RESUMO
OBJECTIVES: Haemodynamic changes following intravenous acetaminophen are well studied in adults. Limited data are published in critically ill paediatric patients, especially from the Middle East. We aim to investigate haemodynamic effects and incidence of hypotension with intravenous acetaminophen in critically ill children, with a focus on understanding factors influencing these effects. METHODS: We retrospectively reviewed patients who received intravenous acetaminophen between July and December 2022. A haemodynamic event was defined as drop of >15% in systolic blood pressure (SBP) or mean arterial blood pressure (MAP) within 120 min after drug administration. Hypotension was defined as either drop in SBP below the 5th percentile for age, or a haemodynamic event associated with tachycardia, increased lactate or treatment with fluid/vasopressors. Logistic regression was performed to quantify relationships between patients' characteristics and the occurrence of haemodynamic event and hypotension. RESULTS: A haemodynamic event was observed in 50/156 patients (32%) post-acetaminophen. Mean MAP (SD) before and after acetaminophen was 69.6 mm Hg (14.8) and 67.4 mm Hg (13.9), respectively (p=0.001). Mean SBP (SD) before and after acetaminophen was 95.4 mm Hg (18.2) and 92.8 mm Hg (19.2), respectively (p=0.006). Baseline MAP, median (interquartile range (IQR)) was 76.0 (64.0-85.3) and 66.0 (57.0-74.5) in patients with and without haemodynamic events, respectively (p=0.004). Only 38/156 patients (24%) met the definition for hypotension. Baseline MAP, median (IQR) was 62.0 (51.8-79.0) in patients with, and 68.5 (62.0, 79.3) in patients without hypotension (p=0.036). Baseline shock, vasoactives, mechanical ventilation and paediatric sequential organ failure assessment were not significantly associated with hypotension. Only MAP was found to be associated with both haemodynamic event (adjusted odds ratio (AOR) 1.05, 95% CI 1.02-1.10) and hypotension (AOR 1.06, 95% CI 1.02-1.10) even after controlling for other confounders. CONCLUSIONS: Administration of intravenous acetaminophen in critically ill children can lead to haemodynamic changes, including clinically significant hypotensive events.
RESUMO
OBJECTIVES: Vancomycin is a glycopeptide antibiotic commonly used in neonatal intensive care units (NICUs) to treat late onset sepsis. It is recommended that vancomycin trough levels at steady state following intermittent dosing regimen be maintained at 10-20 mg/L, which is largely dependent on the type of infection. Our objective is to assess the ability of initial vancomycin dosing regimens to obtain target trough levels and to assess the percentage and risk factors associated with the development of acute kidney injury (AKI) while on vancomycin. METHODS: This is a retrospective review of all NICU patients admitted between January 2016 and December 2017 who received vancomycin according to the NeoFax at either 10 mg/kg/dose (low-dose group, LDG) or 15 mg/kg/dose (high-dose group, HDG), with a frequency based on the postmenstrual age (PMA) and postnatal age (PNA). Both regimens were compared by their ability to attain target trough levels and the episodes of vancomycin-induced AKI. Other outcomes included identification of risk factors associated with the development of vancomycin-induced nephrotoxicity. RESULTS: Of 182 patients evaluated, 44 (24%) were in the LDG and 138 patients (76%) were in the HDG. Ninety-one patients (50%) attained target trough levels of 10-20 mg/L. Among these and according to patients' PMA, 48% in the HDG versus 7% in the LDG in PMA ≤29 weeks and 69% in the HDG versus 18% in the LDG in PMA 30-36 weeks attained target trough levels (p=0.006 and p<0.001, respectively). According to PNA, 47% in the HDG versus none in the LDG in patients <7 days old and 61% in the HDG versus 10% in the LDG in patients aged 8-14 days attained target trough levels (p=0.025 and p=0.016, respectively). A total of 14% developed AKI in the LDG vs 7% in the HDG (p=0.225). Only PMA ≤29 weeks (OR, 4.5, 95% CI 1.5 to 13), vancomycin trough levels >20 mg/L (OR 5.1, 95% CI 1.5 to 17), hypotension (OR 11.02, 95% CI 3.5 to 34) and furosemide (OR 4.4, 95% CI 1.4 to 13.5) were significantly associated with vancomycin-induced AKI in our NICU. CONCLUSION: Vancomycin dosing in neonates according to the NeoFax did not provide sufficient attainment of target trough levels (10-20 mg/L). However, using the higher dosing range at 15 mg/kg/dose was more likely to reach target levels, with no measured increased risk of nephrotoxicity. Extreme premature neonates, supratherapeutic vancomycin trough levels, hypotension and furosemide use are associated with an increased incidence of vancomycin-induced nephrotoxicity.
