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Johnson PN, Parman A, Miller JL. Training the next generation of peer reviewers: Steps for guiding pharmacy learners through the peer review process. Am J Health Syst Pharm 2024; 81:e137-e140. [PMID: 37946575 DOI: 10.1093/ajhp/zxad277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Avery Parman
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Casten M, Miller JL, Neely SB, Harkin M, Johnson PN. Variability in opioid conversion calculators in critically ill children transitioned from fentanyl to hydromorphone. Am J Health Syst Pharm 2024; 81:153-158. [PMID: 37880811 DOI: 10.1093/ajhp/zxad270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 10/27/2023] Open
Abstract
PURPOSE Opioid conversion calculators (OCCs) are used to convert between opioids. The purpose of this study was to describe the variability in OCC results in critically ill children transitioned from fentanyl to hydromorphone infusions. METHODS This was a descriptive, retrospective study. Seventeen OCCs were identified and grouped into 6 groups (groups 1-6) based on the equianalgesic conversions. The OCCs were used to calculate the hydromorphone rate in critically ill children (<18 years) converted from fentanyl to hydromorphone. Information from a previous study on children stabilized on hydromorphone (defined as the first 24-hour period with no change in the hydromorphone rates, <3 hydromorphone boluses administered, and 80% of State Behavior Scale scores between 0 and -1) were utilized. The primary objective was to compare the median hydromorphone rates calculated using the 17 OCCs. The secondary objective was to compare the percent variability of the OCC-calculated hydromorphone rates to the stabilization rate. RESULTS Seventeen OCCs were applied to data on 28 children with a median age and hydromorphone rate of 2.4 years and 0.08 mg/kg/h, respectively. The median hydromorphone rate calculated using the 17 OCCs ranged from 0.06 to 0.12 mg/kg/h. Group 3 and group 6 OCCs resulted in a calculated hydromorphone rate that was higher than the stabilization rate in 96% and 75% of patients, respectively. Use of group 4 and group 5 OCCs resulted in a calculated hydromorphone rate that was lower than the stabilization rate in 64% and 75% of patients, respectively. CONCLUSION Given the considerable variability of OCCs, caution should be used when applying OCCs to critically ill children.
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Affiliation(s)
- Madison Casten
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Stephen B Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Maura Harkin
- Oklahoma Children's Hospital at OU Health, Oklahoma City, OK, USA
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Bradford CV, Parman AM, Johnson PN, Miller JL. Pharmacologic Management of Sialorrhea in Neonatal and Pediatric Patients. J Pediatr Pharmacol Ther 2024; 29:6-21. [PMID: 38332959 PMCID: PMC10849690 DOI: 10.5863/1551-6776-29.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/10/2023] [Indexed: 02/10/2024]
Abstract
Sialorrhea, defined as an excess flow of saliva or excessive secretions, is common in patients with cerebral palsy and other neurologic disorders and is associated with clinical complications such as increased risk of local skin reactions, infections, aspiration, pneumonia, and dehydration. Upon failure of non-pharmacologic measures, clinicians have several noninvasive pharmacologic options available to manage sialorrhea. This review of the literature provides detailed descriptions of medications used, efficacy, safety, and practical considerations for use of non-injectable pharmacologic agents. The literature search included published -human studies in the English language in PubMed and Google Scholar from 1997 to 2022. Relevant citations within articles were also screened. A total of 15 studies representing 719 pediatric patients were included. Glycopyrrolate, atropine, scopolamine, and trihexyphenidyl all have a potential role for sialorrhea management in children; however, glycopyrrolate remains the most studied option with 374 (n = 52.0%) of the 719 patients included in the systematic review receiving this medication. Overall, glycopyrrolate showed similar efficacy but higher tolerability than its comparators in 2 comparative studies and is often considered the first-line agent. Patient-specific (age, route of administration) and medication-specific (dosage formulation, medication strength) considerations must be weighed when initiating a new therapy or switching to another medication upon treatment failure. Owing to the high propensity of adverse events with all agents, clinicians should consider initiating doses at the lower end of the dosage range, as previous studies have noted a dose-dependent relationship.
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Affiliation(s)
- Caitlyn V. Bradford
- Department of Pharmacy Practice (CVB), Philadelphia College of Pharmacy at Saint Joseph’s University, Philadelphia, PA
| | - Avery M. Parman
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Jamie L. Miller
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
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Bradford C, Miller JL, Harkin M, Chaaban H, Neely SB, Johnson PN. Melatonin Use in Infants Admitted to Intensive Care Units. J Pediatr Pharmacol Ther 2023; 28:635-642. [PMID: 38025149 PMCID: PMC10681084 DOI: 10.5863/1551-6776-28.7.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 03/04/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVES Sleep deprivation is a risk factor for delirium development, which is a frequent complication of intensive care unit admission. Melatonin has been used for both delirium prevention and treatment. Melatonin safety, efficacy, and dosing information in neonates and infants is lacking. The purpose of this study was to describe melatonin use in infants regarding indication, dosing, efficacy, and safety. METHODS This descriptive, retrospective study included infants <12 months of age admitted to an intensive care unit receiving melatonin. Data collection included demographics, melatonin regimen, sedative and analgesic agents, antipsychotics, and delirium-causing medications. The primary objective was to identify the melatonin indication and median dose. The secondary objectives included change in delirium, pain, and sedation scores; change in dosing of analgesic and sedative agents; and adverse event identification. Wilcoxon signed rank tests and linear mixed models were employed with significance defined at p < 0.05. RESULTS Fifty-five patients were included, with a median age of 5.5 months (IQR, 3.9-8.2). Most (n = 29; 52.7%) received melatonin for sleep promotion. The median body weight-based dose was 0.31 mg/kg/dose (IQR, 0.20-0.45). There was a statistical reduction in cumulative morphine equivalent dosing 72 hours after melatonin administration versus before, 17.1 versus 21.4 mg/kg (p = 0.049). No adverse events were noted. CONCLUSIONS Most patients (n = 29; 52.7%) received melatonin for sleep promotion at a median dose was 0.31 mg/kg/dose. Initiation of melatonin was associated with a reduction of opioid exposure; however, there was no reduction in pain/sedation scores.
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Affiliation(s)
- Caitlyn Bradford
- Department of Pharmacy Practice (CB), Philadelphia College of Pharmacy, Saint Joseph’s University, Philadelphia, PA
| | - Jamie L. Miller
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Maura Harkin
- Department of Pharmacy (MH), Oklahoma Children’s Hospital at OU Health, Oklahoma City, OK
| | - Hala Chaaban
- Department of Pediatrics (HC), College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Stephen B. Neely
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Bradford CV, Fung MY, Wang A, Benefield EC, Bashqoy F, Neely SB, Johnson PN. Delirium Assessment Treatment Strategies in Critically Ill Pediatric Patients: A Pediatric Pharmacy Association Practice-Based Research Network Survey Study. J Pediatr Pharmacol Ther 2023; 28:540-552. [PMID: 38130349 PMCID: PMC10731945 DOI: 10.5863/1551-6776-28.6.540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES The purpose of this study was to describe overall screening, prevention, and treatments for pediatric delirium at various neonatal intensive care units (NICUs), cardiac intensive care units (CICUs), and pediatric intensive care units (PICUs) from the Pediatric Pharmacy Association (PPA) membership. The primary objective was to identify the number of respondents that had a defined delirium-based protocol. The secondary objectives included identification of delirium assessment tools used, first- and second-line delirium treatment options, and monitoring practices for antipsychotics for delirium management. METHODS A cross-sectional questionnaire was distributed to PPA members from February 8, 2022, to March, 25, 2022. Comparisons between the NICUs, PICUs, and CICUs were conducted by using chi-square tests, with a priori p value of <0.05. RESULTS The questionnaire was completed by 84 respondents at 62 institutions; respondents practiced in the PICU or mixed PICU (n = 48; 57.1%), CICU (n = 13; 15.5%), and NICU (n = 23; 27.4%). Sixty-one respondents (72.6%) noted their units routinely screen for delirium, and there was a significant difference between the respondents of different units that use a delirium scoring tool (p < 0.01). Only 33 respondents (39.3%) had a defined delirium protocol, and there was no difference between units (p = 0.31). The most common agents used for delirium treatment were quetiapine and risperidone. There was variability in the monitoring used between respondents, but the majority (n = 74; 88%) monitor electrocardiograms to assess the corrected QT interval, but practice variability existed. CONCLUSIONS Most respondents did not have a defined delirium protocol. Variations were noted in the treatment options and monitoring for critically ill pediatric patients with delirium.
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Affiliation(s)
- Caitlyn V. Bradford
- Department of Pharmacy Practice (CVB), Philadelphia College of Pharmacy, Saint Joseph’s University, Philadelphia, PA
| | - Mon-Yee Fung
- Department of Pharmacy (M-YF), University of Michigan MOTT Children’s Hospital, Ann Arbor, MI
| | - Alexander Wang
- Department of Pharmacy (AW), Children’s National Hospital, Washington, DC
| | | | - Ferras Bashqoy
- Department of Pharmacy (FB), Hassenfeld Children’s Hospital at NYU Langone Health, New York City, NY
| | - Stephen B. Neely
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Stephens K, Miller JL, Harkin M, Neely SB, Haws L, Johnson PN. Effect of Phytonadione on Correction of Coagulopathy in Pediatric Patients With Septic Shock. J Pediatr Pharmacol Ther 2023; 28:423-429. [PMID: 38130503 PMCID: PMC10731929 DOI: 10.5863/1551-6776-28.5.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 09/13/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate phytonadione in children with septic shock with disseminated intravascular coagulopathy (DIC). The primary objective was to identify the number of patients with an international normalized ratio (INR), defined as ≤1.2, following phytonadione. Secondary objectives were to compare patients who achieved a normalized INR versus those with INR >1.2 and to determine factors associated with a normalized INR. METHODS A retrospective study of children <18 years of age receiving phytonadione from October 1, 2013, to August 31, 2020, with a diagnosis of septic shock, were included. Data collection included demographics, phytonadione regimen, INR values, Pediatric Index of Mortality 2 (PIM2) and Pediatric Risk of Mortality III (PRISM III) scores, fresh frozen plasma (FFP) and cryoprecipitate use. A logistic regression model and generalized linear model were used to explore factors associated with a normalized INR and evaluate phytonadione dosing. RESULTS Data for initial phytonadione course for 156 patients were evaluated. Sixty-six (42.3%) patients had a normalized INR. Most patients (n = 145; 92.9%) received ≤3 phytonadione doses, with the largest reduction in INR occurring after the second dose. In the logistic regression model, baseline INR, FFP, cryoprecipitate, vasopressors, PIM2, PRISM III, or cumulative phytonadione dose were not associated with achieving a normalized INR. CONCLUSIONS Less than half of patients achieved a normalized INR. The median cumulative dose of phytonadione and receipt of FFP or cryoprecipitate was not associated with an increased odds of a normalized INR. Future studies are needed to further explore phytonadione use in children with sepsis-induced coagulopathy.
