Admission to a pediatric intensive care unit for poisoning: a review of 105 cases

Intensive Care Interventions Among Children With Toxicologic Exposures to Cardiovascular Medications

OBJECTIVES

Interventions requiring a PICU are rare in toxicologic exposures, but cardiovascular medications are high-risk exposures due to their hemodynamic effects. This study aimed to describe prevalence of and risk factors for PICU interventions among children exposed to cardiovascular medications.

DESIGN

Secondary analysis of Toxicology Investigators Consortium Core Registry from January 2010 to March 2022.

SETTING

International multicenter research network of 40 sites.

PATIENTS

Patients 18 years old or younger with acute or acute-on-chronic toxicologic exposure to cardiovascular medications. Patients were excluded if exposed to noncardiovascular medications or if symptoms were documented as unlikely related to exposure.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 1,091 patients in the final analysis, 195 (17.9%) received PICU intervention. One hundred fifty-seven (14.4%) received intensive hemodynamic interventions and 602 (55.2%) received intervention in general. Children less than 2 years old were less likely to receive PICU intervention (odds ratio [OR], 0.42; 95% CI, 0.20-0.86). Exposures to alpha-2 agonists (OR, 2.0; 95% CI, 1.11-3.72) and antiarrhythmics (OR, 4.26; 95% CI, 1.41-12.90) were associated with PICU intervention. In the sensitivity analysis removing atropine from the composite outcome PICU intervention, only exposures to calcium channel antagonists (OR, 2.12; 95% CI, 1.09-4.11) and antiarrhythmics (OR, 4.82; 95% CI, 1.57-14.81) were independently associated with PICU intervention. No independent association was identified between PICU intervention and gender, polypharmacy, intentionality or acuity of exposure, or the other medication classes studied.

CONCLUSIONS

PICU interventions were uncommon but were associated with exposure to antiarrhythmic medications, calcium channel antagonists, and alpha-2 agonists. As demonstrated via sensitivity analysis, exact associations may depend on institutional definitions of PICU intervention. Children less than 2 years old are less likely to require PICU interventions. In equivocal cases, age and exposure to certain cardiovascular medication classes may be useful to guide appropriate disposition.

Acute medication poisoning causing hospital admissions in childhood: a 3-year prospective observational single-center study

Although the risks of medication poisoning in children are often reported, there is a lack of studies addressing this issue. The majority of papers deal with a wide range of xenobiotics poisoning and, in particular, alcohol intoxications. All hospital admissions during three years were prospectively recorded. Patients younger than 19 years of age admitted for acute drug intoxications were further evaluated. A total of 15,069 children were admitted. Of them, 55 were hospitalized for acute medication poisoning. The condition was more common in girls (72.7 % vs. 27.3 %, p<0.01). Toddlers were the largest patient group (36.4 %). Non-steroidal anti-inflammatory drugs (NSAIDs) were the most frequently used agents, with ibuprofen being the leading drug (20 % of all cases). The route of intoxication was almost exclusively oral. Solid drug forms were involved in 40 (72.7 %) cases. There was one fatal accidental poisoning. The highest occurrence of accidental drug intoxications was in the age group from one to three years. Attempted suicides were most frequent among adolescents. We are currently actively dealing with the issue. The cohort has been expanded to include a period of ten years and is being analyzed.

Prospective evaluation of a clinical decision tool to reduce childhood admissions to PICUs for poisoning: ReCAP2

