Taste and/or Odour Disturbances in Pediatric Patients Undergoing IV Flush with Normal Saline Administered by Prefilled Syringe.

BACKGROUND: At the Children's Hospital of Eastern Ontario, more than 6000 inpatients per year undergo IV saline flushes by prefilled syringe to assess and maintain patency of IV tubing. In studies involving adults, it has been reported that volatile substances may leach from syringe materials into the saline, leading to taste and/or odour disturbances. OBJECTIVE: To determine the incidence of taste and/or odour disturbances in pediatric patients after flushing of IV tubing with 0.9% sodium chloride (normal saline [NS]) from prefilled syringes. METHODS: Inpatients aged 5-18 years who had undergone routine flushing of central or peripheral IV tubing with commercially available prefilled NS syringes were interviewed. Children aged 5-10 years used a visual hedonic scale to rate taste and odour sensations, and those aged 11-18 years used a numeric rating scale. RESULTS: During the study period (April to July 2011), a total of 104 pediatric inpatients (21 aged 5-10 years and 83 aged 11-18 years) underwent NS flushing of central (10 patients [10%]) or peripheral (94 patients [90%]) tubing. For 100 of these patients, BD Posiflush NaCl 0.9% 10-mL sterile prefilled syringes were used, and for 4 patients BD Saline XS NaCl 0.9% 10-mL sterile prefilled syringes were used. Taste and/or odour disturbances were reported by 76 (73%) of the patients. Twelve patients described more than one taste or odour sensation. Taste and odour disturbances were detected by children in both age groups. CONCLUSIONS: Flushing of IV tubing with prefilled NS syringes resulted in taste and/or odour disturbances in a pediatric population.

Volunteer satisfaction and program evaluation at a pediatric hospice.

RATIONALE: Volunteers are essential to the functioning of palliative care programs and serve as important members of the hospice team. They devote much time, effort, and diverse skills and talent to enhance the quality of care at Roger's House--a pediatric palliative care hospice. OBJECTIVES: To evaluate volunteering in a pediatric palliative care hospice and to assess the level of satisfaction from the perspective of hospice volunteers. METHODS: A survey was sent to all active Roger's House volunteers. Questions were related to their demographics, their overall impression of their volunteering experience, and 47 closed (fixed-choice) statements, divided into 6 parts: 1) Orientation; 2) Training; 3) Feedback/Performance; 4) Communication; 5) Social Contacts; and 6) Value and Respect. Each statement was rated by the participants using a six-point Likert rating scale. RESULTS: Volunteers fully completing the survey were 159 online and 4 on paper, giving a response rate of 66%. The greater number (66, 40.5%) of respondents were 50 years or older and they were mostly female (141, 86.5%). Successes identified included the volunteers' orientation, training, and feedback and performance. Challenges identified included certain aspects of communication, social contacts, and respect/value for the volunteer. CONCLUSION: Volunteers at Roger's House are generally satisfied with their volunteer position and the environment in which they work. Greater insight into volunteer satisfaction and factors that bring feelings of reward and/or dissatisfaction to the volunteers have allowed Roger's House to identify informed and effective interventions to improve the quality of and satisfaction with the hospice volunteer program.

Evaluation, modification and validation of a set of asthma illustrations in children with chronic asthma in the emergency department.

OBJECTIVES: To test, modify and validate a set of illustrations depicting different levels of asthma control and common asthma triggers in pediatric patients (and/or their parents) with chronic asthma who presented to the emergency department at the Children's Hospital of Eastern Ontario, Ottawa, Ontario. METHODS: Semistructured interviews using guessability and translucency questionnaires tested the comprehensibility of 15 illustrations depicting different levels of asthma control and common asthma triggers in children 10 to 17 years of age, and parents of children one to nine years of age who presented to the emergency department. Illustrations with an overall guessability score <80% and/or translucency median score <6, were reviewed by the study team and modified by the study's graphic designer. Modifications were made based on key concepts identified by study participants. RESULTS: A total of 80 patients were interviewed. Seven of the original 15 illustrations (47%) required modifications to obtain the prespecified guessability and translucency goals. CONCLUSION: The authors successfully developed, modified and validated a set of 15 illustrations representing different levels of asthma control and common asthma triggers. PRACTICE IMPLICATIONS: These illustrations will be incorporated into a child-friendly asthma action plan that enables the child to be involved in his or her asthma self-management care.

