Neonatal Abstinence Syndrome: A Review of Treatment in the Neonatal Intensive Care Unit.

Background: Neonatal abstinence syndrome (NAS) is a collection of symptoms that neonates may experience following antenatal exposure to substances that induce withdrawal. Optimal management remains unknown, and there is variation in management and outcomes. Objectives: To describe the management, length of hospitalization, and adverse events in near-term and full-term neonates with NAS for whom treatment (pharmacotherapy and/or supportive care) was initiated in the neonatal intensive care unit (NICU). Methods: A chart review was conducted of neonates admitted to the NICU of Surrey Memorial Hospital, Surrey, British Columbia, who received treatment for NAS between September 1, 2016, and September 1, 2021. Results: A total of 48 neonates met the inclusion criteria. Opioids represented the most frequent type of antenatal exposure. Polysubstance exposures occurred in 45 (94%) of the neonates. Morphine was given to 29 (60%) of the neonates, and phenobarbital to 6 (13%); 5 of these neonates received both medications. The average duration of morphine treatment was 14 days, and the average length of hospitalization (all patients) was 16 days. All of the neonates experienced adverse events; in particular, 9 (30%) of the 30 who received pharmacotherapy were too sedated to feed, compared with 0% of the 18 with no pharmacotherapy. Conclusions: The common finding of polysubstance antenatal exposure, involving predominantly opioids, was associated with scheduled morphine pharmacotherapy for the majority of patients, prolonged hospitalization, and frequent adverse events. Pharmacotherapy for NAS was associated with levels of sedation that interfered with feeding in neonates.

Contexte: Le syndrome d'abstinence néonatale (SAN) est un ensemble de symptômes que les nouveau-nés peuvent ressentir après une exposition prénatale à des substances qui induisent le sevrage. La prise en charge optimale reste inconnue et il existe des variations quant à la prise en charge et les résultats. Objectifs: Décrire la prise en charge, la durée de l'hospitalisation et les événements indésirables chez les nouveau-nés prématurés et nés à terme atteints d'un SAN pour lesquels un traitement (pharmacothérapie et/ou soins de soutien) a été initié dans l'unité de soins intensifs néonatals (USIN). Méthodes: Un examen des dossiers a été effectué sur les nouveau-nés admis à l'USIN de Surrey Memorial Hospital, en Surrey (Colombie-Britannique) qui ont reçu un traitement pour le SAN entre le 1er septembre 2016 et le 1er septembre 2021. Résultats: Au total, 48 nouveau-nés répondaient aux critères d'inclusion. Les opioïdes représentaient le type d'exposition prénatale le plus fréquent. Des polyexpositions étaient présentes chez 45 (94 %) des nouveau-nés. De la morphine a été administrée à 29 (60 %) nouveau-nés et du phénobarbital à 6 (13 %) nouveau-nés, 5 ayant reçu les deux médicaments. La durée moyenne du traitement morphinique était de 14 jours et la durée moyenne d'hospitalisation (tous patients confondus) était de 16 jours. Tous les nouveau-nés ont présenté des événements indésirables; en particulier, 9 (30 %) des 30 qui avaient reçu une pharmacothérapie n'étaient pas capables de se nourrir à cause de la sédation, contre 0 % des 18 n'ayant pas reçu de pharmacothérapie. Conclusions: La découverte commune d'une exposition prénatale à plusieurs substances, impliquant principalement des opioïdes, était associée à une pharmacothérapie programmée à base de morphine pour la majorité des patients, à une hospitalisation prolongée et à des événements indésirables fréquents. La pharmacothérapie était associée à des niveaux de sédation empêchant l'alimentation.

Antimicrobial stewardship intervention to reduce unnecessary antibiotic doses in neonates.

The wording of the antibiotic duration orders for neonatal sepsis was changed as an antimicrobial stewardship initiative to reduce the administration of unnecessary antibiotic doses. The change in wording allowed the patient to stop receiving antibiotics after they received 48 hours of therapy if the health care team had not received notification of a positive culture. This initiative led to a decrease in the number of neonates that received extra unnecessary doses from 50% to 7.2%.

Development of Gentamicin Resistance During Treatment of Escherichia coli Ventilator-Associated Pneumonia in a Neonate.

