Impact of implementing smart infusion pumps in a pediatric intensive care unit

PURPOSE

The impact of smart infusion pumps on the interception of errors in the programming of i.v. drug administrations on a pediatric intensive care unit (PICU) is investigated.

METHODS

A prospective observational intervention study was conducted in the PICU of a hospital in Madrid, Spain, to estimate the patient safety benefits resulting from the implementation of smart pump technology (Alaris System, CareFusion, San Diego, CA). A systematic analysis of data stored by the devices during the designated study period (January 2010-June 2011) was conducted using the system software (Guardrails CQI Event Reporter, CareFusion). The severity of intercepted errors was independently classified by a group of four clinical pharmacists and a group of four intensive care pediatricians; analyses of intragroup and intergroup agreement in perceptions of severity were performed.

RESULTS

During the 17-month study period, the overall rate of user compliance with the safety software was 78%. The use of smart pump technology resulted in the interception of 92 programming errors, 84% of which involved analgesics, antiinfectives, inotropes, and sedatives. About 97% of the errors resulted from user programming of doses or infusion rates above the hard limits defined in the smart pump drug library. The potential consequences of the intercepted errors were considered to be of moderate, serious, or catastrophic severity in 49% of cases.

CONCLUSION

The use of smart pumps in a PICU improved patient safety by enabling the interception of infusion programming errors that posed the potential for severe injury to pediatric patients.

Impact of clinical pharmacist interventions in reducing paediatric prescribing errors

OBJECTIVE

To assess the impact of pharmacist intervention in reducing prescribing errors in paediatrics, and to analyse the clinical significance and reasons behind the errors detected.

METHODS

Cross-sectional epidemiological study analysing the activities of the paediatric pharmacist in a maternity and children's hospital with 180 paediatric beds, between January 2007 and December 2009. The following variables were analysed: impact of the pharmacist's recommendation on patient care, reason for the intervention, clinical significance, type of negative outcome associated with the medication, acceptance rate, medication involved, intervention detection date and observations.

RESULTS

A total of 1475 interventions in medical orders for 14,713 paediatric patients were recorded (40 (2.9%) extremely significant interventions and 155 (11.1%) very significant interventions). There were 1357 prescribing errors, 833 of which were dosing errors. 2.2% of the errors detected were potentially fatal (30 cases) and 14.3% (194 cases) were clinically serious. The main reason for interventions was detection of a dosage between 1.5 and 10 times higher than that recommended. The overall rate of acceptance of the pharmacist's suggestions was 94.3%. The pharmacist carried out an average of 0.019 interventions per patient day throughout the study period.

CONCLUSION

Interventions by a clinical pharmacist had a major impact on reducing prescribing errors in the study period, thus improving the quality and safety of care provided.

Smart pump alerts: all that glitters is not gold

INTRODUCTION

The implementation of smart pump technology can reduce the incidence of errors in the administration of intravenous drugs. This approach involves developing drug libraries for specific units and setting hard and soft limits for each drug. If a programming error occurs and these limits are exceeded, an alarm sounds and the infusion can be blocked. A detailed analysis of these alarms is essential in order not to bias the results in favor of a positive impact of this technology.

PURPOSE

To evaluate the results of the first analysis of the use of smart infusion pumps and to assess the significance and practical implications of the alarms sounded.

METHODS

The study was performed by a multidisciplinary team that consisted of a clinical pharmacist, a pediatrician from the pediatric intensive care unit (PICU), and the chief nurse of the unit. A library of 108 drugs was developed over a 7-month period and introduced into 40 syringe pumps and 12 volumetric pumps (Alaris(®) with Plus software) before being applied in 6 of the 11 beds in the PICU. After four month's use, data were analyzed using the Guardrails(®) CQI v4.1 Event Reporter program.

RESULTS

Following the first four months of implementation, compliance with the drug library was 87%. By analyzing the alerts triggered, we were able to detect problems such as the need to increase user training, readjust limits that did not correspond to clinical practice, correct errors in the editing of the drug library and including a training profile.

CONCLUSION

It is difficult to obtain accurate data on the true impact of this technology in the early stages of its implementation. This preliminary analysis allowed us to identify improvement measures to distinguish, in future evaluations, the alarms triggered by a real programming error from those caused by incorrect use.

