Oral pentobarbital suspension for children sedation during MR imaging.

OBJECTIVES: The efficacy and safety of an oral pentobarbital suspension for sedation during pediatric MR imaging were assessed. METHODS: Data were recorded from October 2016 to January 2017. The exact dose of oral pentobarbital suspension was given for each child with an oral syringe. Parameters recorded included the patient's age and weight, the time required to sedate, the duration of sedation, the time required to discharge, and quality of MR imaging. The adverse effects were recorded. RESULTS: Oral pentobarbital suspension was administered to 81 children aged from 8 months to 8 years at a dose of 5mg/kg of body weight. The mean time required to sedate was 30±21min, a mean time of sedation of 47±23min, and a mean time to discharge of 77±32min. Sedation occurred a satisfied quality of MR imaging in 67% of patients. The failure of examination was essentially due to bad taste of the drug suspension. The overall success rate of sedation in patients less than 12 months was 100%. For ages 1 to 3 years, the success rate decreased to 76% and for ages 4 to 8 years, it decreased to 42%. CONCLUSIONS: Oral pentobarbital suspension used in MR imaging demonstrated its high rate of successful sedation in infants less than 12 months with no adverse effects during the study period.

[Which useful Apps are installed on my smartphone as a clinical pharmacist?] / Quelles Apps utiles sur mon smartphone de pharmacien clinicien ?

Since the advent of PDAs (Personal Digital Assistants), smartphones and Apps have been widely adopted by medical professionals. This craze has increased since 2007 and the first generation iPhone. In this context, 3 questions emerged for the pharmacist that we studied in this review: (1) What Apps are available for practice and how to find them? (2) What is useful for practice? (3) What precautions should be taken?

[Oral administration of medications to infants: Implementation of a preliminary risk analysis in a hospital service of pediatrics]. / Administration orale de médicaments au nourrisson : réalisation d'une analyse préliminaire des risques dans un service d'hospitalisation pédiatrique.

PURPOSE: The objective of this study was to reduce the risk of errors when administering oral medications to infants aged 28 days to 2 years. MATERIAL AND METHODS: The method of the preliminary risk analysis (PRA) was implemented by a multidisciplinary group in a hospital service of pediatrics. The study focused on the phase of preparation of drugs by nurses before administration. RESULTS: This analysis revealed 41 scenari, 16 were criticality unacceptable. In particular, their analysis highlighted the impact of the drug dosage form, the lack of scientific information and the human factor on this preparation. Eleven action sheets have been written. DISCUSSION: The risk management requires significant human investment, material resources and organizational solutions: formations, information, i.e. computerized prescribing, dispensing and administering system, centralized drug preparations, automated drugs cabinets or unit drug daily dispensing system. CONCLUSION: Control these risks means to get specific actions at pediatric wards, enhance dispensing system by the hospital pharmacist and the support of the pharmaceutical industry to get commercially available pediatric drugs.

[Drug interactions in an elderly population. Prospective assessment of their frequency and seriousness among 56 patients]. / Interactions médicamenteuses dans une population âgée.

OBJECTIVE: To assess the nature and the number of potential adverse drug interactions by analysis of outpatient prescriptions for elderly patients, of medications taken during the week before hospitalization in a general surgery department. METHOD: The study of 56 patients older than 65 years was conducted from November 2002 through February 2003. The outpatient prescriptions corresponding to medications taken during the 7 days before admission were analyzed by a pharmacy resident, who used data-processing tools and databases. RESULTS: Most patients (83%) knew the reason for their prescription. Thirteen (28%) reported using over-the-counter medication. Only 89% of the patients reported complete compliance with the prescription. The average age of the patients was 72.1 +/- 6.3 years and the median was 71 years [65-91]; 43% were women and 57% men. The 257 lines of prescriptions analyzed averaged 5.7 +/- 2.6 drugs (range: 2-10) per prescription. The average number of possible interactions was 3.1 +/- 2.8 per prescription for a total of 89 listed potential interactions. The levels observed were 3 warnings (3%), 37 precautions (42%) and 49 possible adverse interactions (55%). No contraindication was noted. The drugs mentioned most often were benzodiazepines, diuretics, conversion enzyme inhibitors, angiotensin II inhibitors, and beta-blockers. The potential risks most often found were hypotension, depression of the central nervous system, hypoglycemia and acute renal failure. The drug interactions were mainly due to the accumulation of the effects of separate drug classes. Deterioration in renal function was often noted as plasma concentration of the second drug increased. DISCUSSION: This exploratory study shows the reality of the iatrogenic risk for elderly patients. This analysis of outpatient prescriptions is consistent with findings in the literature. Analysis of interactions is conducted on a pairwise basis. It is thus difficult to envisage the consequences of the association of 5 or more drugs in patients with complex illnesses and diminished physiological and metabolic capacity. Patient files kept by the pharmacist could provide information about individual combinations ofthe prescription and over-the-counter drugs.