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Affiliation(s)
- Katy Stephens
- Department of Pharmacy (KS, MH), Oklahoma Children’s Hospital at OU Health, Oklahoma City, OK
| | - Jamie L. Miller
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Maura Harkin
- Department of Pharmacy (KS, MH), Oklahoma Children’s Hospital at OU Health, Oklahoma City, OK
| | - Stephen B. Neely
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Laura Haws
- Department of Pediatrics (LH), College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (JLM, SBN, PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Flanagan T, Mercer K, Johnson PN, Miller J, Yousaf FS, Fuller JA. Ketamine Use in Adult and Pediatric Patients Receiving Extracorporeal Membrane Oxygenation (ECMO): A Systematic Review. J Pharm Pract 2023:8971900231198928. [PMID: 37670605 DOI: 10.1177/08971900231198928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Background: Analgesia and sedation are often critical elements of therapy for patients undergoing extracorporeal membrane oxygenation (ECMO). Aside from potential drug-drug interactions, the PK changes associated with ECMO make appropriate analgosedative selection challenging. Ketamine is less lipophilic and has lower protein binding than alternative agents, and may be less impacted by the PK changes during ECMO. Objective: To systematically identify all instances of ketamine use during ECMO support in the literature to elucidate associated efficacy and safety outcomes and prevalence of use, as well as commonly used dosing strategies and pharmacokinetic data. Methods: Web of Science, Cochrane Library, Scopus, Ovid MEDLINE, PubMed, and OVID Embase were searched through 02/2023 using keywords ketamine and ECMO or extracorporal life support (ECLS). Case reports, case series, and studies were included that had (1) original data, (2) included patients that were on ECMO and continuous infusion ketamine, and (3) reported pertinent ketamine related clinical endpoints or prevalence of use. Results: Of the 307 articles screened, 25 were identified as relevant and 11 met our inclusion criteria. Heterogeneity of patient population, ketamine indication, reported outcomes, and reported safety endpoints were identified in the included articles. Commonly reported information includes indications, pharmacokinetics, dosing, adverse effects and use in pediatrics for ketamine, and suspected opioid sparing effect. Conclusion: Our review has found a lack of consistency in reporting and results in adult and pediatric patients. Increased consistency in reporting and larger studies are required to increase our knowledge of ketamine use in both the adult and pediatric patient population.
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Affiliation(s)
- Trenton Flanagan
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Kevin Mercer
- Department of Pharmacy, Memorial Hermann-Texas West Hospital, Houston, TX, USA
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie Miller
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | | | - Jordan A Fuller
- Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, The University of Oklahoma Health Science Center, Oklahoma City, OK, USA
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Chang E, Johnson PN, Medina MS, Dennis VC, Neely SB, Miller JL. Sculpting a teaching and learning curriculum to better meet the career needs of postgraduate year 1 and 2 pharmacy residents. Am J Health Syst Pharm 2023:7086910. [DOI: 10.1093/ajhp/zxad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Abstract
Disclaimer
In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Purpose
To describe implementation of the University of Oklahoma College of Pharmacy (OUCOP) teaching and learning curriculum (TLC) for postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) residents, including the required components, evaluation structure, residency graduate outcomes and perceptions captured by a survey following program completion, generalizability to other institutions, and opportunities for future directions.
Summary
As part of their residency training, pharmacy residents are required to develop and refine teaching, precepting, and presentation skills. To meet the required and elective competency areas, goals, and objectives on teaching, precepting, and presentation skills, many American Society of Health-System Pharmacists–accredited residency programs have utilized TLC programs. OUCOP offers 2 distinct TLC programs based on whether residents are a PGY1 or PGY2 resident.
Conclusion
The OUCOP TLC program provided residents with opportunities for development of teaching and presentation skills in a variety of settings. The majority of residency graduates currently practice as a clinical specialist, and the majority lecture, precept, and deliver continuing education presentations. Graduates felt that the mentorship and diversity of teaching activities were the most beneficial qualities of the program. In addition, the majority noted that mentorship in lecture preparation was helpful in creating presentations after graduation. On the basis of the feedback from the survey, several changes have been made to better prepare residents for their postgraduate careers. TLC programs should conduct ongoing assessments to continue to foster the development of precepting and teaching skills for residents’ future careers.
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Bradford CV, Miller JL, Ranallo CD, Neely SB, Johnson PN. Vasopressin-Induced Hyponatremia in Infants Following Cardiovascular Surgery. Ann Pharmacother 2023; 57:259-266. [PMID: 35713009 DOI: 10.1177/10600280221103576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Vasopressin is increasingly used in infants following cardiac surgery. Hyponatremia is a noted adverse event, but incidence and risk factors remain undefined. OBJECTIVE The primary objective was to identify the incidence of vasopressin-induced hyponatremia. Secondary objectives included comparing baseline and change in serum sodium concentrations between infants receiving vasopressin with and without hyponatremia, and comparing vasopressin dose, duration, and clinical characteristics in those with and without hyponatremia. METHODS This Institutional Review Board-approved, retrospective case-control study included infants <6 months following cardiac surgery receiving vasopressin for ≥6 hours at a tertiary care, academic hospital. Patients who developed hyponatremia, cases, were matched to controls in a 1:2 fashion. Demographics and clinical characteristics were collected. Descriptive and inferential statistics were employed. A conditional logistic regression was used to assess odds of hyponatremia. RESULTS Of the included 142 infants, 20 (14.1%) developed hyponatremia and were matched with 40 controls. There was significant difference in median nadir between controls and cases, 142.0 versus 128.5 mEq/L (<0.001). A significantly higher number of cases received corticosteroids, loop diuretics, and chlorothiazide versus controls. The regression analysis demonstrated that each additional hour of vasopressin increased the odds of developing hyponatremia by 5% (adjusted odds ratio 1.05 [confidence interval 1-1.1]). CONCLUSIONS AND RELEVANCE Vasopressin-induced hyponatremia incidence was <15%. Vasopressin duration was independently associated with hyponatremia development.
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Affiliation(s)
- Caitlyn V Bradford
- PGY2 Pediatric Pharmacy Resident, The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Courtney D Ranallo
- Department of Pediatrics, The University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Stephen B Neely
- Dean's Office, The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Chang E, Ballard KE, Johnson PN, Nandyal R, Miller JL. Azithromycin for Eradication of Ureaplasma and Prevention of Bronchopulmonary Dysplasia in Preterm Neonates in the Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2023; 28:10-19. [PMID: 36777984 PMCID: PMC9901312 DOI: 10.5863/1551-6776-28.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023]
Abstract
Azithromycin has been explored as a treatment option for eradication of Ureaplasma and prevention of bronchopulmonary dysplasia (BPD) in preterm neonates. However, there is debate about the need for eradication of Ureaplasma and whether azithromycin is safe and efficacious for this indication. This literature review provides an overview of the evidence for use of azithromycin for eradication of Ureaplasma and prevention of BPD, including dosing and duration of azithromycin used in these studies. The literature search included articles published in the English language in Medline and PubMed from 1946 to January 2022. Relevant citations within identified articles were also reviewed. A total of 9 studies representing 388 neonates were included. The percentage of neonates that tested positive for Ureaplasma in these studies ranged from 18.6% to 57.1%. Azithromycin was initiated at <3 days of life in 8 studies (88.9%). Dosing was variable and ranged from 5 to 20 mg/kg/dose administered once daily, and the duration of treatment ranged from 1 to 35 days. Most studies used intravenous azithromycin. Overall, azithromycin was more efficacious than placebo at Ureaplasma eradication; however, most of these studies did not find a difference in the incidence of BPD between patients receiving azithromycin versus placebo. No adverse effects, specifically pyloric stenosis or QT interval prolongation, were noted in these studies.
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Affiliation(s)
- Eugenie Chang
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Kaci E Ballard
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Raja Nandyal
- Section of Neonatology (RN), Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences (EC, KEB, PNJ, JLM), University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
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Hintze TD, Miller JL, Neely SB, Lim SY, Gupta N, Johnson PN. Characterization of early versus late opioid iatrogenic withdrawal syndrome in critically ill children transitioning from fentanyl -infusions to methadone. J Opioid Manag 2023; 19:43-56. [PMID: 36683300 DOI: 10.5055/jom.2023.0758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Methadone is used to prevent opioid iatrogenic withdrawal syndrome (IWS) in children, but the optimal dose and overlap time with an opioid infusion have not been elucidated. The purpose was to compare clinical manifestations among patients who developed opioid IWS within 24 hours (early) versus ≥24 hours (late) of fentanyl discontinuation when enteral methadone was initiated. DESIGN A retrospective, descriptive study. SETTING Pediatric and cardiovascular intensive care units at a tertiary care health system. PARTICIPANTS Sixty-seven children received fentanyl infusions for ≥3 days and initiated on methadone prior to fentanyl discontinuation. MAIN OUTCOME MEASURES The primary objective was to compare clinical characteristics between those with early versus late opioid IWS. Opioid IWS was defined as a Withdrawal Assessment Tool-1 score ≥3 within 5 days of fentanyl discontinuation. Secondary objectives included a comparison of time to IWS, clinical characteristics, and risk factors among patients with and without IWS. RESULTS Fifty children (74.6 percent) developed opioid IWS within a median time of 3.5 hours. No differences were noted for those with and without IWS. Thirty-seven patients (74.0 percent) with IWS developed early IWS. A higher percentage of males in the late versus early group developed IWS, 100 percent versus 51.4 percent, p = 0.002. The median overlap time with methadone and fentanyl was shorter in the early versus late IWS group without reaching statistical significance, 27.5 versus 64.0 hours, p = 0.127. CONCLUSIONS The majority developed opioid IWS, with most developing early IWS, despite methadone initiation. Future studies should evaluate the optimal methadone dosing and overlap time to prevent opioid IWS.
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Affiliation(s)
- Trager D Hintze
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, Kingsville, Texas
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Ok-lahoma College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Stephen B Neely
- Department of Pharmacy: Clinical and Administrative Sciences, The University of Oklahoma College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Sin Yin Lim
- Pharmacy Practice Division, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin
| | - Neha Gupta
- Department of Pediatrics, Division of Critical Care, University of Oklahoma Health Sciences Center, Okla-homa City, Oklahoma
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. ORCID: https://orcid.org/0000-0003-3022-4403
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Schwier NC, Stephens K, Johnson PN. Management of Idiopathic Viral Pericarditis in the Pediatric Population. J Pediatr Pharmacol Ther 2022; 27:595-608. [DOI: 10.5863/1551-6776-27.7.595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/06/2022] [Indexed: 11/11/2022]
Abstract
Idiopathic (viral) pericarditis (IP) is one of the most common etiologies of acute and recurrent pericarditis in children. IP is associated with significant morbidity, and recurrence rates of IP are high and require treatment to decrease risk of recurrence and pericarditis-related chest pain. Despite significant morbidity, sparse guidance exists to comprehensively address management of IP in children. The purpose of this review is to provide an overview of the pharmacotherapy of IP in children, including clinical pearls for managing pediatric patients. Clinicians should consider using the combination of colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy, in order to reduce the risk of recurrence and foster symptom improvement in IP. Colchicine dosing may vary depending on patient age, weight, concomitant pharmacotherapies, and disease states. Choice of NSAID should be based on cost, tolerability, and adverse drug events (ADEs). Children should receive higher NSAID attack dosing for >1 week to ensure a reduction in high sensitivity C-reactive protein concentrations and symptom relief. Corticosteroids should be considered last-line for treatment of IP in children, because they increase the risk of recurrence. Immunotherapies may be considered for children with multiple recurrences related to IP despite the use of NSAIDs, colchicine, and/or corticosteroids. Similar to adults, diligent monitoring should be implemented, to prevent drug-drug interactions, drug-disease interactions, and/or ADEs in children.