A neonate born at 25 + 1/7 weeks developed ventilator-associated pneumonia at 29 + 3/7 weeks post-menstrual age with Escherichia coli that was originally sensitive to gentamicin. After 3 days of treatment with gentamicin, the minimum inhibitory concentration (MIC) changed from less than 1 mg/L to more than 16 mg/L. It appears that suboptimal gentamicin dosing led to the development of gentamicin resistance. As the patient was not improving clinically, the antibiotics were changed once the gentamicin resistance was identified. To minimize resistance and treatment failure, clinicians should consider the patient-specific pharmacokinetic parameters, achieved peak level, and the amount of time the gentamicin level will remain below the MIC of the organism being treated.

Expanding the role of pharmacy technicians to facilitate a proactive pharmacist practice.

PURPOSE: This study describes a change in pharmacy practice to expand pharmacy technician roles to allow dispensing without a pharmacist check, thereby enhancing the pharmacist role in direct patient care. SUMMARY: In an effort to optimize patient care with limited resources, we set out to change our pharmacy practice model. We transferred duties that did not require clinical judgment in the dispensary from the pharmacist to the regulated technician. The transferred roles included order entry, order entry verification, and final check of medications and preparations. The changes in roles were well received by the pharmacy staff. The pharmacist practice changed from a reactive process, where the pharmacist waited for orders to be sent to the pharmacy, to a proactive process where the pharmacist collaborated directly with patients and the health care team. The pharmacists were able to provide daily medication therapy management for every inpatient in the new practice model compared with only reactive targeted care in the former practice model. Implementation of the new practice model at our site led to a reduction in time for medications to be delivered to the patient and reduced pharmacy-related medication errors. CONCLUSION: A new pharmacy practice model was successfully implemented whereby the pharmacy technician roles were expanded to the point where they perform all the distribution roles in the dispensary. This, in turn, allowed a change in the pharmacist role, which was focused on daily proactive direct patient care and medication therapy management.

Assessment of Empiric Vancomycin Regimen in the Neonatal Intensive Care Unit.

BACKGROUND: Vancomycin is used to treat serious gram-positive infections in neonates. Currently, there is no consensus on the preferred empiric dosing regimen or target trough vancomycin levels for neonates. The current Fraser Health empiric dosing regimen, implemented in 2010, was designed to achieve target trough levels of 5 to 15 mg/L. OBJECTIVES: To determine the percentage of neonates receiving vancomycin in whom target trough levels of 5 to 15 mg/L were achieved, to identify the times to negative culture result and clinical resolution, and to determine the incidence of nephrotoxicity. METHODS: A chart review was completed for patients who had received vancomycin in the neonatal intensive care unit of either Surrey Memorial Hospital or Royal Columbian Hospital from June 2012 to May 2017 and for whom at least 1 interpretable vancomycin level was available. RESULTS: A total of 87 vancomycin encounters (in 78 neonates) were identified in which the drug had been given according to the Fraser Health empiric dosing regimen. Target trough vancomycin level (5 to 15 mg/L) was achieved in 75% of these encounters. The mean times to negative culture result and clinical resolution were 5 and 6 days, respectively. There was no statistically significant correlation between vancomycin level and time to clinical resolution (rs = 0.366, p = 0.072). Among cases in which the trough vancomycin level exceeded 15 mg/L, the incidence of nephrotoxicity was 22% (4/18). CONCLUSIONS: The current Fraser Health empiric dosing regimen for vancomycin achieved target trough levels of the drug for most neonates in this study. Targeting trough levels less than 15 mg/L when appropriate to the infection type may limit nephrotoxicity associated with vancomycin in neonates. Further studies are needed to evaluate the clinical significance of various vancomycin levels.

