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Meng L, Rasmussen M, Abcejo AS, Meng DM, Tong C, Liu H. Causes of Perioperative Cardiac Arrest: Mnemonic, Classification, Monitoring, and Actions. Anesth Analg 2024; 138:1215-1232. [PMID: 37788395 DOI: 10.1213/ane.0000000000006664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Perioperative cardiac arrest (POCA) is a catastrophic complication that requires immediate recognition and correction of the underlying cause to improve patient outcomes. While the hypoxia, hypovolemia, hydrogen ions (acidosis), hypo-/hyperkalemia, and hypothermia (Hs) and toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), and thrombosis (coronary) (Ts) mnemonic is a valuable tool for rapid differential diagnosis, it does not cover all possible causes leading to POCA. To address this limitation, we propose using the preload-contractility-afterload-rate and rhythm (PCARR) construct to categorize POCA, which is comprehensive, systemic, and physiologically logical. We provide evidence for each component in the PCARR construct and emphasize that it complements the Hs and Ts mnemonic rather than replacing it. Furthermore, we discuss the significance of utilizing monitored variables such as electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA. To aid in investigating POCA causes, we suggest the Anesthetic care, Surgery, Echocardiography, Relevant Check and History (A-SERCH) list of actions. We recommend combining the Hs and Ts mnemonic, the PCARR construct, monitoring, and the A-SERCH list of actions in a rational manner to investigate POCA causes. These proposals require real-world testing to assess their feasibility.
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Affiliation(s)
- Lingzhong Meng
- From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mads Rasmussen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Arnoley S Abcejo
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Deyi M Meng
- Choate Rosemary Hall School, Wallingford, Connecticut
| | - Chuanyao Tong
- Department of Anesthesiology, Wake Forest University, Winston-Salem, North Carolina
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis, Sacramento, California
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Samara E, Karakosta A, Tseniklidis P, Tzimas P. Supraventricular Tachycardia Associated With Ondansetron. Hosp Pharm 2023; 58:327-328. [PMID: 37360206 PMCID: PMC10288460 DOI: 10.1177/00185787231158772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Affiliation(s)
- Evangelia Samara
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, University of Ioannina, Ioannina, Epirus, Greece
| | - Agathi Karakosta
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, University of Ioannina, Ioannina, Epirus, Greece
| | - Paraskevas Tseniklidis
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, University of Ioannina, Ioannina, Epirus, Greece
| | - Petros Tzimas
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, University of Ioannina, Ioannina, Epirus, Greece
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Cabral MD, Patel DR, Greydanus DE, Deleon J, Hudson E, Darweesh S. Medical perspectives on pediatric sports medicine–Selective topics. Dis Mon 2022; 68:101327. [DOI: 10.1016/j.disamonth.2022.101327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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van der Zanden TM, Mooij MG, Vet NJ, Neubert A, Rascher W, Lagler FB, Male C, Grytli H, Halvorsen T, de Hoog M, de Wildt SN. Benefit-Risk Assessment of Off-Label Drug Use in Children: The Bravo Framework. Clin Pharmacol Ther 2021; 110:952-965. [PMID: 34145575 PMCID: PMC8518427 DOI: 10.1002/cpt.2336] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/04/2021] [Indexed: 11/08/2022]
Abstract
A drug is granted a license for use after a thorough assessment of risks and benefits based on high-quality scientific proof of its efficacy and safety. Many drugs that are relevant to children are not licensed for use in this population implying that a thorough assessment of risks and benefits in the pediatric population has not been made at all, implying a negative risk-benefit balance in children, or implying insufficient information to establish the risk-benefit balance. Use of drugs without positive assessment of risks and benefits exposes children to potential lack of efficacy, unknown toxicity, and harm. To aid guideline committees and individual prescribers, we here present a tutorial of the Benefit and Risk Assessment for Off-label use (BRAvO) decision framework. This pragmatic framework offers a structured assessment of benefits and risks of off-label drug use, including a clinical pharmacological based approach to age-appropriate dose selection. As proof of concept and to illustrate the practical use, we have applied the framework to assess benefits and risks of off-label use of ondansetron for gastroenteritis-induced nausea and vomiting. The framework could also guide decisions on off-label use in other special populations (e.g., pregnant women, elderly, obese, or critically ill patients) where off-label drug use is frequent, thereby contributing to effective and safe pharmacotherapy.
