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Pokorná P, Michaličková D, Tibboel D, Berner J. Meropenem Disposition in Neonatal and Pediatric Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy. Antibiotics (Basel) 2024; 13:419. [PMID: 38786147 PMCID: PMC11117356 DOI: 10.3390/antibiotics13050419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/25/2024] Open
Abstract
This study aimed to characterize the impact of extracorporeal membrane oxygenation (ECMO) on the pharmacokinetics (PK) of meropenem in neonates and children and to provide recommendations for meropenem dosing in this specific population of patients. Therapeutic drug monitoring (152 meropenem plasma concentrations) data from 45 patients (38 received ECMO) with a body weight (BW) of 7.88 (3.62-11.97) kg (median (interquartile range)) and postnatal age of 3 (0-465) days were collected. The population PK analysis was performed using NONMEM V7.3.0. Monte Carlo simulations were performed to assess the probability of target achievement (PTA) for 40% of time the free drug remained above the minimum inhibitory concentration (fT > MIC) and 100% fT > MIC. BW was found to be a significant covariate for the volume of distribution (Vd) and clearance (CL). Additionally, continuous renal replacement therapy (CRRT) was associated with a two-fold increase in Vd. In the final model, the CL and Vd for a typical patient with a median BW of 7.88 kg that was off CRRT were 1.09 L/h (RSE = 8%) and 3.98 L (14%), respectively. ECMO did not affect meropenem PK, while superimposed CRRT significantly increased Vd. We concluded that current dosing regimens provide acceptably high PTA for MIC ≤ 4 mg/L for 40% fT > MIC, but individual dose adjustments are needed for 100% fT > MIC.
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Affiliation(s)
- Pavla Pokorná
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
- Department of Physiology and Pharmacology, Karolinska Institute and Karolinska University Hospital, 171 77 Stockholm, Sweden
- Department of Pediatric Surgery, Erasmus Medical Center Sophia Children’s Hospital, 3062 PA Rotterdam, The Netherlands
| | - Danica Michaličková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
| | - Dick Tibboel
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
- Department of Pediatric Surgery, Erasmus Medical Center Sophia Children’s Hospital, 3062 PA Rotterdam, The Netherlands
| | - Jonas Berner
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, 128 00 Prague, Czech Republic
- Department of Physiology and Pharmacology, Karolinska Institute and Karolinska University Hospital, 171 77 Stockholm, Sweden
- Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 76 Stockholm, Sweden
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Almohaish S, Cook AM, Brophy GM, Rhoney DH. Personalized antiseizure medication therapy in critically ill adult patients. Pharmacotherapy 2023; 43:1166-1181. [PMID: 36999346 DOI: 10.1002/phar.2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/01/2023]
Abstract
Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision-making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point-of-care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug-drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aaron M Cook
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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Kuntz MT, Pereira LM, Matte GS, Connor K, Staffa SJ, DiNardo JA, Nasr VG. Sequestration of Midazolam, Fentanyl, and Morphine by an Ex Vivo Cardiopulmonary Bypass Circuit. ASAIO J 2021; 67:1342-1348. [PMID: 34415712 DOI: 10.1097/mat.0000000000001506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cardiopulmonary bypass (CPB) circuits can significantly sequester intravenous anesthetics. Adsorption of medications by our institution's standard circuit (Terumo CAPIOX FX05 oxygenator; noncoated polyvinylchloride tubing) has not been described. We prepared ex vivo CPB circuits with and without oxygenators. Medication combinations studied included midazolam (0.5 mg), fentanyl (50 µg), midazolam (0.5 mg) with morphine (0.5 mg), and midazolam (0.5 mg) with fentanyl (50 µg). Medications were administered after obtaining baseline samples. Samples were drawn at 2, 5, 15, 30, 60, 120, and 180 minutes, and analyzed for concentration of injected medications. Midazolam demonstrated no sequestration after 180 minutes. Fentanyl concentration at 180 minutes was lower with an oxygenator (52.7 ± 12.5 vs. 110.9 ± 12.0 ng/ml, P = 0.00432). More fentanyl was found in solution after 180 minutes when given with midazolam compared to fentanyl given alone in the presence of an oxygenator (101 ± 22.3 vs. 52.7 ± 12.5 ng/ml, P = 0.044). Less midazolam was present after 180 minutes when given with morphine compared to midazolam given alone in the absence of an oxygenator (1264.9 ± 425.6 vs. 2124 ± 254 ng/ml, P = 0.037). We successfully characterized the adsorption of various combinations of midazolam, fentanyl, and morphine to our CPB circuit, showing that fentanyl and midazolam behave differently based on other medications present.