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Affiliation(s)
- Nicholas C. Schwier
- Department of Pharmacy Practice and the Office of Experiential Education (NCS), School of Pharmacy and Pharmaceutical Sciences, SUNY Binghamton, Johnson City, NY
| | - Katy Stephens
- Department of Pharmacy (KS), Oklahoma Children's Hospital at OU Health, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences (PNJ), College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Harkin M, Johnson PN, Neely SB, White L, Miller JL. Frequency and Severity of Chlorothiazide-Induced Hyponatremia in the Neonatal Intensive Care Unit. Am J Perinatol 2022; 39:1354-1361. [PMID: 33406536 DOI: 10.1055/s-0040-1722598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Although thiazide diuretics are commonly used in the neonatal intensive care unit (NICU), the risk of thiazide-induced hyponatremia in infants has not been well documented. The primary objective of this study was to determine the frequency and severity of hyponatremia in neonates and infants receiving enteral chlorothiazide. Secondary objectives included identifying: (1) percent change in serum sodium from before chlorothiazide initiation to nadir, (2) time to reach nadir serum sodium concentration, and (3) percentage of patients on chlorothiazide receiving sodium supplementation. STUDY DESIGN This was a retrospective cohort study of NICU patients admitted between July 1, 2014, and July 31, 2019, who received ≥1 dose of enteral chlorothiazide. Mild, moderate, and severe hyponatremia were defined as serum sodium of 130 to 134 mEq/L, 120 to 129 mEq/L, and less than 120 mEq/L, respectively. Data including serum electrolytes, chlorothiazide dosing, and sodium supplementation were collected for the first 2 weeks of therapy. Descriptive and inferential statistics were performed in SAS software, Version 9.4. RESULTS One hundred and seven patients, receiving 127 chlorothiazide courses, were included. The median gestational age at birth and postmenstrual age at initiation were 26.0 and 35.9 weeks, respectively. The overall frequency of hyponatremia was 35.4% (45/127 courses). Mild, moderate, and severe hyponatremia were reported in 27 (21.3%), 16 (12.6%), and 2 (1.6%) courses. The median percent decrease in serum sodium from baseline to nadir was 2.9%, and the median time to nadir sodium was 5 days. Enteral sodium supplements were administered in 52 (40.9%) courses. Sixteen courses (12.6%) were discontinued within the first 14 days of therapy due to hyponatremia. CONCLUSION Hyponatremia occurred in over 35% of courses of enteral chlorothiazide in neonates and infants. Given the high frequency of hyponatremia, serum sodium should be monitored closely in infants receiving chlorothiazide. Providers should consider early initiation of sodium supplements if warranted. KEY POINTS · One-third of infants on chlorothiazide develop hyponatremia.. · Nadir serum sodium typically occurs within 5 days.. · Monitor sodium closely after chlorothiazide initiation..
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Affiliation(s)
- Maura Harkin
- Department of Pharmacy, The Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Peter N Johnson
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Stephen B Neely
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Lauren White
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jamie L Miller
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
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Bennett KK, Fox AN, Miller JL, Neely S, Dennis VC, Johnson PN. Publication rates of pharmacy residents involved in a team-based research program. Am J Health Syst Pharm 2022; 79:2141-2149. [PMID: 35979934 DOI: 10.1093/ajhp/zxac233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The University of Oklahoma College of Pharmacy (OUCOP) implemented an individualized residency research committee and skill development program to facilitate completion and publication of research projects. The purpose of this study was to evaluate the outcomes the program had on project publication rates and subsequent publications after graduation for postgraduate year 1 (PGY1) and postgraduate year 2 (PGY2) residents. METHODS This study included OUCOP PGY1 and PGY2 residents from classes graduating from 2011 through 2019. Literature searches for all resident projects and subsequent publications were performed. Data collection included residency type (PGY1 vs PGY2), initial position after residency, and project type. The primary objective was to identify the publication rate of research projects. Secondary objectives included a comparison of the number of publications after residency graduation between residents who did and did not publish their residency project and analysis of factors associated with subsequent publications. Zero-inflated Poisson regression was utilized to analyze subsequent publication status controlling for other factors. Statistical analyses were performed using SAS/STAT with an a priori P value of <0.05. RESULTS Eighty-two projects were completed by 73 residents. Forty-three of 82 projects were published (52.4%) by 39 of 73 residents (52.1%). After residency graduation, 54 residents (74.0%) had a subsequent publication. Factors associated with subsequent publications were initial position in an academic role and completion of additional training after residency. CONCLUSION After implementation of the program, the majority of residents published their projects and had subsequent publications. Future efforts should be taken to identify opportunities to foster independence in research and scholarship for residents.
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Affiliation(s)
- Kiya K Bennett
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | | | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Stephen Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Vincent C Dennis
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Mayes RA, Johnson PN, White BP, Neely SB, Chaaban H, Miller JL. Impact of Ceftazidime Use on Susceptibility Patterns in a Neonatal Intensive Care Unit: A 7.5-year Evaluation. J Pediatric Infect Dis Soc 2022; 11:349-350. [PMID: 35390154 DOI: 10.1093/jpids/piac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/15/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Rebecca A Mayes
- Department of Pharmacy, OU Health, Oklahoma City, Oklahoma, USA
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, USA
| | - Bryan P White
- Department of Pharmacy, OU Health, Oklahoma City, Oklahoma, USA
| | - Stephen B Neely
- Department of Pharmacy, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, USA
| | - Hala Chaaban
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, USA
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Mayes RA, Johnson PN, White BP, Neely SB, Chaaban H, Miller JL. Evaluation of Ceftazidime Use in the Neonatal Intensive Care Unit and Association With Cephalosporin-Resistant Gram-Negative Bacteria. Ann Pharmacother 2022; 56:1325-1332. [PMID: 35484966 DOI: 10.1177/10600280221088270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Cefotaxime shortage in 2015 led to increased ceftazidime use in the neonatal intensive care unit (NICU). OBJECTIVE The purpose was to explore whether ceftazidime increases risk for development of resistant gram-negative organisms. METHODS Retrospective evaluation of NICU patients with cultures positive for Escherichia coli, Pseudomonas aeruginosa, Klebsiella species, or Stenotrophomonas maltophilia between January1, 2015 and August 31, 2020. Isolates were excluded if obtained from same patient and source within 90 days or if patient ≤7 days of life or admitted from a referring hospital. Data collection included demographics and clinical parameters, and culture/susceptibility data. The primary objective was comparison of pathogens and clinical parameters in those with and without third-generation cephalosporin resistance. The secondary objectives included a comparison between those with and without ceftazidime exposure and identification of factors associated with resistance. Comparisons were made using χ2, Fisher exact tests, or Wilcoxon tests. A logistic regression was used to identify risk factors for resistance. RESULTS Overall, 349 isolates, representing 215 patients, were included. The most common source was endotracheal (n = 192, 55.0%) and pathogens were E coli (31.8%) and P aeruginosa (29.2%). Overall, 12.3% (n = 43) were resistant and these were obtained after longer parenteral nutrition (PN), central line access, and antibiotic days versus susceptible isolates. Higher resistance was noted after ceftazidime exposure versus no exposure, 19.1% versus 6.6%. Each day of ceftazidime was associated with 13% greater odds of P aeruginosa resistance (adjusted odds ratio: 1.13 [95% confidence interval: 1.03-1.23]). CONCLUSION AND RELEVANCE Ceftazidime duration was associated with increased risk for P aeruginosa resistance. Additional studies are needed to confirm these findings.
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Affiliation(s)
- Rebecca A Mayes
- PGY2 Critical Care Pharmacy Resident, Department of Pharmacy, OU Health, Oklahoma City, OK, USA
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Bryan P White
- Department of Pharmacy, OU Health, Oklahoma City, OK, USA
| | - Stephen B Neely
- Department of Pharmacy, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Hala Chaaban
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Bobo KS, Cober MP, Eiland LS, Heigham M, King M, Johnson PN, Miller JL, Sierra CM. Correction to: Key articles and guidelines for the pediatric clinical pharmacist from 2019 and 2020. Am J Health Syst Pharm 2022; 79:823. [PMID: 35451011 DOI: 10.1093/ajhp/zxac088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kelly S Bobo
- Le Bonheur Children's Hospital, Memphis, TN, USA
| | - M Petrea Cober
- Akron Children's Hospital, Akron, OH, and Northeast Ohio Medical University, Rootstown, OH, USA
| | - Lea S Eiland
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | | | - Morgan King
- Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022; 23:e74-e110. [PMID: 35119438 DOI: 10.1097/pcc.0000000000002873] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.
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Affiliation(s)
- Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - James B Besunder
- Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH
- Department of Pediatrics, Northeast Ohio Medical University, Akron, OH
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK
- The Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne Stormorken
- Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Elizabeth Farrington
- Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Aaron J Godshall
- Department of Pediatrics, AdventHealth For Children, Orlando, FL
| | - Larkin Acinelli
- Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Christina Almgren
- Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA
| | | | - Jenny M Boyd
- Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC
- Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Cisco
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Mihaela Damian
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L deAlmeida
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA
- Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA
| | - James Fehr
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
- Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
| | | | - Frances Gilliland
- Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL
- College of Nursing, University of South Florida, Tampa, FL
| | - Mary Jo C Grant
- Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT
| | - Joy Howell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Shari Simone
- University of Maryland School of Nursing, Baltimore, MD
- Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD
| | - Felice Su
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Janice E Sullivan
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Stacey Williams
- Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
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Frazier CA, Scott BM, Johnson PN, LaRochelle JM. Antimicrobial Prophylaxis and Anticoagulation Therapy in Pediatric ECMO: A Survey Study. J Pediatr Pharmacol Ther 2022; 27:72-79. [PMID: 35002562 DOI: 10.5863/1551-6776-27.1.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose was to characterize antimicrobial and anticoagulation therapies used in health systems with children receiving extracorporeal membrane oxygenation (ECMO). METHODS An anonymous electronic survey assessing health system demographics and antimicrobial and anticoagulation therapies during ECMO was distributed to the American College of Clinical Pharmacy Pediatric Practice and Research Network and the Pediatric Pharmacy Association Critical Care Special Interest Group. The primary objective was to identify the number of respondents using antimicrobial prophylaxis for ECMO cannulation and ECMO runs. Secondary objectives included the first- and second-line anticoagulants and anticoagulation laboratory parameters. Additionally, the antimicrobial regimens and the dosing and administration of antithrombin III (AT III) with systemic anticoagulation were collected. Descriptive statistics were employed. RESULTS The questionnaire was completed by 38 respondents from 33 health systems; respondents practiced in the pediatric ICU (n = 20; 52.6%), cardiovascular ICU (n = 14; 36.8%), and neonatal ICU (n = 4; 10.5%). Twenty-eight (73.6%) respondents use antimicrobial prophylaxis during ECMO cannulation or ECMO runs, with most units using cefazolin monotherapy. Thirty-five (92.1%) respondents use heparin as the first-line anticoagulant and used a variety of laboratory tests including anti-factor Xa, activated clotting time, and activated partial thromboplastin time. The most common second-line anticoagulant was bivalirudin (n = 24; 63.2%). Thirty-six (94.7%) respondents use AT III with heparin, with most patients receiving AT III dosing calculated based on a formula for the desired AT III concentration. CONCLUSIONS The majority of respondents use antimicrobial prophylaxis, but variations in the regimens were noted. Heparin was the most common anticoagulant, but variations in laboratory monitoring and concomitant use of AT III were found.