Stability of doxorubicin combined with Radioselectan, a contrast agent, for chemoembolization.

OBJECTIVE: To assess the stability of doxorubicin combined with Radioselectan. METHODS: Solutions of doxorubicin 5 mg/mL were prepared from commercially available 50 mg powder with 10 mL of Radioselectan. They were stored in glass syringes at 4, 25 and 45 degrees C. The concentrations of doxorubicin were determined using a stability-indicating high-performance liquid chromatography method. The initial and final pHs of solutions were compared. The times (t90) needed for doxorubicin to fall to 90% of its initial concentration were calculated by a linear regression analysis. RESULTS: The t90 [95% confidence limits] were 79 [75-83], 56 [53-59] and 22 [21-23] hours for the solutions stored at 4, 25 and 40 degrees C respectively. The initial pH of the solutions stored at 4, 25 and 40 degrees C were 6.52, 6.50 and 6.51 respectively. The final pH of solutions stored at 25 and 40 degrees C decreased significantly by 0.3 and 0.9 respectively. No change of pH solution stored at 4 degrees C was observed. CONCLUSION: Doxorubicin combined with Radioselectan stored at room temperature is stable for 48 h.

Bacterial contamination of enteral nutrition in a paediatric hospital.

A prospective study was performed in a paediatric hospital to evaluate the incidence of bacterial contamination in enteral nutrition bags and to determine the critical points of process. During two separate one-month periods, all children receiving pump-assisted enteral nutrition were enrolled in the study. Samples for microbiological analysis were collected from enteral nutrition bags after administration in the first and second study period (sample T(2)). In the second study period, two additional samples were made at the end of the feed preparation process. One was refrigerated immediately (sample T(0)) and the other was sealed in a tube that followed the enteral nutrition solution until the end of its administration (sample T(1)). Bacterial contamination was detectable above 10(2)cfu/mL. Twenty-six out of 40 patients were included in the first study period and 14 out of 44 in the second study period. Contamination (>10(2)cfu/mL) occurred in nine of 26 samples (35%) and seven of 14 samples (50%) in the first and second study periods, respectively. Of these, five (20%) and three (21%) contained significant contamination (>/=10(4)cfu/mL). Bacteria of low pathogenicity were found in T(0) samples. Bacteria present in T(2) samples were pathogenic and multiple in 50% of cases. These results suggest that manipulation of the enteral nutrition bags at the bedside is critical for bacterial safety.

[Drug administration to paediatric inpatient]. / L'administration des médicaments à l'enfant hospitalisé.

