Safety of prolonged magnesium sulfate infusions during treatment for severe pediatric status asthmaticus

OBJECTIVE

Magnesium sulfate (Mg) is one of several "second-tier" therapies for treating severe status asthmaticus. Pediatric reports primarily describe bolus use with limited data regarding prolonged infusions. We sought to describe the safety of prolonged Mg infusions during therapy of status asthmaticus in critically ill children.

DESIGN

Single center, retrospective study.

SETTING

Thirty-four-bed tertiary level medical/surgical/cardiac surgical pediatric intensive care unit.

PATIENTS

Pediatric patients 2 to 18 years of age admitted with status asthmaticus receiving Mg infusion for more than 24 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN FINDINGS

A total of 154 children received Mg infusions for a median of 53.4 hours (interquartile range = 36.6-74.8). The most common adverse event (AE) was hypotension (48.1%), almost exclusively diastolic (94%), and was mostly limited to 1 blood pressure measurement (78%). 2.9% of events required intervention (fluids, decrease Mg infusion). Other AEs included nausea/emesis (22.7%), transient weakness (14.9%), and flushing (6.5%). Five patients experienced serious AEs including hypotonia (n = 1), escalation to continuous or bilevel positive airway pressure (n = 3), and sedation (n = 1), all attributed to progression of underlying medical disease. No patient required endotracheal intubation. Supratherapeutic levels (>6 mg/dL) were uncommon (2%) and were not more likely to be associated with AEs. Most (81%) patients were therapeutic by the 2nd Mg level check.

CONCLUSION

Prolonged Mg infusions were well tolerated in pediatric status asthmaticus patients. While diastolic hypotension was not uncommon, rarely were interventions deemed necessary. No serious AEs were attributed to Mg. Toxicity was uncommon suggesting that Mg levels could potentially be checked less frequently than historically reported.

Concussion Management in the Classroom

There is a new emphasis on the team approach to pediatric concussion management, particularly in the classroom. However, it is expected that educators are unfamiliar with the "Returning to Learning" recommendations. The authors' primary objective was to assess and improve high school educators' knowledge regarding concussions and management interventions using an online education tool. A total of 247 high school educators completed a 12 question pretest to assess core knowledge of concussions and classroom management followed by a 20-minute online literature-based education module. Participants then completed an identical posttest. The improvement in core knowledge was statistically significant (P < .001). Initial areas of weakness were the description and identification of concussions. Questions regarding concussion classroom management also showed a statistically significant increase in scores (P < .001). This study identifies the deficits in the knowledge of educators regarding concussions and classroom management as well as the significant improvement after an online educational module.

Case Report of Methemoglobinemia in a Toddler Secondary to Topical Dapsone Exposure

Aczone gel 5% contains dapsone and is a commonly used topical dermatologic therapy for acne in adolescents and adults. We describe the first reported pediatric case of a previously healthy girl presenting with acute onset of methemoglobinemia after exposure to her sibling's Aczone gel. The patient was successfully treated with methylene blue initially and subsequently needed an additional dose for rebound methemoglobinemia. This case demonstrates the complications of systemic absorption of dapsone in the pediatric population resulting in clinically significant methemoglobinemia from a single topical application.

Cardiac tamponade from central venous catheters

BACKGROUND

This retrospective study was undertaken to determine the mechanism by which cardiac tamponade (CT) occurs after placement of central venous catheters (CVC), and to determine if physicians are aware of this potentially lethal complication.

MATERIALS AND METHODS

Twenty-five previously unreported cases of CT from CVC were reviewed. The chest radiographs and postmortem records were reviewed when available. Two hundred physicians were interviewed about their knowledge of CT from CVC. They were specifically asked if they had reviewed the three-volume video, "CVC Complications," that was sent by the Food and Drug Administration to all hospitals where CVC are inserted.

RESULTS

All postinsertion chest radiographs showed the tip of the catheter to be within the pericardial silhouette. All patients developed unexplained hypotension from hours to 1 week after CVC placement. Eight patients complained of chest tightness, 12 of shortness of breath, and 15 were noted to have air hunger. The electrocardiogram showed inferior wall injury in 7 patients. None of the physicians surveyed had seen the FDA video.

CONCLUSIONS

Cardiac tamponade from central venous catheters is preventable if the tip of the catheter is outside the cardiac silhouette on chest radiograph. Any patient with a CVC in place who develops unexplained hypotension, chest tightness, or shortness of breath should have an emergency echocardiogram to rule out cardiac tamponade.