Use of romiplostim for primary immune thrombocytopenia in children

Very little has been published on the use of romiplostim to treat primary immune thrombocytopenia (ITP), refractory to previous treatments, in children. The objective of this study was to determine its efficacy and safety in pediatric patients in a university general hospital. Retrospective, longitudinal observational study of pediatric patients on treatment with romiplostim. The principal efficacy variable was platelet count. Safety was evaluated by recording possible adverse reactions to the medication, monitoring the appearance of thrombosis, thrombocytopenia during dose reduction, hemorrhage, and myelodysplastic syndromes. Three patients in the authors' center have been treated with romiplostim (subcutaneous [SC], initial dose: 1 μg/kg/week) for ITP refractory to various treatments: 1 with newly diagnosed ITP and 2 with chronic ITP. Patients were followed up for 27 to 39 weeks after starting treatment. Responses were achieved in 7 to 28 days, and complete responses were maintained for 37% to 91% of the follow-up period, with median platelet counts between 40 × 10(3)/μL and 215 × 10(3)/μL. The adverse reactions observed during follow-up were headache and asthenia in one patient and mucocutaneous bleeding after dose suspension in another one. With regard to effectiveness, the response in the 3 patients was varied. The drug was considered to be safe, as there were only mild adverse reactions. Although further studies and long-term follow-up are required, these results show that romiplostim could be considered an alternative to immunosuppressive therapies, such as rituximab, or splenectomy in refractory chronic ITP.

Developing a drug library for smart pumps in a pediatric intensive care unit

BACKGROUND

The most serious medication errors occur during intravenous administration. The potential consequences are more serious the more critical and younger the patient. Smart pumps can help to prevent infusion-related programming errors, thanks to associated dose-limiting software known as "drug library". Drug libraries alert the user if pre-determined high dosage limits are exceeded or if entry is below pre-determined low dosage limits.

OBJECTIVE

To describe the process for developing a specific drug library for a pediatric intensive care unit (PICU) and the key factors for preventing programming errors.

METHODS AND MATERIALS

The study was performed by a multidisciplinary team consisting of a clinical pharmacist, a PICU pediatrician, and the chief nurse of the unit. The process of developing the drug library lasted seven months. A literature review was carried out to determine standard concentrations and accurate limits for intravenous administration of high-risk drugs. Alaris(®) syringe pumps and Guardrails(®) CQI v4.1 Event Reporter software were used.

RESULTS

Several manufacturers offer smart pump technology. Users should be aware of differences in features, such as definition of parameters and associations between them, definition of safety limits, organization of the drug library, and data use. Our infusion pump technology covered 108 drugs. Compliance with the drug library was 85% and nurses' acceptance of the drug library was high as 94% would recommend implementation of this technology in other units. After nine months of implementation, several potentially harmful infusion-related programming errors were intercepted.

CONCLUSIONS

Drug libraries are specifically designed for a particular hospital unit, and may condition the success in implementing this technology. Implementation of smart pumps proved effective in intercepting infusion-related programming errors after nine months of implementation in a PICU.

Survey on the situation of telepharmacy as applied to the outpatient care in hospital pharmacy departments in Spain during the COVID-19 pandemic

OBJECTIVE

To analyze the status of the implementation and development of  telepharmacy as applied to the pharmaceutical care of outpatients treated at  hospital pharmacy services in Spain during the COVID-19 pandemic.

METHOD

Six weeks after the beginning of the confinement period, an online 10- question survey was sent to all members of the Spanish Society of Hospital  Pharmacists. A single response per hospital was requested. The survey included  questions on the provision of remote pharmaceutical care prior to the onset of  the health crisis, patient selection criteria, procedures for home delivery of  medications and the means used to deliver them, the number of patients who  benefited from telepharmacy, and the number of referrals made. Finally,  respondents were asked whether a teleconsultation was carried out before  sending patients their medication and whether these deliveries were recorded.