OBJECTIVE: Available commercial drugs in France are often unsuitable for children. The aim of this study was, for every medicinal form orally or parenterally administered, to identify and to quantify difficulties met by the nurses administering drugs to paediatric inpatients and to propose solutions to main identified problems. MATERIAL AND METHOD: The study was realized in 14 hospitals by direct observation. The observer, provided with a questionnaire, followed during a time slot of at least 2 h for one or several nurses and raised all the oral or injectable administrations. RESULTS: One thousand and nine hundred forty-six observations were performed. The children were 12.6 +/- 17 months old, and weighed 8.5 +/- 9.4 kg. Injectable drugs: half of the observations showed a posology and a mode of dilution not corresponding to the summary of product characteristics. Eight percent of orally administered drugs were injectable drugs. In 35.5% of cases, administered amount was lower than the quarter of the present quantity in the therapeutic unity. The rest of the therapeutic unity was thrown (77.2% of cases). Liquid oral forms: liquid oral forms were ready for use regarding 83.8% of cases. The medicine was readministered to the same patient (23.5%), and/or administered to other patients (80.0%). Capsules: 66.9% of the administered capsules were prepared by the hospital pharmacies. The pharmacies organized with an unit dose drug dispensing system produced significantly more preparations than those working by global distribution (P < 0.0001). In 58.4% of cases, the administered capsule was an off-label drug. Tablets: 46% of drug administration concerned a tablet without pediatric indication. 46.7% of tablets were cut, 74% were crushed. Bags: in 35.2% of observations, the bag was not administered in its entirety. CONCLUSION: Our study confirms the unsuitability of drugs to paediatric inpatients, the necessity of recommendations of good practices in the administration of drugs to paediatric inpatients, and proposes corrective actions.

Outbreak of Burkholderia cepacia bacteremia in a pediatric hospital due to contamination of lipid emulsion stoppers.

We describe a 7-month outbreak of nosocomial Burkholderia cepacia bacteremia involving eight children in a pediatric hospital and the results of epidemiological investigations. A B. cepacia strain genotypically identical to the blood isolates was recovered from the upper surface of capped rubber stoppers of bottles of a commercial lipid emulsion used for parenteral nutrition.

The relationship between introduction of American society of clinical oncology guidelines and the use of colony-stimulating factors in clinical practice in a Paris university hospital.

BACKGROUND: Clinical practice guidelines are issued periodically by professional medical societies or committees to assist practitioners in clinical decision making. However, it is unclear whether such guidelines have any lasting impact on clinical practice. OBJECTIVE: The purpose of this study was to assess the impact of the American Society of Clinical Oncology (ASCO) guidelines regarding use of hematopoietic colony-stimulating factors (CSF) on cancer care in a university hospital in Paris. METHODS: The study was performed at Hjpital Tenon, an 830-bed university hospital in Paris, in 1996 and 1997, both before and after the ASCO guidelines were implemented. The guidelines were first disseminated as a continuing medical education program and then actively implemented using a CSF prescription order form summarizing the guidelines. This form had to be used during the patient consultation and was sent to the Hjpital Tenon pharmacy for CSF dispensation. Even if CSF use did not comply with the ASCO guidelines, the pharmacy filled the prescription. Seven other university hospitals in Paris, where the ASCO guidelines were not actively implemented, comprised the control group. The main outcome measure was the proportion of prescriptions in compliance with the 1996 update of the ASCO guidelines. Secondary outcome measures were the proportions of prescriptions in compliance with ASCO guidelines regarding primary prophylactic, secondary prophylactic, and therapeutic CSF administration. RESULTS: Before implementation of the ASCO guidelines, CSF use in compliance with the guidelines was 39% (41/105) at the study site and 31% (16/51) at the control sites (P > 0.05). Six months after dissemination and implementation of the guidelines, the proportion of CSF prescriptions complying with ASCO guidelines increased significantly versus baseline (P = 0.003) in the study group, to 61% (50/82). However, even after the guidelines were implemented, compliance with guidelines on primary prophylactic CSF administration did not change significantly versus before implementation in the study group (12% [5/41] before implementation vs 6% [2/33] after implementation; P > 0.05). CONCLUSIONS: The results suggest an association between the active implementation strategy (continuing medical education and CSF prescription reminder form) and physician compliance with the ASCO guidelines. Implementation of the ASCO guidelines appears to have had some impact on medical practice.

[Pediatric drug preparations in French hospitals. Pediatric Group of the French Clinical Pharmacy Society]. / Les préparations pédiatriques dans les hôpitaux français. Groupe pédiatrique de la Société française de pharmacie clinique.

