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To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost.This is a pre- and postimplementation quality improvement study.An 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital.Patients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion.Change in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs.Timing studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p0.01). Nursing satisfaction increased from 19.3% pre- to 100% post implementation. Safety was assessed via barcode scanning compliance, which decreased by 1.4% for patients and 1% for medications, and smart pump limit overrides. The percentage of infusion pump bolus overrides increased as expected, with the majority (99%) of these exceeding soft maximum limits by less than two-fold. Central line entries were unaffected post implementation. To assess medication utilization, a total of 50 patients in each intervention group were selected for retrospective chart review. Daily fentanyl boluses increased from one to three (p = 0.021). However, midazolam infusion dose and fentanyl infusion duration decreased (p = 0.026 and p = 0.005, respectively). Medication utilization was otherwise unchanged post implementation (p0.05). Annualized cost avoidance was $124,160.Implementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.

ObjectiveFactors contributing to postoperative complications include blood loss and a heightened inflammatory response. The objective of this study was to test the hypothesis that aprotinin would decrease perioperative blood product use, reduce biomarkers of inflammation, and result in improved clinical outcome parameters in neonates undergoing cardiac operations.MethodsThis was a secondary retrospective analysis of a clinical trial whereby neonates undergoing cardiac surgery received either aprotinin (n = 34; before May 2008) or tranexamic acid (n = 42; after May 2008). Perioperative blood product use, clinical course, and measurements of cytokines were compared.ResultsUse of perioperative red blood cells, cryoprecipitate, and platelets was reduced in neonates receiving aprotinin compared with tranexamic acid (P

Gabapentin is a gamma-aminobutyric acid analog used for numerous neurologic conditions, including neuropathic pain and epilepsy. We describe a 39-week gestational age, male infant with hypotonicity, functional short gut, and microduplication of chromosome 22 who was treated with gabapentin to control pain and irritability. During his hospitalization, the infant experienced multiple complications including respiratory distress, persistent pulmonary hypertension of the newborn, hypocalcemia, hypoglycemia, hyperbilirubinemia, gastroesophageal reflux, necrotizing enterocolitis, and cholestatic jaundice. Pain associated with related invasive procedures and surgeries was treated with intermittent and scheduled morphine. In addition to postoperative and procedural pain, the infant continued to experience pain and irritability attributed to neurologic impairment, presumably secondary to his chromosomal abnormality. Trials of scheduled lorazepam along with intermittent morphine and phenobarbital were unsuccessful in managing these symptoms. After failure of nonpharmacologic treatment and continued trials of sedatives and analgesics, gabapentin 5 mg/kg at bedtime was started on day of life 98. Improvement in the infant's tone and disposition was noted by numerous health care professionals and the infant's mother. In addition, the infant's pain scores, using the Pain Assessment in Neonates Scale, showed marked improvement. The infant continued to receive gabapentin; the dosage was increased to 10 mg/kg at bedtime after 6 days, then to 5 mg/kg in the morning and 10 mg/kg at bedtime 10 days later. When the infant was 7 months old, his mother requested that gabapentin be discontinued. He was slowly weaned, and the drug was discontinued when he was 11 months old. The infant tolerated gabapentin well except for experiencing nystagmus, which was noted 31 days after starting the drug and resolved after drug discontinuation. Clinicians should be aware of gabapentin as an alternative treatment for pain and irritability in neurologically impaired infants. Further study is needed, however, to verify the drug's safety and efficacy in neonates and infants. Standardized pain scales along with close patient monitoring will help to guide clinicians in dosage titration to optimize therapy.