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Affiliation(s)
- Cierra A Frazier
- Xavier University of Louisiana College of Pharmacy (BMS, CAF, JML), New Orleans, LA
| | - Brittany M Scott
- Xavier University of Louisiana College of Pharmacy (BMS, CAF, JML), New Orleans, LA
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy (PNJ), Oklahoma City, OK
| | - Joseph M LaRochelle
- Xavier University of Louisiana College of Pharmacy (BMS, CAF, JML), New Orleans, LA
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Johnson PN, Drury AS, Gupta N. Continuous Magnesium Sulfate Infusions for Status Asthmaticus in Children: A Systematic Review. Front Pediatr 2022; 10:853574. [PMID: 35391743 PMCID: PMC8983002 DOI: 10.3389/fped.2022.853574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Magnesium sulfate is a second-tier therapy for asthma exacerbations in children; guidelines recommend a single-dose to improve pulmonary function and decrease the odds of admission to the in-patient setting. However, many clinicians utilize prolonged magnesium sulfate infusions for children with refractory asthma. The purpose of this review is to describe the efficacy and safety of magnesium sulfate infusions administered over ≥ 1 h in children with status asthmaticus. METHODS Medline was searched using the keywords "magnesium sulfate" and "children." Articles evaluating the use of magnesium sulfate infusions for ≥1 h published between 1946 and August 2021 were included. Published abstracts were not included because of lack of essential details. All articles were screened by two reviewers. RESULTS Eight reports including 447 children were included. The magnesium regimens evaluated included magnesium delivered over 1 h (n = 148; 33.1%), over 4-5 h (n = 105; 23.5%), and over >24 h (n = 194; 43.4%). Majority of patients received a bolus dose of 25-75 mg/kg/dose prior to initiation of a prolonged infusion (n = 299; 66.9%). For the patients receiving magnesium infusions over 4-5 h, the dosing regimen varied between 40 and 50 mg/kg/h. For those receiving magnesium infusions >24 h, the dosing varied between 18.4 and 25 mg/kg/h for a duration between 53.4 and 177.5 h. Only three reports including 186 patients (41.6%) included an evaluation of clinical outcomes including evaluation of lung function parameters, reduction in PICU transfers, and/or decrease in emergency department length of stay. Five reports including 261 patients (58.4%) evaluated magnesium serum concentrations. In most reports, the goal concentrations were between 4 and 6 mg/dL. Only 3 (1.1%) out of the 261 patients had supratherapeutic magnesium concentrations. The only reports finding adverse events attributed to magnesium were noted in those receiving infusions for >24 h. Clinically significant adverse events included hypotension (n = 74; 16.6%), nausea/vomiting (n = 35; 7.8%), mild muscle weakness (n = 22; 4.9%), flushing (n = 10; 2.2%), and sedation (n = 2; 0.4%). CONCLUSION Significant variability was noted in magnesium dosing regimens, with most children receiving magnesium infusions over >4 h. Most reports did not assess clinical outcomes. Until future research is conducted, the use of prolonged magnesium sulfate infusions should be reserved for refractory asthma therapy.
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Affiliation(s)
- Peter N Johnson
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Anna Sahlstrom Drury
- Department of Pharmacy, University of Kentucky Chandler Medical Center, Lexington, KY, United States
| | - Neha Gupta
- Division of Critical Care Medicine, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK, United States
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Taher KW, Johnson PN, Miller JL, Neely SB, Gupta N. Efficacy and Safety of Prolonged Magnesium Sulfate Infusions in Children With Refractory Status Asthmaticus. Front Pediatr 2022; 10:860921. [PMID: 35757130 PMCID: PMC9218095 DOI: 10.3389/fped.2022.860921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There is a paucity of data on the use of intravenous magnesium sulfate infusion in children with refractory status asthmaticus. The purpose of this study was to evaluate the efficacy and safety of prolonged magnesium sulfate infusion as an advanced therapy. METHODS This is a single center retrospective study of children admitted to our pediatric intensive care unit (PICU) with status asthmaticus requiring continuous albuterol. Treatment group included patients receiving magnesium for ≥4 h and control group included those on other therapies only. Patients were matched 1:4 based on age, sex, obesity, pediatric index of mortality III and pediatric risk of mortality III scores. Primary outcomes included PICU length of stay (LOS) and mechanical ventilation (MV) requirement. Secondary outcomes included mortality, extracorporeal membrane oxygenation (ECMO) requirement, analyses of factors associated with PICU LOS and MV requirement and safety of magnesium infusion. Logistic and linear regressions were employed to determine factors associated with MV requirement and PICU LOS, respectively. RESULTS Treatment and control groups included 27 and 108 patients, respectively. Median initial infusion rate was 15 mg/kg/hour, with median duration of 28 h. There was no difference in the MV requirement between the treatment and control groups [7 (25.9%) vs. 20 patients (18.5%), p = 0.39]. Median PICU LOS and ECMO use were significantly higher in treatment vs. control group [(3.63 vs. 1.09 days, p < 0.01) and (11.1 vs. 0%, p < 0.01), respectively]. No mortality difference was noted. On regression analysis, patients receiving ketamine and higher prednisone equivalent dosing had higher odds of MV requirement [OR 19.29 (95% CI 5.40-68.88), p < 0.01 and 1.099 (95% CI 1.03-1.17), p < 0.01, respectively]. Each mg/kg increase in prednisone equivalent dosing corresponded to an increase in PICU LOS by 0.13 days (95% CI 0.096-0.160, p < 0.01). Magnesium infusions were not associated with lower MV requirement or lower PICU LOS after controlling for covariates. Fourteen (51.9%) patients in the treatment group had an adverse event, hypotension being the most common. CONCLUSION Magnesium sulfate infusions were not associated with MV requirement, PICU LOS or mortality.
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Affiliation(s)
- Khalid W Taher
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Stephen B Neely
- Office of Instruction, Assessment, and Faculty/Staff Development, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Neha Gupta
- Department of Pediatrics, Division of Critical Care Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, United States
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Johnson PN, Mayes R, Moore E, Neely S, Nguyen AL, Miller JL. Ketamine infusions as an adjunct for sedation in critically ill children. J Opioid Manag 2022; 18:57-68. [PMID: 35238014 DOI: 10.5055/jom.2022.0695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Limited reports have described ketamine's role as an adjunct sedative. The purpose was to describe ketamine's role as an adjunct to achieve goal sedation in mechanically ventilated children. DESIGN Retrospective, descriptive study. SETTING Thirteen-bed pediatric intensive care unit (ICU) and 12-bed pediatric cardiovascular ICU. PARTICIPANTS Seventy-three ketamine courses were included, representing 62 mechanically ventilated children <18 years receiving ketamine for ≥12 hours. MAIN OUTCOME MEASURE(S) The primary outcome was to determine the median dose and time to achieve goal sedation (80 percent of State Behavioral Scale scores between 0 and -1) based on ketamine's place in therapy as an adjunct in the sedation regimen. Secondary outcomes included a comparison of sedative dosing pre- and post-ketamine initiation between place in therapy groups and paralyzed/nonparalyzed patients, and identification of ketamine-attributed adverse drug event (ADEs) or iatrogenic withdrawal syndrome (IWS). RESULTS The median age was 1.0 years (interquartile range: 0.4-4.9). Ketamine was initiated as first-line (n = 7; 9.6 percent), second-line (n = 39; 53.4 percent), third-line (n = 26; 35.6 percent), or fourth-line (n = 1; 1.4 percent) sedation. The median initial and peak doses were 0.6 mg/kg/h (0.3-0.6) and 0.9 mg/kg/h (0.9-1.2), respectively. The median dose and time to achieve goal sedation was 0.8 mg/kg/h (0.6-1.1) and 2 hours (1-7), respectively. ADEs were noted during three courses (4.1 percent) and IWS after discontinuation of one course (1.4 percent). CONCLUSIONS The majority were initiated on ketamine as a second- or third-line adjunct sedative. The median initial dose was 0.6 and dose to achieve goal sedation was 0.8 mg/kg/h. Ketamine-attributed ADEs and IWS episodes were rare.
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Affiliation(s)
- Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma. ORCID: https://orcid.org/0000-0003-3022-4403
| | - Rebecca Mayes
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Eszter Moore
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Stephen Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Amy L Nguyen
- Department of Pharmacy, Phoenix Children's Hospital, Phoenix, Arizona
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
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Bobo KS, Cober MP, Eiland LS, Heigham M, King M, Johnson PN, Miller JL, Sierra CM. Key articles and guidelines for the pediatric clinical pharmacist from 2019 and 2020. Am J Health Syst Pharm 2021; 79:364-384. [PMID: 34864839 DOI: 10.1093/ajhp/zxab426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To summarize recently published research reports and practice guidelines deemed to be significantly impactful for pediatric pharmacy practice. SUMMARY Our author group was composed of 8 board-certified pediatric pharmacists. Eight major themes were identified: critical care, hematology/oncology, medication safety, general pediatrics, infectious diseases, neurology/psychiatry, gastrointestinal/nutrition, and neonatology. The author group was assigned a specific theme(s) based on their practice expertise and were asked to identify articles using MEDLINE and/or searches of relevant journal articles pertaining to each theme that were published from January 2019 through December 2020 that they felt were "significant" for pediatric pharmacy practice. A final list of compiled articles was distributed to the authors, and an article was considered significant if it received a vote from 5 of the 8 authors. Thirty-two articles, including 16 clinical practice guidelines or position statements and 16 review or primary literature articles, were included in this review. For each of these articles, a narrative regarding its implications for pediatric pharmacy practice is provided. CONCLUSION Given the heterogeneity of pediatric patients, it is difficult for pediatric pharmacists to stay up to date with the most recent literature, especially in practice areas outside their main expertise. Over the last few years, there has been a significant number of publications impacting the practice of pediatric pharmacists. This review of articles that have significantly affected pediatric pharmacy practice may be helpful in staying up to date on key articles in the literature.
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Affiliation(s)
- Kelly S Bobo
- Le Bonheur Children's Hospital, Memphis, TN, USA
| | - M Petrea Cober
- Akron Children's Hospital, Akron, OH, and Northeast Ohio Medical University, Rootstown, OH, USA
| | - Lea S Eiland
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
| | | | - Morgan King
- Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Johnson PN, Shaddix BP, Weller BM, Oschman A, George D, Neely SB, Miller JL. Exploring Residency Program Directors, Preceptors, and Residents' Intentions to Participate in Multicenter Pediatric Pharmacy Resident Research Projects. J Pediatr Pharmacol Ther 2021; 26:708-717. [PMID: 34588934 DOI: 10.5863/1551-6776-26.7.708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose was to explore preceptors, residency program directors (RPDs), and residents' beliefs and intentions in participating in multicenter pediatric resident research projects (PRRPs). METHODS This exploratory qualitative study used the theory of planned behavior to explore beliefs, attitudes, and intentions toward participation in a multicenter PRRP. Two focus groups were formed: RPDs/preceptors and pharmacy residents. The primary objective was to identify attitudes/salient beliefs, subjective norms, and perceived behavioral controls regarding participation in multicenter PRRPs. The secondary objectives included identifying potential barriers and mitigation strategies for multicenter PRRPs. Descriptive statistics and a thematic analysis were performed. RESULTS The 2 focus groups included 24 participants: RPDs/preceptors (n = 16) and pharmacy residents (n = 8). The RPD/preceptor group had a mean of 7.4 ± 5.4 years of research experience; all residents had prior research experience as students. Participants shared and contrasted their salient beliefs, subjective norms, and perceived behavioral control beliefs about logistical challenges, networking, mentoring, sample size, collaboration, workload, shared responsibilities for data collection and the institutional review board application, and resources associated with participation in multicenter PRRPs. Other items that participants felt were important were discussion of authorship order and dedicated research time for residents. CONCLUSIONS Participants provided favorable comments toward multicenter PRRPs but acknowledged some barriers. The resident, preceptor, and RPD intention to participate in multi-center PRRPs is very likely if they perceive this as an opportunity for increased networking and mentorship, increased likelihood of publication, enhanced research skill experience, and shared resources and responsibilities.
