily intended to be used as a helpful guide for junior faculty members as well as mid-level individuals seeking advancement; however, it will also benefit students, trainees, and practicing pharmacists seeking increased knowledge of pediatric academic career paths.
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Siu A, Blackmer AB, Thornton AM, Johnson PN, Nichols KR, Hagemann TM. Overview and Preparation Guide for Academic Careers in Pediatric Pharmacy, Part 1: Career as a Pediatric Pharmacy Practice Faculty Member. J Pediatr Pharmacol Ther 2019; 24:79-89. [PMID: 31019400 PMCID: PMC6478359 DOI: 10.5863/1551-6776-24.2.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2018] [Indexed: 11/11/2022]
Abstract
Pediatric clinical pharmacy is a growing and evolving field with an increasing number of pediatric clinical pharmacists in academia. In 2017, pediatric practice faculty members represented approximately 7.6% of all pharmacy practice faculty in the United States. The benefits of practicing in an academic environment are many, including, but not limited to, the ability to shape the future of pharmacy practice through the training of the next generation of pharmacists, contributing to science through research and scholarly activities for the care of pediatric patients, and positively impacting patient care for the most vulnerable of patients. Part one of this two-part series describes careers in academic pediatric pharmacy, as well as faculty roles and responsibilities, and provides information and advice related to the preparation and transition into careers in academic pediatric pharmacy.
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Capino AC, Johnson PN, Williams PK, Anderson MP, Bedwell S, Miller JL. Pilot Study Comparing Modified Finnegan Scoring Versus Adjusted Scoring System for Infants With Iatrogenic Opioid Abstinence Syndrome After Cardiothoracic Surgery. J Pediatr Pharmacol Ther 2019; 24:148-155. [PMID: 31019408 DOI: 10.5863/1551-6776-24.2.148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the modified Finnegan Scoring System (modified Finnegan) with an Adjusted Scoring System Criteria (adjusted Finnegan) for infants after cardiothoracic surgery with iatrogenic opioid abstinence syndrome (IOAS). METHODS This was a retrospective, observational pilot study. This study was conducted in a tertiary care academic hospital. Infants after cardiothoracic surgery with IOAS transferred between the pediatric intensive care unit and neonatal intensive care unit between January 1, 2014, and January 31, 2016, were included retrospectively. The main outcome variable was to compare the area under the curve for the mean modified Finnegan versus adjusted Finnegan. RESULTS Twenty-five patients were included in the study. Twenty patients with at least 30 scores were included in the final analysis. Overall, the modified Finnegan scores were at least 2 points higher than the adjusted Finnegan. The difference in area under the curve was 34.6 (p < 0.001). CONCLUSIONS Use of the modified Finnegan tool for older infants with IOAS could overestimate withdrawal, leading to unnecessary interventions.
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Johnson PN, Mitchell-Van Steele A, Nguyen AL, Stoffella S, Whitmore JM. Pediatric Pharmacists' Participation in Cardiopulmonary Resuscitation Events. J Pediatr Pharmacol Ther 2019; 23:502-506. [PMID: 30697139 DOI: 10.5863/1551-6776-23.6.502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Pediatric Pharmacy Advocacy Group (PPAG) understands the dilemma and varying factors that many institutions face concerning the routine participation of pharmacists in emergency resuscitation events. Acknowledging these obstacles, the PPAG encourages all institutions to strongly consider creating, adopting, and upholding policies to address pharmacists' participation in cardiopulmonary resuscitation (CPR) as evidenced by the impact pharmacist participation has shown on the reduction of hospital medication error and mortality rates in children. The PPAG advocates that pharmacists be actively involved in the institution's CPR, medical emergency team committees, and preparation of emergency drug kits and resuscitation trays. The PPAG advocates that all institutions requiring a pharmacist's participation in CPR events consider adoption of preparatory training programs. Although the PPAG does not advocate any one specific program, consideration should be taken to ensure that pharmacists are educated on the pharmacotherapy of drugs used in the CPR process, including but not limited to basic life support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support algorithms; medication preparation and administration guidelines; medication compatibility; recommended dosing for emergency medications; and familiarity with the institutional emergency cart.
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Miller JL, Ernst K, Neely SB, Stephens K, Barker P, Skrepnek GH, Johnson PN. Low-dose versus high-dose methadone for the management of neonatal abstinence syndrome. J Opioid Manag 2019; 15:159-167. [PMID: 31343717 DOI: 10.5055/jom.2019.0497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The primary objective was to compare median time to symptom relief (time from methadone initiation until two consecutive modified Finnegan [neonatal abstinence syndrome, NAS] scores < 8) between neonates receiving low-dose (≤0.275 mg/kg/day) versus high-dose (>0.275 mg/kg/day) methadone. Secondary objectives included assessment of factors associated with symptom relief. DESIGN Retrospective cross-sectional study. SETTING Ninety-nine bed neonatal intensive care unit within a tertiary-care academic hospital. PARTICIPANTS Seventy-two neonates who received methadone for NAS over a 7.5-year period. MAIN OUTCOME MEASURES(S) Kaplan-Meier curves with a log-rank test and a stepwise Cox proportional-hazard model were used to analyze outcomes. RESULTS The median dose for the low-dose (n = 40) and high-dose (n = 32) groups were 0.19 mg/kg/day (interquartile range [IQR], 0.12-0.24) divided every 6-12 hours and 0.4 mg/kg/day (0.3-0.44) divided every 6-8 hours, respectively. The median time to symptom relief was higher in the low-dose versus high-dose groups, 9.3 (5.8-24.6) versus 6.0 (5.4-12.5) hours, respectively (p = 0.014). Low-dose males had a longer time to symptom resolution than other groups (p = 0.008). Female premature neonates (<37 weeks gestation) had a shorter time to symptom relief than term neonates [adjusted hazard ratio = 2.96 (1.02-8.62)]. The median total duration of methadone was shorter but not statistically significant between high- versus low-dose groups, 17.5 (IQR: 11.0-25.0) versus 21.0 days (IQR: 10.0-28.0), respectively (p = 0.483). CONCLUSIONS Neonates receiving high-dose methadone had a significantly shorter time to symptom relief. Differences in sex were noted in response to therapy with low-dose males having a longer time to symptom relief and premature neonates a shorter time to symptom relief.
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Matson KL, Johnson PN, Tran V, Horton ER, Sterner-Allison J. Opioid Use in Children. J Pediatr Pharmacol Ther 2019; 24:72-75. [PMID: 30837819 PMCID: PMC6397009 DOI: 10.5863/1551-6776-24.1.72] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2018] [Indexed: 11/11/2022]
Abstract
Limited guidance on opioid use exists in the pediatric population, causing medication safety concerns for pain management in children and adolescents. Opioid misuse and use disorder continue to greatly affect adolescents and young adults in the United States, furthering the apprehension of their use. Pediatric Pharmacy Advocacy Group (PPAG) recommends pharmacists contribute their knowledge to pain management in children, including the discussion of appropriate use of non-opioid alternatives for pain and when to recommend coprescribing of naloxone. PPAG also supports the review of electronic prescription drug-monitoring programs prior to opioid prescribing and dispensing by both prescribers and pharmacists. Education by pharmacists of children and their families regarding proper administration, storage, and disposal, as well as the awareness of opioid misuse and use disorder among adolescents and young adults, is key to prevention. If opioid use disorder is diagnosed, PPAG encourages improved access among adolescents to evidence-based medications including methadone, buprenorphine, and naltrexone. Furthermore, pharmacists should assist in screening and referral to evidence-based treatment.
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