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Affiliation(s)
- Michael T Kuntz
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luis M Pereira
- Pharmacometrics Research Core, Pharmacokinetics Laboratory, Boston Children's Hospital, Boston, Massachusetts
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin Connor
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Steven J Staffa
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - James A DiNardo
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viviane G Nasr
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Rapid Increase in Clearance of Phenobarbital in Neonates on Extracorporeal Membrane Oxygenation: A Pilot Retrospective Population Pharmacokinetic Analysis. Pediatr Crit Care Med 2020; 21:e707-e715. [PMID: 32639476 DOI: 10.1097/pcc.0000000000002402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study characterizes the changes in the pharmacokinetics of phenobarbital associated with extracorporeal membrane oxygenation treatment in neonates, to illustrate our findings and provide guidance on dosing. DESIGN Retrospective pilot population pharmacokinetic analysis. SETTING Neonatal ICU. PATIENTS Thirteen critically ill neonates (birth body weight, 3.21 kg [2.65-3.72 kg]; postnatal age at start of treatment: 2 d [0-7 d]; gestational age: 38 wk [38-41 wk]) receiving venovenous or venoarterial extracorporeal membrane oxygenation. INTERVENTIONS Phenobarbital administered in a loading dose of 7.5 mg/kg (8.5-16 mg/kg) and maintenance dose of 6.9 mg/kg/d (4.5-8.5 mg/kg/d). MEASUREMENTS AND MAIN RESULTS Therapeutic drug monitoring data were available, yielding 5, 31, and 19 phenobarbital concentrations before, during, and after extracorporeal membrane oxygenation, respectively. Population pharmacokinetic analysis was performed using NONMEM 7.3.0 (ICON Development Solutions, Ellicott City, MD). Maturation functions for clearance and volume of distribution were obtained from literature. In a one-compartment model, clearance and volume of distribution for a typical neonate off extracorporeal membrane oxygenation and with a median birth body weight (3.21 kg) at median postnatal age (2 d) were 0.0096 L/hr (relative SE = 11%)) and 2.72 L (16%), respectively. During extracorporeal membrane oxygenation, clearance was found to linearly increase with time. Upon decannulation, phenobarbital clearance initially decreased and subsequently increased slowly driven by maturation. Extracorporeal membrane oxygenation-related changes in volume of distribution could not be identified, possibly due to sparse data collection shortly after extracorporeal membrane oxygenation start. According to the model, target attainment is achieved in the first 12 days of extracorporeal membrane oxygenation with a regimen of a loading dose of 20 mg/kg and a maintenance dose of 4 mg/kg/d divided in two doses with an increase of 0.25 mg/kg every 12 hours during extracorporeal membrane oxygenation treatment. CONCLUSIONS We found a time-dependent increase in phenobarbital clearance during the first 12 days of extracorporeal membrane oxygenation treatment in neonates, which results in continuously decreasing phenobarbital exposure and increases the risk of therapeutic failure over time. Due to high unexplained variability, frequent and repeated therapeutic drug monitoring should be considered even with the model-derived regimen.
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De Rose DU, Cairoli S, Dionisi M, Santisi A, Massenzi L, Goffredo BM, Dionisi-Vici C, Dotta A, Auriti C. Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age. Int J Mol Sci 2020; 21:E5898. [PMID: 32824472 PMCID: PMC7460644 DOI: 10.3390/ijms21165898] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Sara Cairoli
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Marco Dionisi
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Luca Massenzi
- Neonatal Intensive Care Unit and Neonatal Pathology, Fatebenefratelli Hospital, 00186 Rome, Italy;
| | - Bianca Maria Goffredo
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Carlo Dionisi-Vici
- Laboratory of Metabolic Biochemistry Unit, Department of Specialist Pediatrics, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (S.C.); (M.D.); (B.M.G.); (C.D.-V.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Medical and Surgical Neonatology, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.S.); (A.D.)
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Sedative and Analgesic Drug Sequestration After a Single Bolus Injection in an Ex Vivo Extracorporeal Membrane Oxygenation Infant Circuit. ASAIO J 2020; 65:187-191. [PMID: 29595531 DOI: 10.1097/mat.0000000000000793] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Patient sedation and analgesia on extracorporeal membrane oxygenation (ECMO) is vital for safety and comfort. However, adsorption to the circuit may alter drug pharmacokinetics and remains poorly characterized. This study characterizes drug adsorption of morphine, fentanyl, midazolam, and dexmedetomidine in an ex vivo infant ECMO circuit utilizing polymethylpentene (PMP) membrane oxygenator (MO) with protein-bounded polyvinylchloride (PVC) tubing. Twelve closed-loop ex vivo ECMO circuits were prepared using P.h.i.s.i.o (phosphorylcholine)-coated PVC tubing (Sorin Group USA, Inc.) and a Quadrox-iD pediatric polymethylpentene MO (Maquet Cardiopulmonary AG). Once the circuits were primed and running, a single medication was injected as a bolus into the circuit with three circuits per drug. Drug samples were drawn following injection, at 2, 5, 15, 30, 60, 120 minutes and at 4, 12, 24, 36, and 48 hours and analyzed using ultra high-performance liquid chromatography with mass spectrometry. Compared with morphine, the other drugs are highly sequestered with fentanyl 68.5%, dexmedetomidine 50.8%, and midazolam 26.2% affecting the availability of free drug in the circuit. Sequestration of fentanyl, midazolam, and dexmedetomidine in an ECMO circuit with P.h.i.s.i.o-coated PVC tubing and PMP MO may limit drug delivery to infants. Future in vivo studies are needed to determine the clinical impact of sequestration.