RESULTS

A total of 39.3% (n = 185) of all the hospitals in the National Health  System (covering all of Spain's autonomous regions) responded to the survey.  Before the beginning of the crisis, 83.2% (n = 154) of hospital pharmacy  services did not carry out remote pharmaceutical care activities that included  telepharmacy with remote delivery of medication. During the study period,  119,972 patients were treated, with 134,142 deliveries of medication being  completed. Most hospitals did not use patient selection criteria. A total of 30.2%  of hospitals selected patients based on their personal circumstances. Home  delivery and informed delivery (87%; 116,129 deliveries) was the option used in most cases. The means used to deliver the medication mainly included the use  of external courier services (47.0%; 87 hospitals) or the hospital's own transport services (38.4%; 71 hospitals). As many as 87.6% of hospitals carried out  teleconsultations prior to sending out medications and 59.6% recorded their  telepharmacy activities in the hospital pharmacy appointments record.

CONCLUSIONS

The rate of implementation of telepharmacy in outpatient care in  Spain during the study period in the pandemic was high. This made it possible to guarantee the continuity of care for a large number of patients.

Two-round Delphi technique for the consensual design of a paediatric pharmaceutical care model

The main goal of clinical pharmacists is to improve patient care quality by providing individualised care. This is achieved by validating prescriptions and performing pharmacotherapeutic follow-up, leading to effective, safe and efficient drug therapy. However, there is no specific model for medication order validation in paediatrics addressing the distinct issues of paediatric drug use or the greater susceptibility of medication errors occurring in this patient group. For this reason we intended to design and reach consensus on a paediatric pharmaceutical care model by applying a two-round Delphi technique. In order to define the levels of complexity in reaching consensus for the model, three variables were taken into account: level of access to patient medical and drug records (partial vs. total), access to medical and nursing staff attending the patient (on-site vs. off-site) and the pharmacist available time (limited vs. adequate). In order to describe the minimum items to be included in the validation process at each of the three levels of complexity, we analysed the safety profile in the medication order prescription previously defined in an epidemiological study in eight hospitals with a total capacity of 1565 paediatric beds. A panel of experts was recruited (50 experts from 20 different hospitals) and the questionnaire was completed. Consensus was established at 70% of agreement by experts for an item. Following debate on the items that did not obtain consensus, a second round was performed, after which the final consensus model was defined. After two rounds of consultation, consensus was obtained for 39 out of the 41 items that were surveyed. Of these, 17 were then used for the basic validation model (e.g. weight/age check, dose/weight check), 13 were implemented in the intermediate level (e.g. identification of adverse effects from excipients) and 9 were incorporated at advanced level (e.g. reconciliation at discharge for patients at risk). By applying the model, based on homogenous criteria for action, the clinical pharmacist's role will improve, and in turn, this will doubtlessly reduce drug errors through medication order validation.

Antimicrobial defined daily dose adjusted by weight: a proposal for antibiotic consumption measurement in children

INTRODUCTION

Antimicrobial defined daily dose (DDD), has limitations for antimicrobial consumption measurement in paediatrics. An alternative DDD design applicable for children is proposed.

METHODS

Children (<16 years-old) from 10 Spanish hospitals during a 12-months period were included. Weight for age (50th percentile) was calculated for the median age of the cohort using standardized World Health Organization tables. DDD (g) for each antimicrobial was calculated by multiplying the obtained weight times the recommended dose (mg/kg) of the antimicrobial for the most common infectious indication.

RESULTS

A total of 40,575 children were included. Median age was 4.17 (IQR: 1.36-8.98) and 4.81 (IQR: 1.42-9.60) years for boys and girls, respectively. Mean weight for this age was 17.08kg. Standardized DDD for representative antimicrobials were calculated.

CONCLUSIONS

A useful method for antimicrobial DDD measurement in paediatrics has been proposed and should be validated in future studies for its use in paediatric antimicrobial stewardship programmes.

Implementing smart pump technology in a pediatric intensive care unit: a cost-effective approach

OBJECTIVE

To analyze the cost effectiveness of implementing smart infusion pump technology in a pediatric intensive care unit (PICU).