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Salemi LA, Sahlstrom AL, Lim SY, Johnson PN, Dannaway D, Miller JL. Evaluation of the Use of Caffeine Citrate Maintenance Doses >5 mg/kg/day in Preterm Neonates for Apnea of Prematurity. J Pediatr Pharmacol Ther 2021; 26:608-614. [PMID: 34421411 DOI: 10.5863/1551-6776-26.6.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Caffeine citrate doses >5 mg/kg/day are frequently used for apnea of prematurity. The primary objective was identification of patients maintained on 5 mg/kg/day (Group 1). Secondary objectives included identification of patients requiring dose increases: 7.5 mg/kg every 24 hours (Group 2), 10 mg/kg every 24 hours (Group 3), and 5 mg/kg every 12 hours (Group 4); comparison of demographics and clinical characteristics; and identification of patients requiring dose adjustments owing to caffeine-associated tachycardia. METHODS Retrospective study of neonates born between 23 to <31 weeks' gestation, receiving caffeine between January 1, 2015, and July 31, 2019. Patients receiving caffeine <1 week, initial maintenance dose >5 mg/kg/day, or with congenital abnormalities were excluded. Descriptive and inferential statistics were performed, with a p < 0.05. RESULTS Overall, 281 patients were included, with 99 (35.2%) in Group 1; 56 (19.9%) in Group 2; 47 (16.7%) in Group 3; and 79 (28.1%) in Group 4. Significant differences in gestational age were noted, with Group 3 and 4 patients being more premature than Groups 1 and 2 (p < 0.001). Dose increases occurred at a median postnatal age and postmenstrual age of 13.0 days and 31.4 weeks in Group 2; 17.0 days and 30.3 weeks in Group 3; and 16.0 days and 30.1 weeks in Group 4. Significant differences were noted for development of tachycardia requiring dose adjustment, with Groups 3 and 4 having the highest percentage (p < 0.001). CONCLUSIONS Two-thirds received caffeine citrate doses >5 mg/kg/day, with 44% receiving 10 mg/kg/day. Further exploration is necessary to determine the optimal PNA or PMA for dose adjustments.
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Weller BM, Shaddix BP, Oschman A, Johnson PN, Neely SB, Chaaban H, Williams PK, Miller J. A Pilot Evaluation of the Possible Association of Metronidazole With Neurodevelopmental Outcomes in Premature Neonates. J Pediatr Pharmacol Ther 2021; 26:455-459. [PMID: 34239396 PMCID: PMC8244961 DOI: 10.5863/1551-6776-26.5.455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Metronidazole is recommended as a first-line treatment of necrotizing enterocolitis (NEC) in neonates. Metronidazole-associated neurotoxicity has been reported, but long-term neurodevelopmental effects in neonates have not been explored. The primary objective was to evaluate the relationship of cumulative metronidazole dose with each Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) composite score in neonates with NEC. Secondary objectives included comparison of seizure rates, mean Bayley-III scores, and neurodevelopmental impairment defined as 2 of 3 Bayley-III composite scores ≤ 79 or 1 score ≤ 70 between the metronidazole exposed and non-exposed groups. METHODS This multisite, retrospective cohort study compared infants with a birth weight < 1500 grams between January 1, 2011, and December 31, 2016, who developed stage 2 or greater NEC or spontaneous intestinal perforation and were followed up at a developmental clinic visit at approximately 1 year of age. Patients were excluded if admitted >72 hours of life, had congenital neurodevelopmental anomalies, hypoxic ischemic encephalopathy, grade III or IV intraventricular hemorrhage, or seizures prior to treatment of NEC. Included patients were stratified into 2 groups based on metronidazole exposure versus no metronidazole. Data were assessed using descriptive and inferential statistical techniques, using SAS 9.4. RESULTS Forty-one patients were included. Seven patients received metronidazole and 34 patients were in the non-metronidazole group. The only statistical difference noted between groups was for gestational age, with the non-exposed group being more premature. There was no statistical difference in Bayley-III scores, seizure rates, or neurodevelopmental impairment between groups. CONCLUSION No differences in neurodevelopmental outcomes were found between those with and without metronidazole exposure. Further studies are needed to validate our results.
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Harkin M, Miller J, Lim SY, Neely S, Walsh C, Johnson PN. "Reply: Conversion From Continuous Infusion Fentanyl to Hydromorphone in the Pediatric Intensive Care Unit". Ann Pharmacother 2021; 56:370-371. [PMID: 34165365 DOI: 10.1177/10600280211028672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Maura Harkin
- Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Jamie Miller
- Oklahoma Children's Hospital, Oklahoma City, OK, USA.,University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | | | - Stephen Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Christina Walsh
- Oklahoma Children's Hospital, Oklahoma City, OK, USA.,University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Peter N Johnson
- Oklahoma Children's Hospital, Oklahoma City, OK, USA.,University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Nguyen AL, Johnson PN, Neely SB, Hughes KM, Sekar KC, Welliver RC, Miller JL. Comparison of Amikacin Pharmacokinetics in Neonates With and Without Congenital Heart Disease. J Pediatr Pharmacol Ther 2021; 26:372-378. [PMID: 34035682 DOI: 10.5863/1551-6776-26.4.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/17/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The primary objective was to compare the volume of distribution (Vd), clearance (CL), elimination rate (Ke), and half-life (t½) of amikacin in neonates with cyanotic defects, acyanotic defects, and controls, adjusted for gestational and postnatal age. Secondary objectives were to compare the incidence of acute kidney injury (AKI) between controls and the congenital heart disease (CHD) group and to identify potential risk factors. METHODS This retrospective cohort study included neonates receiving amikacin from January 1, 2013 to August 31, 2016. Patients were excluded if concentrations were not appropriately obtained or if AKI or renal anomalies were identified prior to amikacin initiation. Congenital heart disease was classified as acyanotic or cyanotic. Patients with CHD were matched 1:1 with non-CHD controls according to postmenstrual age. Bivariate analyses were performed using Wilcoxon-Mann-Whitney test, Pearson χ2 tests, or Fisher exact as appropriate with a p value <0.05. Regression analyses included logistic and analysis of covariance. RESULTS Fifty-four patients with CHD were matched with 54 controls. Median (IQR) postnatal age (days) at amikacin initiation significantly differed between CHD and controls, 3.0 (1.0-16.0) versus 1.0 (1.0-3.0), p = 0.016. After adjusting for gestational and postnatal age, there was no difference in the mean (95% CI) Vd (L/kg) and CL (L/kg/hr) between CHD and controls, 0.47 (0.44-0.50) versus 0.46 (0.43-0.49), p = 0.548 and 0.05 (0.05-0.05) versus 0.05 (0.05-0.05), p = 0.481, respectively. There was no difference in Ke or t½ between groups. There was no difference in AKI between the CHD and controls, 18.5% versus 9.3%, p = 0.16. CONCLUSIONS Clinicians should consider using standard amikacin dosing for neonates with CHD and monitor renal function, since they may have greater AKI risk factors.
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Miller JL, Stephens K, Johnson PN, Medina M. Teaching residents how to deliver active learning during didactic lectures. Am J Health Syst Pharm 2021; 78:944-948. [PMID: 33755109 DOI: 10.1093/ajhp/zxab100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences University of Oklahoma College of Pharmacy Oklahoma City, OK, USA
| | - Katy Stephens
- University of Oklahoma College of Pharmacy Oklahoma City, OK, USA
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Melissa Medina
- Department of Pharmacy: Clinical and Administrative Sciences University of Oklahoma College of Pharmacy Oklahoma City, OK, USA
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Lim SY, Miller JL, Henry E, Heltsley R, Woo S, Johnson PN. Analysis of fentanyl pharmacokinetics, and its sedative effects and tolerance in critically ill children. Pharmacotherapy 2021; 41:359-369. [PMID: 33604895 DOI: 10.1002/phar.2515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Fentanyl pharmacokinetic and pharmacodynamic data are limited in mechanically ventilated children. This study aimed to assess the fentanyl pharmacokinetics (PK), the sedation outcome, and the development of tolerance in children receiving fentanyl continuous infusion. METHODS This study included children admitted to the pediatric or cardiovascular intensive care unit between January 1 and October 31, 2016, who were >30 days to <18 years of age, receiving ventilatory support via endotracheal tube or tracheostomy, and receiving a fentanyl infusion. Population PK analysis was performed using a nonlinear mixed-effects model. The relationship between initial sedation outcome using State Behavioral Scale (SBS) and fentanyl exposure was assessed, and the observations consistent with tolerance were described. RESULTS Seventeen children, with a median age of 0.83 years (range: 0.1-12) and weight of 8.7 kg (range: 3.4-52), were included. The fentanyl PK was adequately described by a weight-based allometry model with the power of 0.75 for clearance (CL=89.8 L/hr/70 kg) and distributional CL, and 1 for volumes of distribution. In infants <6.6 months, age was an additional factor for CL (31.4 L/h/70 kg) to account for age-related maturation. Seven of twelve nonparalyzed patients achieved goal sedation, defined as >80% of SBS scores ≤0 per 24 h, on the first day of fentanyl infusion with a median plasma concentration of 1.29 ng/ml (interquartile range: 0.78-2.05). Eight of the nine tolerant patients developed tolerance within a day of reaching goal sedation. CONCLUSION Different weight-based fentanyl dosing rates may be required for infants and children of different ages to achieve similar plasma concentrations. Using SBS scores may guide the dosing titration of fentanyl that resulted in plasma concentrations within the therapeutic range of 1-3 ng/ml. For those who developed tolerance to fentanyl and/or a sedative, it was noted one day after goal sedation was achieved.
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Affiliation(s)
- Sin Yin Lim
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Jamie L Miller
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Emilie Henry
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | | | - Sukyung Woo
- Department of Pharmaceutical Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, USA
| | - Peter N Johnson
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Harkin M, Miller JL, Lim SY, Neely SB, Walsh CK, Johnson PN. Conversion From Continuous Infusion Fentanyl to Continuous Infusion Hydromorphone in the Pediatric Intensive Care Unit. Ann Pharmacother 2021; 55:1439-1446. [DOI: 10.1177/10600280211003170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background: Opioid rotations from fentanyl to hydromorphone may reduce opioid/sedative exposure in critically ill children. Objective: The primary objective was to determine the conversion percentage from fentanyl to hydromorphone infusions using equianalgesic conversions (0.1 mg fentanyl = 1.5 mg hydromorphone). Secondary objectives included identification of the median time and hydromorphone rate at stabilization (defined as the first 24-hour period no hydromorphone rates changed, 80% of State Behavioral Scale [SBS] scores between 0 and −1, and <3 hydromorphone boluses administered). Additional outcomes included a comparison of opioid/sedative requirements on the day of conversion versus the three 24-hour periods prior to conversion. Methods: This retrospective study included children <18 years old converted from fentanyl to hydromorphone infusions over 6.3 years. Linear mixed models were used to determine if the mean cumulative opioid/sedative dosing differed from the day of conversion versus three 24-hour periods prior to conversion. Results: A total of 36 children were converted to hydromorphone. The median conversion percentage of hydromorphone was 86% of their fentanyl dose (interquartile range [IQR] = 67-100). The median hydromorphone rate at stabilization was 0.08 mg/kg/h (IQR = 0.05-0.1). Eight (22%) were stabilized on their initial hydromorphone rate; 8 (22%) never achieved stabilization. Patients had a significant decrease in opioid dosing on the day of conversion versus the 24-hour period prior to conversion but no changes in sedative dosing following conversion. Conclusion and Relevance: A median 14% fentanyl dose reduction was noted when transitioning to hydromorphone. Further exploration is needed to determine if opioid rotations with hydromorphone can reduce opioid/sedative exposure.