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Kalisvaart ACJ, Prokop BJ, Colbourne F. Hypothermia: Impact on plasticity following brain injury. Brain Circ 2019; 5:169-178. [PMID: 31950092 PMCID: PMC6950515 DOI: 10.4103/bc.bc_21_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/28/2019] [Indexed: 12/13/2022] Open
Abstract
Therapeutic hypothermia (TH) is a potent neuroprotectant against multiple forms of brain injury, but in some cases, prolonged cooling is needed. Such cooling protocols raise the risk that TH will directly or indirectly impact neuroplasticity, such as after global and focal cerebral ischemia or traumatic brain injury. TH, depending on the depth and duration, has the potential to broadly affect brain plasticity, especially given the spatial, temporal, and mechanistic overlap with the injury processes that cooling is used to treat. Here, we review the current experimental and clinical evidence to evaluate whether application of TH has any adverse or positive effects on postinjury plasticity. The limited available data suggest that mild TH does not appear to have any deleterious effect on neuroplasticity; however, we emphasize the need for additional high-quality preclinical and clinical work in this area.
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Pokorná P, Šíma M, Vobruba V, Bašková M, Posch L, Slanař O. Sufentanil pharmacokinetics in a full-term neonate treated with extracorporeal membrane oxygenation: a case report. Perfusion 2019; 34:433-436. [PMID: 30632944 DOI: 10.1177/0267659118824011] [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: 11/15/2022]
Abstract
INTRODUCTION Sufentanil is a potent analgesic drug used for pain management. A few studies describe the pharmacokinetics of sufentanil in neonates; however, no pharmacokinetic data about sufentanil during extracorporeal membrane oxygenation have been published yet. CASE REPORT A 1-day-old neonate with moderate hypoxic-ischemic encephalopathy received veno-arterial extracorporeal membrane oxygenation support for refractory respiratory and circulatory failure. Sufentanil plasma concentrations were determined during both extracorporeal membrane oxygenation (n = 14) and non-extracorporeal membrane oxygenation (n = 17) period. Based on these measurements, individual sufentanil pharmacokinetic parameters were calculated. DISCUSSION We observed increased sufentanil volume of distribution (11.6 vs 5.6 L/kg) and decreased sufentanil clearance (0.535 vs 0.746 L/h/kg) in extracorporeal membrane oxygenation period. The increment of volume of distribution was attributed to ECMO influence, while difference in clearance was probably due to drug interaction. CONCLUSIONS This is the first description of sufentanil pharmacokinetics in neonate treated with extracorporeal membrane oxygenation. We observed considerably larger volume of distribution during extracorporeal membrane oxygenation period in comparison with non-extracorporeal membrane oxygenation period.
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Affiliation(s)
- Pavla Pokorná
- 1 Department of Pediatrics and Adolescent Medicine (PICU/NICU), First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,2 Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,3 Intensive Care and Department of Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martin Šíma
- 2 Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Václav Vobruba
- 1 Department of Pediatrics and Adolescent Medicine (PICU/NICU), First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martina Bašková
- 1 Department of Pediatrics and Adolescent Medicine (PICU/NICU), First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Lenka Posch
- 1 Department of Pediatrics and Adolescent Medicine (PICU/NICU), First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,2 Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ondřej Slanař
- 2 Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Pokorná P, Šíma M, Vobruba V, Tibboel D, Slanař O. Phenobarbital pharmacokinetics in neonates and infants during extracorporeal membrane oxygenation. Perfusion 2018; 33:80-86. [PMID: 29788839 DOI: 10.1177/0267659118766444] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The disposition of drugs is potentially changed due to extracorporeal membrane oxygenation (ECMO) in neonates and infants. METHODS The aim of the study was to evaluate the individual pharmacokinetics (PK) of phenobarbital and the effect of PK covariates in neonates and infants undergoing ECMO. Sixteen patients (7 neonates, 9 infants) treated with phenobarbital during ECMO (centrifugal-flow pump circuits) were enrolled in the PK study. Phenobarbital serum concentrations were measured using a fluorescence polarization immunoassay. Individual PK parameters - volume of distribution (Vd) and clearance (CL) were calculated in a one-compartmental pharmacokinetic model. RESULTS The mean (SD) Vd and CL values in neonates were 0.46 (0.24) L/kg and 8.0 (4.5) mL/h/kg, respectively. Respective values in infants were 0.56 (0.23) L/kg and 8.5 (3.1) mL/h/kg. PK parameters in neonates and infants were not significantly different. We observed high inter-individual variability in PK parameters (coefficients of variation [CV] were 52% and 53% for CL and Vd, respectively). Doses were adjusted based on therapeutic drug monitoring (TDM) in 87.5% patients. Only 50% of the first measured phenobarbital serum concentrations in each patient were within the therapeutic range of 10-40 mg/L, in comparison with 88.6% concentration measured after TDM implementation. Linear regression models showed that both Vd and CL are significantly related with body weight (BW) and length. Median optimal phenobarbital loading dose (LD) and maintenance dose (MD), calculated from pharmacokinetic data, were 15 mg/kg and 4 mg/kg/day, respectively. CONCLUSIONS Body weight was shown to be the main PK covariate of phenobarbital disposition. Subsequent dosing nomograms are provided for phenobarbital dosing during ECMO.