MATERIAL AND METHODS

An observational, prospective, intervention study with analytical components was carried out. A drug library was developed and integrated into the Carefusion Alaris Guardrails® infusion systems. A systematic analysis of all the data stored on the devices during use was performed by the data processing program Guardrails® CQI v4.1 Event Reporter. Intercepted errors were classified in terms of their potential severity and probability of causing an adverse effect (PAE) had they reached the patient. Knowing the estimated cost of a preventable adverse effect (AE), we analyzed costs saved and the profit/cost ratio resulting from the implementation process.

RESULTS

Compliance with the drug library was 92% and during the study period 92 infusion-related programming errors were intercepted, leading to a saving of 172,279 euros by preventing AEs. This means that 2.15 euros would be obtained for each euro invested in hiring a pharmacist to implement this technology.

DISCUSSION

The high percentage of use of safety software in our study compared to others allowed for the interception of 92 errors. The estimation of the potential impact of these errors is based on clinical judgment. The cost saved might be underestimated because the cost of an AE is usually higher in pediatrics, indirect and intangible costs were not considered and pharmacists involved do not spend the whole day on this task.

CONCLUSIONS

Smart pumps have shown to be profitable in a PICU because they have the ability to intercept potentially serious medication errors and reduce costs associated with such errors.

Validation of a method for recording pharmaceutical interventions

WHAT IS KNOWN AND OBJECTIVE

The validation of a method for recording pharmaceutical interventions measures the instrument's ability to provide consistent values when the same analysis is performed several times. Our aim was to validate the inter-rater reliability of the method used to record pharmaceutical interventions in our hospital.

METHODS

We recorded interventions in a database, entering variables related to the patient, treatment and impact of the recommendation. We also recorded the type, cause and clinical significance of the negative outcome associated with use of the medicinal product (NOM). Twenty interventions performed during a 3-year study period (2007-2009) were randomly tested for consistency to analyse the kappa (κ) coefficient statistic of the recommendations as coded by nine senior and junior clinical pharmacists.

RESULTS AND DISCUSSION

There were 87·8% global consistency for NOM cause, 66·1% for intervention impact and 95·0% for NOM type. Agreement was substantial for 'intervention reasons', with a κ value of 0·74 (95%CI 0·61-0·87), fair for 'intervention impact', with a κ value of 0·24 (95%CI 0·15-0·32) and excellent for 'NOM type', with a κ value of 0·87 (95%CI 0·71-1·00), respectively. Our results are globally good, especially with regard to the analysis of intervention reasons and NOM type, which matches other authors' findings. Furthermore, our validation method is suitable for recording and considering the impact of pharmaceutical interventions.

WHAT IS NEW AND CONCLUSION

We describe a systematic method for clinical pharmacists to record their activities and assess their value. This methodology should help in the development of clinical pharmacy in Spain and should be translatable to other settings.

Implementation of smart pump technology in a paediatric intensive care unit

Patient safety is a matter of major concern that involves every health professional. Nowadays, emerging technologies such as smart pumps can diminish medication errors as well as standardise and improve clinical practice with the subsequent benefits for patients. The aim of this paper was to describe the smart pump implementation process in a paediatric intensive care unit (PICU) and to present the most relevant infusion-related programming errors that were prevented. This was a comparative study between CareFusion Alaris Guardrails(®) and Hospira MedNet(®) systems, as well as a prospective and intervention study with analytical components carried out in the PICU of Gregorio Marañón General and Teaching Hospital. All intravenous infusions programmed with a pump in the eleven beds of the unit were analyzed. A drug library was developed and subsequently loaded into CareFusion and Hospira pumps that were used during a three month period each. The most suitable system for implementation was selected according to their differences in features and users' acceptance. Data stored in the pumps were analyzed to assess user compliance with the technology, health care setting and type of errors intercepted. The implementation process was carried out with CareFusion systems. Compliance with the technology was 92% and user acceptance was high. Vacation substitution and drug administration periods were significantly associated with a greater number of infusion-related programming errors. High risk drugs were involved in 48% of intercepted errors. Based on these results we can conclude that implementation of smart pumps proved effective in intercepting infusion-related programming errors from reaching patients. User awareness of the importance of programming infusions with the drug library is the key to succeed in the implementation process.