Aim: To prospectively validate a pediatric clinical prediction model to identify children at low risk of clinically significant ingestions to prevent unnecessary pediatric intensive care unit (PICU) admissions.Methods: Calls received by the Georgia Poison Center about children for acute ingestions between May 25, 2017 and May 17, 2018 were scored in real time using the full, age-stratified, and simplified clinical scoring tool to reduce childhood admissions to PICUs for poisoning (RECAP²). Clinically significant ingestions with a poison center recommendation of PICU admission are defined in the simple RECAP² model as ingestion of clonidine, ethanol, an oral anti-hyperglycemic agent, or exposure to carbon monoxide, as well as the presence of symptoms occurring within 2 h for an immediate release, or 4 h for an extended release, medication exposure. Model statistics and percent reduction in PICU admissions were computed.Results: There were 886 children admitted after ingestions, of which 454 (51.2%) children were admitted to intensive care. At the time of the initial poison center call to report the ingestion, 44 cases (5%) were incomplete using the full, age-stratified model compared to the complete scoring using the simple scoring model. Seventy-two children (8.1%) required monitoring or interventions performed only in a PICU. Real-time application of the full model compared with the simple model would have reduced PICU admissions by 33.3 and 31.7%, respectively.Conclusions: The simple RECAP² clinical scoring model is a sensitive prediction tool to identify children at very low risk for clinically significant ingestions for whom PICU admission can be avoided. Clinical implementation of the simple RECAP² model and recommendation for admission to an inpatient unit versus PICU should be further evaluated, to reduce unnecessary PICU admissions following acute ingestions.

Reducing Childhood Admissions to the PICU for Poisoning (ReCAP2) by Predicting Unnecessary PICU Admissions After Acute Intoxication

OBJECTIVE

To derive and validate clinical prediction models to identify children at low risk of clinically significant intoxications for whom intensive care admission is unnecessary.

DESIGN

Retrospective review of data in the National Poison Data Systems from 2011 to 2014 and Georgia Poison Center cases from July to December 2016.

SETTING

United States PICUs and poison centers participating in the American Association of Poison Control Centers from 2011 to 2016.

PATIENTS

Children 18 years and younger admitted to a United States PICU following an acute intoxication.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary study outcome was the occurrence of clinically significant intoxications defined a priori as organ system-based clinical effects that require intensive care monitoring and interventions. We analyzed 70,364 cases. Derivation (n = 42,240; 60%) and validation cohorts (n = 28,124; 40%) were randomly selected from the eligible population and had similar distributions of clinical effects and PICU interventions. PICU interventions were performed in 1,835 children (14.1%) younger than 6 years, in 374 children (15.4%) 6-12 years, and in 4,446 children (16.5%) 13 years and older. We developed highly predictive models with an area under the receiver operating characteristic curve of 0.834 (< 6 yr), 0.771 (6-12 yr), and 0.786 (≥13 yr), respectively. For predicted probabilities of less than or equal to 0.10 in the validation cohorts, the negative predictive values were 95.4% (< 6 yr), 94.9% (6-12 yr), and 95.1% (≥ 13 yr). An additional 700 patients from the Georgia Poison Center were used to validate the model and would have reduced PICU admission by 31.4% (n = 110).

CONCLUSIONS

These validated models identified children at very low risk of clinically significant intoxications for whom pediatric intensive care admission can be avoided. Application of this model using Georgia Poison Center data could have resulted in a 30% reduction in PICU admissions following intoxication.

Analysis of Interventions Required in 12,021 Children With Acute Intoxications Admitted to PICUs

OBJECTIVES

Acute intoxications in children account for 4.6% of annual admissions to the PICU. We aimed to describe the interventions and monitoring required for children admitted to the PICU following intoxications with the ultimate goal of determining patient and intoxication characteristics associated with the need for PICU interventions.

DESIGN

Retrospective review of prospectively collected data from Virtual Pediatric Systems, LLC.

SETTING

United States PICUs participating in the Virtual Pediatric Systems database from 2011 to 2014.

PATIENTS

Less than or equal to 18 years old admitted to a PICU with a diagnostic code for poisoning, ingestion, intoxication, or overdose.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In total, 12,021 patients were included with a median PICU length of stay of 0.97 days (interquartile range, 0.67-1.60). Seventy-eight percent of the intoxications were intentional. The top five classes of medications ingested were unknown substances (21.6%), antidepressants (11.5%), other chemicals (10.7%), analgesics (7.3%), and antihypertensives (6.2%). Seventy-six (0.61%) patients died. Any of the interventions reported in the Virtual Pediatric Systems database were performed in only 29.1% of the total cases.