CONTEXTE: La vancomycine est utilisée dans le traitement d'infections graves à bactéries à Gram positif chez le nouveau-né. Il n'y a pour l'instant pas de consensus quant à la posologie empirique ou aux concentrations minimales visées de vancomycine à privilégier chez le nouveau-né. La posologie empirique actuelle de la Fraser Health, instaurée en 2010, visait des concentrations minimales de 5 à 15 mg/L. OBJECTIFS: Déterminer le pourcentage de nouveau-nés ayant reçu les concentrations minimales visées de 5 à 15 mg/L de vancomycine, établir le temps nécessaire à l'obtention d'un résultat de culture négatif et celui nécessaire à la disparition clinique des symptômes et déterminer l'incidence de la néphrotoxicité. MÉTHODES: Les investigateurs ont analysé des dossiers de patients ayant reçu de la vancomycine pendant leur séjour à l'unité de soins intensifs néonatals du Surrey Memorial Hospital ou du Royal Columbian Hospital entre juin 2012 et mai 2017, qui mentionnaient au moins une concentration de vancomycine interprétable. RÉSULTATS: Ils ont répertorié 87 traitements de vancomycine (chez 78 nouveau-nés) administrés selon la posologie empirique de la Fraser Health. Les concentrations minimales visées de 5 à 15 mg/L ont été atteintes dans 75 % de ces traitements. Le temps moyen nécessaire à l'obtention d'un résultat de culture négatif ou à la disparition clinique des symptômes était respectivement de cinq et de six jours. Aucune corrélation statistiquement significative entre les concentrations de vancomycine et le temps nécessaire à la disparition clinique des symptômes n'a été relevée (rs = 0,366, p = 0,072). Parmi les cas où les concentrations minimales de vancomycine dépassaient 15 mg/L, l'incidence de néphrotoxicité était de 22 % (4/18). CONCLUSIONS: La posologie empirique de vancomycine actuellement en place à la Fraser Health a permis d'atteindre les concentrations minimales visées de médicament pour la plupart des nouveau-nés de la présente étude. Cibler des concentrations minimales de moins de 15 mg/L lorsque cela est pertinent en fonction du type d'infection pourrait limiter le nombre de cas de néphrotoxicité associés à la vancomycine chez les nouveau-nés. De plus amples études sont nécessaires pour évaluer la portée clinique de différentes concentrations de vancomycine.

Barriers and Strategies for Transition from Student to Successful Hospital Pharmacist.

BACKGROUND: Many health care professionals experience a process of transition when entering the workforce. Various barriers have been documented in the literature, including a lack of confidence, challenging interactions with patients and colleagues, workload, increased responsibility, and a fear of making mistakes. Strategies to overcome these barriers, such as orientation and support programs, have been proposed. However, evidence for the transition of students into successful hospital pharmacists is limited. OBJECTIVES: To identify key barriers to the transition from student to successful hospital pharmacist and to outline strategies to overcome these barriers. METHODS: An electronic survey was distributed to Lower Mainland Pharmacy Services (LMPS) pharmacists, and subsequent one-on-one interviews were completed with a subgroup of new pharmacists. RESULTS: A total of 137 LMPS pharmacists (about 32% of potential respondents) responded to the survey, and 3 of these also participated in an interview. A performance score (used to quantify the transition experience) was calculated for 113 respondents, and there was a correlation between performance score and role satisfaction (r = 0.550, p < 0.001). Performance score was also correlated with years spent working as a hospital pharmacist (r = 0.333, p < 0.001) and with highest level of pharmacy education (r = 0.210, p = 0.026). Work in a specialty area and presence of an orientation program were additional factors associated with higher average performance scores. The greatest need for transitional support was during the first year of work, with trainers and social supports being identified as the most helpful resources. Various perspectives were offered during the interviews, with multiple barriers and strategies proposed. CONCLUSIONS: Among respondents to this survey, the key barriers faced during the transition from student to successful hospital pharmacist were limited time working as a hospital pharmacist, lack of additional pharmacy education, lack of knowledge, rotation among multiple areas, uncertainty about role identity, and limited university preparation. Given that successful transition is associated with subsequent job satisfaction, workplace strategies such as limiting the number of practice areas, developing an orientation program, and providing continued support during the first year of work should be encouraged.

