Hospital Readmissions in Children with Pulmonary Hypertension: A Multi-Institutional Analysis.

OBJECTIVE: To assess the rate of and risk factors for 30-day hospital readmission in children with pulmonary hypertension. STUDY DESIGN: The Pediatric Health Information System database was analyzed for patients ≤18 years old with pulmonary hypertension (International Classification of Diseases, Ninth Revision, diagnosis codes of 416.0, 416.1, 416.8, or 416.9) admitted from 2005 through 2014. A generalized hierarchical regression model was used to determine significant ORs and 95% CIs associated with 30-day readmission. RESULTS: A total of 13580 patients met inclusion criteria (median age 1.7 years [IQR 0.3-8.7], 45.3% with congenital heart disease). Admissions increased 4-fold throughout the study period. Associated hospital charges increased from $119 million in 2004 to $929 million in 2014. During initial admission, 57.4% of patients required admission to the intensive care unit, and 48.2% required mechanical ventilation. The 30-day readmission rate was 26.3%. Mortality during readmission was 4.2%. Factors increasing odds of readmission included a lower hospital volume of pulmonary hypertension admissions (1.41 [1.23-1.57], P < .001) and having public insurance (1.26 [1.16-1.38], P < .001). Decreased odds of readmission were associated with older age and the presence of congenital heart disease (0.86 [0.79-0.93], P < .001). CONCLUSIONS: The pediatric pulmonary hypertension population carries significant morbidity, as reflected by a high use of intensive care unit resources and a high 30-day readmission rate. Younger patients and those with public insurance represent particularly at-risk groups.

Evaluating the safety of intermittent intravenous sildenafil in infants with pulmonary hypertension.

OBJECTIVE: To compare the occurrence of hypotension following administration of intermittent intravenous (IV) and enteral sildenafil for treatment of pulmonary hypertension (PH) in infants. We hypothesized there may be more adverse effects associated with intermittent IV sildenafil compared with enteral sildenafil. METHODS: This was a retrospective matched-cohort study conducted in a tertiary care children's hospital. Patients were included if they were less than 1 year of age and received intermittent sildenafil for PH. Exclusion criteria consisted of concurrent extracorporeal membrane oxygenation during the initiation of sildenafil, the utilization of sildenafil as a one-time dose, continuation of home-dosing regimen, or inclusion in the other cohort. A total of 40 patients were matched 1:1 based on postmenstrual age and primary diagnosis. RESULTS: There was no statistically significant difference in the primary outcome, as 30% (6/20) of patients receiving IV sildenafil required a hypotension intervention compared with 10% (2/20) in the enteral cohort (P = 0.24). The majority of interventions occurred within 24 hr of the initiation of sildenafil with 4/6 patients (67%) in the IV group and 2/2 patients (100%) in the enteral group, respectively. Baseline mean arterial pressure was significantly lower in the IV patients that required an intervention compared with those that did not (44 ± 6.3 vs. 65 ± 13.4 mmHg, P = 0.0024). CONCLUSIONS: There were no statistically significant differences in safety outcomes between intermittent IV and enteral sildenafil in infants with PH. Hemodynamic parameters should be monitored closely upon sildenafil initiation. Limitations include the retrospective nature and small sample size. Pediatr Pulmonol. 2017;52:232-237. © 2016 Wiley Periodicals, Inc.

Readmissions for warfarin-related bleeding in pediatric patients after hospital discharge.

BACKGROUND: Warfarin therapy in pediatric patients can be difficult to manage with bleeding as a primary adverse event. Therapy initiation can be difficult as doses to achieve therapeutic outcomes are being determined. Evaluation of readmission for bleeding in pediatric patients discharged on warfarin therapy may be useful to prevent adverse events. METHODS: The Pediatric Health Information System (PHIS) was queried to identify all patients <19 years of age who were discharged from a pediatric hospital on warfarin therapy. Patients who were readmitted with bleeding in the first 30 days after discharge were identified and patient variables, hospital stay variables, and medications at discharge were identified. Univariate and multivariate analysis was performed to identify independent risk factors for bleeding readmission. RESULTS: A total of 4,883 patients met study criteria (56% male, mean age 10.1 + 5.9 years). The two most common indications for warfarin therapy were cardiac valve replacement (23.6%) and Fontan procedure (19.5%). Ninety-seven patients (1.99%) were readmitted with bleeding within 30 days of discharge [median time 9 days (IQR 5-16 days)]. Multivariate analysis identified Asian race (OR 4.0, P < 0.01); mitral valve replacement (OR 2.5, P < 0.01); escitalopram at discharge (OR 4.2, P = 0.02); levofloxacin at discharge (OR 8.3, P < 0.01); lansoprazole at discharge (OR 1.7, P = 0.047); and length of stay (OR 1.01, P = 0.047) as significant for bleeding readmission. CONCLUSION: Pediatric patients discharged on warfarin may be readmitted for bleeding within 30 days if risk factors are present. Risk factors include patient genetic profile, drug interactions, and indications with higher goal INR values.