AIMS: Drug formulations that are specifically intended for pediatric use have not been widely developed in France and do not adequately meet therapeutic needs, particularly as regards hospital requirements. A multicenter study was therefore carried out to evaluate the situation. MATERIALS AND METHODS: A questionnaire was sent out in June 1998 to all French university hospital pharmacies and also to those public and private hospitals known to be involved in pediatric care. Of the 78 questionnaires mailed, 63 answers were received. The information requested concerned all the drug formulations prepared in 1997. RESULTS: Ten out of the 63 hospitals that replied stated that the questionnaire was not relevant in their particular case. Fifty-three answers were therefore evaluated, i.e., corresponding to data from 35 university hospitals, 15 public general hospitals, and three private hospitals. For 7,022 pediatric beds, 1,155,544 units were prepared consisting of 968,520 capsules prepared from 220 active substances, 33,493 liquid preparations for oral intake, 87,592 parenteral nutrition bags, 48,225 injectable antibiotic drugs, 10,663 injectable anticancer agents, and 7,051 miscellaneous sterile preparations. The most frequently prescribed active substances were, in decreasing order of importance, as follows: diphemanil, captopril, fludrocortisone, ranitidine, spironolactone, and ursodesoxycholic acid. A marked heterogeneity was displayed in galenic forms and drug dosages. CONCLUSION: In conclusion, this study has shown the most commonly prescribed drugs and the most frequently prepared dosages for pediatric use. Drug manufacturing companies may find it an useful source of information on the limited pediatric market; it may also encourage pediatricians to homogenize and optimize their therapeutic strategies, and pharmacists to establish specific quality-control procedures. The authors recommend that national guidelines be set up, and it is suggested that the health authorities could participate in organizing the means whereby drugs for pediatric use are made more readily available.

Multicenter study of the impact of prescription guidelines on the use of colony stimulating factors.

The aim of this work was to assess the impact of circulating guidelines for correct prescription practices of colony stimulating factors (CSF). Two hospital groups were compared, a 'guidelines' group (seven teaching hospitals) that circulated the guidelines and a control group (eight teaching hospitals) that did not. In addition, two periods were compared before and after distribution of the guidelines: from 17 February to 2 March 1996 and from 17 February to 2 March 1997. The assessment involved compliance with the guidelines for the following parameters: indications, dose regimen, time to start of CSF therapy and duration of CSF therapy between the control and guideline groups and also between the two periods. The population included 404 patients analyzed (209 in 1996 and 195 in 1997) for the indication of post-chemotherapy neutropenia. Total compliance in the first period (all four items) was 44.2% in the control group and 50.8% in the guideline group (nonsignificant), and during the second period was 31.9 and 59.6% in the two groups (p<0.001). During the first period, the differences in compliance with the guidelines for indication, dose regimen, time to start of treatment and duration between the groups were not significant. In the second period, this difference became significant and in favor of the guideline group for dose regimen (p = 0.009) and treatment duration (p = 0.02). The results of this study show the need to continuously define prescription reference systems according to available data, and to circulate them widely to improve the quality of health care and to control expenses.

Impact of ASCO guidelines for the use of hematopoietic colony stimulating factors (CSFs): survey results of fifteen Paris university hospitals.

To assess whether physicians comply with American Society of Clinical Oncology (ASCO) guidelines for the use of CSFs, a prospective survey was performed in 15 Paris university hospitals involved in cancer treatment in 1997. If 45% of the prescriptions complied with the guidelines, primary prophylactic administration, which represented 52% of cases, did not comply with ASCO guidelines. These results suggested that primary prophylactic administration was one major clinical situation in which physicians could benefit from guidance to use a CSFs and that criteria defined by ASCO to allow primary prophylactic administration were not applied in clinical practice.

Baxa MicroMacrocompounder for parenteral nutrition solutions in a pediatric hospital.