CONCLUSIONS

The majority of cases (70.9%) admitted to the PICU following an intoxication did not undergo any significant intervention. Future studies should focus on distinguishing patient and intoxication characteristics associated with need for PICU intervention to optimize patient safety and minimize resource burden.

Poisonings requiring admission to the pediatric intensive care unit: A 5-year review

BACKGROUND

Poisonings represent a significant number of preventable admissions to the pediatric intensive care unit (PICU), but data about poisonings requiring PICU-level care are limited.

OBJECTIVES

To identify the demographics of patients admitted with poisonings and characterize their clinical courses related to their poisoning.

METHODS

All poisonings over a 5-year period (2008-2012) at an academic medical center in New England were retrospectively reviewed using electronic medical records in an observational case series. Poisonings were identified using key search terms within an admissions database.

RESULTS

There were 273 admissions for poisonings, which represent 8% of total PICU admissions over this time period. The poisonings were unintentional in 148 (54%) cases and intentional in 125 (46%). The vast majority of poisonings occurred in patients either 3 years or below (N = 121, 44%) or 13 years or above (N = 124, 45%). Most (96%) admissions were for less than 48 h and 41% were for less than 24 h. Mean PICU length of stay was 1.2 + 0.7 days. A total of 468 substances were ingested in 54 different drug classes, with analgesics and antidepressants being the most common. Eighty-five (31%) poisonings were polypharmaceutical. The most commonly used therapies were naloxone, activated charcoal, and benzodiazepines. Twenty-seven patients (10%) received mechanical ventilation. There was one fatality, an adolescent with a polypharmacy overdose in a suicide attempt.

CONCLUSION

Pediatric poisonings are a significant percentage of admissions to the PICU. The majority of poisonings are non-fatal, require supportive care, close monitoring, and some specific treatment. Drug classes causing poisonings have changed to a higher percentage of opioids in younger patients and atypical antidepressants in adolescents.

Epidemiology of poisoning in children: a 7-year survey in a paediatric emergency care unit

Acute poisoning in children is still a major public health problem, and represents a frequent cause of admission in emergency departments. We carried out an epidemiological study of poisonings leading to admission to a paediatric emergency care unit (PECU). We analysed data from 2988 children who were admitted to the PECU of Bordeaux, France with acute poisoning from 1989 through 1995. During the 7-year period, the poison exposure numbers decreased slightly from 490 to 382 (6% vs. 3% of total medical emergencies). This represented a mean annual incidence of 1.4 poison exposures per 1000 children younger than 18 years of age and living in Bordeaux and its surroundings. Characteristics of the study population, circumstances of poisoning and substances involved were similar to those previously described. Eighty per cent of children were younger than 5 years of age, presented with a benign course. Forty per cent were not treated and 75% were discharged home either immediately or within 24 hours of admission. Only 1.5% of cases, mainly adolescent girls who attempted suicide, were admitted to a paediatric intensive care unit. Overall mortality rate was 0.33/1000. In children, most cases of acute poisoning are accidental, benign, and mainly attributed to the ingestion of a non-toxic substance. This points to the need for better information of the population on availability of poison control centre calling facilities, in order to decrease the number of admissions to the PECU. Patients suspected of having ingested a potentially dangerous substance can be managed in short-stay observation units, thus avoiding unnecessarily prolonged hospitalization. Acute poisoning in children remains a frequent problem, highlighting the need to develop an education programme on primary prevention in our region.

Massive overdose with controlled-release carbamazepine resulting in delayed peak serum concentrations and life-threatening toxicity

INTRODUCTION

Peak serum levels following overdose with immediate-release formulations of carbamazepine have been reported to occur up to 2 days postingestion. We report a case of poisoning with carbamazepine controlled-release resulting in peak levels 96 h postingestion.