CONTEXTE: Bien des professionnels de la santé passent par un processus de transition lorsqu'ils intègrent le marché du travail. Différents obstacles ont déjà fait l'objet d'études, notamment le manque de confiance, les interactions difficiles avec les patients et les collègues, la charge de travail, l'augmentation des responsabilités et la peur de faire des erreurs. Des stratégies visant à surmonter ces obstacles, comme des programmes d'orientation et de soutien, ont été mises de l'avant. Or il y a peu d'information sur la transition de l'étudiant vers le pharmacien d'hôpital accompli. OBJECTIFS: Repérer les principaux obstacles à la transition de l'étudiant vers le pharmacien d'hôpital accompli et décrire les stratégies permettant de surmonter ces obstacles. MÉTHODES: Un sondage électronique a été envoyé aux pharmaciens du Lower Mainland Pharmacy Services (LMPS) (c.-à-d. les services de pharmacie des basses-terres continentales), puis des entrevues individuelles ont été réalisées auprès d'un sous-groupe de nouveaux pharmaciens. RÉSULTATS: Au total, 137 pharmaciens du LMPS (environ 32 % des répondants potentiels) ont répondu au sondage et trois d'entre eux ont participé à une entrevue. Pour quantifier la transition vécue, les investigateurs ont calculé la cote de rendement de 113 répondants et ils ont établi une corrélation entre la cote de rendement et la satisfaction au travail (r = 0,550, p < 0,001). Ils ont également corrélé la cote de rendement au nombre d'années passées à travailler comme pharmacien d'hôpital (r = 0,333, p < 0,001) et à des niveaux plus élevés de scolarité en pharmacie (r = 0,210, p = 0,026). Un travail dans un domaine spécialisé et la présence d'un programme d'orientation représentaient des facteurs supplémentaires associés à une moyenne plus élevée des cotes de rendement. C'est au cours de la première année de travail que le besoin de soutien à la transition se faisait le plus sentir, et les formateurs ainsi que le soutien social se sont révélés comme étant les meilleures ressources. Différents points de vue ont été exprimés pendant les entrevues et de multiples obstacles et stratégies ont été abordés. CONCLUSIONS: Selon les répondants au sondage, les principaux obstacles évoqués pendant la transition du rôle d'étudiant à celui de pharmacien d'hôpital accompli étaient : le peu de temps consacré au travail de pharmacien d'hôpital, l'absence de formation supplémentaire en pharmacie, des connaissances insuffisantes, la rotation entre différents domaines, les incertitudes concernant la définition du rôle et l'insuffisance de la préparation offerte par l'université. Étant donné qu'une transition réussie est associée à une plus grande satisfaction au travail, il faudrait encourager la mise en place de stratégies en milieu de travail, notamment limiter le nombre de domaines de pratique, établir un programme d'orientation et offrir un soutien continu durant la première année de travail.

Levofloxacin Use in the Neonate: A Case Series.

We report 6 cases of intravenous levofloxacin use to treat multidrug-resistant nosocomial respiratory infections in neonates with a postmenstrual age ranging from 27 to 42 weeks. Because of a lack of neonatal-specific information for levofloxacin, the usual pediatric dosage (10 mg/kg per dose every 12 hours) was used in these patients. Clinical cure occurred in 5 of the 6 patients. Only minimal short-term adverse effects were noted.

Respiratory Syncytial Virus Infection Rates with Limited Use of Palivizumab for Infants Born at 29 to 31+6/7 Weeks Gestational Age.

BACKGROUND: Immunoprophylaxis with palivizumab can reduce respiratory syncytial virus (RSV) infections and hospitalizations. Criteria in British Columbia limit the use of palivizumab to infants born at 29 to 31+6/7 weeks gestational age, which differ from guidelines of the American Academy of Pediatrics (AAP) and the Canadian Paediatric Society (CPS). OBJECTIVE: To determine whether the limited use of palivizumab affected the frequency of hospital visits by RSV-positive infants (termed "RSV-positive hospital visits") who received approval for palivizumab and those who met the AAP/CPS criteria but did not receive approval for palivizumab. METHODS: Data sets were generated for the period May 1, 2008, to April 30, 2011, to identify infants with gestational age of 29 to 31+6/7 weeks who were born in or transferred to the Fraser Health authority, RSV-positive results for infants less than 12 months of age who had visited Fraser Health sites and BC Children's Hospital, and palivizumab approvals. Infants were matched across these 3 data sets through their personal health numbers. RESULTS: The study included 359 infants born at 29 to 31+6/7 weeks, of whom 297 met the AAP/CPS criteria. However, only 46 of these 297 received approval for palivizumab according to the BC criteria. Sixteen (4.5%) of the 359 infants had RSV-positive hospital visits during the RSV season (November through March). Of the 46 infants who received approval for palivizumab, 2 (4.3%) had RSV-positive hospital visits, and of the 251 who met the AAP/CPS criteria but did not receive palivizumab approval, 14 (5.6%) had RSV-positive hospital visits. Of the 359 infants, 6 (1.7%) had RSV-positive results while admitted to the neonatal intensive care unit, and 10 (2.8%) tested positive for RSV during a subsequent hospital visit. CONCLUSIONS: The frequency of RSV-positive hospital visits did not differ between infants who received and those who did not receive approval for palivizumab in the Fraser Health authority. Limited use of palivizumab for RSV prophylaxis led to reasonable rates of RSV-positive hospital visits in the study population.