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Affiliation(s)
- Maura Harkin
- Oklahoma Children’s Hospital at OU Health, Oklahoma City, OK, USA
| | - Jamie L. Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Sin Yin Lim
- University of Wisconsin School of Pharmacy, Madison, WI, USA
| | - Stephen B. Neely
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | | | - Peter N. Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Miller JL, Lewis TV, Walling J, O'Donnell A, Neely SB, Johnson PN. Publication Rates of Pediatric-Focused Resident Research Projects Presented at The Pediatric Pharmacy Association Bruce Parks Memorial Residency Showcase. J Pediatr Pharmacol Ther 2021; 26:163-171. [PMID: 33603580 PMCID: PMC7887887 DOI: 10.5863/1551-6776-26.2.163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 06/10/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The primary objective was to identify the number of residency projects presented at the Pediatric Pharmacy Association (PPA) Bruce Parks Memorial Residency Showcase that were subsequently published. Secondary objectives included a comparison of subsequent publications after residency completion between those who did and did not publish their residency project and an analysis of factors associated with subsequent publications. METHODS This was a descriptive study including all pediatric-focused resident projects presented at the PPA Bruce Parks Memorial Residency Showcase from 2006 to 2015. Literature searches for all the pediatric-focused residency projects and any subsequent publications were performed. Data collection included residency type (i.e., postgraduate year 1 [PGY1], postgraduate year 2 [PGY2]), project category, and initial position after residency. A zero-inflated Poisson regression was used to analyze subsequent publication status while controlling for other factors. Statistical analyses were performed using SAS/STAT, with a priori p value < 0.05. RESULTS There were 434 projects presented by 401 residents. Seventy-four (17.1%) were published, with the majority being PGY2s (74.3%). Subsequent publications were identified for 162 residents (40.4%), with a higher percentage in those who published their pediatric-focused residency project versus those who did not, 59.5% versus 32.8%, p < 0.001. Factors associated with subsequent publications were those who published their residency project, initial position in academia, and PGY2s. CONCLUSIONS Of the residency projects presented at the showcase <20% were subsequently published. Those who published their residency research project were more likely to have subsequent publications. Future efforts should be taken to ensure that residents have the tools/confidence to independently publish their research/scholarship.
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Fox AN, Nation BE, Autry MT, Johnson PN. Possible role for acetylcysteine as a treatment for acute liver failure secondary to antitubercular medication use. Am J Health Syst Pharm 2020; 77:1482-1487. [PMID: 32885827 DOI: 10.1093/ajhp/zxaa202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Drug-induced liver injury (DILI) that progresses to acute liver failure (ALF) has a high mortality rate, and therapeutic options are limited. Acetylcysteine has a labeled indication for use as an antidote for acetaminophen toxicity and has also been used with limited success in treatment of non-acetaminophen-induced liver injury, with small clinical trials indicating an increase in transplant-free survival. Recommendations for management of non-acetaminophen-induced DILI include withdrawal of the offending agent and supportive care. Treatment guidelines generally discourage a rechallenge with an offending medication, except in cases where there are no other therapeutic options for management of a serious disease, such as active tuberculosis (TB). SUMMARY This case report describes the reversal of ALF due to DILI in a patient receiving antitubercular agents for active TB. After withdrawal of initially prescribed antitubercular agents, the patient was switched to a less hepatotoxic anti-TB regimen and intravenous acetylcysteine pending results of antimicrobial susceptibility testing. After stabilization of the patient's liver enzyme levels, intravenous acetylcysteine was discontinued and oral acetylcysteine was continued for 5 days without an increase in hepatic enzyme levels or clinical deterioration. After 5 days, oral acetylcysteine was discontinued due to patient-reported nausea and vomiting. CONCLUSION Given the limited number of therapeutic interventions shown to be beneficial in ALF and data suggesting a protective effect against DILI with initiation of acetylcysteine at the start of treatment with anti-TB medications, acetylcysteine can be considered for patients with anti-TB - associated DILI.
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Affiliation(s)
- Ashley N Fox
- Department of Pharmacy, University of New Mexico Hospitals, Albuquerque, NM
| | | | - Marcus Tad Autry
- Department of Hematology/Oncology, Stevenson Cancer Center, Oklahoma City, OK
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK
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Cox CL, Todd TJ, Lubsch L, Klein KC, Prescott WA, Knoderer CA, Johnson PN, Meyers R, Cole JW, LaRochelle JM, Worthington MA, Smith K. Joint Statement on Pediatric Education at Schools of Pharmacy. Am J Pharm Educ 2020; 84:ajpe7892. [PMID: 32934387 PMCID: PMC7473221 DOI: 10.5688/ajpe7892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/04/2020] [Indexed: 05/07/2023]
Abstract
Providing health care for children is a unique specialty, and pediatric patients represent approximately 25% of the population. Education of pharmacy students on patients across the lifespan is required by current Accreditation Council for Pharmacy Education standards and outcomes; thus, it is essential that pharmacy students gain a proficiency in caring for children. A collaborative panel of pediatric faculty members from schools and colleges of pharmacy was established to review the current literature regarding pediatric education in Doctor of Pharmacy curricula and establish updated recommendations for the provision of pediatric pharmacy education. This statement outlines five recommendations supporting inclusion of pediatric content and skills in Doctor of Pharmacy curricula.
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Affiliation(s)
- Christina L. Cox
- University of South Carolina, College of Pharmacy, Columbia, South Carolina
| | - Timothy J. Todd
- Midwestern University Chicago, College of Pharmacy, Downers Grove, Illinois
| | - Lisa Lubsch
- Southern Illinois University Edwardsville, School of Pharmacy, St. Louis, Missouri
| | - Kristin C. Klein
- University of Michigan, College of Pharmacy, Ann Arbor, Michigan
| | - William A. Prescott
- University at Buffalo, School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York
- Editorial Board Member, American Journal of Pharmaceutical Education, Arlington, Virginia
| | - Chad A. Knoderer
- Butler University, College of Pharmacy and Health Sciences, Indianapolis, Indianapolis
| | - Peter N. Johnson
- University of Oklahoma, College of Pharmacy, Oklahoma City, Oklahoma
| | - Rachel Meyers
- Rutgers University Ernest Mario, School of Pharmacy, Piscataway, New Jersey
| | - Justin W. Cole
- Cedarville University, School of Pharmacy, Cedarville, Ohio
| | - Joseph M. LaRochelle
- Xavier University of Louisiana, Louisiana State University Health Sciences Center, School of Medicine, New Orleans, Louisiana
| | | | - Katherine Smith
- Roseman University of Health Sciences, College of Pharmacy, South Jordan, Utah
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Harkin M, Shaddix BP, Neely SB, Peek LA, Stephens K, Barker P, McMullan L, Gormley A, Johnson PN. Evaluation of dosing and safety outcomes of low-dose prophylactic warfarin in children after cardiothoracic surgery. Am J Health Syst Pharm 2020; 77:1018-1025. [PMID: 32470108 DOI: 10.1093/ajhp/zxaa111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Prophylactic warfarin with an International Normalized Ratio (INR) goal of 1.5 to 2.0 is one antithrombotic therapy utilized in children after cardiothoracic surgery (CTS); published sources suggest a dose of 0.1 mg/kg per day to achieve this goal. However, few studies have evaluated dosing in this population. The purpose of this study was to evaluate dosing and safety outcomes in children receiving warfarin after CTS. METHODS A descriptive, retrospective review was conducted to evaluate warfarin dosing and INR outcomes in patients 18 years of age or younger who underwent CTS and received prophylactic warfarin with an INR goal of 1.5 to 2.0 from January 2014 through December 2018. The primary objective was to determine the median initial warfarin dose. Secondary objectives included identifying the percentage of documented INR values that were outside the therapeutic range, the percentage of patients with therapeutic INRs at discharge, and the 30-day readmission rate. RESULTS Twenty-six patients were included in the review. The median initial warfarin dosage was 0.07 mg/kg/d (interquartile range [IQR], 0.05-0.10 mg/kg/d). Of the total of 177 INR values collected during the entire study period, 67 (37.9%) were therapeutic, 64 (36.2%) were subtherapeutic, and 46 (26.0%) were supratherapeutic. Eighteen patients (69.2%) had at least 1 supratherapeutic INR at any point during the study period, most frequently on days 2 through 4 of therapy. At discharge, 11 patients (42.3%) had therapeutic INRs. Four patients (15.4%) were readmitted within 30 days, with bleeding documented in 2 patients during their readmission. CONCLUSION The majority of patients received an initial warfarin dose less than that specified in published recommendations but still had a supratherapeutic INR at least once during the study period. When initiating warfarin after CTS, a dosage of <0.1 mg/kg per day and frequent monitoring may be needed to achieve an INR goal of 1.5 to 2.0.
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Affiliation(s)
- Maura Harkin
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Brittany Powers Shaddix
- Department of Pharmacy Services, Ascension: The Children's Hospital at Sacred Heart, Pensacola, FL
| | - Stephen B Neely
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Leigh A Peek
- Department of Pharmacy, Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Katy Stephens
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinic, Iowa City, IA
| | - Philip Barker
- Pharmacy Department, Primary Children's Hospital, Salt Lake City, UT
| | - Lauren McMullan
- Department of Pharmacy, Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Andrew Gormley
- Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK
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Nguyen TT, Bergeron E, Lewis TV, Miller JL, Hagemann TM, Neely S, Johnson PN. Descriptive study of discharge medications in pediatric patients. SAGE Open Med 2020; 8:2050312120927945. [PMID: 32547752 PMCID: PMC7271562 DOI: 10.1177/2050312120927945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/27/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Limited studies have evaluated medications in children discharged from
hospitals. Knowledge of the number of medications and dosage forms could
provide a baseline to establish a medication discharge prescription
program. Objectives: To identify the median number of discharge prescriptions per patient.
Secondary objectives included an evaluation of the dosage formulations and
frequency, and comparisons of the prevalence of unrounded medication doses
between service type (medical vs surgical) and physician provider level
(trainees vs attendings). Methods: This retrospective study included children <18 years receiving
>1 discharge prescription during 4 selected
months over a 1-year time frame. Comparisons were made via Pearson’s
chi-square tests, Fisher’s Exact tests, and Kruskal–Wallis nonparametric
rank tests as appropriate with a priori p value of
<0.05. Results: A total of 852 patients were evaluated, with most (78.8%) on a medical
service. The median (interquartile range) number of new medications at
discharge was 2 (1–3), with the median total number of discharge medications
of 3 (2–6). There was no difference in the net change of the median number
of home medications stopped and new medications started between service
types. The majority (72.2%) received >1 oral
liquid medications. There was no difference in prescribing rates per service
type and provider level. There was a difference in the number of unrounded
doses between trainees versus attendings, 17.8% versus 9.5%,
p = 0.048. Conclusion: Patients were discharged on a median of three medications, and most received
>1 oral liquid medications. These data can be
used to target children who would benefit from medication discharge
prescription programs.