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Affiliation(s)
- Pavla Pokorná
- 1 Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University, Prague 2, Czech Republic.,2 Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University, Prague 2, Czech Republic.,3 Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Childrens Hospital, Rotterdam, the Netherlands
| | - Martin Šíma
- 2 Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University, Prague 2, Czech Republic
| | - Václav Vobruba
- 1 Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University, Prague 2, Czech Republic
| | - Dick Tibboel
- 1 Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University, Prague 2, Czech Republic.,3 Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Childrens Hospital, Rotterdam, the Netherlands
| | - Ondřej Slanař
- 2 Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University, Prague 2, Czech Republic
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van den Anker J, Reed MD, Allegaert K, Kearns GL. Developmental Changes in Pharmacokinetics and Pharmacodynamics. J Clin Pharmacol 2018; 58 Suppl 10:S10-S25. [DOI: 10.1002/jcph.1284] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022]
Affiliation(s)
- John van den Anker
- Division of Clinical Pharmacology; Children's National Health System; Washington DC USA
- Division of Paediatric Pharmacology and Pharmacometrics; University of Basel Children's Hospital; Basel Switzerland
- Intensive Care and Department of Pediatric Surgery; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
| | - Michael D. Reed
- Emeritus Professor of Pediatrics; School of Medicine; Case Western Reserve University; Cleveland OH USA
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Erasmus Medical Center-Sophia Children's Hospital; Rotterdam the Netherlands
- Department of Development and Regeneration; KU Leuven; Leuven Belgium
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11
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Sherwin J, Thompson E, Hill KD, Watt K, Lodge AJ, Gonzalez D, Hornik CP. Clinical pharmacology considerations for children supported with ventricular assist devices. Cardiol Young 2018; 28:1082-1090. [PMID: 29991374 PMCID: PMC6299825 DOI: 10.1017/s1047951118001075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The ventricular assist device is being increasingly used as a "bridge-to-transplant" option in children with heart failure who have failed medical management. Care for this medically complex population must be optimised, including through concomitant pharmacotherapy. Pharmacokinetic/pharmacodynamic alterations affecting pharmacotherapy are increasingly discovered in children supported with extracorporeal membrane oxygenation, another form of mechanical circulatory support. Similarities between extracorporeal membrane oxygenation and ventricular assist devices support the hypothesis that similar alterations may exist in ventricular assist device-supported patients. We conducted a literature review to assess the current data available on pharmacokinetics/pharmacodynamics in children with ventricular assist devices. We found two adult and no paediatric pharmacokinetic/pharmacodynamic studies in ventricular assist device-supported patients. While mechanisms may be partially extrapolated from children supported with extracorporeal membrane oxygenation, dedicated investigation of the paediatric ventricular assist device population is crucial given the inherent differences between the two forms of mechanical circulatory support, and pathophysiology that is unique to these patients. Commonly used drugs such as anticoagulants and antibiotics have narrow therapeutic windows with devastating consequences if under-dosed or over-dosed. Clinical studies are urgently needed to improve outcomes and maximise the potential of ventricular assist devices in this vulnerable population.
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Affiliation(s)
- Jennifer Sherwin
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Kevin D. Hill
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kevin Watt
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Andrew J. Lodge
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University Hospital, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Marano M, Goffredo BM, Pisani M, Filippelli S, Cecchetti C, Drago F, Barbieri MA, Nunziata J, Genuini L, Di Nardo M. Pediatric extracorporeal cardiopulmonary resuscitation settled in an emergency department for a propafenone intentional intoxication. Am J Emerg Med 2018; 36:2132.e1-2132.e3. [PMID: 30082186 DOI: 10.1016/j.ajem.2018.08.001] [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: 07/19/2018] [Revised: 07/29/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022] Open
Abstract
The use of drugs in suicide attempts is becoming more and more frequent among adolescents. Intentional intoxication with propafenone is very rare and mainly reported in adults associated with other drugs. The therapeutic approach is symptomatic, since there is no specific antidote for propafenone. We present a pediatric case of intentional ingestion of 1.8 g of propafenone that caused refractory cardiogenic shock. The patient was successfully rescued with extracorporeal cardiopulmonary resuscitation in the emergency department of a secondary level peripheral hospital.