CONTEXTE: L'immunoprophylaxie à l'aide du palivizumab peut permettre de réduire le nombre de cas d'infection par le virus respiratoire syncytial (VRS) et d'hospitalisation qui en résulte. Les critères de la Colombie-Britannique restreignent l'utilisation du palivizumab aux nourrissons dont l'âge gestationnel se situait entre 29 semaines et 31 semaines et 6 jours. En cela, ils diffèrent des lignes directrices de l'American Academy of Pediatrics (AAP) et de la Société canadienne de pédiatrie (SCP). OBJECTIF: Vérifier si l'utilisation restreinte du palivizumab a eu un effet sur la fréquence des visites à l'hôpital de nourrissons séropositifs pour le VRS pour lesquels on a autorisé la prescription de palivizumab et de ceux qui ont satisfait aux critères de l'AAP et de la SCP, mais pour lesquels la prescription de palivizumab n'était pas autorisée. MÉTHODES: Des ensembles de données ont été produits pour la période s'étendant du 1er mai 2008 au 30 avril 2011 afin d'identifier: les nourrissons nés dans les établissements de la Régie de la santé du Fraser ou y ayant été transférés dont l'âge gestationnel se situait entre 29 semaines et 31 semaines et 6 jours; les résultats positifs pour le VRS chez les nourrissons de moins de 12 mois ayant visité les établissements de la Régie de la santé du Fraser et l'Hôpital pour enfants de la Colombie-Britannique; et les cas où l'on a autorisé la prescription de palivizumab. On a assorti les données des nourrissons entre les trois ensembles à l'aide de leur numéro d'assurance-maladie personnel. RÉSULTATS: L'étude a recensé 359 nourrissons dont l'âge gestationnel se situait entre 29 semaines et 31 semaines et 6 jours. Parmi eux, 297 répondaient aux critères de l'AAP et de la SCP. Or, le traitement par palivizumab n'a été accordé qu'à 46 de ces 297 nourrissons selon les critères de la Colombie-Britannique. Seize (4,5 %) des 359 nourrissons qui avaient visité l'hôpital au cours de la saison du VRS (novembre à mars) se sont révélés séropositifs pour le VRS. Parmi les 46 nourrissons admissibles au traitement par palivizumab, deux (4,3 %) ont visité l'hôpital et se sont avérés séropositifs pour le VRS. Parmi les 251 autres enfants répondant aux critères de l'AAP et de la SCP, mais n'ayant pas été autorisés à recevoir du palivizumab, 14 (5,6 %) ont visité l'hôpital et se sont révélés séropositifs pour le VRS. Parmi les 359 nourrissons, 6 (1,7 %) se sont avérés séropositifs pour le VRS alors qu'ils étaient admis à l'unité de soins intensifs néonatals et 10 (2,8 %) ont été déclarés séropositifs pour le VRS lors d'une visite subséquente à l'hôpital. CONCLUSIONS: La fréquence des visites de nourrissons séropositifs pour le VRS aux établissements de la Régie de la santé du Fraser n'était pas différente entre ceux qui étaient autorisés à recevoir du palivizumab et ceux qui n'y étaient pas autorisés. Une utilisation restreinte du palivizumab pour la prophylaxie du VRS a donné des taux raisonnables de visites à l'hôpital par les nourrissons séropositifs pour le VRS dans la population de l'étude.

Tetracaine (ametop) compared to placebo for reducing pain associated with intramuscular injection of palivizumab (synagis).

Infants receive many painful immunizations before they are 2 years old. The purpose of this study was to evaluate if topical tetracaine reduces the pain of intramuscular palivizumab compared to placebo. There were two study injections, one with tetracaine and one with placebo. Pain was scored by their parents and a pediatric nurse. Topical tetracaine was not associated with a significant reduction in pain score, although it did lead to faster recovery times. Additional pain-reduction strategies are required.