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Affiliation(s)
- Tjitske M. van der Zanden
- Department of PediatricsErasmus MC – Sophia Children’s HospitalRotterdamThe Netherlands
- Departments of Pharmacology and Toxicology, and Intensive CareRadboud Institute Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
- Dutch Knowledge Center Pharmacotherapy for ChildrenDen HaagThe Netherlands
| | - Miriam G. Mooij
- Department of PediatricsLeiden University Medical Centre – Willem‐Alexander Children’s HospitalLeidenThe Netherlands
| | - Nienke J. Vet
- Department of PediatricsSt. Antonius HospitalNieuwegeinThe Netherlands
| | - Antje Neubert
- Department of Pediatric and Adolescent MedicineUniversity Hospital ErlangenErlangenGermany
| | - Wolfgang Rascher
- Department of Pediatric and Adolescent MedicineUniversity Hospital ErlangenErlangenGermany
| | - Florian B. Lagler
- Department for Pediatrics and Institute for Inherited Metabolic DiseasesParacelsus Medical UniversitySalzburgAustria
| | - Christoph Male
- Department of Paediatrics and Adolescent MedicineMedical University of ViennaAustria
| | - Helene Grytli
- The Norwegian Medicines Manual for Health Personnel and Institute for Cancer ResearchOslo University HospitalOsloNorway
| | - Thomas Halvorsen
- Department of Pediatric and Adolescent MedicineMedicines for Children Network, NorwayHaukeland University HospitalBergenNorway
| | - Matthijs de Hoog
- Department of PediatricsErasmus MC – Sophia Children’s HospitalRotterdamThe Netherlands
| | - Saskia N. de Wildt
- Departments of Pharmacology and Toxicology, and Intensive CareRadboud Institute Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
- Dutch Knowledge Center Pharmacotherapy for ChildrenDen HaagThe Netherlands
- Intensive Care and Pediatric SurgeryErasmus MC Sophia Children’s HospitalRotterdamThe Netherlands
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Wu HL, Zhan X. Effect of ondansetron on vomiting associated with acute gastroenteritis in a developing country: a meta-analysis. Eur J Pediatr 2020; 179:1181-1189. [PMID: 32495146 DOI: 10.1007/s00431-020-03680-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
In high-income countries. ondansetron is an effective antiemetic in children with gastroenteritis, but data from low- and middle-income countries are sparse. This study aimed to evaluate evidences of the effectiveness of ondansetron in preventing vomiting and reducing the use of intravenous fluids in children with gastroenteritis in developing countries. A total of nine randomized controlled trials (RCTs) involving 2313 participants met the inclusion criteria. Compared with placebo, ondansetron reduced the use of intravenous rehydration (three RCTs, n = 1126, relative risk (RR) 0.60, 95% confidence interval (CI) 0.38-0.95, no significant heterogeneity, I2 = 43%), the risk of failure of oral rehydration therapy among children with gastroenteritis-associated vomiting and dehydration (four RCTs, n = 1370, RR 0.58, 95% CI 0.43-0.79; no significant heterogeneity was found, I2 = 39%) and risk of hospitalization (2 RCTs, n = 264, RR 0.25, 95% CI 0.09-0.73, no heterogeneity, I2 = 0).Conclusions: Compared with placebo, ondansetron reduced the use of intravenous fluids in children with gastroenteritis and dehydration. It has no effect on children with gastroenteritis who do not present with dehydration in developing countries. While ondansetron is effective in controlling vomiting and reducing the rate of hospitalization, there is no evidence that it is effective in reducing the rate of readmission. What is Known: • In high-income countries, ondansetron can reduce the use of intravenous fluids in children with gastroenteritis and dehydration. • No systematic review and meta-analysis of randomized controlled trials were done in a developing country setting. What is New: • In developing countries, ondansetron reduces the use of intravenous fluids in children with gastroenteritis and dehydration. • It has no effect on children with gastroenteritis but without dehydration.
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Affiliation(s)
- Hai-Lin Wu
- Department of Gastroenterology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R China., Chongqing Key Laboratory of Pediatrics, No.136, Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China
| | - Xue Zhan
- Department of Gastroenterology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R China., Chongqing Key Laboratory of Pediatrics, No.136, Zhongshan 2nd Road, Yuzhong District, Chongqing, 400014, China.