Evaluation of weight-based dosing of unfractionated heparin in obese children.

OBJECTIVE: To determine whether pediatric patients with obesity receiving weight-based dosages of unfractionated heparin (UFH) exhibit an enhanced response when dosed by actual body weight compared with nonobese patients as assessed primarily by the frequency of supratherapeutic anticoagulation. Secondary measures included UFH doses associated with therapeutic anticoagulation. STUDY DESIGN: This single-institution retrospective case-matched study included children with and without obesity, matched on a 1:1 basis, who received a weight-based continuous infusion of UFH. Therapeutic monitoring values were defined for activated partial thromboplastin time (aPTT) level (70-101 seconds) and anti-activated factor X (Xa) level (0.35-0.7 U/mL). RESULTS: The study included 50 children. The percentage of patients with supratherapeutic anticoagulation at any point in the study, as measured by either aPTT or anti-Xa level, was similar in the obese and nonobese groups (76% vs 72%; P = 1.0). However, compared with patients without obesity, those with obesity received a lower mean starting dose (17.4 vs 20.2 U/kg/hour; P = .013) and a lower mean maintenance dose (19.1 vs 24.3 U/kg/hour; P = .033) to achieve stable therapeutic monitoring test values. There was no difference in mean initial post-UFH aPTT between the 2 groups, but the mean initial anti-Xa level was higher in the obese group (0.45 vs 0.29 U/mL; P = .045). CONCLUSION: Compared with children without obesity, those with obesity who received actual body weight-based continuous UFH infusions did not exhibit a higher frequency of supratherapeutic anticoagulation, but did require lower dosages to achieve comparable anticoagulation. Our results highlight recognized discrepancies between aPTT and anti-Xa monitoring assays.

Comparison of anti-Xa levels in obese and non-obese pediatric patients receiving treatment doses of enoxaparin.

OBJECTIVE: To determine if using actual body weight to dose enoxaparin in obese pediatric patients results in higher anti-Xa levels compared with non-obese pediatric patients. STUDY DESIGN: This was a retrospective case-matched study of obese and non-obese pediatric patients receiving treatment doses of enoxaparin in a tertiary care children's hospital. Patients were included if they were initiated on treatment doses of enoxaparin, had appropriate anti-Xa levels drawn, and were between 2 and 18 years of age. Patients with renal insufficiency, hyperbilirubinemia, goal anti-Xa level <0.5 or >1 unit/mL, or receiving mechanical circulatory support were excluded. Obese patients who met study criteria were matched on a 1:1 basis with non-obese patients. RESULTS: All baseline characteristics were similar except for body mass index percentile (98.2 ± 2 vs 48.7 ± 15, P < .01). Obese patients had higher initial anti-Xa levels (0.67 ± 0.27 vs 0.53 ± 0.24 unit/mL, P = .028). Over time, obese patients required a lower mean dose to achieve therapeutic anti-Xa levels than non-obese patients (0.81 ± 0.19 vs 1.1 ± 0.4 mg/kg, P = .005). CONCLUSIONS: The mean initial anti-Xa level was higher in obese pediatric patients compared with non-obese pediatric patients, but a dosage adjustment was not required. Obese patients may need closer monitoring over time to avoid supratherapeutic levels and possible bleeding events.

Vancomycin dosing in obese pediatric patients.

BACKGROUND: Data are lacking to guide antimicrobial dosing for overweight children. The authors hypothesized that obese children would have increased vancomycin serum trough concentrations compared with nonobese children. METHODS: A matched study design was employed to compare retrospectively vancomycin trough concentrations. RESULTS: Among 24 matched pairs, obese patients received 14.1 ± 1.5 mg per kilogram and nonobese children 14.9 ± 0.9 mg per kilogram of vancomycin per kilogram of vancomycin (P = .03). There was a trend toward higher vancomycin serum concentrations in obese (6.9 ± 4.30 µg/mL) versus nonobese children (4.8 ± 3.08 µg/mL; P = .052). Mean half-life in obese patients was 2.9 ± 0.29 hours and volume of distribution was 0.35 ± 0.15 L/kg. CONCLUSIONS: Since obesity did not alter vancomycin trough concentrations, overweight children should receive vancomycin based on actual body weight. However, since vancomycin troughs were substantially lower than those recommended for adults, further studies of vancomycin metabolism in children are needed.

Comparison of L-selectin and CD11b on neutrophils of adults and neonates during the first month of life.

The newborn infant is particularly susceptible to infection in the first weeks of life and this may be, in part, related to functional impairment of neonatal neutrophils in regard to adherence, chemotaxis, and migration. Differences in expression of the neutrophil adherence molecules, L-selectin and CD11b/CD18 (Mac-1), have been previously demonstrated in cord blood and in very young infants (