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Affiliation(s)
- Thao T Nguyen
- The Children’s Hospital at Saint
Francis, Tulsa, OK, USA
| | - Erica Bergeron
- Department of Pharmacy: Clinical and
Administrative Sciences, The University of Oklahoma College of Pharmacy, Oklahoma
City, OK, USA
| | - Teresa V Lewis
- Department of Pharmacy: Clinical and
Administrative Sciences, The University of Oklahoma College of Pharmacy, Oklahoma
City, OK, USA
| | - Jamie L Miller
- Department of Pharmacy: Clinical and
Administrative Sciences, The University of Oklahoma College of Pharmacy, Oklahoma
City, OK, USA
| | | | - Stephen Neely
- Department of Pharmacy: Clinical and
Administrative Sciences, The University of Oklahoma College of Pharmacy, Oklahoma
City, OK, USA
| | - Peter N Johnson
- Department of Pharmacy: Clinical and
Administrative Sciences, The University of Oklahoma College of Pharmacy, Oklahoma
City, OK, USA
- Peter N Johnson, Department of Pharmacy:
Clinical and Administrative Sciences, The University of Oklahoma College of
Pharmacy, O’Donoghue Research Building, Suite ODON4415, 1122 Northeast 13th
Street, Oklahoma City, OK 73117, USA.
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Moore E, Mayes R, Harkin M, Miller JL, Johnson PN. Extended Duration Ketamine Infusions in Critically Ill Children: A Case Report and Review of the Literature. J Pediatr Intensive Care 2020; 10:221-227. [PMID: 34395041 DOI: 10.1055/s-0040-1713144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022] Open
Abstract
Ketamine is an N -methyl-D-aspartate receptor antagonist that has been used as an adjunct analgesic and sedative in critically ill children. Previous reports noted that ketamine has been used for a variable duration of 12 to 408 hours for this indication. We report on the use of ketamine infusions for >720 hours as a second-line sedative in addition to an opioid and dexmedetomidine infusion in a 2-month old and 17-month old. The purpose of this case report and review of the literature is to highlight the prolonged ketamine exposure of these two patients and to provide awareness to clinicians on the potential of withdrawal with extended ketamine administration. These children were started on initials doses of 5 and 15 µg/kg/min and titrated to peak doses of 20 and 25 µg/kg/min, respectively. They were continued for a total of 987 and 792 hours, respectively. No adverse events were noted during the ketamine infusions. One patient developed possible withdrawal symptoms 17 hours after ketamine discontinuation despite tapering of the infusion. These symptoms resolved with administration of as needed intravenous opioids and benzodiazepines, and the agitation normalized within 24 hours after ketamine discontinuation. Clinicians should consider tapering ketamine infusions in children receiving >72 hours of a continuous infusion by 5 µg/kg/min every 8 to 12 hours. Patients should be monitored for potential withdrawal symptoms including anxiety, allodynia, hyperalgesia, sweating, and drowsiness.
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Affiliation(s)
- Eszter Moore
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Rebecca Mayes
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Maura Harkin
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States.,Department of Pharmacy, Division of Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States.,Department of Pharmacy, Division of Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States.,Department of Pharmacy, Division of Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
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Shaddix BP, Harkin M, Miller JL, Johnson PN. Which PGY1 Pharmacy Residency Is Right for Me? Advantages and Disadvantages of Pediatric-Focused and Traditional PGY1 Pharmacy Programs. J Pediatr Pharmacol Ther 2020; 25:273-277. [DOI: 10.5863/1551-6776-25.4.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Students interested in pediatric pharmacy may face difficulty choosing a postgraduate year 1 (PGY1) Pharmacy residency program. These students can complete their PGY1 Pharmacy residency in a traditional PGY1 Pharmacy program, a program with less than 50% of pediatric rotation experiences, or a pediatric-focused PGY1 Pharmacy program, a program with at least 50% of pediatric rotation experiences. These programs differ in rotational experiences, types of projects available, service commitment, and preceptor backgrounds. This article provides potential advantages and disadvantages that students may consider when selecting between these 2 different PGY1 Pharmacy residency programs. In addition, the article includes advice for students to consider when evaluating the best fit for themselves, and many of the recommendations were developed following a presentation that was given to students at the Pediatric Pharmacy Association's Annual Meeting in April 2019. Ultimately, the best residency program fit for a student interested in pediatrics should be based on each student's priorities, preferences, and career goals.
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Capino AC, Thomas AN, Baylor S, Hughes KM, Miller JL, Johnson PN. Antipsychotic Use in the Prevention and Treatment of Intensive Care Unit Delirium in Pediatric Patients. J Pediatr Pharmacol Ther 2020; 25:81-95. [PMID: 32071582 PMCID: PMC7025750 DOI: 10.5863/1551-6776-25.2.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To describe the antipsychotics, route of administration, dosage regimen, and outcomes reported to prevent or treat delirium in hospitalized children. METHODS Medline, Embase, and International Pharmaceutical Abstracts were searched using the keywords "haloperidol," "olanzapine," "quetiapine," "risperidone," "ziprasidone," and "delirium." Articles evaluating the use of these agents to manage delirium in hospitalized children that were published between 1946 and August 2019 were included. Two authors independently screened each article for inclusion. Reports were excluded if they were published abstracts or included fewer than 3 patients in the report. RESULTS Thirteen reports that included 370 children receiving haloperidol, quetiapine, olanzapine, and/or risperidone for delirium treatment were reviewed. Most children received haloperidol (n = 131) or olanzapine (n = 125). Significant variability in dosing was noted. A total of 23 patients (6.2%) had an adverse drug event, including 13 (56.5%) who experienced dystonia and 3 (13.0%) with a prolonged corrected QT interval. Most reports described improvement in delirium symptoms; however, only 5 reports used a validated screening tool for PICU delirium to evaluate antipsychotic response. CONCLUSIONS Most reports noted efficacy with antipsychotics, but these reports were limited by sample size and lacked a validated PICU delirium tool. Future research is needed to determine the optimal agent and dosage regimen to treat PICU delirium.
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Stephens K, Barker P, Bergeron E, Miller JL, Hagemann TM, Lewis TV, Neely S, Johnson PN. Comparison of Clinical Outcomes and Medication Use of Obese Versus Nonobese Children Admitted to the Pediatric Intensive Care Unit. Hosp Pharm 2019; 56:287-295. [PMID: 34381263 DOI: 10.1177/0018578719893373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Few studies have compared clinical outcomes and medication use between obese and nonobese children in the pediatric intensive care unit (PICU). Objectives: The primary objective was to compare clinical outcomes including mortality, PICU length of stay (LOS), and mechanical ventilation (MV) requirement between obese and nonobese children. Secondary objectives included analysis of factors associated with these outcomes and medication use between groups. Methods: This retrospective study included children 2 to 17 years old admitted to the PICU over a 1-year time frame. Patients were categorized as obese, body mass index (BMI) ≥ 95th percentile, and nonobese (BMI < 95th percentile). Three binary regression models assessed the impact of obesity on clinical outcomes. Results: There were 834 admissions, with 22.1% involving obese children. There was no difference in mortality, MV requirement, or PICU LOS between groups. There were no associations with obesity and clinical outcomes found, but an association was noted for medication classes and receipt of continuous infusions on clinical outcomes. There was no difference noted in the median number (interquartile range [IQR]) of medications between obese and nonobese children, 8 (6-13) versus 9 (6-15), P = .38, but there was a difference in patients receiving a continuous infusion between obese and nonobese children, 24.4% versus 8.8%, P < .01. The 15 most used medications in both groups included analgesics, antimicrobials, corticosteroids, bronchodilators, and gastrointestinal agents. Conclusions: One-fifth of all admissions included obese children. Obesity was not associated with mortality, PICU LOS, and MV requirement, but the number of medication classes and continuous infusions were associated with these outcomes.
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Affiliation(s)
- Katy Stephens
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Philip Barker
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Erica Bergeron
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Jamie L Miller
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Tracy M Hagemann
- The University of Tennessee Health Science Center, Nashville, USA
| | - Teresa V Lewis
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Stephen Neely
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
| | - Peter N Johnson
- The University of Oklahoma College of Pharmacy, Oklahoma City, USA
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Johnson PN, Gildon BL, Condren M, Miller JL, Hagemann TM, Lewis TV, John B, Farmer K. A survey of pediatric degree option program graduates in a doctor of pharmacy curriculum: Confidence and initial employment position. Curr Pharm Teach Learn 2019; 11:1296-1302. [PMID: 31836156 DOI: 10.1016/j.cptl.2019.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/28/2019] [Accepted: 09/07/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND PURPOSE Graduates from the pediatric degree option program (PDOP) were tracked to identify confidence with pediatric pharmacotherapy and categorize initial employment following graduation. EDUCATIONAL ACTIVITY AND SETTING The PDOP was established in 2011 and requires 16 credits of pediatric-focused didactic coursework and advanced pharmacy practice experiences. Thirty PDOP graduates completed a 30-item questionnaire to assess confidence in pediatric pharmacotherapy knowledge and skill statements and employment position following graduation. Responses were compared between those completing post-graduate pediatric pharmacy training and those who did not. FINDINGS Nineteen (63.3%) graduates responded. All expressed "very high" or "high" confidence with dose calculations, first-line treatment selection for otitis media, and counseling caregivers on medications. However, <75% expressed "very high" or "high" confidence with identification of pharmacokinetic differences in neonates vs. children, utilization of growth charts, and counseling children. Ten (52.6%) respondents completed post-graduate training, and the remainder had an initial position in community or hospital pharmacy. There were no significant differences in pharmacotherapy skill and knowledge statements between those completing residency vs. those who did not. The most beneficial experiences reported were gaining clinical experience in pediatric pharmacy and medication safety. SUMMARY Overall, PDOP graduates noted high confidence in pediatric pharmacotherapy skills and knowledge. Most felt that the PDOP influenced their initial career plans and made them more competitive for their initial position following graduation. The PDOP was well received and provided an opportunity for additional knowledge and skill development for students interested in pediatrics.
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Affiliation(s)
- Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, United States of America.
| | - Brooke L Gildon
- Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, United States of America.
| | - Michelle Condren
- Deparment of Pediatrics; University of Oklahoma School of Community Medicine; Tulsa, Oklahoma.
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, United States of America.
| | - Tracy M Hagemann
- Department of Pharmacy Practice, University of Tennessee College of Pharmacy, United States of America.
| | - Teresa V Lewis
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, United States of America.
| | - Bob John
- The Children's Hospital at Saint Francis, United States of America.
| | - Kevin Farmer
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, United States of America.
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Johnson PN, Stephens K, Barker P, Bergeron E, Lim SY, Hagemann TM, Lewis TV, Neely S, Miller JL. Prescribing Patterns of Continuous Infusions in Nonobese versus Obese Children Admitted to the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2019; 8:226-232. [DOI: 10.1055/s-0039-1692669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/15/2019] [Indexed: 10/26/2022] Open
Abstract
AbstractThis retrospective study compared the continuous infusions prescribed for obese and nonobese children. Ninety-five (13.2%) received an infusion. A greater percentage of obese (n = 42/168) versus nonobese (53/552) children received infusions, p < 0.01. No difference was noted in the median number of infusions between the obese and nonobese groups, 2 versus 2, p = 0.975. The top 20 prescribed infusions included ten (50%) for sedation/analgesia or neuromuscular blockade and six (30%) for hemodynamic support. A literature search was performed for these 20 agents to determine pharmacokinetics, pharmacodynamics, and dosing in obese children and revealed six studies evaluating fentanyl (n = 2), midazolam (n = 1), and propofol (n = 3).