Multicenter randomized clinical trial comparing dexamethasone versus placebo in preventing upper airway obstruction after extubation in critically ill children

To analyze the effectiveness of dexamethasone in preventing upper airway obstruction (UAO) symptoms after extubation and the need of reintubation in critically ill children. Multicenter, prospective, double-blind, randomized, phase IV clinical trial involving five pediatric intensive care units. Children between 1 month and 16 years-of-age intubated for more than 48 h were included. Patients were randomized to receive placebo or dexamethasone 0.25 mg/kg every 6 h, 6-to-12 h prior to extubation (four doses). 48 h follow-up was carried out after extubation. Severity of UAO symptoms (Taussig score, stridor) and reintubation requirement were compared. 147 patients were randomized (10 were excluded), 70 patients received dexamethasone and 67 placebo. No global differences were found in the presence of stridor or moderate-to-severe UAO symptoms (Taussig ≥ 5), but Taussig ≥ 5 was less frequent in patients less than 2 years-of-age treated with steroids (p = 0.014). Median Taussig score was lower in the dexamethasone group 1 h after extubation, p < 0.001. 27 patients required reintubation, 9 due to UAO: 3 (4.3%) in the dexamethasone group and 6 (8.9%) in the placebo group, p = 0.319. In those intubated > 5 days, reintubation due to UAO was higher in the placebo group (2.4% vs. 14.3, p = 0.052). Nebulized epinephrine and budesonide were required more frequently in the placebo group in the first 2 h (p = 0.041) and 1 h (p = 0.02) after extubation, respectively. No relevant side effects were observed. Dexamethasone prior to extubation did not significantly reduce moderate-severe UAO symptoms, except for patients under 2-years of age. Dexamethasone could decrease Taussig score and the need of rescue therapies, as well as reintubation rates in those intubated for more than 5 days.

[Development of the Q-PEX standard for quality certification of pharmaceutical care for outpatients of Pharmacy services]

OBJECTIVE

The objective of this study is to describe the process of creation and development of the quality certification standard for pharmaceutical care for outpatients of the Pharmacy services.

METHOD

The methodology was carried out by a group of experts from the Spanish Society of Hospital Pharmacy (SEFH) and consisted of three phases: situation analysis, development of the standard and definition of the self-assessment tool and, finally, piloting in several hospitals, determining its feasibility, carrying out a new revision and readaptation.

RESULTS

A standard was defined with 118 items distributed in ten areas. Of these, 19 were considered compulsory, 36 basic, 40 medium and 23 advanced. Three levels of certification were established, as well as the definition and percentages of compliance with the requirements. The certification process was divided into two stages, the one of previous preparation and the audit itself, where the initial certification would be covered, with four phases - first three led by the certification Company, and the last one by SEFH and the subsequent follow-up and re-certification audits. Two hospitals piloted the process carried out the piloting of the whole process, both obtaining a basic level after the adoption of measures and corrective actions, after which the final definition of the external evaluation of the standard and the name of the standard was agreed upon «Q-PEX», as well as, the registration of the intellectual property of said standard in July-2020.

CONCLUSIONS

The standard for certification of the quality of pharmaceutical care for outpatients developed aims to help the continuous advancement of Hospital Pharmacy services.

Outpatients' Opinion And Experience Regarding Telepharmacy During The COVID-19 Pandemic: The Enopex Project

Background

Telepharmacy, as a remote pharmaceutical care procedure, is being used worldwide during the COVID-19 pandemic, with the aim of preserving the health of patients and professionals. Its future development should incorporate the assessment of patient perception, but no research study has investigated it.

Objective

The objective was to poll the opinions and experiences of outpatients with telepharmacy through a purpose-developed questionnaire and to assess it’s quality through an internal validity and reliability analysis.

Methods

Cross-sectional observational study of adult patients who used telepharmacy services during the COVID-19 lockdown period in Spain. The subjects answered a 24-item questionnaire, after giving their informed consent. Place of delivery, informed pharmacotherapeutic follow-up, opinion about telepharmacy, future development, ethics/satisfaction, and coordination constituted the six questionnaire categories. After assessing the adequate sample size with the Kaiser–Meyer–Olkin test, the Bartlett sphericity test analyzed the validity of the questionnaire. The intraclass correlation coefficient and Cronbach’s α coefficient calculations verified the reliability and internal consistency.