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Affiliation(s)
- Marco Marano
- Emergency Department, IRCCS, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Bianca M Goffredo
- Laboratory of Analytical Biochemistry, IRCCS, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Mara Pisani
- Emergency Department, IRCCS, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Sergio Filippelli
- Department of Pediatric Cardiology and Cardiac Surgery, Children's Hospital Bambino Gesù, Rome, Italy
| | - Corrado Cecchetti
- Emergency Department, IRCCS, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Fabrizio Drago
- Department of Pediatric Cardiology and Cardiac Surgery, Children's Hospital Bambino Gesù, Rome, Italy
| | - Maria A Barbieri
- Emergency Department, IRCCS, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Joseph Nunziata
- Emergency Department, IRCCS, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Leonardo Genuini
- Emergency Department, IRCCS, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Matteo Di Nardo
- Emergency Department, IRCCS, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy.
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13
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Zeilmaker GA, Pokorna P, Mian P, Wildschut ED, Knibbe CAJ, Krekels EHJ, Allegaert K, Tibboel D. Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients. Expert Opin Drug Metab Toxicol 2018; 14:417-428. [PMID: 29623729 DOI: 10.1080/17425255.2018.1461836] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Adequate postoperative analgesia in pediatric patients in the intensive care unit (ICU) matters, since untreated pain is associated with negative outcomes. Compared to routine postoperative patients, children undergoing hypothermia (HT) or extracorporeal membrane oxygenation (ECMO), or recovering after cardiac surgery likely display non-maturational differences in pharmacokinetics (PK) and pharmacodynamics (PD). These differences warrant additional dosing recommendations to optimize pain treatment. Areas covered: Specific populations within the ICU will be discussed with respect to expected variations in PK and PD for various analgesics. We hereby move beyond maturational changes and focus on why PK/PD may be different in children undergoing HT, ECMO or cardiac surgery. We provide a stepwise manner to develop PK-based dosing regimens using population PK approaches in these populations. Expert opinion: A one-dose to size-fits-all for analgesia is suboptimal, but for several commonly used analgesics the impact of HT, ECMO or cardiac surgery on average PK parameters in children is not yet sufficiently known. Parameters considering both maturational and non-maturational covariates are important to develop population PK-based dosing advices as part of a strategy to optimize pain treatment.
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Affiliation(s)
- Gerdien A Zeilmaker
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Paula Pokorna
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Pediatrics, General Faculty Hospital Prague, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic.,c Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
| | - Paola Mian
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Enno D Wildschut
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Catherijne A J Knibbe
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands.,e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Elke H J Krekels
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands
| | - Karel Allegaert
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,f Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Dick Tibboel
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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14
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Di Nardo M, Wildschut ED. Drugs pharmacokinetics during veno-venous extracorporeal membrane oxygenation in pediatrics. J Thorac Dis 2018; 10:S642-S652. [PMID: 29732182 DOI: 10.21037/jtd.2017.11.02] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Data evaluating pharmacokinetic/pharmacodynamic (PK/PD) aspect in the pediatric population are scarce especially regarding the pediatric intensive care unit. Dosing of frequently used drugs (sedatives, analgesics, antibiotics and cardiovascular drugs) are mainly based on non "pediatric intensive care unit (PICU)" patients, and sometimes are translated from adult patients. Among PICU patients, the most complex patients are the ones who are critically ill and are receiving mechanical circulatory/respiratory support for cardiac and/or respiratory failure. The use of extracorporeal membrane oxygenation is associated with major PK and PD changes, especially in neonates and children. The objective of this review is to assess the current literature for pediatric PK data in patients receiving extracorporeal membrane oxygenation (ECMO).
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Enno Diederick Wildschut
- Intensive Care and Department of Pediatric Surgery Erasmus MC, Sophia Children's Hospital, Rotterdam, Netherlands
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15
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Population Pharmacokinetics and Dose Optimization of Teicoplanin during Venoarterial Extracorporeal Membrane Oxygenation. Antimicrob Agents Chemother 2017; 61:AAC.01015-17. [PMID: 28674057 DOI: 10.1128/aac.01015-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 06/24/2017] [Indexed: 12/14/2022] Open
Abstract
The pharmacokinetics (PK) of drugs are known to be significantly altered in patients receiving extracorporeal membrane oxygenation (ECMO). However, clinical studies of the PK of drugs administered during ECMO are scarce, and the proper dosing adjustment has yet to be established. We developed a population PK model for teicoplanin, investigated covariates influencing teicoplanin exposure, and suggested an optimal dosing regimen for ECMO patients. Samples for PK analysis were collected from 10 adult patients, and a population PK analysis and simulations were performed to identify an optimal teicoplanin dose needed to provide a >50% probability of target attainment at 72 h using a trough concentration target of >10 μg/ml for mild to moderate infections and a trough concentration target of >15 μg/ml for severe infections. Teicoplanin was well described by a two-compartment PK model with first-order elimination. The presence of ECMO was associated with a lower central volume of distribution, and continuous renal replacement therapy (CRRT) was associated with a higher peripheral volume of distribution. For mild to moderate infections, an optimal dose was a loading dose (LD) of 600 mg and a maintenance dose (MD) of 400 mg for ECMO patients not receiving CRRT and an LD of 800 mg and an MD of 600 mg for those receiving CRRT. For severe infections, an optimal dose was an LD of 1,000 mg and an MD of 800 mg for ECMO patients not receiving CRRT and an LD of 1,200 mg and an MD of 1,000 mg for those receiving CRRT. In conclusion, doses higher than the standard doses are needed to achieve fast and appropriate teicoplanin exposure during ECMO. (This study has been registered at ClinicalTrials.gov under identifier NCT02581280.).