Improved practices for safe administration of intravenous bolus morphine in a pediatric setting.

Postoperative pain control is a clinical imperative, for which morphine is a preferred opioid. However, interpatient variability and drug accumulation with repeated doses, as well as medication errors, may result in respiratory arrest with this medication. Early detection of respiratory depression is essential for safe use of morphine, following both initial and repeated doses. A multidisciplinary team contributed to development of an intravenous (IV) bolus morphine monitoring guideline that reflects current knowledge of morphine pharmacokinetics. Monitoring over a 22-week period in a postsurgical unit was then assessed via record review. A total of 270 postsurgical patients received a first dose of IV bolus morphine, with 784 subsequent doses also administered. Complete monitoring (heart rate, respiratory rate, blood pressure, sedation score, oxygen saturation, and pain score) after the morphine bolus was documented at baseline and 10 and 20 minutes for 34%, 30%, and 23%, respectively, of the patients; partial monitoring (respiratory rate and oxygen saturation) was documented for an additional 22%, 15%, and 9% of patients; 43% of subsequent morphine doses were followed with complete monitoring, and an additional 30% with at least partial monitoring. Adherence to the monitoring procedure fluctuated over the study period with no consistent upward or downward trend. A small number of children exhibited a reduced respiratory rate potentially indicating respiratory depression, but no child required antidote or respiratory support. Despite suboptimal guideline adherence, potential signs of respiratory depression were detected that might otherwise have gone unnoticed. This validates the improved guideline and suggests that some incidents may have remained undetected. Front-line staff must be involved to optimize change, champion the initiative, and promote patient safety.

Review of prescribing practices for intermittent bolus administration of morphine.

BACKGROUND: Several changes to medication safety practices were proposed in a pediatric hospital, including changing the period of patient observation after administration of opioids and limiting the availability of various concentrations of morphine in the patient care unit. OBJECTIVE: To document and review postoperative pain management for children on a surgical ward, specifically with regard to intermittent IV bolus administration of morphine, to help in assessing the impact of the proposed nursing practice changes. METHODS: Data were collected from records for narcotics and controlled drugs for the surgical ward over a 3-month period (April to June 2006). For each patient, data had been recorded for up to 7 consecutive days after surgery. A patient's data were included in the review if he or she had received at least 2 doses of morphine by IV bolus, except for the review of weight-based dosing pattern (mg/kg), for which all patients who had received at least one dose of IV morphine were included. RESULTS: Charts for 193 patients were audited. Of these, 163 patients (84.5%) had recieved up to 0.1 mg/kg per dose, and 53 (27.5%) had received only one dose of morphine. Among patients who received more than one dose, the median dose was 0.080 mg/kg on day 1, with a decrease by day 5 to 0.065 mg/kg. Most patients received morphine over the first 2 days after surgery. The median time elapsed between doses was 4.3 h on day 1 and 6.2 h on day 2. Of the 1020 doses included in the analysis, most (801 [78.5%]) were 4 mg or less. CONCLUSION: The intermittent administration of IV bolus doses of morphine at the study hospital followed common standards for the treatment of postoperative pain. Most doses were no more than 4 mg. On the basis of this information, only 2-mg vials of morphine are now stocked on the ward. The hospital's change in monitoring practices will increase the surveillance of patients receiving IV bolus doses of morphine.

Off-label drug use in pediatric anesthesia and intensive care according to official and pediatric reference formularies.