Assessment of gentamicin 7 mg/kg once daily for pediatric patients with febrile neutropenia: a pilot project.

CONTEXT: Use of once daily aminoglycosides continues to increase for the pediatric population, including oncology patients. Concerns have been identified and still need to be resolved including the optimal dose, frequency, and monitoring parameters. OBJECTIVE: We completed a study to determine if empiric use of gentamicin 7 mg/kg once daily in pediatric patients admitted with febrile neutropenia provided extrapolated peaks and drug-free intervals consistent with suggested preferred levels. DESIGN: A review of the patient's chart was completed following their discharge from the hospital between September 2006 and October 2007. SETTING: A community hospital. PATIENTS: A consecutive sample of 17 encounters for pediatric patients admitted for febrile neutropenia that received once daily gentamicin. MAIN OUTCOME MEASURES: Extrapolated peak levels and drug-free intervals. RESULTS: There were seven patients with a total of 17 encounters. The mean extrapolated peak level was 16.9 mg/L. The mean drug-free interval was 15.7 h. Both target peak and drug-free interval were obtained for two encounters (12%), which was one patient. CONCLUSION: Gentamicin 7 mg/kg/dose once daily does not provide preferred levels for all pediatric febrile neutropenic patients. Further investigation is required to ensure that once daily gentamicin regimens for pediatric oncology patients provide adequate clinical success.

Development of a simplified protocol for administration of 20% magnesium sulphate for prophylaxis and treatment of eclampsia.

BACKGROUND: Magnesium sulphate is a high-risk medication that is used extensively for prophylaxis and treatment of eclampsia. To accommodate recommendations related to fluid restrictions and patient safety, a protocol was developed for the administration of 20% magnesium sulphate. OBJECTIVES: To determine whether administration of 20% magnesium sulphate increased the risk of phlebitis relative to 2% to 8% magnesium sulphate solutions, to determine if the institution's protocol for administration of 20% magnesium sulphate reduced errors during administration, and to identify strategies to further reduce potential errors. METHODS: A retrospective chart audit was undertaken for patients who had received magnesium sulphate for prophylaxis of eclampsia from December 2004 to December 2007. A failure mode and effect analysis was used to identify additional safety strategies. RESULTS: A total of 47 patients received magnesium sulphate according to the old administration protocol (2% to 8% solution) and 29 according to the new protocol (20% solution). No evidence of phlebitis was documented for any of these 76 patients. A few errors occurred with changes in rates or concentrations and because of failure to reset the pump after the loading dose, but there was no documented harm to any of the patients. Strategies to further reduce errors in the administration of magnesium sulphate included development of preprinted orders, use of 20% magnesium sulphate for all infusion rates, changes to pump settings to enable use of fractional infusion rates, preparation of magnesium sulphate in mini-bags in the pharmacy, double-check of pump settings by nurses, anesthesiology consult, and distribution of protocols to all areas in the hospital (to limit errors associated with patient transfers). CONCLUSIONS: There was no documented phlebitis, and fewer errors occurred when 20% magnesium sulphate was used. Several additional strategies were identified to reduce errors in the administration of this high-risk medication.

Effect of indomethacin on closure of ductus arteriosus in very-low-birthweight neonates.

AIM: To identify factors related to indomethacin non-responsiveness for patent ductus arteriosus (PDA) closure in very-low-birthweight (VLBW) neonates. METHODS: A chart review of 107 VLBW neonates with a clinical diagnosis of PDA who received indomethacin, admitted to a tertiary neonatal intensive care unit in Toronto, Canada, was conducted (study period November 2001 to October 2003). Positive responders were those with no clinical evidence of PDA for 72 h after indomethacin. RESULTS: Response to the first course of indomethacin was 75%, and to the second course 67% among initial responders. Higher CRIB score (OR 1.15, 95% CI 1.02-1.31) and early surfactant administration (OR 3.74, 95% CI 1.04-13.47) were associated with non-responsiveness to indomethacin. CONCLUSION: Indomethacin is effective for PDA closure. The response rate diminished with subsequent courses. Early surfactant and severity of illness at admission were associated with non-responsiveness to indomethacin.