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Affiliation(s)
- Peter N. Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Katy Stephens
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Nashville, Tennessee, United States
| | - Philip Barker
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Nashville, Tennessee, United States
| | - Erica Bergeron
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Nashville, Tennessee, United States
| | - Sin Yin Lim
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Tracy M. Hagemann
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Nashville, Tennessee, United States
| | - Teresa V. Lewis
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Stephen Neely
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Nashville, Tennessee, United States
| | - Jamie L. Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
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Abstract
Background: Intravenous (IV) sulfamethoxazole/trimethoprim (SMX/TMP) has been associated with hyponatremia in adults. Objective: The primary objective was to identify the number of patients with a serum sodium <135 mEq/L. Secondary objectives between the hyponatremic versus nonhyponatremic groups included demographic comparisons, median serum sodium concentrations, SMX/TMP cumulative dose, number of diuretics, and other medications causing hyponatremia. Methods: This was a retrospective study of children <18 years receiving IV SMP/TMX. Comparisons were conducted via Mann-Whitney-Wilcoxon and Mantel-Haenszel χ2 tests with an a priori P value <0.05. Results: Sixty-one patients received 66 total courses; 20 courses (30.3%) were associated with hyponatremia with a decrease in the median nadir serum sodium concentration of 133 and 138 mEq/L in the hyponatremic and nonhyponatremic groups, respectively (P<0.001). The median age (interquartile range) was lower in the hyponatremic versus nonhyponatremic group, but this was not statistically significant: 0.6 (0.1-5.5) versus 3.9 (0.3-11.0) years; P=0.077. There was no significant difference in the median cumulative dose (mg/kg) between groups; P=0.104. In addition, there was a significant difference in the number of children in the hyponatremic versus nonhyponatremic groups receiving diuretics (16 [80.0%] vs 23 [50.0%], P=0.023) and other medications that cause hyponatremia (7 [35.0%] vs 5 [10.9%], P=0.034), respectively. Furosemide was noted to be the medication most associated with hyponatremia. Conclusion and Relevance: Approximately one-third administered IV SMX/TMP developed hyponatremia. Concomitant furosemide administration was one of the most common risk factors. Clinicians should be aware of this potential adverse event when initiating IV SMX/TMP in children.
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Affiliation(s)
- Katy Stephens
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Jamie L Miller
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Teresa V Lewis
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Stephen Neely
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Peter N Johnson
- The University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
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Affiliation(s)
- Peter N Johnson
- Department of Pharmacy University of Oklahoma College of Pharmacy Oklahoma City, OK
| | - Jamie L Miller
- Department of Pharmacy University of Oklahoma College of Pharmacy Oklahoma City, OK
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Blackmer AB, Siu A, Thornton A, Johnson PN, Nichols KR, Hagemann TM. Academic Careers in Pediatric Pharmacy: Part 2—Academic Advancement. J Pediatr Pharmacol Ther 2019; 24:183-193. [DOI: 10.5863/1551-6776-24.3.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An increasing number of pediatric clinical pharmacists are pursuing careers in academia. Once in an academic position, questions, challenges and benefits related to the processes of academic evaluation and advancement unique to pediatric academia often arise. This is the second article in a 2-part series that attempts to demystify pediatric faculty positions and address gaps in the literature regarding careers in pediatric-focused academic positions. The purpose of this article is to review key aspects pertaining to academic evaluation and the preparation for and process of academic advancement/promotion. A question and answer format is used to discuss common questions related to these processes and tips for success are provided. This article is primarily intended to be used as a helpful guide for junior faculty members as well as mid-level individuals seeking advancement; however, it will also benefit students, trainees, and practicing pharmacists seeking increased knowledge of pediatric academic career paths.
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Siu A, Blackmer AB, Thornton AM, Johnson PN, Nichols KR, Hagemann TM. Overview and Preparation Guide for Academic Careers in Pediatric Pharmacy, Part 1: Career as a Pediatric Pharmacy Practice Faculty Member. J Pediatr Pharmacol Ther 2019; 24:79-89. [PMID: 31019400 PMCID: PMC6478359 DOI: 10.5863/1551-6776-24.2.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2018] [Indexed: 11/11/2022]
Abstract
Pediatric clinical pharmacy is a growing and evolving field with an increasing number of pediatric clinical pharmacists in academia. In 2017, pediatric practice faculty members represented approximately 7.6% of all pharmacy practice faculty in the United States. The benefits of practicing in an academic environment are many, including, but not limited to, the ability to shape the future of pharmacy practice through the training of the next generation of pharmacists, contributing to science through research and scholarly activities for the care of pediatric patients, and positively impacting patient care for the most vulnerable of patients. Part one of this two-part series describes careers in academic pediatric pharmacy, as well as faculty roles and responsibilities, and provides information and advice related to the preparation and transition into careers in academic pediatric pharmacy.
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Capino AC, Johnson PN, Williams PK, Anderson MP, Bedwell S, Miller JL. Pilot Study Comparing Modified Finnegan Scoring Versus Adjusted Scoring System for Infants With Iatrogenic Opioid Abstinence Syndrome After Cardiothoracic Surgery. J Pediatr Pharmacol Ther 2019; 24:148-155. [PMID: 31019408 DOI: 10.5863/1551-6776-24.2.148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare the modified Finnegan Scoring System (modified Finnegan) with an Adjusted Scoring System Criteria (adjusted Finnegan) for infants after cardiothoracic surgery with iatrogenic opioid abstinence syndrome (IOAS). METHODS This was a retrospective, observational pilot study. This study was conducted in a tertiary care academic hospital. Infants after cardiothoracic surgery with IOAS transferred between the pediatric intensive care unit and neonatal intensive care unit between January 1, 2014, and January 31, 2016, were included retrospectively. The main outcome variable was to compare the area under the curve for the mean modified Finnegan versus adjusted Finnegan. RESULTS Twenty-five patients were included in the study. Twenty patients with at least 30 scores were included in the final analysis. Overall, the modified Finnegan scores were at least 2 points higher than the adjusted Finnegan. The difference in area under the curve was 34.6 (p < 0.001). CONCLUSIONS Use of the modified Finnegan tool for older infants with IOAS could overestimate withdrawal, leading to unnecessary interventions.
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Johnson PN, Mitchell-Van Steele A, Nguyen AL, Stoffella S, Whitmore JM. Pediatric Pharmacists' Participation in Cardiopulmonary Resuscitation Events. J Pediatr Pharmacol Ther 2019; 23:502-506. [PMID: 30697139 DOI: 10.5863/1551-6776-23.6.502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The Pediatric Pharmacy Advocacy Group (PPAG) understands the dilemma and varying factors that many institutions face concerning the routine participation of pharmacists in emergency resuscitation events. Acknowledging these obstacles, the PPAG encourages all institutions to strongly consider creating, adopting, and upholding policies to address pharmacists' participation in cardiopulmonary resuscitation (CPR) as evidenced by the impact pharmacist participation has shown on the reduction of hospital medication error and mortality rates in children. The PPAG advocates that pharmacists be actively involved in the institution's CPR, medical emergency team committees, and preparation of emergency drug kits and resuscitation trays. The PPAG advocates that all institutions requiring a pharmacist's participation in CPR events consider adoption of preparatory training programs. Although the PPAG does not advocate any one specific program, consideration should be taken to ensure that pharmacists are educated on the pharmacotherapy of drugs used in the CPR process, including but not limited to basic life support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support algorithms; medication preparation and administration guidelines; medication compatibility; recommended dosing for emergency medications; and familiarity with the institutional emergency cart.
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Miller JL, Ernst K, Neely SB, Stephens K, Barker P, Skrepnek GH, Johnson PN. Low-dose versus high-dose methadone for the management of neonatal abstinence syndrome. J Opioid Manag 2019; 15:159-167. [PMID: 31343717 DOI: 10.5055/jom.2019.0497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The primary objective was to compare median time to symptom relief (time from methadone initiation until two consecutive modified Finnegan [neonatal abstinence syndrome, NAS] scores < 8) between neonates receiving low-dose (≤0.275 mg/kg/day) versus high-dose (>0.275 mg/kg/day) methadone. Secondary objectives included assessment of factors associated with symptom relief. DESIGN Retrospective cross-sectional study. SETTING Ninety-nine bed neonatal intensive care unit within a tertiary-care academic hospital. PARTICIPANTS Seventy-two neonates who received methadone for NAS over a 7.5-year period. MAIN OUTCOME MEASURES(S) Kaplan-Meier curves with a log-rank test and a stepwise Cox proportional-hazard model were used to analyze outcomes. RESULTS The median dose for the low-dose (n = 40) and high-dose (n = 32) groups were 0.19 mg/kg/day (interquartile range [IQR], 0.12-0.24) divided every 6-12 hours and 0.4 mg/kg/day (0.3-0.44) divided every 6-8 hours, respectively. The median time to symptom relief was higher in the low-dose versus high-dose groups, 9.3 (5.8-24.6) versus 6.0 (5.4-12.5) hours, respectively (p = 0.014). Low-dose males had a longer time to symptom resolution than other groups (p = 0.008). Female premature neonates (<37 weeks gestation) had a shorter time to symptom relief than term neonates [adjusted hazard ratio = 2.96 (1.02-8.62)]. The median total duration of methadone was shorter but not statistically significant between high- versus low-dose groups, 17.5 (IQR: 11.0-25.0) versus 21.0 days (IQR: 10.0-28.0), respectively (p = 0.483). CONCLUSIONS Neonates receiving high-dose methadone had a significantly shorter time to symptom relief. Differences in sex were noted in response to therapy with low-dose males having a longer time to symptom relief and premature neonates a shorter time to symptom relief.
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Affiliation(s)
- Jamie L Miller
- Associate Professor, Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Kimberly Ernst
- Professor, Department of Pediatrics, Section of Neonatology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Stephen B Neely
- Research Biostatistician, Dean's Office, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Katy Stephens
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Philip Barker
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Grant H Skrepnek
- Associate Professor, Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Peter N Johnson
- Associate Professor, Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
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Abstract
Limited guidance on opioid use exists in the pediatric population, causing medication safety concerns for pain management in children and adolescents. Opioid misuse and use disorder continue to greatly affect adolescents and young adults in the United States, furthering the apprehension of their use. Pediatric Pharmacy Advocacy Group (PPAG) recommends pharmacists contribute their knowledge to pain management in children, including the discussion of appropriate use of non-opioid alternatives for pain and when to recommend coprescribing of naloxone. PPAG also supports the review of electronic prescription drug-monitoring programs prior to opioid prescribing and dispensing by both prescribers and pharmacists. Education by pharmacists of children and their families regarding proper administration, storage, and disposal, as well as the awareness of opioid misuse and use disorder among adolescents and young adults, is key to prevention. If opioid use disorder is diagnosed, PPAG encourages improved access among adolescents to evidence-based medications including methadone, buprenorphine, and naltrexone. Furthermore, pharmacists should assist in screening and referral to evidence-based treatment.
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