PURPOSE: In pediatric practice, the official drug label often does not accurately reflect the contemporary use of many drugs prescribed to children. Therefore, clinicians frequently use contemporary drug references as a source of prescribing information instead of national formularies. The objective of this study was to compare drug prescriptions between two national formularies and two commonly used contemporary pediatric reference guidelines in the operating room/postanesthetic care unit (OR/PACU), pediatric intensive care unit (PICU), and neonatal intensive care unit (NICU). METHODS: We performed a retrospective chart review of patients admitted over a one-month period to the NICU and PICU, and for one week during the same month, we reviewed charts of patients in the OR/PACU. The data collected included patients' demographic information, drugs prescribed, and dosage information. We assessed conformity with two national formularies, the Canadian Compendium of Pharmaceuticals and Specialties (CPS) and France's 2009 Dictionnaire Vidal (Vidal), and two contemporary pediatric references, the Hospital for Sick Children Handbook and Formulary and the Lexi-Comp Pediatric Dosage Handbook. RESULTS: Across the three clinical units, 59.7% (95% confidence interval [CI] 57.1-62.1%) of prescriptions were identified as being off-label, as defined by the CPS formulary. The odds of having an off-label prescription would have been substantially lower if the contemporary pediatric references (odds ratio [OR] = 0.074; 95% CI 0.065-0.084) or Vidal (OR = 0.70; 95% CI 0.63-0.77) had been used to define the label (both P < 0.001 compared with the CPS). CONCLUSION: Drugs are less likely to be off-label if prescribed according to a contemporary pediatric reference rather than according to national formularies. Methodologies used to compile contemporary references might serve as templates to inform a drug's official label.

Targeted inactivation of EGF receptor inhibits renal collecting duct development and function.

The ureteric bud (UB) expresses high levels of the EGF receptor (EGFR) during kidney development, but its function in this setting is unclear. Here, Egfr mRNA was abundant in medullary portions of the UB trunk but absent from the branching UB tips during embryogenesis. Homozygous Egfr knockout did not affect the pattern of UB arborization, but renal papillae were hypoplastic and exhibited widespread apoptosis of tubular cells. Because these EGFR-deficient mice die within 1 week of life, we targeted Egfr inactivation to the renal collecting ducts using Cre-lox technology with a Hoxb7-Cre transgene. This targeted inactivation of Egfr led to a thin renal medulla, and at 7 weeks of age, the mice had moderate polyuria and reduced urine-concentrating ability. At 30 to 33 weeks, water deprivation demonstrated a continued urine-concentrating defect despite similar levels of vasopressin between knockout mice and littermate controls. Taken together, these results suggest that unlike other tyrosine kinases expressed at the UB tip, EGFR functions primarily to drive elongation of the emerging collecting ducts and to optimize urine-concentrating ability.

Stability of diclofenac sodium oral suspensions packaged in amber polyvinyl chloride bottles.

BACKGROUND: Prescribing of diclofenac for children usually involves a dose different from commercially available strengths. This drug is available only as tablets, which can be divided only so many times before the dose obtained becomes inaccurate. In addition, children may have difficulty swallowing tablets. For these reasons, a compounding formula for a liquid dosage form is essential to ensure effective delivery of the drug to pediatric patients. OBJECTIVES: To develop a compounding formula for diclofenac sodium and to determine the extended physical and chemical stability of this compound when stored in amber polyvinyl chloride (PVC) prescription bottles under refrigeration and at room temperature. METHODS: A suspension of diclofenac sodium (10 mg/mL) was prepared from commercially available diclofenac sodium tablets, with Ora-Blend as the suspending and flavouring agent. The suspension was packaged in 60-mL amber PVC prescription bottles and stored at either room temperature (23°C) or under refrigeration (5°C). Samples were collected on days 0, 7, 14, 21, 27, 56, and 93. Chemical stability was determined using a validated stability-indicating high-performance liquid chromatography method. At each sampling time, the suspensions were checked for changes in appearance (i.e., colour, layering, caking, ease of resuspension), odour, and pH. RESULTS: The diclofenac sodium suspensions were very stable, retaining at least 99.5% of the original concentration for up to 93 days, regardless of storage temperature. There were no apparent changes in the physical appearance of the suspensions, nor were there any substantial changes in odour or pH. CONCLUSIONS: Suspensions of diclofenac sodium (10 mg/mL) were quantitatively stable but difficult to prepare because of the enteric coating of the tablets. Therefore, it is recommended that diclofenac powder be used for the preparation of suspensions. For pediatric use, palatability is a consideration, and a masking agent should be added before administration. An expiry date of up to 93 days is suggested.

