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Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil's safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks' gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.
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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.
RESUMEN
STUDY OBJECTIVE: To compare the likelihood of alternative vancomycin dosing strategies based on weight, height, or body surface area (BSA) in achieving isometric vancomycin area under the serum concentration-time curve (AUC) values across the body size distribution of children and young adults. DESIGN: Maximum a posteriori probability Bayesian (MAP-Bayesian) pharmacokinetic analysis using retrospectively collected medical record data. SETTING: Children's hospital. PATIENTS: A total of 115 patients 1-20 years of age managed outside of the intensive care unit who were treated with vancomycin between May 1, 2011, and August 31, 2012, and had a minimum of two serum vancomycin concentration measurements. MEASUREMENTS AND MAIN RESULTS: Vancomycin dosing and concentration-time information along with demographic and laboratory data related to kidney function estimation were extracted from the patients' medical records. A previously structured one-compartment model was used to derive MAP-Bayesian estimates of pharmacokinetic system parameters for each patient. Post hoc linear and power function regression were used to compare clearance (Cl) and the volume of distribution of the central compartment (Vc) to body size descriptors (weight, height, and BSA). The relationship of the body size descriptor-indexed parameter across the body size distribution was assessed. The AUC from time 0 to 24 hours (AUC24 ) values associated with vancomycin dosing regimens based on weight, height, and BSA were estimated. The 115 patients (56.5% male) had a mean ± SD age, height, and weight of 9.7 ± 5.4 years, 133 ± 32.3 cm, and 38.0 ± 24.2 kg, respectively. Each patient received a minimum of four doses of vancomycin and had two to nine serum vancomycin concentration measurements, for a total of 313 measurements for all patients. Vancomycin Cl was a nonlinear function of weight and a linear-proportionate function of BSA, whereas the volume of distribution of the central compartment (Vc) was a linear-proportionate function of weight. The expected median (5th-95th percentile) AUC24 values with weight-based dosing of vancomycin 60-70 mg/kg/day were 446 (315-834) mg·hour/L and 649 (385-1165) mg·hour/L in patients weighing less than 40 kg (n=72) and those weighing 40 kg or more (n=43), respectively. In contrast, isometric AUC24 values were predicted with BSA-based dosing across the body size distribution. CONCLUSION: BSA-based dosing is more likely than weight-based (mg/kg) dosing of vancomycin to achieve isometric AUC24 values across the body size distribution of children and young adults. Pharmacokinetic studies that compare these two vancomycin dosing strategies in children are clearly needed to validate these findings.