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INTRODUCTION: The objective of this project was to assess the percentage of interoperability compliance within our pediatric hematology/oncology patient care areas for intravenous chemotherapy medications before and after the implementation of circle priming. METHODS: We conducted a retrospective quality improvement project at an inpatient pediatric hematology/oncology floor and outpatient pediatric infusion center before and after implementation of circle priming. RESULTS: There was a statistically significant increase in percent interoperability compliance for the inpatient pediatric hematology/oncology floor from 4.1% prior to implementation of circle priming to 35.6% after (odds ratio 13.1 (95% CI, 3.96-43.1), p < 0.001), as well as for the outpatient pediatric infusion center from 18.5% to 47.3%, respectively (odds ratio 3.9 (95% CI, 2.7-5.9), p < 0.001). CONCLUSION: Implementation of circle priming has significantly increased the percentage of interoperability compliance for intravenous chemotherapy medications in our pediatric hematology/oncology patient care areas.

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Type B lactic acidosis can occur secondary to several factors, including thiamine deficiency, and is not as common as type A. Recognizing thiamine deficiency-associated lactic acidosis is challenging because serum thiamine concentrations are not routinely obtained, and a thorough and specific history is necessary for clinicians to suspect thiamine deficiency as a root cause. Furthermore, the appropriate dose and duration of thiamine treatment are not well defined. Untreated thiamine deficiency-associated lactic acidosis can lead to critical illness requiring lifesaving extracorporeal therapies. Additionally, if thiamine and glucose are not administered in an appropriate sequence, Wernicke encephalopathy or Korsakoff syndrome may occur. This review aims to summarize therapeutic treatment for thiamine deficiency-associated lactic acidosis, based on case reports/series and nutritional guidance. After a literature search of the PubMed database, 63 citations met inclusion criteria, of which 21 involved pediatric patients and are the focus of this review. -Citations describe dosing regimens ranging from 25 to 1000 mg of intravenous (IV) thiamine as a single dose, or multiple daily doses for several days. Specific guidance for critically ill adults recommends a thiamine range of 100 mg IV once daily to 400 mg IV twice daily. Although there are no specific recommendations for the pediatric population, given the relative safety of thiamine administration, its low cost, and our review of the literature, treatment with thiamine 100 to 200 mg IV at least once is supported, with ongoing daily doses based on clinical response of the patient, regardless of age.

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OBJECTIVE: Meningococcal disease, caused by Neisseria meningitidis, is associated with severe illness and death. The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices have published recommendations for the use of meningococcal vaccines in the United States. The primary objective of this study is to compare meningococcal serogroup B vaccination rates among adolescents at 4 diverse outpatient clinics. METHODS: In this retrospective chart review, patients between the ages of 16 and 23 years were identified by using automated dispensing cabinet records of meningococcal serogroup ACWY vaccine removal. Immunization records were reviewed to determine if meningococcal serogroup B vaccine had been administered. Patients from 2 pediatric clinics and 2 family medicine clinics were included in our analysis. RESULTS: Two hundred sixty-five patients were identified for review and 134 patients were included in our study. Of these, 43 (32%) had received the full meningococcal serogroup B vaccine series and 32 (24%) had completed the vaccine series for both meningococcal serogroup B and meningococcal serogroup ACWY series. Most patients who had completed a meningococcal serogroup B vaccine series presented to a pediatric clinic. CONCLUSIONS: Less than half of adolescent patients completed their meningococcal B vaccine series at 4 diverse outpatient clinics, with a greater number of patients receiving vaccinations at pediatric clinics than family medicine clinics. Our findings highlight a need for increased education to providers regarding the current meningococcal B vaccination recommendations.