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16
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Treatment of bronchial foreign body aspiration with extracorporeal life support in a child: A case report and literature review. Int J Pediatr Otorhinolaryngol 2017; 94:82-86. [PMID: 28167019 DOI: 10.1016/j.ijporl.2017.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 11/20/2022]
Abstract
We present a case in which extracorporeal life support treatment of a 6-year-old girl asphyxiated by aspiration of an elliptic plastic ball is described. The attempts for extraction of the foreign body by conventional bronchoscopy under critically ill conditions had failed. Thus, a skin incision was made in the midline, and an emergency open-chest cardiopulmonary bypass (CPB) with aortic, superior vena cava and inferior vena cava cannulation was performed for circulatory support. Following tracheal extubation, a video-assisted rigid bronchoscope was inserted to clear the airway and remove the foreign body. The CPB lasted for 68 min, and the endotracheal tube was pulled out 6 h after the surgery. On the 10th day, the patient was discharged and followed up for 3 months when no neurological symptoms or other complications were documented. The removal of the aspirated bronchial foreign body under extracorporeal life support has been rarely reported. Here, we review the indication, cannulation method, support mode, surgical procedure, and patient outcome in the 8 papers retrieved from the PubMed database and compare their clinical characteristics with those of our case to justify the safe and effective use of CPB for critically ill patients with bronchial foreign body aspiration.
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Baarslag MA, Allegaert K, Van Den Anker JN, Knibbe CAJ, Van Dijk M, Simons SHP, Tibboel D. Paracetamol and morphine for infant and neonatal pain; still a long way to go? Expert Rev Clin Pharmacol 2016; 10:111-126. [PMID: 27785937 DOI: 10.1080/17512433.2017.1254040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered: Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary: Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models.
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Affiliation(s)
- Manuel A Baarslag
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Karel Allegaert
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,b Department of development and regeneration , KU Leuven , Leuven , Belgium
| | - John N Van Den Anker
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,c Division of Clinical Pharmacology , Children's National Health System , Washington , DC , USA.,d Division of Pediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Catherijne A J Knibbe
- e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands.,f Division of Pharmacology, Leiden Academic Center for Drug Research , Leiden University , Leiden , the Netherlands
| | - Monique Van Dijk
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Sinno H P Simons
- g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Dick Tibboel
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
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18
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Baarslag MA, Allegaert K, Knibbe CAJ, van Dijk M, Tibboel D. Pharmacological sedation management in the paediatric intensive care unit. J Pharm Pharmacol 2016; 69:498-513. [DOI: 10.1111/jphp.12630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
Abstract
Objective
This review addresses sedation management on paediatric intensive care units and possible gaps in the knowledge of optimal sedation strategies. We present an overview of the commonly used sedatives and their pharmacokinetic and pharmacodynamic considerations in children, as well as the ongoing studies in this field. Also, sedation guidelines and current sedation strategies and assessment methods are addressed.
Key findings
This review shows that evidence and pharmacokinetic data are scarce, but fortunately, there is an active research scene with promising new PK and PD data of sedatives in children using new study designs with application of advanced laboratory methods and modelling. The lack of evidence is increasingly being recognized by authorities and legislative offices such as the US Food and Drug Administration (FDA) and European Medicines Agency (EMA).
Conclusion
The population in question is very heterogeneous and this overview can aid clinicians and researchers in moving from practice-based sedation management towards more evidence- or model-based practice. Still, paediatric sedation management can be improved in other ways than pharmacology only, so future research should aim on sedation assessment and implementation strategies of protocolized sedation as well.
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Affiliation(s)
- Manuel A Baarslag
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of development and regeneration, KU Leuven, Belgium
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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19
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Himebauch AS, Kilbaugh TJ, Zuppa AF. Pharmacotherapy during pediatric extracorporeal membrane oxygenation: a review. Expert Opin Drug Metab Toxicol 2016; 12:1133-42. [PMID: 27322360 DOI: 10.1080/17425255.2016.1201066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Pediatric critical illness and associated alterations in organ function can change drug pharmacokinetics (PK). Extracorporeal membrane oxygenation (ECMO), a life-saving therapy for severe cardiac and/or respiratory failure, causes additional PK alterations that affect drug disposition. AREAS COVERED The purposes of this review are to discuss the PK changes that occur during ECMO, the associated therapeutic implications, and to review PK literature relevant to pediatric ECMO. We discuss various classes of drugs commonly used for pediatric patients on ECMO, including sedatives, analgesics, antimicrobials and cardiovascular drugs. Finally, we discuss future areas of research and recommend strategies for future pediatric ECMO pharmacologic investigations. EXPERT OPINION Clinicians caring for pediatric patients treated with ECMO must have an understanding of PK alterations that could lead to either therapeutic failures or increased drug toxicity during this life-saving therapy. Limited data currently exist for optimal drug dosing in pediatric populations who are treated with ECMO. While there are clear challenges to conducting and analyzing data associated with clinical pharmacokinetic-pharmacodynamic studies of children on ECMO, we present techniques to address these challenges. Improved understanding of the physiology and drug disposition during ECMO combined with PK-PD modeling will allow for more adaptable and individualized dosing schemes.