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Abstract
Nausea and vomiting are common symptoms with many possible causes, including the adverse effects of drugs. If a drug is indicated, the cause guides the choice of antiemetic drug
The main antiemetic classes include antagonists of the serotonin, dopamine, histamine, muscarinic and neurokinin systems, corticosteroids and benzodiazepines. Some antiemetics appear more effective for specific indications
Serotonin and neurokinin antagonists, such as ondansetron and aprepitant, are highly effective in treating chemotherapy-induced nausea and vomiting. Metoclopramide and antihistamines are first-line options for nausea and vomiting in pregnancy
Serotonin antagonists and some dopamine antagonists, such as metoclopramide, can prolong the QT interval on the ECG. Dopamine antagonists can cause extrapyramidal adverse effects, particularly in children
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Affiliation(s)
- Akshay Athavale
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney.,MyHealth Medical Centre, Macquarie Park, Sydney.,Department of Clinical Pharmacology and Toxicology, and Department of Renal Medicine and Transplantation, St Vincent's Hospital, Sydney.,St Vincent's Clinical School, University of New South Wales, Sydney
| | - Tegan Athavale
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney.,MyHealth Medical Centre, Macquarie Park, Sydney.,Department of Clinical Pharmacology and Toxicology, and Department of Renal Medicine and Transplantation, St Vincent's Hospital, Sydney.,St Vincent's Clinical School, University of New South Wales, Sydney
| | - Darren M Roberts
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney.,MyHealth Medical Centre, Macquarie Park, Sydney.,Department of Clinical Pharmacology and Toxicology, and Department of Renal Medicine and Transplantation, St Vincent's Hospital, Sydney.,St Vincent's Clinical School, University of New South Wales, Sydney
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Malaki M. Ondansetron and arrhythmia: An adverse effect, medical error, or insufficient guidelines. JOURNAL OF PHARMACEUTICAL NEGATIVE RESULTS 2020. [DOI: 10.4103/jpnr.jpnr_2_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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8
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Patel P, Paw Cho Sing E, Dupuis LL. Safety of clinical practice guideline-recommended antiemetic agents for the prevention of acute chemotherapy-induced nausea and vomiting in pediatric patients: a systematic review and meta-analysis. Expert Opin Drug Saf 2019; 18:97-110. [DOI: 10.1080/14740338.2019.1568988] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Priya Patel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Pediatric Oncology Group of Ontario, Toronto, Canada
| | - Edric Paw Cho Sing
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
| | - L. Lee Dupuis
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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Trends in Outpatient Prescription Medicine Use in New Zealand Children 2010-2015: A National Population-Based Study. Paediatr Drugs 2018; 20:465-474. [PMID: 30043272 DOI: 10.1007/s40272-018-0303-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Research examining trends in the outpatient prescription medicine use of New Zealand children is limited. OBJECTIVES Our objective was to provide an overview of prescription medicine use in New Zealand children and assess changing patterns in use from 2010 to 2015. METHODS We conducted a retrospective cohort study including all New Zealand primary care-registered children aged < 18 years using data from the national pharmaceutical claims database. We calculated the prevalence of use within four age groups in each year by anatomical therapeutic class, therapeutic group and drug. Rate ratios were calculated to compare the prevalence of use in 2010 and 2015. RESULTS In total, 1,496,026 children with a mean of 2.7 years of potential drug exposure were included. The overall prevalence of drug use was 70% in 2010 and 73% in 2015. In 2015, medicine use was highest in children aged < 2 years (90%) and lowest in children aged 12-17 years (65%). Antibacterials, analgesics, topical corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs) and antihistamines were the most widely used medicines. The prevalence of use of systemic and topical antibiotics decreased by 2 and 10%, respectively, between 2010 and 2015, but there was increased use of analgesics (10%), NSAIDs (39%), antihistamines (15%) and antinausea and vertigo agents (306%). CONCLUSIONS Our findings indicate areas for further research focusing on inappropriate prescribing to children and safety issues in children's medicine use. Monitoring changing patterns of use over time is important for the evaluation of effective therapies in children and any potential harmful consequences of prescribing.
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Danielsson B, Webster WS, Ritchie HE. Ondansetron and teratogenicity in rats: Evidence for a mechanism mediated via embryonic hERG blockade. Reprod Toxicol 2018; 81:237-245. [PMID: 30149139 DOI: 10.1016/j.reprotox.2018.08.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 01/02/2023]
Abstract
The potent hERG channel blocking drug ondansetron is used off-label for treatment of nausea and vomiting in early pregnancy. Some human epidemiological studies have associated ondansetron with fetal cardiovascular defects and orofacial clefts. This study investigated the effects of ondanestron on embryonic heart rhythm of gestational day (GD) 13 rat embryos in vitro and then integrated the results with published animal teratology, and animal and human pharmacokinetic studies to perform a risk evaluation. Ondansetron caused concentration dependent bradycardia and arrhythmia. Cardiovascular malformations in rats occurred at exposures slightly higher than those in early human pregnancy. Together the results suggest that ondansetron can have teratogenic potential in rats and humans mediated via hERG block and severe heart rhythm disturbances in the embryo. The risk may be increased in human pregnancy if additional risk factors are present such as hypokalemia.
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Affiliation(s)
- B Danielsson
- Swedish National Board of Health and Welfare, Stockholm, Sweden.
| | - William S Webster
- Discipline of Anatomy and Histology, Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia.
| | - Helen E Ritchie
- Discipline of Biomedical Sciences, Sydney Medical School, The Unvieristy of Sydney, Sydney, NSW 2006, Australia.