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BACKGROUND: Dinutuximab, an immune-mediated therapy indicated for high-risk neuroblastoma, targets the protein disialoganglioside (GD2) on neuroblastoma cells, neurons, and peripheral nerve fibers. Off-target effects lead to severe nerve pain. Pain regimens including continuous infusion opioids are required during treatment courses. Our institution utilizes a combination of intravenous (i.v.) lidocaine infusions and morphine for the treatment of dinutuximab-associated neuropathic pain. OBJECTIVE: The primary outcome of this study was to compare morphine equivalents for cycle 1 of dinutuximab at an institution that uses i.v. lidocaine (primary) versus those that do not (comparison). Secondary outcomes included both dinutuximab infusion time and safety of i.v. lidocaine. METHODS: A retrospective, multicentered, electronic chart review was performed at three tertiary academic medical centers. Patients between 0 and 18 years of age during their first course of dinutuximab were included to evaluate the primary outcome of adjuvant morphine equivalents needed. RESULTS: Twenty-one patients were identified for inclusion. Total morphine equivalents at the primary institution were 1.87 mg/kg versus 1.79 mg/kg at the comparison institutions (P = 0.413). Dinutuximab infusion time was statistically significantly less at the primary institution: 610.5 minutes versus 676.23 minutes (P = 0.046). Only one patient at the primary institution experienced nausea, vomiting, and paresthesias. CONCLUSIONS: This study did not find a statistically significant difference in morphine equivalents between patients receiving i.v. lidocaine and those who did not. Lidocaine use resulted in a statistically significant lower dinutuximab infusion time. Our data suggest it is a safe adjuvant medication, for use outside of the pediatric intensive care unit, in the treatment of dinutuximab-associated neuropathic pain.

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BACKGROUND: Approximately 30% of antimicrobials prescribed in the outpatient setting are unnecessary and up to 50% are inappropriate. Despite this, antimicrobial stewardship (AS) efforts mostly focus on the inpatient setting, and limited data describe AS interventions at hospital discharge. Acknowledging the potential value of discharge AS, we used our existing resources to review discharge oral antimicrobial prescriptions. OBJECTIVE: The primary objective of this retrospective, single-center study was to evaluate the impact of an AS program on discharge oral antimicrobial prescriptions. METHODS: Discharge oral antimicrobial prescriptions sent to our hospital-operated outpatient pharmacy, reviewed by an infectious diseases (ID) pharmacist, and recorded into our data collection tool from September 1, 2020, to February 28, 2021, were evaluated retrospectively. The primary outcome was to identify the frequency a drug-related problem (DRP) was identified by an ID pharmacist. Secondary outcomes included DRP characterization, percentage of prescriptions with interventions, intervention acceptance rate, and reduction in antimicrobial days dispensed at discharge when interventions to limit treatment duration were accepted. RESULTS: Of the 803 discharge oral antimicrobial prescriptions reviewed, at least 1 DRP was identified in 43.1% (346/803). The most frequently identified DRPs pertained to treatment duration, drug selection, and dose selection. At least 1 intervention was recommended in 42.8% (344/803) of prescriptions. In total, 438 interventions were made and the acceptance rate was 75.6% (331/438). The most common types of interventions included recommendations for a different duration, a different dose or frequency, and antimicrobial discontinuation. When interventions to reduce treatment duration were accepted, the median (interquartile range) number of antimicrobial days decreased from 8 (5-10) days to 4 (0-5.5) days (P < 0.001). CONCLUSION AND RELEVANCE: An ID pharmacist's review of discharge oral antimicrobial prescriptions sent to our hospital-operated outpatient pharmacy resulted in identification of DRPs and subsequent interventions in a substantial number of prescriptions.

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Purpose: The purpose of the article is to describe the successful use of parenteral olanzapine intravenously (IV) in a critically ill patient with severe agitated delirium. Summary: A 70-year-old man was admitted to the medical intensive care unit requiring plasmapheresis with platelet counts consistently below 20 000/µL secondary to thrombotic thrombocytopenic purpura (TTP). The patient had experienced agitated delirium requiring treatment, which was complicated by electrocardiogram (EKG) findings of a prolonged QTc interval. The antipsychotics the patient was receiving were believed to be responsible and, as such, the team desired an option that would have a lesser chance of worsening QTc (baseline-corrected QT) interval. Olanzapine was chosen and given IV versus the U.S. Food and Drug Administration (FDA)-approved parenteral route of intramuscular (IM) due to concern of bleeding. The patient's delirious state responded to treatment to varying degrees and showed no increase in EKG abnormalities. To our knowledge, there is a paucity of published literature regarding this route of administration. Conclusion: Intramuscular olanzapine used IV may be a safe and effective option for the treatment of acutely agitated, delirious, critically ill patient.