A comparative cost-minimization analysis of providing paediatric palliative respite care before and after the opening of services at a paediatric hospice.

A palliative care service provider may add or decrease overall operational costs to the healthcare system. This study assessed the costs of managing respite care for children with life-limiting illness at the Children's Hospital of Eastern Ontario for the 12-month period both before and after services at Roger's House (RH, a paediatric hospice) was made available. The opening and operation of RH for providing respite care resulted in a minimization of operational costs (n = 66 patients, mean decrease of $4,251.95 per month per patient).

Common variants of the glial cell-derived neurotrophic factor gene do not influence kidney size of the healthy newborn.

Glial cell-derived neurotrophic factor (GDNF) plays an important role in renal development, serving as a trophic factor for outgrowth of the ureteric bud and its continued arborisation. Our previous studies have shown that common variants of the human paired-box 2 (PAX2) gene (a transcriptional activator of GDNF) and rearranged during transfection (RET) gene (encoding the cognate receptor for GDNF) are associated with a subtle reduction in the kidney size of newborns. Since heterozygosity for a mutant GDNF allele causes mild renal hypoplasia and modest hypertension in mice, we considered the possibility that common variants of the GDNF gene might also contribute to renal hypoplasia in humans. We studied the relationship between newborn renal size or umbilical cord cystatin C and 19 common GDNF gene variants [minor allele frequency (MAF) >5%], three single nucleotide polymorphisms (SNPs) related to a putative PAX binding site and one rare SNP (rs36119840 A/G) which changes an amino acid (R93W), based on data from the haplotype map of the human genome (HapMap). However, none of these 23 SNPs was associated with reduced newborn kidney size or function. Among the 163 Caucasians in our cohort, none had the R93W allele.

Buffered lidocaine hydrochloride solution with and without epinephrine: stability in polypropylene syringes.

BACKGROUND: Pain associated with infiltrating the skin with lidocaine can be reduced by buffering the solution with sodium bicarbonate. OBJECTIVES: To determine the physical compatibility and chemical stability of lidocaine hydrochloride solution buffered with 8.4% sodium bicarbonate, with and without epinephrine, packaged in polypropylene syringes and stored at 5°C with protection from light. METHODS: Lidocaine solutions (1% and 2%), with and without epinephrine 1:100 000, were diluted 10:1 with 8.4% sodium bicarbonate, packaged in 3-mL polypropylene syringes, and stored at 5°C (range 3°C to 8°C). On each of days 0, 3, 7, 10, 14, 17, 21, 24, and 28, the contents of 3 syringes for each solution of lidocaine combined with epinephrine were collected separately in glass vials and frozen at -70°C for subsequent analysis. In addition, on days 0, 7, 14, 21, and 28, the contents of 3 syringes for each lidocaine solution without epinephrine were collected separately in glass vials and frozen at -70°C for subsequent analysis. Chemical stability was determined with a validated, stability-indicating high-performance liquid chromatography method. Changes in colour, clarity, and pH were used to determine physical compatibility of the solutions. RESULTS: All buffered lidocaine solutions containing epinephrine (1:100 000) retained at least 93.3% of the original concentration of epinephrine and 97.5% of the lidocaine concentration for 7 days when stored at 5°C with protection from light. In contrast, the epinephrine-free solutions retained at least 94.7% of the initial concentration of lidocaine for the duration of the study (28 days). All samples remained clear, colourless, and free of precipitate throughout the study, and there were no significant changes in pH. CONCLUSION: Extemporaneously prepared buffered lidocaine (1% and 2%) packaged in polypropylene syringes remained stable for up to 28 days when properly refrigerated with protection from light. A 7-day expiry date was established for buffered lidocaine solutions containing epinephrine, packaged in polypropylene syringes, and stored with refrigeration and protection from light.