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Hutchins LM, Temple JD, Hilmas E. Impact of Pharmacist Intervention on Electrocardiogram Monitoring of Pediatric Patients on Multiple QTc Interval-Prolonging Medications. J Pediatr Pharmacol Ther 2017; 22:399-405. [PMID: 29290739 DOI: 10.5863/1551-6776-22.6.399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine whether dedicated pharmacy services improve the rate of electrocardiogram (ECG) monitoring in patients at risk for medication-induced QTc interval prolongation. In addition, determine how pediatric institutions currently monitor patients at risk for medication-induced QTc interval prolongation. METHODS A pharmacist-driven monitoring protocol to detect medication-induced QTc interval prolongation was developed using published literature. If patients were prescribed 3 or more medications known to prolong the QTc interval, they were recommended to have a baseline ECG to assess the QTc interval. If 3 or more QTc interval-prolonging medications were administered for 5 or more days, a follow-up ECG was recommended. Patients prescribed medications known to prolong the QTc interval were identified. Prior to pharmacist intervention, electronic medical records were reviewed to determine if baseline and follow-up ECGs were obtained in patients meeting criteria for monitoring. A dedicated pharmacist then prospectively reviewed charts and recommended monitoring. The rate of monitoring during the intervention and baseline period was compared. To determine current practice at pediatric institutions, a survey was distributed to pharmacists. RESULTS Pharmacist intervention improved the rate of ECG monitoring in patients at risk for medication-induced QTc interval prolongation from 47.8% to 100% (p = 0.0009). Of the 55 survey participants, 6 stated their institution had QTc interval monitoring procedures in place, 35 did not have any, and 3 had procedures in process. CONCLUSIONS Targeted pharmacist intervention improved the rate of ECG monitoring in patients at risk for medication-induced prolonged QTc interval. Our research and survey data reveal that institutions could benefit from targeted pharmacist intervention to monitor patients for medication-induced QTc interval prolongation.
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Affiliation(s)
- Lisa M Hutchins
- Bloomberg Children's Center (LMH), Johns Hopkins Hospital, Baltimore, Maryland, Nemours/Alfred I. duPont Hospital for Children (JDT, EH), Wilmington, Delaware
| | - Joel D Temple
- Bloomberg Children's Center (LMH), Johns Hopkins Hospital, Baltimore, Maryland, Nemours/Alfred I. duPont Hospital for Children (JDT, EH), Wilmington, Delaware
| | - Elora Hilmas
- Bloomberg Children's Center (LMH), Johns Hopkins Hospital, Baltimore, Maryland, Nemours/Alfred I. duPont Hospital for Children (JDT, EH), Wilmington, Delaware
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Hoffman RJ, Alansari K. Effect of intravenous ondansetron on QTc interval in children with gastroenteritis. Am J Emerg Med 2017; 36:754-757. [PMID: 29029798 DOI: 10.1016/j.ajem.2017.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND The potential for ondansetron to cause QT prolongation and fatal dysrhythmia is well-reported, including a 2011 FDA report on the topic. Few clinical trials evaluating this phenomenon in the ED setting exist, and only one is pediatric. OBJECTIVE We have sought to determine the effect of a standardized dose of intravenous ondansetron on the QTc duration of children under 14years of age treated for gastroenteritis-associated vomiting in a pediatric ED. This study is modeled closely after an FDA "thorough QT study". METHODS EGCs were obtained before and 15, 30, 45, and 60min after a 0.15mg/kg IV dose of ondansetron given for gastroenteritis-associated vomiting. QT intervals were measured manually with digital calipers, and the QTc interval calculated both by Bazett's (QTcB) and Fridericia's (QTcF) correction. A paired t-test comparing QTc was conducted, and frequency of categorical outcomes of prolongation>30msec, >60 msec, and absolute prolongation >450 msec, >480 msec, and >500msec were evaluated. RESULTS In a 4-month period, 134 patients were included in the study, 46% were male. The average QTc prior to ondansetron administration was: QTcB 415 msec (95% CI 343-565) and QTcF 373 (95% CI 304-499). The mean difference in QTc after ondansetron was 0.4msec for QTcB (95% CI -35-45msec) and 0.1msec for QTcF (95% CI -40-18msec). CONCLUSION In these children, 0.15mg/kg of intravenous ondansetron did not cause prolongation of QTcB or QTcF measured 15min after administration, nor at later times.
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Affiliation(s)
- Robert J Hoffman
- Sidra Medical and Research Center, Department of Emergency Medicine, PO Box 26999, Doha, Qatar
| | - Khalid Alansari
- Sidra Medical and Research Center, Department of Emergency Medicine, PO Box 26999, Doha, Qatar; Hamad General Hospital, Department of Pediatrics, PO Box 3050, Doha, Qatar.
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