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Affiliation(s)
- Adam S Himebauch
- a Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine , University of Pennsylvania, The Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Center for Clinical Pharmacology , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Todd J Kilbaugh
- a Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine , University of Pennsylvania, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Athena F Zuppa
- a Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine , University of Pennsylvania, The Children's Hospital of Philadelphia , Philadelphia , PA , USA.,b Center for Clinical Pharmacology , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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20
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Vet NJ, Kleiber N, Ista E, de Hoog M, de Wildt SN. Sedation in Critically Ill Children with Respiratory Failure. Front Pediatr 2016; 4:89. [PMID: 27606309 PMCID: PMC4995367 DOI: 10.3389/fped.2016.00089] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 08/09/2016] [Indexed: 01/08/2023] Open
Abstract
This article discusses the rationale of sedation in respiratory failure, sedation goals, how to assess the need for sedation as well as effectiveness of interventions in critically ill children, with validated observational sedation scales. The drugs and non-pharmacological approaches used for optimal sedation in ventilated children are reviewed, and specifically the rationale for drug selection, including short- and long-term efficacy and safety aspects of the selected drugs. The specific pharmacokinetic and pharmacodynamic aspects of sedative drugs in the critically ill child and consequences for dosing are presented. Furthermore, we discuss different sedation strategies and their adverse events, such as iatrogenic withdrawal syndrome and delirium. These principles can guide clinicians in the choice of sedative drugs in pediatric respiratory failure.
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Affiliation(s)
- Nienke J Vet
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Niina Kleiber
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Erwin Ista
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Saskia N de Wildt
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Pharmacology and Toxicology, Radboud University, Nijmegen, Netherlands
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21
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Rodieux F, Wilbaux M, van den Anker JN, Pfister M. Effect of Kidney Function on Drug Kinetics and Dosing in Neonates, Infants, and Children. Clin Pharmacokinet 2015; 54:1183-204. [PMID: 26138291 PMCID: PMC4661214 DOI: 10.1007/s40262-015-0298-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neonates, infants, and children differ from adults in many aspects, not just in age, weight, and body composition. Growth, maturation and environmental factors affect drug kinetics, response and dosing in pediatric patients. Almost 80% of drugs have not been studied in children, and dosing of these drugs is derived from adult doses by adjusting for body weight/size. As developmental and maturational changes are complex processes, such simplified methods may result in subtherapeutic effects or adverse events. Kidney function is impaired during the first 2 years of life as a result of normal growth and development. Reduced kidney function during childhood has an impact not only on renal clearance but also on absorption, distribution, metabolism and nonrenal clearance of drugs. 'Omics'-based technologies, such as proteomics and metabolomics, can be leveraged to uncover novel markers for kidney function during normal development, acute kidney injury, and chronic diseases. Pharmacometric modeling and simulation can be applied to simplify the design of pediatric investigations, characterize the effects of kidney function on drug exposure and response, and fine-tune dosing in pediatric patients, especially in those with impaired kidney function. One case study of amikacin dosing in neonates with reduced kidney function is presented. Collaborative efforts between clinicians and scientists in academia, industry, and regulatory agencies are required to evaluate new renal biomarkers, collect and share prospective pharmacokinetic, genetic and clinical data, build integrated pharmacometric models for key drugs, optimize and standardize dosing strategies, develop bedside decision tools, and enhance labels of drugs utilized in neonates, infants, and children.
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Affiliation(s)
- Frederique Rodieux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
| | - Melanie Wilbaux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
| | - Johannes N van den Anker
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA.
- Intensive Care, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Marc Pfister
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
- Quantitative Solutions LP, Menlo Park, CA, USA
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Abstract
Drug metabolism importantly determines drug concentrations. The efficacy and safety of many drugs prescribed for children are, therefore, dependent on intraindividual and interindividual variation in drug-metabolising enzyme activity. During growth and development, changes in drug-metabolising enzyme activity result in age-related differences in drug disposition, most pronounced in preterm infants and young infants. The shape of the developmental trajectory is unique to the drug-metabolising enzyme involved in the metabolism of individual drugs. Other factors impacting drug metabolism are underlying disease, drug-drug interactions and genetic variation. The interplay of age with these other factors may result in unexpected variation in drug metabolism in children of different ages. Extrapolation of adult data to guide drug dosing in children should be done with caution. The younger the child, the less reliable is the extrapolation. This review aims to identify the primary sources of variability of drug metabolism in children, the knowledge of which can ultimately guide the practitioner towards effective and safe drug therapy.