Stability of celecoxib oral suspension.

BACKGROUND: Celecoxib is a selective cyclo-oxygenase 2 inhibitor that relieves pain without affecting platelet function, causing gastrointestinal toxic effects, or increasing the risk of bleeding. OBJECTIVES: To develop a suspension formulation for oral celecoxib and to determine its physical and chemical stability when packaged in amber polyvinyl chloride (PVC) bottles and stored with refrigeration (5°C) and at room temperature (23°C). METHODS: The contents of celecoxib capsules were used to prepare a single suspension, with Ora-Blend used as the suspending and flavouring agent. The suspension (10 mg/mL) was then packaged in amber PVC bottles and stored at either 5°C or 23°C. Samples were collected on days 0, 7, 14, 21, 27, 56, and 93. Chemical stability was determined using a validated stability-indicating high-performance liquid chromatography method. At each sampling time, the suspensions were checked visually for changes in appearance (i.e., colour, layering, caking, and ease of resuspension), odour, and pH. RESULTS: All of the suspensions were stable for at least 93 days, regardless of storage conditions. There were no apparent changes in physical appearance, nor were there any substantial changes in odour or pH. CONCLUSIONS: Suspensions of celecoxib (10 mg/mL in Ora-Blend) packaged in amber PVC bottles were stable for up to 93 days when stored at 5°C or 23°C. A 3-month expiry date has been established for this oral suspension on the basis of physical compatibility and chemical stability.

A common RET variant is associated with reduced newborn kidney size and function.

Congenital nephron number varies five-fold among normal humans, and individuals at the lower end of this range may have an increased lifetime risk for essential hypertension or renal insufficiency; however, the mechanisms that determine nephron number are unknown. This study tested the hypothesis that common hypomorphic variants of the RET gene, which encodes a tyrosine kinase receptor critical for renal branching morphogenesis, might account for subtle renal hypoplasia in some normal newborns. A common single-nucleotide polymorphism (rs1800860 G/A) was identified within an exonic splicing enhancer in exon 7. The adenosine variant at mRNA position 1476 reduced affinity for spliceosome proteins, enhanced the likelihood of aberrant mRNA splicing, and diminished the level of functional transcript in human cells. In vivo, normal white newborns with an rs1800860(1476A) allele had kidney volumes 10% smaller and cord blood cystatin C levels 9% higher than those with the rs1800860(1476G) allele. These findings suggest that the RET(1476A) allele, in combination with other common polymorphic developmental genes, may account for subtle renal hypoplasia in a significant proportion of the white population. Whether this gene variant affects clinical outcomes requires further study.

A common variant of the PAX2 gene is associated with reduced newborn kidney size.

Congenital nephron number ranges widely in the human population. Suboptimal nephron number may be associated with increased risk for essential hypertension and susceptibility to renal injury, but the factors that set nephron number during kidney development are unknown. In renal-coloboma syndrome, renal hypoplasia and reduced nephron number are due to heterozygous mutations of the PAX2 gene. This study tested for an association between a common haplotype of the PAX2 gene and subtle renal hypoplasia in normal newborns. A PAX2 haplotype was identified to occur in 18.5% of the newborn cohort, which was significantly associated with a 10% reduction in newborn kidney volume adjusted for body surface area. This haplotype was also associated with reduced allele-specific PAX2 mRNA level in a human renal cell carcinoma cell line. Subtle renal hypoplasia in normal newborns may be partially due to a common variant of the PAX2 gene that reduces mRNA expression during kidney development.