The constant increase of parenteral nutrition (PN) manufacturing in our pediatric hospital led us to look for an automatic filling system. The aim of this study was to evaluate the MicroMacrocompounder (MM23) for compounding pediatric PN solutions. MM23 volumetric accuracy was tested with its different inlets (S, D, V) for volumes of sterile water for injection from 0.2 to 2900 mL. The influence of the solution viscosity and the source solution bottle replacements during the filling operation was also investigated. Manufacturing pediatric PN solutions was eventually assessed. Time to set up the system was 30 minutes. Maximum filling speeds with sterile water for injection were 860, 330, 154 mL/min for Vx, V and D inlets, respectively. Inlet S was not tested for MM23 filling speed. Minimal flush volume of 40 mL of sterile water for injection is necessary to clear the tube of residual ions. Average MM23 volumetric accuracy was < 5% for volumes > or = 0.5 mL for S and D inlets, and for volumes > or = 20 mL for V inlet. The volumetric accuracy was equal to 6.25% for 0.2 mL. In all experiments, volumetric accuracy was < 5%. The accuracy of electrolyte measurements performed on bag samples was less than 5% for 150 (74%) samples, between 5 and 10% for 27 (13%) samples and greater than 10% for 27 (13%) samples. Microbiological analysis showed no positive culture. The average manufacturing times were 56.8 +/- 4.5, 188.2 +/- 7.7 and 447.2 +/- 13.8 seconds for 130, 660 and 1800 mL bags, respectively. The MM23 compounder is suitable for compounding pediatric admixtures with source solutions volumes > or = 0.5 mL. This system has been used daily for five months in our department.

Evaluation of a filling system for binary pediatric solutions.

The aim of this study was to assess the use of an automatic filling system (Siframix M31 and M32 system) to prepare pediatric parenteral nutrition. Volumetric accuracy was measured for each siframix system loads cells (< 5% for 5 ml with the Siframix M32 and < 5% for 9 ml with the Siframix M31) with sterile water for injection. The minimal 20 ml of flushing sterile water of the common tubulure of the Siframix M32 (p = 0.211 for 20 ml and p = 0.75 for 500 ml), the use of viscous solutions (70% dextrose) on the Siframix M31 (p = 0.28 for 20 ml and p = 0.12 for 500 ml) and the use of a special tubulure for using E.V.A. Luer-lock bags (p = 0.89 for 20 ml and p = 0.103 for 500 ml) do not modify the accuracy. Changing bags or bottles during the filling operation modify the accuracy (p = 0.004 for 20 ml and p = 0.009 for 500 ml). A flushing operation is necessary to lower the risk of electrolytic pollution for the filling of little bags. The filling speed for each module was also measured (the maximal filling speed was five liters per minute). The Siframix system allows one to prepare pediatric parenteral nutrition bags when volumes are above 4 ml and with adapted source solutions in terms of concentration and conditioning volumes.

[Abortion induced by mifepristone and sulprostone combination: attempting analgesia with acetominophen or dipropyline]. / Interruptions volontaires de grossesse induites par l'association mifepristone-sulprostone: essai d'antalgie par le paracetamol ou la dipropyline.

PIP: 45 women undergoing 1st trimester abortions induced by RU-486 were divided into 3 groups for a double-blind randomized vs. placebo trail of analgesia following sulprostone administration. 600 mg of RU-486 was administered orally 36-48 hours before admission to the hospital. After admission, 10 women received 600 mg of acetaminophen, 14 received 80 mg of dipropyline, and 14 received a placebo. 500 mcg of sulprostone was injected about 30 minutes later. The study excluded method failures, expulsions occurring before hospital admission, deviations from the protocol, and delays to expulsion greater than 8 hours. There was no significant difference between the 3 groups in maximal pain, but the placebo group appeared to experience less discomfort than the other two. The delay to expulsion was significantly longer in the acetaminophen group than in the other two. The relatively lower amount of pain in the placebo group was probably due to the reduced proportion of nulliparas in it compared to the other 2 groups. 6 women in the acetaminophen group, 9 in the dipropyline group, and only 5 in the placebo group were nulliparas. Comparing nulliparas with mothers within groups, the maximal pain was significantly less intense among mothers than among nulliparas in the placebo group and to a lesser extent in the dipropyline group but not in the acetaminophen group. Based on these results it is recommended that a systematic study be made of analgesia for RU-486 and sulprostone-induced abortions. An antispasmodic effect on the cervical fibers should be sought more than analgesia per se.^ieng