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Affiliation(s)
- Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - D Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J S Leeder
- Department of Pediatrics, Division of Clinical Pharmacology, Toxicology, and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Missouri, USA
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Abstract
INTRODUCTION Extensive within-population variability is the essence of neonatal pharmacology. Despite this, infants remain one of the last therapeutic orphans. Together with additional legal initiatives, tailoring of already available tools (modeling, covariates, pharmacovigilance) may significantly improve pharmacotherapy in infants. AREAS COVERED Modeling approaches that hold the promise to improve pharmacotherapy in infants are between-compound extrapolation for compounds that undergo the same route of elimination and integration of time-varying physiology to adapt for the fast maturational changes. Besides these maturational covariates (size, age), newly emerging covariates relate to novel treatment modalities (extracorporeal circulation, hypothermia), environmental issues (microbiome, critical illness) or pharmacogenetics. All these covariates interact with the maturational variation. Finally, pharmacovigilance also needs to be tailored to the characteristics of this population. This relates to preventive strategies, signal detection and assessment of causality. EXPERT OPINION Knowledge on pharmacotherapy in infants is lagging. Tailoring available tools to the specific characteristics (maturation) and clinical needs (newly emerging covariates) of infants is feasible but needs creativity and a multidisciplinary collaboration between modelers, academia, clinical researchers and, obviously, the public, including parents.
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Affiliation(s)
- Karel Allegaert
- University Hospitals Leuven, Neonatal Intensive Care Unit , Herestraat 49, 3000 Leuven , Belgium +32 16 343850 ; +32 16 343209 ;
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24
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Abstract
Drug therapy is a powerful tool for improving neonatal outcome. Despite this, neonatologists still routinely prescribe off-label compounds developed for adults and extrapolate doses from those used for children or adults. Knowledge integration through pharmacokinetic modeling is a method that could improve the current situation. Such predictive models may convert neonatal pharmacotherapy from explorative to confirmatory. This can be illustrated by research projects related to the prediction of neonatal renal clearance and neonatal glucuronidation. This type of model will also improve the current knowledge of neonatal (patho)physiology. In the meanwhile, the fields of clinical pharmacology (e.g. pharmacokinetic/pharmacodynamic modeling and pharmacogenetics) and neonatology (e.g. whole-body cooling and the lower limit of viability) have both matured, resulting in new research topics. However, in order for the modeling and the newly emerging topics to become effective tools, they need to be tailored to the specific characteristics of neonates. Consequently, the field of neonatal pharmacotherapy needs dedicated neonatologists who continue to raise the awareness that off-label practices, eminence-based dosing regimens and the absence of neonatal drug formulations all reflect suboptimal care.
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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25
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Shekar K, Roberts JA, Smith MT, Fung YL, Fraser JF. The ECMO PK Project: an incremental research approach to advance understanding of the pharmacokinetic alterations and improve patient outcomes during extracorporeal membrane oxygenation. BMC Anesthesiol 2013; 13:7. [PMID: 23517311 PMCID: PMC3643838 DOI: 10.1186/1471-2253-13-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 02/21/2013] [Indexed: 01/20/2023] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is a supportive therapy and its success depends on optimal drug therapy along with other supportive care. Emerging evidence suggests significant interactions between the drug and the device resulting in altered pharmacokinetics (PK) of vital drugs which may be further complicated by the PK changes that occur in the context of critical illness. Such PK alterations are complex and challenging to investigate in critically ill patients on ECMO and necessitate mechanistic research. The aim of this project is to investigate each of circuit, drug and critical illness factors that affect drug PK during ECMO. Methods/design An incremental research plan that encompasses ex vivo experiments for drug stability testing in fresh human and ovine whole blood, ex vivo drug disposition studies in standard and modified adult ECMO circuits primed with fresh human or ovine whole blood, PK studies in healthy and critically ill ovine models of ECMO with appropriate non ECMO controls and an international mutli-centre clinical population PK study will be utilised to comprehensively define the PK alterations that occur in the presence of ECMO. Novel drug assays that will allow quantification of multiple drugs in small volumes of plasma will also be developed. Mixed-effects regression models will be used to estimate the drug loss over time in ex vivo studies. Data from animal and clinical studies will be analysed using non-linear mixed-effects models. This will lead to generation of PK data that enables the development evidence based guidelines for antibiotic, sedative and analgesic drug therapy during ECMO. Discussion Systematic research that integrates both mechanistic and clinical research is desirable when investigating the complex area of pharmacokinetic alterations during ECMO. The above research approach will provide an advanced mechanistic understanding of PK during ECMO. The clinical study when complete will result in development robust guidelines for prescription of 18 commonly used antibiotic, sedative and analgesic drugs used in ECMO patients. This research may also pave the way for further refinements in circuitry, drug chemistry and drug prescriptions during ECMO. Trial registration ACTRN12612000559819.
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Affiliation(s)
- Kiran Shekar
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles, Hospital and The University of Queensland, Brisbane, QLD, 4032, Australia.
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