Pentobarbital sedation for patients in the pediatric intensive care unit.

We present our experience with pentobarbital for sedation during mechanical ventilation in six infants when fentanyl and midazolam failed. The patients ranged in age from 2 to 17 months and in weight from 3.0 to 11.4 kg. Before the switch to pentobarbital, the maximum doses of fentanyl ranged from 7 to 13 micrograms/kg/hr and the midazolam infusions, from 0.2 to 0.4 mg/kg/hr. Pentobarbital was administered as a bolus dose followed by a continuous infusion. The hourly infusion rates ranged from 1 to 4 mg/kg. Adequate sedation was achieved in all six patients. In the four patients who required neuromuscular blocking agents, their use was discontinued after pentobarbital was given. The antihypertensive agents (diazoxide and nitroprusside) required by the two patients receiving extracorporeal membrane oxygenation were also discontinued after pentobarbital administration. Although we continue to use fentanyl and benzodiazepines as first-line drugs for sedation, pentobarbital may be an effective alternative when these agents fail.

Outpatient therapy of iatrogenic drug dependency following prolonged sedation in the pediatric intensive care unit.

The authors present their clinical experience with the oral administration of lorazepam, methadone, and pentobarbital to prevent or treat withdrawal symptoms following prolonged sedation in the PICU patient. The 3 patients presented required prolonged sedation for mechanical ventilation. Different agents were used for sedation in the 3 patients including intravenous fentanyl, midazolam, and pentobarbital. The switch to oral agents must take into consideration the differences in potency, half-life, and oral bioavailability between the agents. The authors discuss the appropriate conversion factors for opioids, benzodiazepines, and barbiturates. The switch to oral administration eliminated the need for intravenous access in the 3 patients and allowed for earlier discharge home. All 3 patients were discharged home on an oral, taper schedule. Such an approach may lead to earlier home discharge thereby improving the patient's quality of life as well as saving health care dollars.

Stability of midazolam prepared for oral administration.

Midazolam is used frequently as an oral premedication in children. To make it more palatable, it is often mixed in various syrups and solutions. No previous studies have documented the stability of midazolam when mixed in these solutions. Using high-pressure liquid chromatography, we assayed midazolam concentrations over time when mixed at two different concentrations (2.5 mg/mL and 3.0 mg/mL) in a sucrose-based syrup (Simple Syrup, NF). Each assay was done in triplicate on three different days (days 1, 14, and 38). Solution A concentrations (2.5 mg/mL) were 2.28 mg/mL on day 1, mg/mL) were 2.82 mg/mL on day 1, 2.91 mg/mL on day 14, and 2.24 mg/mL on day 38. Our results confirm the stability of midazolam for up to 14 days when mixed for oral administration.

Ondansetron to prevent emesis following N-acetylcysteine for acetaminophen intoxication.

We present a 17-year-old girl who developed persistent vomiting following acetaminophen overdose. Because of the amount of drug ingested (300 mg/kg acetaminophen) and the four-hour postingestion level (256 micrograms/ml), administration of N-acetylcysteine (NAC) was indicated. Emesis occurred immediately following the first three doses of NAC despite administering the drug by continuous nasogastric drip over one hour. Prior to the next attempt, ondansetron (0.15 mg/kg) was administered intravenously as an antiemetic. Thirty minutes following ondansetron, NAC was tolerated without further emesis. Although several antiemetics may have prevented further emesis, we chose ondansetron since, as a serotonin antagonist, it does not cause extrapyramidal side effects or sedation. In patients with potentially toxic drug ingestions, these side effects may be confused with or mask the adverse effects of the ingested drug, thereby interfering with the ongoing evaluation of the patient. Although not previously administered for this indication, ondansetron has several advantages over other antiemetic agents in the setting of an acute drug ingestion.

Group A meningococcal disease in the U.S. Pacific Northwest: epidemiology, clinical features, and effect of a vaccination control program.

In 1975 an outbreak of group A meningococcal disease began in Seattle, Washington, and cases subsequently were recognized throughout the Pacific Northwest. Nearly one-half of the affected persons were Native Americans; two-thirds were alcohol abusers and/or habitués of skid road communities. In Seattle, group A meningococci colonized asymptomatic persons only if these individuals had contact with skid road (P = .006). The epidemic strain may have spread from American Indians in Manitoba, Canada. Traditional migration routes connect the two populations; asymptomatic American Indians on reservations in Washington carried group A meningococci. Vaccination programs were undertaken in four cities but only after cases occurred. In Seattle, vaccination reached 80% of the target population and was associated with a significant decrease in incidence of the disease, but cases recurred after the program ended. The social habits of skid road communities, combined with the "case-triggering" approach to, and premature termination of, vaccination programs, may have resulted in 56% of regional cases occurring after the start of the vaccination program in Seattle.