Results

A total of 9442 interviews were administered to patients from 81 hospitals, of which 8079 were valid (52.8% female). A 54.1% were aged between 41–65 years; 42.7% had been in treatment for more than 5 years; 42.8% lived between 6–31 miles from the hospital. As many as 96.7% of patients were “satisfied” or “very satisfied” with telepharmacy, 97.5% considering it complementary to their usual follow-up; 55.9% expressed a preference for being followed up face to face when visiting the hospital. 75.6% said they had rather receive their medication at home. The sample size obtained was deemed appropriate [the Kaiser–Meyer–Olkin test (0.789) and Bartlett’s sphericity test (p<0.005)]. The reliability analysis resulted in a Cronbach α = 0.7.

Conclusion

Patients have shown high satisfaction with telepharmacy and the ENOPEX questionnaire is a tool with sufficient validity and reliability to be used in the evaluation of the care that patients receive through telepharmacy.

[Adecuacy of pediatric antimicrobial prescribing in the Emergency Department at discharge]

INTRODUCTION

In January 2019, Community of Madrid's Health Department published a guide about the use of antimicrobials in outpatient children. Taking this regional Guide as reference, this study was aimed at estimating the adequacy of the antimicrobial stewardship at discharge from a pediatric Emergency Department (ED). Secondarily, the differences in adequacy according to the diagnosis and the prescriber were studied, and the agreement between this Guide and the protocols of the ED was assessed.

MATERIAL AND METHODS

An observational, descriptive, retrospective study was conducted on patients under 16 years old, with a diagnosis included in the regional Guide who were discharged from a pediatric ED between March of 2018 and February of 2019. Prescription was considered adequate when the indication, the antibiotic and the posology (dosage, dosing interval, length of treatment and route of administration) were correct.

RESULTS

165 out of 648 (25,5%) infectious diseases processes analyzed received antimicrobial treatment. In 23 processes treated with antimicrobial, the adequacy could not be evaluated due to the absence of data necessary to assess any aspect of posology. Therapy was considered appropriate in 550/625 processes (88.0%). When antimicrobial treatment was prescribed, 70/142 (49.3%) were appropriate and no statistically significant differences in adequacy were found between prescribers. Posology was the worst handled point of the prescription (26.3%). Tract urinary infection, conjunctivitis and otitis media were the pathologies with the lowest adecuacy (44.4%; 50.0% and 52.2%) and presented the highest discrepancy between the Guide and the center protocols (k=0.308; k=0.000; k=0.586).

CONCLUSIONS

The adequacy of the management of infectious processes to the reference Guide in our pediatric ED was high, but it was below 50% when antimicrobial treatment was required. The degree of adequacy to the local protocols of the center was greater than to the regional Guide. This reveals a discrepancy between the 2documents that should be analyzed and corrected according to the available scientific evidence.

Safe intravenous administration in pediatrics: A 5-year Pediatric Intensive Care Unit experience with smart pumps

OBJECTIVES

To estimate the impact of smart pump implementation in a pediatric intensive care unit in terms of number and type of administration errors intercepted.

DESIGN

Observational, prospective study carried out from January 2010 to March 2015 with syringe and great volumen infusion pumps available in the hospital.

SETTING

A tertiary level hospital pediatric intensive care unit.

PARTICIPANTS

Infusions delivered with infusion pumps in all pediatric intensive care unit patients.

INTERVENTIONS

Design of a drug library with safety limits for all intravenous drugs prescribed.

MAIN VARIABLES

Users' compliance with drug library as well as number and type of errors prevented were analyzed.

RESULTS

Two hundred and eighty-three errors were intercepted during 62 months of study. A high risk drug was involved in 58% of prevented errors, such as adrenergic agonists and antagonists, sedatives, analgesics, neuromuscular blockers, opioids, potassium and insulin. Users' average compliance with the safety software was 84%.

CONCLUSIONS

Smart pumps implementation has proven effective in intercepting high risk drugs programming errors. These results might be exportable to other critical care units, involving pediatric or adult patients. Interdisciplinary colaboration is key to succeed in this process.