CASE REPORTS

A 31-year-old female presented following a suspected polypharmacy overdose. She was haemodynamically stable with a Glasgow Coma Scale score of 3 and was endotracheally intubated in the emergency department. A single-dose of activated charcoal was administered on admission and her neurological status improved gradually Results of qualitative urine drug screen available 24 h postadmission to the intensive care department revealed benzodiazepines and carbamazepine. The serum carbamazepine concentration at this time was 66 micromol/L (therapeutic 17-42 micromol/L). A history of therapy with controlled-release carbamazepine was discovered. Repeat-dose activated charcoal and whole-bowel irrigation were commenced, but poorly tolerated. Serum carbamazepine levels continued to rise and gastrointestinal tract decontamination was ceased due to the presence of an ileus. By day 4, the serum carbamazepine concentration peaked at 196 micromol/L. This was associated with coma, generalized intermittent seizure activity and hypotension. Charcoal haemoperfusion was commenced due the presence of end-organ toxicity and failed gastrointestinal tract decontamination. Serum carbamazepine concentrations fell from 176 to 106 micromol/L after 1 h of haemoperfusion and the patient was rousable to voice and could obey commands at this time. She confirmed ingestion of 300 Tegretol-CR (200 mg) on extubation and was discharged without long-term sequelae.

CONCLUSION

Unrecognized poisoning with controlled-release carbamazepine has the potential to produce significant delayed carbamazepine toxicity and delayed peak serum carbamazepine concentrations. This may occur much later than previously reported with immediate-release carbamazepine preparations.

Unintentional poisoning hospitalisations among young children in Victoria

OBJECTIVES

To describe the epidemiology of unintentional childhood poisoning hospitalisation in Victoria, Australia, in order to monitor trends and identify areas for research and prevention.

METHODS

For children under 5 years, all Victorian public hospital admissions, July 1987 to June 1995, due to unintentional poisoning by drugs, medicines, and other substances were analysed. Similar cases were also extracted from the database of the Royal Children's Hospital intensive care unit, Melbourne for the years 1979-91. Log linear regression modelling was used for trend analyses.

RESULTS

The annual average childhood unintentional poisoning rate was 210.7 per 100,000. Annual rates for males consistently exceeded those for females. The most common agents were those acting on the respiratory system and on smooth and skeletal muscles (muscle relaxants, cough and cold medicines, antiasthmatics), aromatic analgesics (paracetamol), and systemic agents (including antihistamines). Further investigation is justified for cardiac agents, some respiratory agents, and asthma medications.

CONCLUSIONS

Childhood poisoning hospitalisation rates have not decreased in Victoria over recent years. A focused, agent specific approach, as well as a series of generic measures for the prevention of poisoning to children under 5 is advocated. The ongoing surveillance, collection and analysis of data, in addition to research on specific poisoning agents are essential components of any prevention strategy.

Poisoning and drug overdose

Poisoning is a common cause for intensive care unit admission for both children and adults, and most poisoning victims are effectively treated using standard decontamination measures and supportive care. For a small number of poisons, acceleration of toxin removal with hemodialysis or hemofiltration is indicated. Similarly, specific antidotes are indicated in a few selected circumstances. Rarely, patients may benefit from more aggressive supportive techniques such as cardiopulmonary bypass.

Suspected paediatric pesticide poisoning in the UK. I--Home Accident Surveillance System 1982-1988

1. Between 1982 and 1988, 239,350 children under 10 years old attended 20 A & E Departments in England and Wales (22 departments throughout the UK in 1988) as a result of a home accident. 15,144 of 239,350 were suspected cases of poisoning and 514 attendances involved pesticides. 2. 501 of 514 children who attended hospital were under 6 years old and 41% were thought to have ingested a rodenticide, 37% an insecticide or other animal poison, 13% an herbicide or fungicide and 9% other pesticides. 3. Overall 189 of 514 children were admitted to hospital and of these 189 cases 35% were discharged home in less than one day; 94% left hospital within 2 days. 4. Using these data we estimate that over the period of study approximately 1,850 children annually attended an Accident and Emergency Department in the UK with suspected pesticide poisoning and that some 450 were admitted to hospital. However, the morbidity from this cause is low and no deaths from pesticide poisoning have been reported in children in England and Wales for more than two decades.