Prevention and treatment of intraluminal catheter thrombosis in children hospitalised in a paediatric intensive care unit

AIM

The aim of the study was to develop and implement a protocol for the prevention and treatment of catheter related intraluminal thrombosis in a paediatric intensive care unit

METHODS

A computerised search was carried out on MEDLINE, through PubMed, using the medical subject heading 'central venous catheter', 'central venous access device', 'central venous line' associated with 'occlusion', 'obstruction', 'catheter-related thrombosis', 'critically ill patients' and 'thrombolytic therapy'. References of reviewed articles were also searched for relevant titles as well as non-randomised controlled trials and series of cases when no information of higher level of evidence was available.

RESULTS

With the information gathered, a protocol for the prevention and treatment of catheter related intraluminal thrombosis was elaborated and those recommendations that best suit our environment were included. They were agreed upon by a broad panel of professionals working in the Pediatric Intensive Care Unit and the Pharmacy Department.

CONCLUSIONS

Due to the variety of options available for the pharmacotherapeutic management of intraluminal catheter thrombosis, one measure to improve the quality of the therapy and to diminish the variability in the prescription could be the implementation of a protocol as described in this paper.

Bromocriptine for the treatment of postoperative cerebellar mutism syndrome in pediatric patients: Three case reports

INTRODUCTION

Cerebellar mutism syndrome (CMS) is a common complication after posterior fossa tumor resection. It is characterized by a significant lack or loss of speech. Its biological origin remains unclear and there are no standardized treatments. However, bromocriptine seems to be a possible treatment for this condition.

CASE REPORT

In this paper, we present three cases of pediatric patients (4, 5, and 17-year old) who developed CMS after posterior fossa tumor surgery. They were treated with bromocriptine to improve neurological symptoms.Management and outcome: Bromocriptine was started at a low dose and was progressively increased to reach the minimum effective dose. After four months of treatment, a normal and fluid speech was observed in the three patients. No discontinuation due to adverse events were reported.

DISCUSSION

Bromocriptine has shown to be an effective and safe treatment for CMS in pediatric patients after posterior fossa tumor resection.

Treatment and prophylaxis of catheter-related thromboembolic events in children

PURPOSE

The therapeutic management of catheter-related thromboembolic events in children is still a challenge due to the large number of potentially effective pharmacological alternatives and the insufficient scientific evidence available. A bibliographic review was performed in order to identify the available pharmacological alternatives for the prophylaxis and therapeutic management of catheter-related thrombosis in children.

METHODS

A literature search was carried out on MEDLINE using the medical subject heading (MeSH) central venous catheter thrombosis and on Google Scholar. The search was limited to review papers, meta-analyses, clinical practice guidelines, and randomized controlled trials performed on pediatric populations until November 2011.

RESULTS

The different options for anticoagulation include unfractionated heparin, low molecular weight heparin and vitamin K antagonists. Thrombus resolution is stimulated more rapidly with thrombolytic agents than with anticoagulants, but the risk-benefit ratio must be considered. Streptokinase is not considered an optimal alternative due to the risk of anaphylactic reactions and has been replaced by urokinase, alteplase or the newer reteplase. Preventive strategies have been considered and most centers have protocols for routine flushing of the catheter with heparin or normal saline. Intraluminal application of urokinase and alteplase has also been studied.

CONCLUSIONS

The wide range of options available for the pharmacotherapeutic management of catheter-related thromboembolism in children and the lack of strong evidence on the comparative efficacy and safety of the different therapeutic options, make its positioning rather difficult. Randomized controlled trials and national plans should be set up urgently.

[Association between paracetamol exposure and asthma: update and practice guidelines]

Asthma prevalence has increased over the last few decades, especially in developed countries, and possibly due to different reasons. An association between paracetamol use or exposure at different periods of life, including gestation and childhood, and asthma prevalence has been observed in the last few years. Causality can not be established from observational reports, due to the arguable presence of many confounding factors and biases. Randomised trials are needed to elucidate the nature of this association. The Spanish Paediatric societies subscribing to this paper consider that current evidence is insufficient to discourage the use of paracetamol during gestation or in children with or at risk of asthma.